by Percy Menzies

We hardly need to repeat the statistics on alcoholism, in terms of deaths and injuries due to accidents, hospitalizations, broken families, lost productivity, etc. Indeed, alcoholism (or alcohol dependence) is one of the major public health issues facing our nation.

It would seem logical that with all the advances we have made in the various fields of medical science, that by now, we should have been able to subdue this beast of alcoholism. Unfortunately, we have barely made a dent in the battle against alcoholism, which costs the nation hundreds of billions of dollars a year.

Millions of dollars are spent each year in researching just about every aspect of alcoholism – from genetics, to blocking the effects of alcohol. Some of the research is very exciting and has certainly advanced our understanding of this devastating disease, and we expect many more equally exciting findings to come in the near future.

A succinct definition of alcoholism (and for that matter, all addiction) is: it is a disorder of the pleasure system of the brain. The ‘pleasure’ system is vital to the survival of the species. If we did not experience pleasure, there would be little incentive to seek water, food, shelter, or reproduce. These functions are called drive states. The body has a finely tuned mechanism to trigger and satiate these instinctive drives. The actual sensation of pleasure occurs when certain biochemicals called ‘neurotransmitters’ are released in anticipation of these drives. These neurotransmitters travel to specific sites in the brain and stimulate very specific clusters of brain cells (or neurons) called ‘receptors’. There are specific receptors for each neurotransmitter – analogous to a lock and key mechanism. When the receptors are stimulated, pleasure is experienced. A major focus of scientific research is to unlock the mystery of the pleasure system and the complex interactions between neurotransmitters and receptor sites.

There are certain substances found in nature that either mimic the actions of the body’s neurotransmitters or excessively stimulate the pleasure system. Morphine, heroin, and other similar drugs either extracted or produced from opium, mimic the actions of one of the most powerful pleasure producing neurotransmitters, called ‘endorphins’. Endorphins, in addition to producing pleasure, protect the person from pain. This is the reason morphine and morphine-like drugs are used as potent painkillers, or analgesics. The effects of alcohol are more complex. Alcohol affects several neurotransmitters, either by stimulating or depressing the release of these neurotransmitters.

Unfortunately, the ingestion of alcohol and certain addicting drugs cause levels of pleasure far more than the body needs. But all human beings are not affected to the same extent by this abnormal pleasure. About 10-15% of the population has a genetic predisposition (or tendency) to experience the pleasure from addicting substances and alcohol in an abnormally exaggerated fashion. The body’s response: “I like it, give me more and give it to me now!” Such people are more vulnerable to addictions and alcoholism. By no means are these people destined to become alcoholics or addicts. There are other factors– like the unpleasant effects of a severe headache or drowsiness– that will make these people turn away from alcohol. The genetic predisposition is more of a warning sign than fate or destiny.

Psychological and psychiatric factors– like depression, stress, and mental illness– may lead people to abuse addictive substances. Another important factor is the social environment. If there is drinking in the family or the friends are into alcohol or drugs, this can become an important contributing factor in reinforcing the disease… and later, a major obstacle to successful treatment.

How does the brain react to these surges of abnormal pleasure? The receptors attempt to accommodate (or adapt to) these bigger and more frequent jolts, through a mechanism called ‘neuroadaptation’. The neurons are no longer satisfied with what they experienced previously; they now want more of it, and more often. Unfortunately, the pleasure experienced the first time cannot be experienced again, and the futile quest leads to a downward spiral. Most alcoholics and addicts are beyond the pleasure stage. They drink or use drugs to lessen the pain or feel ‘less bad’. Neuroadaptation leads to intense cravings, physical dependence, loss of control and tolerance.

Things get worse as the disease progresses. The addiction gets embedded into the neurological circuitry of the memory, emotion and motivation, and becomes part of the drive state so essential to the preservation of life (i.e. food, shelter, sex etc.). The addiction (as evidenced by cravings) can be so overpowering that it often supersedes the normal human instinct to seek food, shelter, safety etc. Seeking drugs or alcohol now becomes the overwhelming, and often the only objective of these patients… with complete disregard to health, safety and personal well-being.

