Why people use drugs and the science of addiction
In a YouTube video, Dr. Gabor Maté, the author of the landmark book “In the Realm of Hungry Ghosts: Close Encounters with Addiction,” has a conversation with Guy Felicella, a former user of drugs and champion harm reduction advocate. Maté asks Felicella what the drugs did for him when he was struggling. He summarizes Felicella’s response: “So the drugs gave you comfort, they gave you a sense of friendly acceptance, and they helped soothe your suffering ... Those are wonderful things. In other words, the drugs weren’t your problem. Your drugs were an attempt to solve your problem.” He goes on to say that while drugs can cause problems, they are not the primary problem. We need to address the primary problem, the roots of the sufferings that drive people to seek relief in drugs.
People don’t use drugs to become lawbreakers, to disrupt their families or communities, or to threaten their own lives. People use drugs because the drugs work for what they need them to do, and that need can become so great it overrules everything else.
Austin Eubanks was a student at Columbine High School when two classmates shot him and killed his best friend along with so many others. He was prescribed painkillers for his injuries but found the pills worked best to blunt his emotional trauma. They helped him survive his great anguish. This boy who had never even smoked marijuana soon became addicted to heroin, alcohol, and methamphetamine. He fought addiction for over a decade before recovering and becoming a national speaker on drug use, offering his message of recovery and hope. I heard him speak in Hartford. Three weeks later he died of a drug overdose. Was it the drugs that killed him or the trauma he suffered that day in Columbine?
Not everyone who uses opioids becomes addicted. Some use only sporadically and can start and stop at will. Unfortunately for many, initial drug use does lead to addiction, based on their genes and environmental factors. Even for those who beat it, relapse is always a possibility, as it was for Austin Eubanks.
The American Psychiatric Association defines addiction as “a complex condition, a brain disease that is manifested by compulsive substance use despite harmful consequence.” Opioids, which are among the most addictive substances, initially produce euphoria, an overwhelming response of dopamine in the brain, followed by an awareness of an ebbing of the drug and then for some, a preoccupation with reproducing the feeling. In time, some people’s brains can become hijacked so people can no longer act in their best interest. These changes are so profound the damage can often be measured in images of the brain in the same way medical imaging can detect damaged hearts and lungs.
An analogy I have heard many substance use experts describe is one about fireworks. If you like pizza, imagine a firework of pleasure going off in your brain whenever you eat a slice. This is the neurotransmitter dopamine making you feel good about pizza. Sometimes, just thinking about pizza sets off a firework of pleasure. Now imagine you do heroin for the first time, and, particularly if you are genetically susceptible, instead of one firework going off in your brain, a Fourth of July grand finale of fireworks goes off in your brain. Your brain gets flooded with more dopamine than you have ever experienced before. The comedian Lenny Bruce described doing heroin as being like kissing God. Amazing, right? This explosion occurs in the part of the brain known as the basal ganglia, the pleasure center.
After a while, another part of the brain starts to notice the pleasure fading. This part of the brain is the extended amygdala, which sets off alerts about the withdrawal of the pleasure and causes anxiety. A third center, the prefrontal cortex, starts thinking about how you are going to get some more. In time, the fireworks set off in the pleasure center increasingly decrease, while the other centers go into overdrive: Help, I need more! I have to get more! The circuitry in the brain gets rewired. It becomes hijacked. The things that used to produce pleasure (dopamine) — such as eating, having sex, and taking care of children — no longer do. They can’t compete with heroin, and the brain starts to believe heroin, which produces much higher levels of dopamine, is the key to the human’s survival. The brain no longer processes information the way it once did. That’s why people steal in front of security guards or shoot up drugs with their kids still in the car. That’s why they use drugs when they know the drugs can kill them. To expect someone damaged by addiction to act rationally is akin to expecting someone with a broken leg to run the 100-yard dash or someone with heart and lung disease to climb Mount Everest in a storm.
People who are addicted see drugs in the same way they see the need to breathe and for their heart to beat. Drugs become central to their existence. Maslov’s hierarchy of needs is a psychological theory consisting of five human needs, ranging from the basic physiological needs of breathing, eating, shelter, sleep, and reproduction to the highest levels of self-actualization and the desire to become the best one can be. For people addicted to drugs, getting and obtaining more drugs occupies that same basic layer of physiological need that comes before any of the other layers, including those of safety, love, esteem, and self-actualization.
Today scientists believe addiction is a chronic, relapsing brain disease that is caused by a confluence of factors, from genetics to environment and mental health. It cannot be cured acutely but needs long-term monitoring. Relapse is common. Even someone who has not used opioids for years can be triggered to use again. Addiction is not a character flaw. It shouldn’t be treated as a crime.
