Addiction: a life long illness not lifestyle choice

February 28, 2011

 

Addiction is a major health problem that costs as much as all other mental illnesses combined (about £40 billion per year) and about as much as cancer and cardiovascular disorders also.

At its core addiction is a state of altered brain function that leads to fundamental changes in behavior that are manifest by repeated use of alcohol or other drugs or engaging in activities such as gambling.  These are usually resisted, albeit unsuccessfully, by the addict.  The key features of addiction is therefore a state of habitual behaviour such as drug taking or gambling that is initially enjoyable but which eventually becomes self-sustaining or habitual. The urge to engage in the behaviour becomes so powerful that it interferes with normal life often to the point of overtaking work, personal relationships and family activities. At this point the person can be said to be addicted: the addict’s every thought and action is directed to their addiction and everything else suffers. 

If the addictive behaviour is not possible e.g. because they don’t have enough money then feelings of intense distress emerge. These can lead to dangerously impulsive and sometimes aggressive actions.  In the case of drug/alcohol addiction the situation is compounded by the occurrence of withdrawal reactions which cause further distress and motivate desperate attempts to find more of the addictive agent. This urge to get the drug may be so overpowering that addicts will commit seemingly random crimes to get the resources to buy more drug. It has been estimated that about 70% of all acquisitive crime is associated with drug and alcohol use.

Addiction is driven by a complex set of internal and external factors.  The external factors are well understood:  the more access to the desired drug or behaviour e.g. gambling the more addiction there is. 

The internal factors are less clear. Although most addiction is to alcohol and other drugs, addiction to gambling and other behaviours such as sex or shopping can occur. These tell us that the brain can develop hard-to-control urges independent of changing its chemistry with drugs.  All addictions share a common thread in that they are initially pleasurable activities, often extremely enjoyable. This results in these behaviours hijacking the brain’s normal pleasure systems so that naturally enjoyable activities such as family life, work, exercise become devalued and the more excessive addiction behaviours take over. 

However, not everyone who engages in drug use or gambling becomes addicted to them so clearly other factors are important. These are not yet understood but are now being actively studied. Some people may be particularly sensitive to the pleasurable effects of alcohol, drugs or gambling, perhaps because of coming from deprived backgrounds. In others, addiction may occur because of an inability to adopt coping strategies.  Others may have an underlying predisposition to develop compulsive behaviour patterns. Some unfortunate people may have several of these vulnerability factors and there are also genetic predispositions to some of them.

Also a significant amount of drug use is for self-medication, examples include  cannabis for insomnia, alcohol to reduce anxiety, opioids for pain control etc. This therapeutic use can escalate into addiction in some people though by no means all. Not all drugs which are used for recreational purposes are addictive. LSD and magic mushrooms seem not addictive at all, and some have a low risk of addiction (MDMA/ecstasy; cannabis). The most addictive drugs are nicotine, heroin and crack cocaine plus metamfetamine (crystal meth) although this is not much used in the UK.

Just because some people – including leading politicians – have used drugs but stopped before they became addicted does not mean that anyone can stop that easily.  Starting to use drugs may be a lifestyle choice but once addiction sets in, choosing to stop is very much more difficult if not impossible.

We are beginning to understand how addictions start in the brain. The pleasurable or rewarding effects of addictions are mediated in the brain through the release of chemicals such as dopamine [by cocaine, amphetamines, nicotine] or endorphins [heroin] or both [alcohol].  The pleasures are then laid down as deep-seated memories, probably through changes in other neurotransmitters such as glutamate and GABA that make memories. These memories link the location, persons and experiences of the addiction with the emotional effects. These memories are often the most powerfully positive ones the person may ever experience, which explains why addicts put so much effort into getting them again.  When the memories re-occur, which is common when people are still using drugs or gambling, as well as when in recovery/abstinence, they are experienced as cravings.  These can be so strong and urgent that they lead to relapse.

