Your son or daughter was just arrested for a DUI. And that was after losing a job at the local hardware store for stealing. Before that he had been thrown off the soccer team for drinking. And now, after all that, you find your child nearly passed out in your basement, still clutching an empty pint of vodka. Can’t he see he is ruining his life? And mine? Why doesn’t he care?
The reality is no, he can’t see what he is doing. He no longer cares about normal pleasures, such as dinner with the family, going to a movie with friends or even paying his car insurance. Addiction has hijacked his brain and it no longer functions normally.
Here’s what happens in a functioning, non-addicted brain
The limbic system, also known as the lizard brain, is in the forebrain. It is the brain’s pleasure and reward center, designed to ensure survival of the species. It values things such as food, water, social connection, and sex, releasing a spike of dopamine with each encounter that tells the brain, this is good, do more of this. For example, when you eat a delicious piece of grandma’s chocolate cake, dopamine, a neurotransmitter that carries information along pathways in the brain, tells the midbrain this is good for survival. This is the brain’s first step in the release of a cascade of feel-good hormones. A corresponding neurotransmitter, glutamate, is released in response to the dopamine and is responsible for laying down memory (what you need to know in order to get that cake again), including where you were, who you were with, how it tasted and what is smelled like. So, the next time you walk in the door at Grandma’s house and smell a chocolate cake baking in the oven, you can just about taste it. The limbic system sends signals to the prefrontal cortex, the front of the brain just behind the forehead, and shouts, there is chocolate cake here! You eat a slice and crave a second piece, but you pause. Reason says, my doctor just told me my cholesterol is a little high, and though it’s hard to resist, you decide not to indulge. The communication between your limbic system and prefrontal lobe, where reason and judgment reside, gives you the power of choice.
Your daughter, suffering from a substance use disorder, does not have that same power of choice because her brain has been seriously compromised. Only it’s not chocolate cake she’s craving, it’s her drug of choice. You beg her to stop, but she can’t. It’s not that simple.
Here’s what happens in an addicted brain.
Normal feel-good pleasures, like a piece of chocolate cake or a holiday celebration with family, release spikes of dopamine. Normal pleasures, normal spikes. But when a drug is introduced, such as alcohol or an opioid, it creates a spike far greater than normal, far greater than what the brain is used to, the difference, say, between a splash of water and a fire hose! The brain takes note. Wow, this is better than expected. THIS is important to survival. Let’s put this higher on the survival priority list. And let’s remember it. When the drug first reached the midbrain’s ventral tegmental area (VTA), it sent a message to the nucleus accumbens (NAc), which released a flood of dopamine. The increased dopamine leads to a huge release of glutamate (responsible for creating memory), so much glutamate that it burns the experience of taking the drug into memory: where you were, who you were with and what was happening, including, perhaps, the smells, colors and sounds. The brain signals that the drug is important to survival and wants to make sure it can be found again, and again. If, for example, your daughter took her first opioid in her friend’s basement, the area of the brain responsible for survival took note. Not only was the intensity of the pleasure burned into her memory, but she will also likely always remember the friend she was with, the color of the walls, the rap music playing in the background, and the feel of the rolled-up dollar bill she used to snort the drug. Glutamate burned all of it into her memory, creating the cues to find that drug again.
The brain’s messaging system breaks down
With continued drug use, the brain’s messaging system breaks down. Dopamine connects with D2 receptors to send its message (something really important is happening), but there is more dopamine than the receptors can handle. The brain responds by reducing the number of D2 receptors, leaving the limbic system with less capacity to transmit messages to other areas of the brain, including the prefrontal cortex, which is responsible for, among other things, reasoning, planning and judgment. The rational brain is not on board. When your child is craving alcohol, or heroin, or whatever his drug of choice is, the reasoning brain is not getting the message and therefore unable to apply the brakes. There is little, if no opportunity for reason to say, hey, if you do this, you might go to jail, get a DUI, even OD. The pleasure/reward system, meant to ensure survival is dysfunctional.
A closer look at brain systems that fail in addiction.
While this is not a complete list of brain areas affected by addiction, it provides an understanding of behaviors that are a result of substance use disorder, including process addictions such as gambling, shopping and internet gaming.
The Orbitofrontal Cortex (OFC), which calculates value, stops working correctly. The addicted brain overvalues a drug’s reward and underestimates the negatives consequences likely to occur. This is what’s happening when your daughter, craving her next high, slips a $20 bill from the register at her deli job to buy drugs, assuming she won’t get caught. She leaves work, gets high, and the next day loses her job. Damage to the OFC also results in the inability to envision the future correctly, such as the consequences for not paying the rent or making a car payment. Doesn’t he realize he will lose his apartment if he uses the rent money to buy drugs?
The Anterior Cingulate Cortex (ACC) is responsible for social cognition. It picks up on social cues and guides behavior. When this system does not function properly, the addicted individual does not pick up on social cues, loses her behavioral guidance system (behavior is not guided by past negative or positive outcomes), becomes impulsive, and is inappropriate with poor self-regulation. Damage to this area can explain why your son or daughter doesn’t seem to learn from past mistakes. How can he skip work again when he knows that’s how he lost his last job? Or, why your daughter uses the F-word in front of Grandma.
The Prefrontal Cortex (PFC) is the seat of reason. Damage to the PFC results in the failure of executive functioning, which can lead to risky behavior, impulsivity, sensation seeking, expression of inappropriate emotions, attention deficits, lack of perseverance and insensitivity to consequences. These deficits in your child’s brain may play out as a car accident, getting arrested for fights, expulsion from college for getting caught drinking again, or stealing your gold bracelet to get that next fix.
You may notice some or most of these behaviors in your own child suffering from substance use disorder. You may see a child who is so self-centered and destructive you wonder if this is narcissistic or antisocial personality disorder, because it sure looks like it. But it’s not. The disturbing conduct occurs as the brain fails. You may no longer recognize your child. The charming little boy you drove to baseball or happy young girl you carted off to ballet seems to have disappeared. Know this: He or she is still in there. The brain has an amazing capacity to heal. The acquired narcissistic or antisocial behavior will change with the work of sobriety when your child is ready. Keep that hope alive, both for you—and your child.
(Information in this article is based on the following lecture by Dr. Kevin McCauley: Reviewed by J. Craig Allen, MD and Emily Laurenza