This article attempts the task of defining “The Addict Brain.” Please note that addiction is a very broad subject which is way beyond the scope of this one article. Here we will examine and try to understand the function of the addict brain.

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Dear Doctor Life Advice,

Recently, I heard the term “the addict brain.” To what does this term refer?

Signed: A Curious Mind

Dear Curious Mind,

Thank you for asking this very interesting question.  I began to answer it, and about five or six paragraphs into the answer, I realized that I had not even begun to describe what an “addict” is. To tackle the definition of an addict would be another paper altogether, so instead I’ve decided to briefly define the term, and then move on to directly answering your question.

In our society we use the term “addict” or “addicted” very loosely.  We say things such as “I’m addicted to Wordplay,” or “my aunt is so addicted to the Oprah show,” and so on. If we were to use the Diagnostic and Statistical Manual of Mental Disorders (DSM) which is used by mental health professionals, then an addict would be defined as a person who engages in an activity with certain behavioral traits. The activity is not necessarily drinking alcohol, doing drugs, or a combination of both.  Addiction can also include behaviors such as eating, playing video games, watching certain programs on TV, browsing the internet, exercising, and an endless variety of other habits. The traits of an addict are:

1. building “tolerance” to the activity, so that more and more of it is required to feel the same effect
2. developing “withdrawal,” such that when the person tries to stop the activity, the body goes through a series of unpleasant symptoms and demands that the person re-engage as soon as possible
3.  larger and/or longer quantities of the activity are required by the body over time
4.  the person desires to quit the activity, and tries repeatedly and unsuccessfully to quit
5.  a lot of time is spent on engaging in or preparing for the activity
6.  other social and work-related activities in the life of the person are given up for the sake of the addiction
7.  the person continues to engage in the activity regardless of the consequences,whether they are health related, or related to the social or work life

Given this definition, we can describe the “addict brain.”  Other terms that have the same meaning are the “addicted brain,” or the “alchie” brain.  The last term is used in the Alcoholics Anonymous (AA) program.  In AA, the opposite of an “alchie” brain is a “normie” brain. The phrase “addict brain” is based on a model of thinking in which addiction is considered a disease,  like cancer or diabetes.  In this model of thinking, the addict is suffering from a disease that is out of his or her control and needs help to put the disease in remission or “recovery,” just as a person battling with cancer would need treatment. I use the example of cancer because addiction is equally – if not more – devastating to the affected person as well as his or her loved ones. I personally agree with this disease approach to addiction.  I have treated addiction for many years now, and I have yet to meet a person that decided consciously to become an addict. In cancer, a mutated cell escapes the body’s defenses and begins to multiply without regulation. In addiction, the addict brain escapes the brain’s powers of logic and common sense and seeks the addictive activity at all costs.

The development of the addict brain is caused by the brain’s response to rewarding stimuli. The brain of every human being has a center at which rewards are recognized.  The center is there to detect situations that are pleasant to the body, and to encourage the body to place itself in those situations again.  Consider the case of  seven-year-old Charlie, who gets an A in his math test.  His teacher is very proud and tells his parents how well he did.  His parents reward him by putting his test up on the refrigerator to celebrate his accomplishment.  Charlie enjoys the reward and is likely to try to get more A’s in his tests.

The reward system in an addict brain has gone awry. The best way to understand the addict brain is through a series of examples that demonstrate it.

Consider Jane, who at the age of 16 drinks her first beer.  She really likes how it feels, so the brain considers this a reward.  For Jane, she may react to this in one of two ways; she could enjoy one or two drinks socially for the rest of her life and never take it further than that.  Alternatively, Jane may decide that she wants to experience the feeling more often. Over the years, she drinks more and more beer and then discovers that hard liquor feels even “better.”  She may experience consequences such as blackouts, hangovers, or even arrests for driving under the influence. She may realize that her drinking has become a problem, but her addict brain makes all kinds of excuses for her to drink. She would get arrested for a DUI and spend the night in jail. The next day, her addict brain convinces her that she is a loser, so she may as well drink some more to drown the shame. She may go to court for her DUI and find out that she has been given another chance and will not lose her license, so her addict brain will tell her that this is an occasion to celebrate with a drink.  Her kids may do very well in school, which require champagne (multiple bottles followed by Vodka), or they may become criminals, which will require Vodka to “numb out.” The reward system in her brain is rewarded by one and only one thing: alcohol. Jane is in trouble; her addict brain has taken control.  Her husband may leave her and that would put her on a “binge” of drinking non-stop for a year. The court may give full custody of her children to her ex-husband because she is deemed unfit to take care of them. Her addict brain will tell her that she cannot handle this loss without drinking.  There are only two ways to end this cycle: Jane will either die, or she will need to get serious help.  Even if Jane checks into a rehab center for the sake of her children, she may relapse several times, and will need to understand her addict brain and learn not to listen to it for the rest of her life.  That is why we never call an addict a “recovered” addict. Instead, we call him or her a “recovering” addict because once one is addicted, he or she is addicted for life.