A great deal of research has been conducted into the role of dopamine in addiction and we now know that the number of dopamine receptors seems to predispose to excessive pleasure responses from stimulant use. This excessive response is thought to initially occur in the reward centre of the brain – [the nucleus accumbens] – but then move into other areas where habits are laid down.  This shift from voluntary (choice use) to involuntary (habit-use) explains a common complaint of addicts that they don’t want to continue with their addictions, and even that they don’t enjoy them anymore, but cant stop themselves.  In this sense addiction can be seen as a loss-of-control over what starts out as a voluntary behavior.  Thus addiction is not, as some like to suggest, simply a “lifestyle” choice. It is a serious, often lethal, disease caused by an enduring (probably permanent) change in brain function.

We know that personality traits especially impulsivity, predict excess stimulant use and in animals this can be shown to correlate with low dopamine and high opioid receptor levels.  Similarly in humans low dopamine and high opioid receptor levels in brain predict drug use and craving.  These observations give new approaches to treatment, both psychological interventions such as behavioural control, and anti-impulse drugs such as those used for ADHD e.g. atomoxetine and modafinil, are being tested. 

For some addictions, especially heroin, the risk to the addict (life expectancy less than that from many cancers) and to society (from crime and infections), is so high that the prescription of substitute opioid drugs or even heroin itself saves lives and reduces crime. These substitute drugs are methadone and buprenorphine [Subutex]. As well as reducing crime and social costs by removing the need for addicts to commit offences to feed their habit, they also protect from accidental overdose and reduce risk of infections such as HIV and hepatitis.  Similar substitute pharmacological approaches exist for other addictions e.g. gammahydroxybutyrate (Alcover) and baclofen for alcohol addiction, and varenicline (Champix) for nicotine dependence.

Another major reason for relapse in addiction is stress. This may work through increasing dopamine release in brain so priming this addiction pathway or by interactions with other neurotransmitters such as the peptide substance P. As antagonists of these neurotransmitters are now available they are being tested in human addictions and may offer an alternative to substitution treatments.
Further reading

Nutt DJ  King LA Phillips LD (2010) Drug harms in the UK: a multicriteria decision analysis  Lancet 376: 1558-66

Nutt DJ Lingford-Hughes A (2008) Addiction the clinical interface Brit J Pharmacology 1-9

Nutt DJ, Law FD (2008) Pharmacological and Psychological aspects of drug abuse. New Oxford Textbook of Psychiatry 2nd edition

Robbins TR, Everitt B,  Nutt DJ (2010) The Neurobiology of Addiction – New Vistas.   OUP

38 Responses to “Addiction: a life long illness not lifestyle choice”

  1. John Ellis Says:

    Dave some good points laid out here, I often wonder about my own cannabis use for mental health alongside a low dose antidepressant.
    Sometime it would be really nice to give up both or take a break from one of them but alas life then falls apart. The doctors will blame the proscribed drug use as it can’t possibly be the prescribed drugs.

  2. anu Says:

    @ john ellis, have you tried researching the cannabinoid cbd to understand its roll in and on the human body, i always find where there is personal wonder it helps to research, so i can understand more, helping to removing the if’s that hinder ,but it makes me a know it all bore at a party , lol

    another great read professor , i take it not all addiction is seen as bad until the self neglect is visible to others and loved ones ,as mine is knowledge , i get the sweats without a book or google to hand , in fact i gave up smoking tobacco five years ago so i didn’t have to go outside to smoke because i was reading such a good book , probly the best thing i have ever done!

    • John Ellis Says:

      @anu lolI help educate the public on the ECSN, iam currently harassing the home office over the scheduling of Sativex.

      still waiting on a reply to this….

      Good Afternoon Mr Brokenshire

      I am writing to you with regards to the current process of the scheduling of Sativex a whole cannabis extract used in the treatment of pain and MS spasticity.

      As I understand the ACMD has recently put forward a request to have Sativex moved from a schedule 1 drug that has no medical use to a schedule 4 drug that has many uses in the treatment of the Human ECSN.

