The most important realization for an addict is that their search for an increasingly elusive high progressively erodes the characteristic that makes them uniquely human: the ability to choose. Denial, always a close companion of addiction, hides that stark reality with the aid of the powerful reward of the addiction and the steady deterioration of motivation and memory that come with it.
Most addicts come into treatment with limited awareness of the impact of their addiction on their ability to make better choices. And, many of their loved ones have little more understanding of why an addict continues to use even as their lives disintegrate around them.
Research over the last decade provides insight into the effect of addiction on the brain and on decision-making. Humans have, in essence, three brains. The primitive or instinctive reptilian brain housed in the brain stem and lower brain focuses on survival. The mammalian or limbic brain controls the emotions of social connection such as love, anger, compassion, jealousy and hope and better enables us to engage in activities that involve others. The human brain resides primarily in the neocortex and controls higher-order thinking, reflection, self-awareness and decision-making.
Addiction largely shuts down the neocortex, a change visible in brain images from fMRI and PET scans. The reptilian brain takes over. The addict moves from self-directed behavior to automatic sensory-driven behavior. Two decision-making areas of the brain are particularly affected in addiction: the orbitofrontal cortex, which helps humans choose the most advantageous course of action, and the anterior cingulate cortex, which helps people evaluate decisions they have made. Consequently, addicts consistently make poor decisions and fail to realize that they have done so.
As the power of the neocortex diminishes, addicts experience increased impulsivity reinforced by memories of the feeling of the high provided by the abused substance. At the same time, they lose awareness of options other than engaging in the addiction. Genetics predispose some addicts to a blunted reward system that is hypersensitive to the flood of dopamine released by addictive substances. They and those who do not have the genetic predisposition to addiction also develop difficulty in decision making, accompanied by deficits in learning and memory. The combination creates the vicious cycle of addiction. Within the brain of the addict, using not only makes sense, it can become the only action that seems sensible or even possible.
Addiction may start with heightened “Reward Sensitivity,” but other factors quickly take over. Over time, repeated substance abuse ingrains the memory of the highs deep in various parts of the brain, particularly the emotional centers. The drive to use becomes overwhelming, and eventually, as the disease progresses, addicts lose their ability to make decisions. Actual decisions recede as instincts take over. The addiction, in a sense, becomes the decision maker rather than the addict.
Because of this complex restructuring of the brain, recovery must start with abstinence. And abstinence is rarely a decision an addict can make and stick to without help because of the power the addiction has over their brain. Once sober, the recovering addict must relearn how to make decisions and how to connect with others, by gradually restoring the functions of both the mammalian and human parts of the brain. They must engage in healthier activities that stimulate the reward pathways. And they must be vigilant. The addict essentially must be supported in a rebellion against a powerful master that has subjugated his or her brain, vanquished their free will, and will destroy their lives and health if not defeated.
Recovery involves learning and relearning many of the most basic human processes and requires strength, commitment and a team of supporters to overcome the power of addiction.