Controversy – a norm in the addiction treatment field – is particularly intense when the concept of powerlessness is raised. Patients entering our outpatient detoxification and rehabilitation program are often preoccupied with this issue. For those in 12 Step recovery programs, acknowledging one’s powerlessness is where recovery starts – the first of the 12 steps of Alcoholics Anonymous states, “We admitted we were powerless over alcohol and drugs – and that our lives had become unmanageable.” SMART Recovery, on the other hand, “teaches self-reliance, rather than powerlessness.”
Newer scientific research using radiological imaging techniques, such as functional magnetic resonance imaging (fMRI) and positive emission tomography (PET), by no means eliminates controversy but can narrow and clarify the areas of disagreement. I had the pleasure of speaking on this issue this past weekend to a very responsive group of people in recovery at the Triangle Club in Washington, D.C. I shared with them some of the newer findings which cast light on the complexity of the struggle that some people have with controlling their use of substances. These included:
- Liking: Part of the pleasurable effect of drinking alcohol comes from the fact that alcohol releases endorphins in our brains. Some people have a genetic variation in their beta-endorphin levels and opioid receptors that makes them more responsive to these pleasurable effects and therefore sometimes more vulnerable to problematic use.
- Wanting and Craving: When repeated heavy substance use is associated with environmental cues (“people, places, and things”), as well as with stressful emotional and physical states (“hunger, anger, loneliness, tiredness,” physical pain, boredom, traumatic memories), these can become triggers (“conditioned stimuli”) that set off a dopamine release in brains that exceed the release caused by the substance itself. The intensity of the dopamine release can propel the person toward the using the substance (“conditioned response”) despite the awareness of the problems associated with use.
- Needing: Regular heavy alcohol use suppresses the action of glutamate, which is the primary excitatory neuron in the brain. In reaction to this, glutamate activity increases, but the person is unaware of this until he or she stops drinking. At that point, the “hyper-glutamergic state” is unmasked, causing alcohol withdrawal symptoms that influence the person to return to drinking for relief.
- The Unbalanced Brain: Persistent heavy drinking weakens the activity in areas of the cerebral cortex, our “higher centers,” that are responsible for reason and judgment. Simultaneously, the more primitive limbic areas of the brain that deal with emotion and stress are enhanced. The result is a shift in the brain toward “bottom up” as opposed to the normal “top down” control.
These are pieces of a puzzle that have not yet come together to form a complete picture. I expect that ongoing research will continue to clarify these issues and, most importantly, lead to more effective treatment methods.