      I understand that one of the concerns of the government is that in rescheduling Sativex to a useful drug with medical value will leave the way open to further legislation regarding the medical use of cannabinoids.

      What I would like to know is when can we expect a fair and just ruling on this classification as there are many sick and disabled people in the UK that need to be lifted out of criminality for using a plants extracts that are now known the world over to alleviate many of the symptoms of these illnesses, but for whom pharmaceutical drugs are either unacceptable due to risk of further illness or shortening of life.

      Many thanks for your time

      John Ellis
      Medical Cannabis user

      Check out Mark Easton’s Blogs my unofficial home :D

  3. Kyle Says:

    I have long had conflicting views over addiction, especially when it comes to drug use. Your article is very clear and helps me understand the the social, neurological and psychological aspects of drug use.

    As someone who has ‘stopped before they became addicted’ it can be difficult to understand the position of an addict and understand who is responsible. You have helped with the first half of that at least. Thanks!


  4. [...] by reading a very good evidence-based WordPress blog from David Nutt, about the nature of addiction, I’ve revived my registration to see if I can make this work. [...]


  5. Much needed rationality. Why societies fight against/attack a medical view of addictive brain disorders needs to be studied. Sems another case of science denialism.

    We are digesting the article so may be back iwth other comments but want to say that the external behavioral symptoms of addiction are well described. Now societies are involved in “symptom chasing” — usually with military guns and equipment.

    However, the internal, brain-based are very well understood. Check out the vast literature and vid/pod casts under the US NIH and Nora Volkow.

    Sadly cures may be impossible and successful treatment generations away — but the medical reasons for the behavior are pretty clear.


  6. Here is mention of this article in Psychology Today blog by anti-science blogger in US.


  7. [...] See the rest here: Addiction: a life long illness not lifestyle choice « David Nutt's … [...]

  8. AshR Says:

    “It is a serious, often lethal, disease caused by an enduring (probably permanent) change in brain function.”

    How much research is there into how these brain states change? If we can effect a change towards susceptibility to dependence then why not away from it too?

    Your addition of the words “probably permamanent” could take hope away from people with these problems.

    Your assertion that –

    “Starting to use drugs may be a lifestyle choice but once addiction sets in, choosing to stop is very much more difficult if not impossible.”

    is another one that made me groan. Why is it impossible for someone to move away from a drug dependence? Many many people have done so. These terms are disempowering Prof Nutt.

    That said I find your article informative and will give me much to follow up and investigate. Many thanks.


  9. David, This is very brain and hard science oriented. I’d very strongly recommend looking at the work of Bruce Alexander on Rat Park: http://sciencethatmatters.com/archives/6

    And that of Peter Cohen: http://www.cedro-uva.org/lib/cohen.empress.html

    The brain is a very tiny part of the world. ‘Addiction’ must be contextualised socially and culturally to understand the origin of the concept and the behaviour.

  10. Steve Rolles Says:

    This feels like a rather old fashioned disease model conceptualisation of addiciton, overly focused on a pharmaco-m,edical paradigm. Not something that I would usually say to Prof Nutt – but; its a bit more complicated than that. This post overlooks the social context of ‘addiction’ and social copntruction of the concept of addiction.

    It would have been really useful, for example, to mention, Bruce Alexander’s ‘Rat park’ experiments (see http://bit.ly/13oI ), and the studies of heroin using servicemen returning from vietnam (Robins 1974).

  11. Steve Rolles Says:

    This feels like a rather old fashioned disease model conceptualisation of addiciton, overly focused on a pharmaco-m,edical paradigm. Not something that I would usually say to Prof Nutt – but; its a bit more complicated than that. This post overlooks the social context of ‘addiction’ and social construction of the concept of addiction.

    It would have been really useful, for example, to mention, Bruce Alexander’s ‘Rat park’ experiments (see http://bit.ly/13oI ), and the studies of heroin using servicemen returning from vietnam (Robins 1974).