To add insult to injury, when patients wake up to the stark reality of the dire situation, and seek help (either voluntarily or through the intervention of family), there are no easy ‘road maps’ to follow. They are drowned by the misinformation present everywhere. Society has little or no sympathy for these patients. “They did it to themselves, so let them suffer!” Is addiction or alcoholism a disease, a crime or a vice? There is no dearth of opinions on the causes and treatment of this most misunderstood disease. “Throw the bums into jail!”, cry the law and order folks… and “Give yourself to a higher power…” intone the folks on the moral front.

Why is this disease so difficult to treat? What is the best treatment for alcoholism and addictions? Is a medical approach better than behavioral approach? Is one treatment better than another? Why does this disease have such a high failure rate? The answers are not easy, and often as complex as the disease itself.

It is generally accepted that alcoholism is a chronic disease, yet the treatment is often non-medical, episodic and based on folklore and personal experiences. The history of this disease is a chronicle of change and resistance to change. Rarely has the treatment of a disease been so mired in rigid belief systems… with little interest in incorporating proven therapies and scientific advances.

A successful treatment approach must take into consideration the very nature of the disease. Compulsive and uncontrolled drug or alcohol use is part of the disease, and is driven by both cravings and urges. The urges are probably going to remain with the patients for the rest of their lives. Fortunately, behavior modification (through counseling) can teach these patients skills to control these urges. We have to accept the fact that alcoholism and addictions– like other chronic diseases such as diabetes or hypertension– can only be controlled, and not cured. Does this mean that the patients are destined to suffer through cycles of abstinence and relapses to drug and alcohol use? Not necessarily, but this is an ever present danger. Why is this? We have to again go back to the neurobiology of the brain.

The pleasure center of the brain is co-located with memory, emotional and motivational centers, and they are inter-connected. The memory has an incredible ability to retrieve things – both good and bad. Patients who have been abstinent for long periods of time can compulsively use drugs or alcohol within minutes of being exposed to sights, sounds, smells, etc. of past drug and alcohol use. Before treatment, the patients’ addiction and alcoholism was reinforced through ‘conditioned stimuli’… visiting bars, liquor in the house, friends drinking, etc. The ‘conditioned abstinence’ brought on by incarceration or inpatient programs can create the illusion of abstinence, but can quickly lead to relapses when patients are exposed to external environmental cues. For successful treatment, both the conditioned stimuli and conditioned abstinence should be extinguished. How can this be achieved?

A good treatment program should address craving – the most persistent and intractable symptom of the disease. Craving is implicated in both reinforcing the disease and in relapses. External or internal stimuli trigger thoughts to use drugs or alcohol. The brain responds by releasing endorphins (the pleasure neurotransmitter), which in turn will bind to the opioid receptors and trigger the sensation of pleasure. This unleashes the desire for more, and the patients often succumb to this craving, resulting in the patient relapsing to drugs or alcohol.

Since craving is a neuro-chemical reaction, it is best treated with medications. Indeed, the most tangible results of recent research and clinical studies have resulted in medications to attenuate craving. We have achieved varying degrees of success in this approach – nicotine patches for cigarette addiction; methadone for heroin addiction; naltrexone for alcoholism. Several very promising medications, all addressing cravings, are undergoing clinical studies.

The effect of addiction on the person (behavior) must be addressed, and is best addressed through various forms of individual or group counseling. The critical areas include: controlling thoughts (urges) that lead to drugs or alcohol use, stress and anger management, life style changes to modify alcohol-related behaviors, etc. Numerous studies have consistently shown that a combination of medications with behavioral therapies has the best results in long-term relapse prevention. Reducing the craving makes counseling far more effective– with improved long-term success.

Why are these proven medications not used more extensively? Sadly, there exists a chasm in research and clinical practice of addiction and alcoholism treatment. Medical advances that have been proven safe and effective over a long period of time are often rejected, or poorly incorporated into the treatment regimen, resulting in failures… which leads to an erroneous perception that medications have no role in “behavioral” diseases, and provides a disincentive to develop newer, even more effective medications.

The future for the successful treatment of alcoholism lies first in destigmatizing the disease, and secondly, in combining the effective medications presently available along with behavioral (or cognitive) therapy. The treatment must be delivered in a structured program to minimize the ambivalence commonly seen in alcoholism and addictions.

Only then we can give a new meaning to the slogan: TREATMENT WORKS.