ISIH S2 E1 / The Opioid Overdose Crisis: Is addiction a brain disease?

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Owen Flanagan: You know if I had to say, I'd say I come from a family of eight people, seven of us had serious drinking problems. Two of them are dead from alcoholism.

Celine Gounder: Owen Flanagan is a philosophy professor at Duke University. He spent thirty years of his life with an on-again, off-again addiction to alcohol and prescription drugs. Owen took his first drink at 13.

OF: And I remember distinctly, I had this friend -- Johnny Estenfeld was his name, I've tried to track him down and I have never been able to -- [00:07:36] And then one day he introduced me to his father's hard cider. I took like half a drink of it and I remember walking home that day, it was a mile and a half back to my house and it was October and the leaves were falling and I remember looking at the world and it felt entirely different. I felt safe. I felt not scared. I didn't know before that that I had ever felt scared. I was just kind of a quiet, shy, vaguely intellectual kid, but I felt relief from that fear. And I remember that. That's just what they call you know that flashbulb kind of memory where you just can't get it out of your head. And so that was the beginning of my... that was the first drink I had. I probably didn’t have another one until three, four or five years later.

CG: Welcome back to "In Sickness and in Health," the podcast about health and social justice.

I’m Celine Gounder. I’m a doctor. I’ve worked all over the country… from the coasts… to Appalachia… to the rural southwest. Wherever I see a need.

In Season 2 of In Sickness and in Health, we’re going to talk about the opioid overdose epidemic. Life expectancy in the U.S. has dropped for the second year in a row… due mainly to drug overdoses… while the life expectancy in other developed countries… continues to rise.

In this season... we won’t be talking about opioids the way you’re used to hearing. We’ll talk about how we think about drugs and why that matters. We’ll get a better understanding of the many downstream effects of drug use. We’ll show you why we’ve got to think bigger--bigger than health care and bigger than law enforcement--if we’re going to solve this problem. We’re going to spend time with all kinds of experts--from former users in recovery and second-hand sufferers... to scientists, legal scholars, economists and philosophers... as well as doctors, nurses, social workers and law enforcement on the frontlines. And we’ll learn from our and other nations’ histories with drugs.

Before we can effectively address this crisis, we need to understand what we’re talking about... get our definitions and terms straight. It’s hard to come together... to come up with solutions... when we don’t have a common understanding of the problem. What is addiction anyway?

So, to begin this season, we’re going to start with the basics: how do we define addiction? What is it?

In 1956... over two decades after Alcoholics Anonymous was founded and its members preached alcoholism as an illness... the American Medical Association declared alcoholism an illness… and in 1987, the AMA and other medical organizations officially declared addiction a disease.

So, for three decades now, the medical community has officially recognized addiction to be a brain disease. But, as more light is shed on the subject… as more scientists have studied the issue… and have come forward with their theories about drug use… even as much of the lay public still thinks of addiction as a moral failing or a lack of willpower… the idea of addiction as a disease... has become a lot more complicated.

So, what’s the science behind this idea?

Nora Volkow: They are many pathways that are actually affected in addiction. Initially, we had thought that it was just the limbic reward systems that was affected by drugs and that produced addiction.

CG: Dr. Nora Volkow is the Director of the National Institute on Drug Abuse. She’s one of the nation’s top experts on drug addiction. Much of her team’s research focuses on dopamine release and receptors… this is what neuroscientists call the brain’s pleasure center… and it behaves differently in people with addiction.

Nora and her team found that people with addiction have a weaker pleasure response when exposed to the drug... or to the everyday things they would have before found rewarding... that  the pleasure center of the brain didn’t function right in the midst of addiction… and it didn’t just revert back to normal when someone stopped using a drug.

NV: But as we started to perform brain imaging studies in people that were actually addicted to the drug, what emerged very rapidly is that there were several areas that were not functioning properly that actually were distinct from people that were non-addicted.

CG: But the pleasure center isn’t the only part of the brain that’s affected by addiction.