  12. You can’t fix a brain that is impaired/”broken” because of family/genetic structural defects. In addition, serious brain impairments accumulate with addictive behavior.

    Remember, the behavior is just one symptom.

    As far as socio-cultural contexts — are these relevant for the disease pathology and treatment of other impairments of other body organs? Is diabetes socio-cultural? Heart disease? We are talking about basic body physiology here.

    Hope comes from treating this as the medical disease it is and not pretending it is not — that is also critical for children and grandchildren who inherit these disease along with others.

    Each individual’s brain is indeed a very tiny part of the world 6.7B/1 — but for each individual, our brains are our whole world.

    In terms of “old fashioned”– this is actually the latest science and research,e.g., done in the last 12 months.

    We are glad to provide citations and links to the biology of addiction. The nih.gov in the US has more than enough info.


  13. [...] people will arguably have an ‘addiction’ (another tricky term) of some sort in their life; tobacco, compulsive eating, caffeine (debatable), [...]

  14. strayan Says:

    This article grossly exaggerates the difficulty of quitting.

    Hundreds of millions of people have quit cigarettes (the vast majority) without any help. It’s about time that we faced up to the fact that most people who succesffly quit an addictive drug go it alone.

    The reason heroin looks so hard to quit is that injecting drugs users tend to be the most down and out in our society. The average person with no history of substance depedence is barely challenged by the act of quitting.

    Reference:

    http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000216

    • frank Says:

      its alot easier to quit if people dont hate you for it i.e l had a temp job once[3days] where the boss
      looked at my eyes said trainspotting sarcasticly
      l thought it was the usaul obstacle initial but the
      agency never employed me again ,you cant be 100%[or
      dig deep] all the time hence relapse
      its true alot of people can quit drugs inc opiates
      if theres no underlining mental problem,physical or
      sexuaL abuse and its not always obvious to others
      or the user as well also being in the drug scene
      can/does bring/add to the above
      l ve seen l wouldnt put my worse enemy through
      as for the average person
      how does anyone know? as long as they are illegal
      careless talk costs you your liberty and a fist in
      your face l.ve lied to the medical people
      cause if l didnt l would be short[and cash as well]
      one guy l knew wasnt getting enough from a heroin
      program in the early 90s said he was doing things
      he didnt want to do to his key worker next thing
      the police are round
      and even if you are healthy[and have the access] for real you are gambling with your neurons and even if p/t for years your neurons may violently disagree with
      your will at times and its more than irritating
      even if you have obeyed the stop signs
      its interesting that david cameron is very anti
      drug use l guess he has to be hard on himself and
      hence harder on others to make his own sit as a
      belief and the truth for others
      theres is a relaxed way to come,and stay off and theres is
      a hard way as well its appears that mr cameron
      still has some way to go before he learns to relax
      despite all the advantages still has some way to go
      l,ve met ex users who still have problems 9.10 years down the line from their last relapse
      so he aint alone
      finally l wont mention the obvious what goes for oneand not the other except to say one mans treatment is another mans torture
      there you are


  15. Addiction: a life long illness not lifestyle choice « David Nutt's ……

    Here at World Spinner we are debating the same thing……


  16. Great article. I’ve been recovering from heroin/cocaine for the past three years, and one of the things that you mentioned(stress) was almost my downfall into relapse a few times. I found that the best thing to do was just breath deep and try to relax . I found that after of 30 min. of waiting for the urge yo go away, it did, and I was fine.


  17. [...] Addiction: a life long illness not lifestyle choice « David Nutt's … [...]


  18. [...] Addiction: a life long illness not lifestyle choice « David Nutt's … [...]


  19. [...] Addiction: a life long illness not lifestyle choice « David Nutt's … [...]

  20. Bernhard Says:

    Dear David Nutt.

    Above you write:

    “These memories are often the most powerfully positive ones the person may ever experience, which explains why addicts put so much effort into getting them again.”

