The Brain in Addiction and Alcoholism

The human brain is a fascinating contraption. It has justifiably been described as the most complex object in the universe. It is a collection of 86 billion nerve cells of many different types that work together in ways that are still scarcely understood. As wonderful as it is, and although it weighs a mere 3.3 lbs and comprises only 2% of our body mass, alcohol or other drugs can manipulate it into shattering our lives.

The human brain - this most formidable of machines, capable of the most wondrous of achievements – becomes utterly bamboozled by what we call alcoholism and addiction. We need to understand our brain to know how and why this happens. But, this is not an easy task. In his New York Times column Harold M. Schmeck Jr. aptly observed: The ultimate goal is to understand the human brain – that incredible three-pound package of tissue that can imagine the farthest reaches of the universe and the ultimate core of the atom but cannot fathom its own functioning.

Addictive substances and behaviors target neurotransmitters

The brain works by transmitting information between neurons, which is why there are so many inter-connections. None of the brain cells actually touch. There is a gap between them, and they communicate by releasing various chemicals across the gap to transmit messages between them. These message chemicals are known as neurotransmitters. Each of the many different neurotransmitters means different things to different brain cells at different times and in different amounts. The sending brain cell produces and releases the neurotransmitter, and the receiving cell picks up these signals on receptors, which recognize the signal.

There are many different neurotransmitters, and they all have various functions. Of course, if the neurotransmitters get knocked off balance for any reason, it will affect brain function and lead to many different problems and disorders. These include Alzheimer’s disease, Parkinson’s disease, depression, schizophrenia, and so on. Addiction and alcoholism are also included on the list.

Addiction pathways

The brain “pathways” – the chain of signals along a sequence of neurons – that are involved in alcoholism-addiction are fairly well understood, although we certainly still have much to learn. Despite how much we have learned about everything that occurs in the brain in addiction, it hasn’t yet done much for us. The bottom line for any medical discovery is using that information to discover a prevention and a cure. Of course, neither of these have happened yet when it comes to alcoholism and addiction. “Just Say No” hasn’t exactly panned out to be a vaccine against addiction.

Although they all have differing pathways to get there, the neurotransmitter dopamine is the common end-point for alcohol and other drugs of addiction, as well as for addictive behaviors. Dopamine is responsible for the euphoria that is brought on by these drugs, which provides positive reinforcement for continued use of these drugs. Conversely, removal of the drug causes reduced production and release of dopamine in the brain, which causes a low mood, and low feelings, which contribute to seeking the drug. Thus, there is positive and negative reinforcement involved in the drug seeking behavior.

During normal brain functions, the dopamine system rewards our natural behaviors: the elation we feel when we accomplish something important, for example. This reward system is meant to ensure that we will seek out and perform activities that we need to do to live, thrive, and reproduce, by rewarding us with feelings of pleasure when we accomplish these activities.

Reward-seeking

Whenever this reward occurs, the brain remembers the activity that produced the reward and we are driven to perform this activity again. The perfect example is the pleasure we feel from a good meal. The memory of the pleasure and relief we felt drives us to seek out food again when we are hungry. In this way we are driven to carry out a behavior necessary for our survival. In normal life rewards usually come only with time and effort. Substances of abuse give us a much bigger and faster burst of reward without all the work involved, providing a shortcut, flooding the brain with dopamine and other neurotransmitters.

The brain is not naturally exposed to these artificially huge substance-induced bursts of dopamine and compensates, trying to get things back to normal. The brain reduces the number of receptors that are stimulated by dopamine release, and we become sensitized to dopamine, so that the good feelings from its release are reduced. Then the brain starts to “down-regulate” production of dopamine in order to further compensate for the repeatedly high levels produced by the addictive substances.

As a result we need more and more of the drug to get the same effect as we continue on in our alcoholism-addiction. This is what is known as tolerance. I have always found it an odd quirk of society that many cultures around the world revere tolerance to alcohol: people who have a high tolerance for drinking are considered to be cool.

When we are not “high” or “drunk” our baseline dopamine levels are now much lower than in a non-drinker/user, and we feel depressed, lifeless, lacking energy, and things that normally produce pleasure no longer do so. We are now the opposite of rewarded. We no longer feel any reward for eating, accomplishing tasks, or even finding a fulfilling relationship. We need the drug just to feel normal, let alone “high.”

These changes become permanent after a while, which partly explains our life-long vulnerability to relapse after the substance use has stopped.

Some drugs, such as marijuana and heroin, have a chemical structure that mimics that of a natural neurotransmitter. This “fools” receptors and allows the drugs to activate the neurons.  Other drugs, such as amphetamines or cocaine, cause the neurons to release abnormally large amounts of natural neurotransmitters or prevent their normal break-down.

Alcohol artificially stimulates the receptors for the neurotransmitter GABA, whose job is to inhibit brain cell function and slow things down when we are too excited. This is why we get so sedated and slow and slurred when we are drinking. This is also why we feel so jittery and excitable and risk having a seizure when we withdraw from chronic alcohol use.