The part of the brain that manages the stress response doesn’t work right either… it magnifies stressful stimuli… so the pull of positive experiences can be overcome by the push of negative ones… which is why for someone with addition… using drugs is about escaping pain, not about getting high. The emotional scales are tipped strongly in one direction.

NV: It's also evident that as people continue to take drugs, as they become more chronic, the emotional circuitry of the brain becomes hypersensitized to stress and to negative moods. Such that in the case of a person that's addicted when they are no longer -- when they are not intoxicated, their mood is very negative. They are very irritable. They are anxious. They cannot tolerate frustration. And this actually in many instances is a very major cause of relapse because a person is trying to feel better. They feel awful without the drug so, and you've heard this, we've all heard this, the person no longer takes the drug to feel high. They take drug to feel better. And this is a transition that happens as the individual passes from taking that drug on occasional periods to becoming addicted and taking it in a compulsive fashion.

CG: But a thinking person should still be able to override these feelings… to know the difference between right and wrong… right? ...except that the part of the brain that helps weigh options, make decisions, and regulate emotions and impulses... is also impaired by addiction... Still... that doesn’t mean people truly become slaves to addiction.

NV: Well they have a profound disruption of the neural circuitry that allows us to self-regulate and to control our impulses. Now the question is, is it completely lost? And the answer: no. And again when you speak about damage to these to these areas it's actually, there is, there is a severity component to it. So, we can speak about the brakes of a car, right, that allow you to basically stop when you want to do it. Well, if you don't have any brakes, you're not going to be able to stop no matter what. But if your brakes are not functioning properly, they may still allow you to brake under certain circumstances, and what you doing in those occasions if you know your brakes are not good is to drive carefully and to avoid dangerous situations. And so that's actually a very good metaphor for the person that's addicted because under certain circumstances they can still exert some level of control. But if you place them in an environment where there are stressors, or they are surrounded by cues that remind them of the drug, they will not be able to exert control.

CG: So addiction isn’t just a disease of the brain… the interplay between the brain and the environment is a key part of the story. We know, intuitively, that someone in recovery from substance abuse is more likely to relapse if they’re around people they used to use with… or if they’re under certain kinds of stress… or in certain situations… what we call triggers.

And just like drugs, life stressors can also interfere with the brain’s signaling pathways… making it harder to weigh consequences... much like drugs do. This means that someone who grew up with neglectful or abusive parents… someone who’s been sexually assaulted… someone who grew up poor… not always having three square meals a day or a safe, reliable place to stay... might be more likely to become addicted to a drug once exposed.

Nora says people who’ve suffered traumatic stress might have trouble saying “no” to what feels good.

NV: Connectivity of the brain, and most notable, is that connectivity that emerges between the prefrontal brain regions that we were discussing are a fundamental part of executive control networks, and the limbic-emotional areas of the brain are delayed. The development of those connections are delayed in children that have been brought up in environments of social neglect. That could explain why they are much more prone to impulsive behaviors, and why they have trouble regulating their emotions, and they can get frustrated and angry, and do behaviors that can be very dangerous.

CG: And it isn’t just those earlier life stressors that can tilt the scales… the age at which someone tries a drug also predicts risk. The brain... in particular, the part of the brain that helps us weigh pros and cons... to make decisions... to control impulses… doesn’t finish maturing until we’re in our mid 20s… years after the rest of the body.

NV: The younger you are when you get exposed to drugs, the greater the risk you become addicted. And this is because, actually, the brain is much more plastic when you are young. And what is plastic? It means neuroplasticity, it means that the brain physically changes itself as a function of its environment. Very important property, because it allows the brain to grow to maximize its ability to actually solve the environment and for you to perform properly in the environment you are growing up with. So that that's why it ultimately gets tailored and modeled by the environmental circumstances.

CG: Inherited genes are another part of the story. They can make someone more susceptible to drug addiction… or alcoholism… or diabetes. But, Nora says, these genes can also be suppressed by the right kind of healthy environment. And the wrong series of life events... can bring out those genes… the predisposition.