    Getting the “most powerfully positive memories” out of substance abuse or other kind of addictive behaviour. Doesn’t this just imply that, whatever we call civilisations, that they as such are very very ill, sick and sickening indeed. Not being able to give relief to our next.
    Ourselves, nowadays even as entire mankind and the other species, also our basis we call environment, threatening it through collective behaviour and excessive use of technology to the very brink of extinction?
    For some time now, I truly believe that the people (to largest extent) “we” call mentally ill or addicted, even people with
    physical illnesses are mere bioindicators, showing and expressing the sickness all around.
    I want to even suggest that a lot, maybe even the vast majority, living in self delusion about the final cost of our “lifestyle”, of the so called healthy population, expressing this health in being able to cope with whatever is necessary to survive at nearly any cost, are those ones who needed relief most.
    Unfortunately, people tend to learn only through pain, loss and these things.
    At times, to me the above mentioned “bioindicators” appear to be like flowers in the desert.
    Kind regards,
    Bernhard

  21. Bob Says:

    Hello,

    I’m sure you’re aware of this already, but the Home Office are asking for comments on the Drug Strategy. Maybe you could post your views…

    http://drugstrategyblog.homeoffice.gov.uk/?p=2

    I’m sure they will welcome your comments

  22. Caroline Says:

    Dear Professor Nutt,

    I came to see you speak last night at ICH but unfortunately had to leave before questions. I am a great supporter of your campaign.

    I hoped I could ask 2 questions, and make 1 point:

    1. In your estimation of the self and societal impact of each drug do you think it would be of interest to include global impact? ie the way in which drug demand in the West skews markets and leads to exploitation of workers. The impacts of British American tobacco and worker exploitation, and the murders in central america due to cocaine are not well known.

    2. Do you think it helpful to compare other drugs to alcohol? We have a bizarre societal attitude to alcohol and trying to argue reason through a model of irrationality is rarely successful in my experience.

    3. I feel to some extent the ‘war on drugs’ was one of the effects of a generalized tying in of the media as a Blair propaganda machine. The feeding of the Labour agenda to the media to support policy’s already decided upon, and an effective disenfranchisement of the people.

  23. doreen Says:

    With regard to point three. At what level of prevalence does drug use despite its illegality represent the disenfranchisement of the government by the people?

    I would suggest that there is more than one type of revolution

  24. Graeme Says:

    I commend your stand against the “drug” war on the youths of each new generation that are born into this bizarre logic created by politicians so out of touch with anything remotely real. It’s quite scary to think that these people govern and dictate us.
    I was a regular solvent user in the late 70′s early 80′s from the age of 9, where were, and still are these so-called laws that were to stop me and should have stop the hundreds of children that have died from that type of behavior?
    I use cannabis and have done for over 30 years, it’s my “mothers little helper”
    I get ill with alcohol, I’ve been drunk twice in 20 years! so I don’t use it!
    People take drugs for pleasure & escapism it’s that simple! Trying to stop what you enjoy isn’t.
    I’ve never heard this government admit the fact that they’ve been legally handing out amphetamine for over 50 years to children as well as adults for obesity up to 1985, I’ve seen what the long term psychological effects of overuse are, and I can tell you – they’re permanent!
    Now it’s called Ritalin! The madness never stops.

    However what brought me hear are none of the reasons above, what brought me hear was hearing you on radio4,
    specificity that you were instrumental in the advising on these SSRI’s Drugs, maybe you should have tried them on yourself before deciding that tests showed they were relatively Safe. I did (SEROXAT)”part curiosity-part ticking the right boxes” and I found the effects were similar to cocaine but with no comedown.
    Those who have never took drugs for recreational use would not know the difference?
    Seeing my 75 year old mother High as a kite(almost tripping) on a cocktail prescribed drugs because some doctor gave her them while she believes these drugs must be for good.The same doctors that told her to give her 11 year old daughter speed back in the 50′s.
    I believe that Monoamine oxidase enzymes/diet and various drugs might cause more of the issues that Paroxetine and it’s brand names are prescribed for? But what do I Know, I don’t own a white lab coat.
    We the general public see large drug companies in it for one thing only – Money.
    But I suppose that’s the price we pay for a Amoral capitalist society.


