Addiction is a disease of the reward pathways in the brain.
The exact receptors affected differ from substance to substance, and the largely uncharted complexity of the brain makes it difficult to pinpoint the exact location where a drug might be acting, but we do know which systems and pathways are altered by addiction. They resemble the pathways that manage other activities that the brain rewards us for — activities as vital as eating, sex, sleep, and escaping from danger.
These functions are so important to survival that the systems controlling them are some of the most powerful systems we have. Failing to eat will lead to illness and death, so finding enough food becomes the first priority for survival; and only brains that could motivate eating and food-seeking were able to survive. A successful brain has to cause the animal it controls, in this case a human, to neglect everything it considers nonessential for survival in order to find food, and then reward the animal with powerful positive sensations so that it won’t go without food for too long again.
This is basic reward theory, and it doesn’t only apply to us humans. All animals have some version of a reward system, though it might not resemble ours physiologically. It’s a safe bet that these pathways of craving and reward have been part of our brains since long before we split from the chimpanzees. These are the pathways that drugs work on, usually by mimicking the chemicals that our brain naturally produces to give us reward sensations.
Addiction affects the reward pathways, but counseling and 12-step-based treatment programs don’t treat the reward pathways. They treat the prefrontal cortex.
The prefrontal cortex is, roughly, the part of the brain that allows us to anticipate complex series of future events, consider our different options when solving a problem, think logically, and control our own behavior. The prefrontal cortex is often considered the part of the brain responsible for inhibitions and gauging what behavior is socially acceptable. It’s what many people would say separates us from the other animals.
The human prefrontal cortex is highly developed, more so than in any animal except our closest evolutionary cousins. But that development was a relatively recent one, and while complex, logical thinking is definitely necessary for our survival, it isn’t on the same basic, primordial level as food and sleep. This is why the reward pathways can override the prefrontal cortex.
We know this is true. It happens all the time in our everyday lives, whenever we find ourselves doing something that we want to do but know might be bad for us — whether it’s driving over the speed limit, or eating a second cookie, or smoking. It’s true that most of us can avoid these behaviors some of the time by willpower — by the prefrontal cortex shouting down the reward pathways. Education is a powerful tool in this regard, since knowing the bad consequences of our actions can strengthen the efforts of our prefrontal cortex to prevent it. Social motivators, like guilt and embarrassment, can also be effective at drowning out the reward pathways. But education, willpower, and social motivation can only go so far. Just as you can’t educate or guilt yourself out of being hungry, there comes a point where the basic survival mechanisms of the reward pathways can’t be contained by the prefrontal cortex.
This is the case in addiction. It is a biological disease which affects the brain, fooling the reward pathways into believing that the addictive substance is absolutely necessary for a person’s continued survival. Teaching people about the negative effects of drugs won’t fix this, because education works in the prefrontal cortex, and that’s not where the source of the illness is. Guilting or shaming people might enable them to temporarily contain the desires of the reward pathway through willpower, but eventually the reward pathways can overcome the influence of the thinking parts of the brain, and drive the addicted person to seek their substance of choice regardless of anything else.
But there’s hope. There’s a treatment for the true source of the illness now, one that fixes the reward pathways — and once the reward pathways have been satisfied, then counseling, education, and social therapy can work on the prefrontal cortex, and the patient can improve his or her behavior. As long as the reward pathways are damaged, it’s very unlikely that a patient can fix their behavior on their own, because their behavior isn’t entirely under their conscious control.
Everything wrong right now in the field of addiction medicine relates to a misunderstanding of the relationship between these structures in the brain. Addicts and counselors have been aggressively attempting to treat the symptoms of addiction for decades, but it simply wasn’t possible as long as the root of the problem was going unaddressed. Now we can fix the underlying illness, and all the treatments which have been wasted up until this point can, on the basis of medication, become truly effective and truly helpful.
Counseling has its place in the treatment of addiction and addictive behavior, but that place should be secondary, behind medication maintenance. Addiction creates all kinds of social and emotional problems in patients’ lives that education and counseling can help, but none of that will be effective until we can calm the reward pathways and put the patient back in control.