The science behind addiction
Feb 25, 2018 | By Jenny Wagner
“What’s missing is an understanding that this is truly a disease,” one medical professional said.
After three years in recovery, getting high is still the first thing David Adamek thinks about when something goes wrong.
Last week was a good example. He started a new job and promptly lost it because of a felony on his record, even though he disclosed it up front, he said.
Not long after, he was offered a better-paying job. But not before the voice in his head broke its silence, telling him to start using heroin or opioid painkillers again.
“It doesn’t matter if you say no out loud or no in your head, you just have to sit there and say no. It’s the hardest thing,” the 33-year-old said.
Instead, Adamek tries to think about all the things that have gone right since he stopped. Some of the big ones: buying a new home in Bristol Township with his wife of 15 years and welcoming their blue-eyed baby boy six months ago.
But the voice in Adamek’s head belongs to addiction.
Experts now refer to addiction as substance use disorder, or opioid use disorder when specific drugs like heroin and opioid painkillers are involved. But a stigma still exists that addiction is a moral flaw or weakness.
“There are still people, both in the political arena and the general public, that believe you should ‘Just say no,’ — Nancy Reagan’s famous statement. Pick yourself up by your bootstraps; stop doing those things to yourself,” said Dr. Michael Shore, an addiction psychiatrist and leader of the medication assistance recovery program at Malvern Institute in Cherry Hill, New Jersey. “What’s missing is an understanding that this is truly a disease.”
The disease process
According to the American Psychiatric Association’s most recent Diagnostic and Statistical Manual of Mental Disorders, addiction is a chronic brain disease marked by compulsive substance use and impaired behavior, including the ability to maintain relationships, take care of obligations at work, school or home, and to exert self-control. Relapse is part of the disease, as is recovery.
The brain’s reward system is designed to naturally release dopamine, a chemical responsible for certain feelings and sensations, after activities such as eating. But according to the National Institute of Drug Abuse, opioids cause the system to release much larger amounts, resulting in stronger feelings of pleasure and sometimes euphoria.
“There are many people that will say they tried (the opioid painkiller) Percocet, for example, and they could not stand the way it made them feel. But others will say things like, ‘The first time I took something I was in love.’ It’s that powerful,” said Shore, the former president of the New Jersey Society of Addiction Medicine and now the director of the American Society of Addiction Medicine region that includes Pennsylvania, New Jersey and Ohio.
People who regularly use opioids, even those prescribed for pain, will develop physical dependence as the brain adapts to them, Shore said, but only some will go on to develop substance use disorder.
Those people want to experience the feelings again and again, and they have a compulsive need to use more and more, regardless of the consequences, according to the NIDA.
“After a while, it doesn’t cause euphoria anymore,” Shore said. “They continue to use to feel normal, to avoid withdrawal.”
“It’s flu-like symptoms, but kind of feels worse,” Adamek explained. “Everything’s sore; you’re achy, your skin hurts. … Whatever is in your stomach comes out.”
People don’t want to experience that, so they seek out the substance again.
“You know if you go back to it you’ll feel better,” Adamek said. “You always think, just one more bag, or just one more pill, and everything will be better. Or you think you can wean yourself down.”
It becomes a cycle and gets worse over time, according to the 2016 Surgeon General’s Report on Alcohol, Drugs, and Health. It affects the prefrontal cortex, responsible for executive function such as decision-making, and it changes other parts of the brain as well.
“It becomes a major priority in your life,” Shore said. “Everything else becomes secondary.”
Who is affected
Adamek was prescribed opioid painkillers after he was shot in the hip 13 years ago during a tour of duty in Afghanistan with the U.S. Navy. When the prescription ran out, he said he began buying them illegally to avoid withdrawal and then in 2013 he began using heroin.
“I was able to keep my life — barely — together, pay the bills and stuff like that when I was on the pills,” the Delaware County native said. “Once I switched to heroin I didn’t care about anything. It didn’t matter. I didn’t care about the bills. I stole, pawned.”
In 2015, Adamek got arrested for stealing from his employer and spent three months in jail.
“That was what finally woke me up,” he said.
Recovery is possible, Adamek stressed.
“Willpower can be what gets you into treatment. It can help you maintain your treatment, it can help you make changes in your life situation so you stay away from people and places where drugs are abused,” Shore said.
But willpower is not going to cure the disease, any more than it is going to cure diabetes or heart disease, Shore said. Even those who have received treatment and achieved long-term recovery still can experience triggers and cravings that lead to a relapse.
Evan Resnikoff, chief of operations for Newtown Ambulance Squad and president of the Bucks County EMS Chiefs’ Association, has responded to overdose calls involving people who relapse after as many as five years in recovery.
“A lot of them don’t want to do this,” he said. “I’ve had people wake up remorseful: ‘I did it again. I’ve been clean for two years. I just had a bad day,’ you know. I see that a lot.”
Experts can’t tell exactly who will develop substance use disorder, but genetics and personal and family history increase risk.
Resnikoff also has seen that the disease does not discriminate.
“It’s anybody; it’s in lower-income areas, it’s in higher-income areas,” he said. “We’ve been fortunate, we haven’t been called to a school around here for (an overdose), but it’s happened in other areas.”
Shore said some people still don’t believe opioid use disorder is a disease, or they don’t believe it will affect them. But it is changing with awareness and as the crisis grows.
“More and more,” he said, “I don’t think there’s too many families out there where — a family member, a neighbor, a colleague at work, some connection — they don’t know of people who have died.”