NV: And it’s important to understand, obviously, these interactions, because, as of now, we cannot cure a genetic disease, for the most part. But what we can do, if we understand how that gene interacts with the environment, we can actually do prevention interventions to buffer those adverse environmental effects.

CG: Nora looks at diabetes… also considered a disease... in much the same way that she looks at drug addiction. Addiction doesn’t happen in a vacuum. It isn’t just between the user and the drug... and using a drug… doesn’t give you addiction… any more than drinking a beer gives you alcoholism… or eating sweets gives you diabetes.

In fact, the vast majority of people… about 90%... who try or use drugs don’t become addicted. Which raises the question, what’s different about people who succumb to addiction? before they ever even try a drug? And what might this mean for the diagnosis and treatment of addiction?

OF: All my friends from college, we drank. And only some of us got hooked, and we certainly didn't do it, as we say, on purpose. We didn't go into it -- but something about our own individual biochemistry, and cultural availability of, in my case, alcohol but also benzos, which doctors gave me, made it available to me, so I just don't think there's, you know, people just don't choose to become, you know problems for themselves or problems for society.

CG: Owen Flanagan never used opioids, but as a philosopher who spent decades struggling with substance abuse, he has a unique perspective on moral psychology and addiction.

The question of choice can be important when we talk about opioid addiction... Owen made some bad choices… but there were also contributing factors that increased his risk of becoming addicted to alcohol... while his friends... didn’t.

OF: I was raised in a good New York suburban post World War II family. My father had been a soldier in Patton's Third Army in Germany, and he went to college on the G.I. Bill, and I was the oldest of six children, and we identified, at least my parents did, as Irish Catholic. And I always knew -- I knew that people drank. That's what I kind of thought adults did. It was just part of what, you know, I saw. Actually I saw my parents for the most part drinking quite responsibly. That wasn't always that way, but, I mean, as a child, I just knew there was something called Cocktail Hour. My father came home from Manhattan. He had his drinks. I remember the, you know, the kind of, almost, it was a little bit sacramental.

CG: Owen describes his father as a pretty responsible drinker... and says he figured that he was just a heavy social drinker like his dad seemed to be… unlike his siblings… who suffered from alcoholism... or couldn’t hold their liquor…. and stopped drinking early in life.

But after college, Owen’s drinking got really serious... serious enough to ruin relationships... or prevent him from engaging in them at all. He became addicted to benzos… drugs like Xanax and Klonopin... after being prescribed them by a psychiatrist… and that addiction... fueled his drinking. He lost his marriage, and his relationships with his kids suffered.

OF: I think that, you know, I mentioned this to you about my own case. There was a powerful feeling of the medicinal effect of alcohol on me. I’m not saying it’s the same for everyone. I know that for some kids my age back then, it might have been more of a, I don’t know, something to make you cool at a party. But for me, I remember the first thing it did was reduce fear and anxiety, and it worked that way for me for a long time. So I take it that opiates have something like the same mind-numbing, you know, when they become cheap and available and they have pharmaceutical effects that are pleasant or needed or wanted because life is bad, I think it’s a recipe for disaster.

CG: Owen was resigned to being dependent on these substances. He didn’t think he could live sober without being miserable.

OF: And then by just going to AA all the time and making friends there, I started, I remember, it was suddenly like a morning and I thought, 'my God I hadn't thought about a drink for like two hours'. And then that started to become half days and that became full days. And then something happened. I think it was you know time and community I guess is my best guess. Obviously my neurochemistry was doing things that I have no access to.

CG: So alcohol and benzos had a medicinal effect on Owen… they helped soothe his fear and anxiety. But friendships he made in AA… were… for Owen... an important part of the treatment for his addiction.

OF: It’s definitely not entirely a brain disease. So that’s where I’m on, and I sometimes just say this. I say, addiction is a lifestyle issue, but it clearly involves the brain.