Unfortunately, the addict brain can be even more manipulative. For example, Joe, who has been using cocaine and alcohol all his life, may decide to quit them and will successfully do so, only to find himself 5 years later using marijuana and crystal meth. This is called “cross-addiction”, and it occurs when the brain replaces one addiction with another.  The addict brain, once it figures out that it won’t get a certain reward no matter how it manipulates the person, will seek another substance or activity to fixate on, and get the rewards that way.  This is why it is so important for recovering addicts to remain vigilant in life and try not to engage in any addictive behavior.

The addict brain also has a tendency to block out all evidence that support the idea that the person is an addict or needs help.  For example, Joe may be doing some drugs regularly. He is convinced that it is his choice to do drugs and that he can stop at any time.  If Joe’s friends or family try to point out to him that he is an addict, he will get irritated or angry with them, and he will shut them out. The harder the family tries to come between Joe and his reward system, the more the addict brain convinces Joe that his familyis against him or even out to get him. The relationship of an addict with his or her family is very complicated because in many cases, the addict becomes financially dependent on others for the support of the drug habit.  In these cases, the addict will become extremely manipulative to keep the family around.  I’ve seen cases where an addict threatens his or her spouse with suicide unless the spouse supplies the addict with the substance. They ask family for money in many different ways, and if they are refused, they may even resort to stealing from their own loved ones. The addict brain will justify any act that will give it the reward it needs. Even when Joe begins to understand that he has a problem, and tries to address it, the addict brain will resort to making up stories such as “I’ll quit this Christmas,” or “this one will be my last fix before I stop,” or a whole slew of other stories that will keep Joe using.

Families of addicts often become prisoners to the manipulative behavior of the addict.  It is heartbreaking to witness this as a psychiatrist. I have had parents ask me what they are supposed to do, and they just don’t want to hear that there is nothing they can do. The only choices the family members have are to: stay in contact with the addict and accept or even support their addictive activity; stay in contact with the addict with strict limits and a clear message that the addict  is not supported by them in anyway in continuing the activity; or completely cutting out the addict and letting him know that he is welcome back into the family only after establishing (with proof) a certain period of sobriety.

In medical school I had the gift of doing a two week rotation in drug and alcohol addiction. This was done by participating in a rehab center as a patient. Although we didn’t sleep there overnight, we participated in all the daily activities. This rotation was life changing for me and I truly understood how the addict brain works and how the addict becomes a slave to his or her addiction. While in residency, I had a patient in his 50’s who was admitted to the medical unit because of  health complications that were caused by years of using IV heroin and other drugs. I contacted his family members to let them know that the patient was incredibly sick and that he could die any day. The family members each informed me that they had long ago decided that they could not handle the patient’s disease any more, and had cut all contact with him. I never judged the family; the stories they had of how they had been manipulated, abused, and subjected to theft by my patient were endless and heartbreaking. My patient never had a visitor while he was in the hospital, and ultimately, he died alone.

During a rotation in medical school we also had a patient who had destroyed her liver by the time she was in her mid-thirties. She was put on a liver transplant list, and needed to stay off of alcohol and all drugs for six months before she would be considered for a transplant.  Seven months into her sobriety, she was called in to be tested for transplantation of a liver that had become available. She went in and the tests revealed that the liver was not a good match for her. Her addict brain used that as an excuse to get her to go drink again. Her liver could not handle the drinks, and by the time she got into the hospital, she was in liver failure.  She died within three days.

I currently have a young patient who is the poster boy for recovery.  He has done very well, and continues to work on his recovery on a daily basis. He loves video games and yet is very vigilant to not play them in an addictive manner.  He gives himself strict time limitations and sticks to them.  He told me yesterday about how he met a young woman and had a few fun weeks with her. Although it did not work out, he dealt with it. Now he realizes that his addict brain is seeking the rewards of dating and is pressing him urgently to meet someone else. He is consciously deciding to give himself a break from trying to meet another woman. He understands his addict brain and is constantly on the watch for the pitfalls that are everywhere.

I have another recovering patient who became addicted to pain medications because of what was prescribed to her by her physicians.  She has a very serious medical illness, requiring multiple surgeries. She also has a very firm and clear understanding of her addict brain, so she is very adamant about how her pain is controlled by her surgeons, and what analgesics are used. I have had the pleasure – mixed with compassionate pain – of watching her go through horrendous procedures with minimal pain control because she would rather deal with insurmountable physical pain rather than having to deal with a relapse on pain medications.

The above two are examples of the everyday heroes I see in my practice, and I am in awe and respect of them. It is a fact, however, that for every one of these recovering stories, there are as many, or many more, relapse stories. The addict brain is as deadly and as hard to recover from as the deadliest of cancers. In both cases you don’t know if someone has truly beaten the disease until they die of another natural cause!

I hope this helps you in understanding the addict brain a bit better.  If you have more questions on how someone becomes an addict, or how to deal with a family member that is an addict, please let me know.

Here, for “words to live by,” I will share the Serenity Prayer used in AA and its associated recovery programs. There are many whose lives have been saved by these words:

“God, grant me the serenity to accept the things I cannot change, courage to change the things I can, and wisdom to know the difference.”

Doctor Life Advice