Alcohol also stimulates receptors that are involved in depression – most notably those of the neurotransmitter serotonin – leaving them lacking in stimulation after the alcohol wears off. This is part of the reason alcohol is called a depressant. Regardless of their mode of action, all substances of addiction, by their various pathways, have the end result of flooding the brain’s reward system with dopamine.

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10 times more rewarding than sex

Because these substances stimulate the natural reward system, albeit to a much higher degree – up to 10 times the amount produced by sex – and much more rapidly and longer lasting, we are driven to seek them out again when the reward effect wears off. When they cause the brain to overproduce dopamine (or to prevent its break-down) the overstimulated reward system produces the euphoric effects that we call a “high” or “being drunk”. Naturally, we are driven to repeat this behavior that produces the euphoria, and this is what we call addiction.

Besides dopamine, many other neurotransmitters are affected, including those that cause depression, anxiety, and other mental health problems. This is why there is such a staggeringly high degree of similarity and interaction between mental health issues and addiction. (See "The Link Between Mental Health and Alcoholism/Addiction Click Here).

Imbalances in dopamine, such as the highs and lows brought on by addictive substances, can have other serious consequences. High levels of dopamine cause the symptom of psychosis, which is defined as a loss of touch with reality. Symptoms of psychosis include hearing things (auditory hallucinations), seeing things (visual hallucinations), paranoia, ideas of reference (believing that people on TV and the radio are talking about us), catatonia (holding absolutely still in statue-like poses for prolonged periods of time), and general weird behavior.

Unfortunately, violent behavior is common, especially if there is paranoia. Since drugs of abuse cause elevated dopamine levels it is not at all surprising that psychotic symptoms are a feature of being under their influence. This is also why violent behavior is so commonplace. Unfortunately, many drugs (most notable marijuana and MDMA, or ecstasy) can cause permanent psychosis, which is known as the psychiatric disease schizophrenia.

Low levels of dopamine is the cause of Parkinson’s Disease, so the lower than normal levels of dopamine that occur when we withdraw from drugs of abuse is the reason that we experience shaking and unsteadiness on our feet. Dopamine is involved in regulating emotions, and the effects are easy to see in the weird and unpredictable emotions displayed by many addicts and alcoholics.

We discuss alcoholic blackouts - a significant and deeply consequential brain effect seen even in beginning drinkers - in another post Click Here.

We discuss a major consequence of alcohol abuse on the brain - “wet brain” - in another post Click Here.

Even though the liver and brain are not located close to each other – our liver is tucked under our right ribcage – an advanced liver disease known as alcoholiccirrhosis also affects the brain. The diseased liver produces toxic substances that travel in the blood and poison the brain, resulting in a condition known as hepatic encephalopathy. (As you can see, one of the toughest parts of medical school is the spelling tests).

This brain impairment occurs in 70% of people with cirrhosis. The effects are barely noticeable in half and debilitating in the other half. Fortunately, it resolves with treatment, which is done by reducing the toxic substances being produced by the liver.

In terms of symptoms, these people look sick from their cirrhosis. They are usually jaundiced (yellow skin and eyes), with swollen bellies from a big liver and abdominal fluid (ascites), with swollen legs, and an overall sickly appearance. The brain effects make them forgetful, confused, and irritable. Oddly enough, they typically get a reversed sleep-wake cycle, where they are up all night and sleep all day.

They often develop a “liver-flap,” which is a jerky, flapping, uncontrollable movement of the limbs. A peculiar smell known as foetor hepaticus (again, with the spelling) is often present. It’s difficult to describe a smell, but the fact that it’s also known as “breath of the dead” should tell you that it’s not pleasant (to me it’s a fruity-rotten eggs-feces smell). As the brain becomes more poisoned they become more and more forgetful and confused, experience personality changes, and are increasingly sleepy. This sleepiness will eventually progress to a coma.

Luckily, hepatic encephalopathy is easily treated, but the important thing is to treat the cirrhosis that caused it, otherwise it will come back.

The future

Looking to the future, perhaps one day a treatment that stabilizes dopamine levels in the brain will be discovered and will lead to a prevention or cure for alcoholism-addiction. However, at this point we don’t seem to be anywhere close to that dream despite all that we have learned. And, I doubt we will be for a very long time. I keep a very close eye on current research and developments in medicine, with an especially keen eye on developments in addictions treatments, and I can say that there doesn’t seem to be anything in the works that would give hope to this happening anytime soon.

There are always new catch-words being thrown around, but unfortunately that is all they have panned out to be. One such catch-word is neuroplasticity, which is simply a word that means that the brain can be changed. The concept is that the brain can be taught to no longer be addicted. Don’t let the fancy name fool you, this is a very old concept, which is the basis of treatment approaches that have not proven effective in treatment of addiction, namely Cognitive therapy, Behavioral therapy, and (of course) Cognitive-behavioral therapy (CBT). Taking advantage of neuroplasticity is an important part of a program of recovery from addiction – as it is in the Twelve Step program – but not when it forms the sole basis of the plan of recovery.

Even though our developing knowledge about the brain’s role in alcoholism-addiction hasn’t yet led us to a cure, we must keep working toward exactly that goal. However, there is another reason that working out the brain pathways in our disease is important: it helps us to work out the genetics of addiction.

And that… is your brain on drugs. Or drink.

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