CG: Owen doesn’t outright reject addiction as brain disease. He thinks of addiction as a little of column A, a little of column B… as a brain issue and a behavioral issue… rooted in family and culture… as well as social circumstances. It’s something that manifests differently for different people… differently with different drugs.

Carl Hart: So I was looking for this I've been looking for this for some time. I started out thinking that dopamine was the answer and I was going to find this sort of thing. So first of all there is, like,  almost no evidence to support this notion that drug addiction is a brain disease. I wrote a paper, an opinion piece in Nature ... and I go through some of the literature to point out that the notion that drug addiction is a brain disease is catchy but weak -- there's no evidence.

CG: Dr. Carl Hart is the Chair of Psychology at Columbia University. He actively resists the word “abuse” when it comes to drug use. To Carl, addictive substances are things that some people struggle with... that pose a problem. These “problem substances” interact a certain way with the brain... but to Carl, that isn’t the same thing as drugs causing a clinical brain disease.

CH: We think about brain diseases that we know, something like Parkinson's disease, something like Huntington's disease, those kind of diseases are progressive and usually, unfortunately, the person will die from the symptoms related to that disease. [00:36:08] Drug addiction is nowhere near that. Oftentimes a person gets better without any treatment. You certainly can't see in somebody's brain, you can't differentiate a brain of someone who's a drug addict versus someone -- drug addiction being defined by the DSM -- you can't differentiate somebody’s brain who's a drug addict from somebody who's not. You can't do it. I mean the thing that we know is that drugs -- this is true -- have neurobiological effects. Like there are specific effects on specific neurons. That’s true.

CG: The way Carl sees it, a brain disease is something that progresses... something intrinsic to the person with the disease. And calling addiction a brain disease muddied the waters of discovery and deliberation for him.

CH: I haven't seen the evidence of this, and I've been studying drugs for 25 years, the neurobiology of drugs, and this is why I got into this study, to try and figure out where, where is it? I want to understand it. I tried to learn everything I could about dopamine. I was, I was a convert. And then you know, and then I realized that I had been hoodwinked. It was, it's a church. It's just like religion.

CG: Carl means he was hoodwinked by popular thought... by the insistence that addiction is indeed a disease... and one linked inextricably to the dopamine signaling pathways in the brain.

CH: But somehow we have, for largely because of funding and political reasons, we've convinced the public. Drug addiction is a brain disease therefore we are a legitimate science. We have hard evidence. So please increase our budgets here at the National Institute on Drug Abuse, for example. That's one of the major drivers that's pushing this sort of brain disease model of drug addiction. But when you ask people to show you the evidence, now, that's a whole different story.

CG: Though Carl resists the notion that addiction is a brain disease, he readily acknowledges it’s something some people are more likely to fall victim to. His concern is with the classification of addiction as a disease... as a medical problem… which might distract clinicians, scientists and policy-makers from addressing the real, underlying drivers of addiction. The way Carl explains it… addiction isn’t a brain problem… an individual problem. It’s a social problem… a societal problem.

CH: So in order that we think about, we have to think about the numbers of people who actually become addicted. Earlier we talked about the relatively low proportion of people who use these drugs who become addicted. So the vast majority of people who use any drug don't become addicted. And so now we're left with this group who are addicted. So what's going on with them? One of the things that we know then, since the vast majority don't become addicted, we know it's not the drug itself. So we can't blame the drug. So now we have to look at those people and see what's going on in those people's lives. So when we think about heroin addiction, for example, one of the things that we know from like recent studies is that you're more likely to be addicted if you are a relatively young male, white, living in rural America, jobless or underemployed, and no health insurance. We know that, right? That's a fact. OK, so you look at that situation and be like, fuck it, that's me.

CG: To Carl, framing addiction as a brain disease sidesteps, maybe even oversimplifies, the real drivers of this problem.