  25. Hi David,

    The British Library is very interested in your website and would like to invite you to participate in our web archiving programme. We select and archive sites to represent aspects of UK documentary heritage and as a result, they will remain available to researchers in the future. The British Library works closely with leading UK institutions to collect and permanently preserve the UK web, and our archive can be seen at http://www.webarchive.org.uk/.

    Please can you supply us with an email address, so that we can have the relevant information sent out to you.

    Regards,

    Permissions Officer (pp. Alison Hill, Curator)

    Web Archiving, Room 150, Floor 2

    The British Library

    96 Euston Road

    London

    NW1 2DB

    Tel: 0843 2081144 (ext. 7211)

    Fax: 020 7412 7691

    E-mail: web-archivist@bl.uk

    UK Web Archive: [http://www.webarchive.org.uk/]

  26. Eric W Says:

    Hi David,

    I saw an old Horizon program by John Marsden on alcohol addiction the other night in which you appeared. As an “alcoholic” and a budding neuropsychopharmacologist, I am fascinated by the research.

    On the role of the DA/opioid pathways in addiction, have you seen the work of John David Sinclair? He has proposed a novel use of Naltrexone in the treatment (specifically) of alcohol, which works on the principal of pharmacological extinction. He has several papers published, and a fair amount of anecdotal evidence supporting his theories.

    I would be interested to hear others opinions.


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  28. Thomas Gilbreath Says:

    No, it’s a choice. I know first hand. There is a person I know who has been on methadone for 20 years. He traded one addiction for another. All this person has done is to mock me and others for our handicap, but is angry when you say something to him. I have Neurofibromatosis all he has done is mock and insult me. People in my family are addicts and they have done the same. When a NF tumor went to cancer I needed medicine, but it wasn’t covered by insurance. The same insurance and medicine they covered for a junkie. YES JUNKIE. This is a joke, addicts are junkies and make choices. I didn’t make a choice to have NF. I HATE PEOPLE WHO SAY THEIR ILL BEING A ADDICT. No, they are junkies. Anyone who thinks that deal with the medicine I needed but junkies can have and it’s fair or oh well. MAY THEY SUFFER IN HELL. i mean HELL… I am a person who didn’t make a choice shoot this NF in my body. CHOICE—CHOICE—CHOICE

    TOM .


  29. [...] the rest at: Addiction: a life long illness not lifestyle choice « David Nutt’s Blog: Evidence not Exagger…. Categories: Addiction, Weeks 8-12 Tags: nutt The Strongest Predictor for Low Stress: [...]

  30. Ramakrishna Rao MV Says:

    I am higly thankful to the writer for his efforts to present precious contents, in a SIMPLE LANGUAGE. I can feel the practicle truths involved in the article,since I too was an addict to smoking for an average 25 years of my life. But I am proud to claim deaddiction from the killer nicotine, mere through my will power, for more than a decade now. I feel I burnt a sizeable portion of my hard earned money, only in barter to occassional to chronic health loss.

    Still, I can affirm that, in most cases of addictions ( from nicotine to deadly drugs ), the life circumstances and a wrong choice (to err is human),play a primary roll. As such, today I sympathize addicts rather than feel an aversion and mean thoughts about the unfortunate lots,suffering in their addictive worlds. No human is a criminal by birth.The so called “forward social culture” can only tend to drag them into the world of addictions but does very little with reg. to the question of their rehabilitation.

    Articles as above,are a ray of hope for those in conflicts to understand where they are/were trapped in the darkness and also such blogs are sure to help those who intend a ‘come out’ from many types of killer addictions.

    Once again,my sincere thanks to this blogger.


  31. Hi, This is a good post, thanks.


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