Some well-meaning people might think that framing addiction as a brain disease will help reduce stigma... and make it easier for people to get treatment. But it isn’t just the framing of addiction in terms of moral failing that can be stigmatizing…  diseases are also stigmatized when they’re hard to treat… when the situation feels hopeless… much as it did in the case of cancer just a few decades ago…  And if we focus just on treating addiction as a brain disease… while ignoring other causes… this could backfire… leading some to give up hope when treatments targeted at the brain’s circuitry... don’t work.

Candice Shelby: Addiction is an experience. It’s a phenomenon that emerges in very, very complex systems, which are largely marked by non-linear causation. … And so we should be thinking about patterns of interaction and directing those patterns of interaction. So, I just think that oversimplifying and employing this sort of billiard ball kind of causality to the concept of addiction is wrong headed and unhelpful, and I know that people are capable of more nuanced thinking than that, and that’s what I would like for those who are leading the field and doing legislation and are developing treatments to think about.

CG: Like Owen Flanagan, Candice Shelby is a professor of philosophy. She teaches at the University of Colorado. And like Owen, Candice comes from a family that’s struggled with addiction… her father, her mother and her sister. Candice has devoted a lot of thought and academic study to why some people… like her family... develop addictions… while others… like herself… don’t. Last year, she published her book, Addiction: A Philosophical Perspective.

CS: ...we say that somebody has a disease, but it’s the individual who is affected, the individual who’s responsible, the individual who came down with this disease on his or her own. And that’s not what happened in cases of addictive experience.

The language of brain disease is just … unfortunate because it suggests something that comes on of its own accord, that it has its own path, that it is some sort of entity that can be treated with medical treatments…

CG: But what if this framing… of moral failing versus brain disease... is a false dichotomy? Is there another way to think about the problem?

We’re a highly individualistic society… but does that individualism… limit our understanding?

CS: The approaches to dealing with the problem of addiction are very much like the approaches to dealing with the problem of poverty and lack of education. These approaches have to be multi-pronged and ideally, ultimately, society-wide. … So, one feature of complex, dynamic systems is that there are lever points in these systems, and these lever points are places at which small inputs can have tremendous differences in output, and because human beings are unique, I don’t think that there is an answer to the problem of addiction.

CG: Candice comes at the problem of addiction from a different point of view… and field of study… but arrives at many of the same conclusions as Carl Hart… That so long as we think about addiction as an individual problem… our solutions will continue to target individuals.

Though addiction as brain disease was a hard-won designation in the medical community, perhaps the real question is… how has calling addiction a brain disease helped prevent and treat addiction?

Has the word “disease” mitigated the stigma of addiction? Or is it just the shifting social landscape of drug addiction… one in which white suburbanites are also susceptible... not just poor people of color?

What medical treatments have researchers developed to treat addiction as a “brain disease”? Or do we keep treating addiction the way we have all along… in classic AA, 12-steps fashion?

Does calling addiction a “brain disease” make it easier to ignore the complex and difficult-to-address social, political and economic factors that contribute to the so-called opioid epidemic?

Over the next several episodes, we’re going to look at many of the complicated contributing factors. We’ll show how understanding those factors can help us come up with solutions. And we’ll speak to the people who are facing them head-on.

Because... even if addiction is, indeed, a brain disease… it’s so much more than that.

That’s next time, on “In Sickness and in Health.”

Today’s episode of “In Sickness and in Health” was produced by Hannah McCarthy and me. Our theme music is by Allan Vest. You can learn more about this podcast and how to engage with us on social media at insicknessandinhealthpodcast.com, that’s insicknessandinhealthpodcast.com.

If you or a loved one needs help, you can reach out anonymously and confidentially to SAMHSA’s National Helpline at 1-800-662-HELP, that’s 800-662-4357. SAMHSA stands for Substance Abuse and Mental Health Services Administration. You can also find information online at www.findtreatment.samhsa.gov, that’s www.findtreatment.samhsa.gov.

I’m Dr. Celine Gounder. This is “In Sickness and in Health.”