The purpose of this essay is to acquaint the reader with the “elephant in the living room”, i.e., the disease of addiction. Addiction, or its secondary manifestations, represents the most common cause of suffering and death in this country today. This idea, however, is a new one and is not widely embraced by the medical community as a whole or by our current society. The failure to identify this mechanism of disease as a primary cause of death and disability relates to how the disease is perceived at the societal level. Most often, people think of addiction as a destructive habit related to the excess use of drugs or alcohol, which results in the violation of social norms or legal standards. The negative societal stereotypes associated with addiction ascribe its cause to: a weakness of character; a moral failing; or an inability to deal with life. Given this set of circumstances, the application of the label “addict” is associated with considerable stigma. To some degree, the presence of denial is understandable given the negative social stigma.
The key to understanding addiction as a primary pathophysiologic mechanism lies in its definition and its relationship to the physiology of brain function. Webster’s Unabridged Dictionary (2001) defines addiction as: “the state of being enslaved to a habit or practice or to something that is psychologically or physically habit-forming, as narcotics, to such an extent that its cessation causes severe trauma.” This is a very good definition and a good starting point. From the standpoint of a disease model, this author defines addiction as: “a pathologic relationship to a mood-altering substance, behavior, emotion, or relationship that results in life damaging consequences.” Using this very broad definition, this author can define his obese, type 2 diabetics as food addicts. These patients use food to mood-alter uncomfortable emotional states. However, the recognition of the primacy of addiction as a cause of obesity is not reflected in the medical literature. Typically, medical reviews of obesity ascribe its cause to: a sedentary lifestyle, genetics, rare endocrine diseases, or a simple excess of caloric intake related to caloric expenditure.
Interestingly, however, the current pharmacologic research in obesity revolves around brain function and the neurotransmitters associated with the endocannabinoid system. Yes, cannabinoids, i.e. receptors in the brain that are stimulated by marijuana. According to the Journal of the American Dietetic Association (2008;108:823-831): “Weight gain, particularly abdominal fat mass gain, along with consumption of a high-fat, high calorie diet are postulated to overstimulate the endocannabinoid system, initiating deregulation contributing to the pathophysiology of body weight regulation.” This statement implies that central nervous system regulation of body weight is a key factor in obesity. But how does the central nervous system regulation of weight relate to the disease of addiction?
From a biological perspective, the disease of addiction is a central nervous system disease. The brain, for the purposes of this discussion, can be divided into three separate areas. The “reptilian brain” consists of the pons and the medulla; this is a very primitive area of the brain that regulates automatic functions such as how often your heart beats and how often you breathe. Above the reptilian brain, is the “emotional brain”; this is the area of the brain that is involved in the disease of addiction. Above the emotional brain and is the cortical brain. The cortical brain is what we think of as representative of the attributes of a human being. The cortical brain is the repository of the ability to plan, to think, to analyze, to philosophize, to moralize, and to exert one’s “willpower”. A general law of brain function is that lower areas of the brain have the capacity to trump higher areas of the brain.
The disease of addiction resides within the emotional brain. From an evolutionary standpoint, the emotional brain exists for a very good reason; the emotional brain contains the pleasure center and stimulation of the pleasure center reinforces a human being to perform acts that are characterized as “essential” to survival. There are certain activities in life that are essential to survival; those activities are: food, sex, exercise, and drinking water when you’re thirsty. All of these natural activities result in the stimulation of the pleasure center, which conveys to the human being (at an irrational, emotional, nonverbal level) that the current activity is “essential” to survival. It turns out that drugs of abuse directly and reliably stimulate these pleasure centers resulting in the feeling that the continued intake of drugs or alcohol is “essential” to survival. In effect, drugs of abuse, of which food may be considered one, hijack the emotional brain and override the impulses of willpower exerted by the cortical brain. This is the essence of addiction at the neurochemical level.
Currently, our country is in the midst of an epidemic of obesity. The medical consequences of obesity are numerous, dangerous, and life limiting. However, this is not the only manifestation of addiction that results in increased suffering and death within the population. Cigarette smoking, a manifestation of addiction to nicotine, is the cause of the number one cancer in American society, i.e., lung cancer. Alcohol, a more traditionally recognized substance of abuse, results in significant morbidity and mortality as noted in the following: 15% of men and 10% of women meet the criteria for alcohol dependence; 25% of medical-surgical inpatients have serious alcohol problems; 10-46% of ER visits are prompted by alcohol; and 17% of ER patients are harmful drinkers. Alcohol is a factor in: 60-70% of homicides; 40% of suicides; 40-50% of fatal motor vehicle accidents; 60% of fatal burns; 40% of fatal falls; and 50% of trauma cases. In addition to all of this, 15-30% of demented nursing home patients have dementia secondary to alcoholism. This devastating litany of statistics demonstrates the primacy of addiction as a pathophysiologic mechanism of disease in modern America.
Given all of the aforementioned objective data, why would someone “choose” to continue their abuse or dependence on food, alcohol, or drugs? The answer is that they don’t “choose”. They are trapped within a deadly obsession and compulsion, which left untreated, will reliably progress to insanity, incarceration, or death. Those who live with the alcoholic or addict can see that their lives are falling apart, the addict, however, doesn’t see this because his emotional brain is telling him that the continued use of his “drug of no choice” is essential to his survival. At this point, the addict’s cortical brain is largely engaged in rationalizing and justifying his continued use. The approach to the patient at this point will be addressed in a separate article. If you are an addict, or the family member of an addict, do not lose heart. There is hope and help for recovery. The purpose of this author’s practice is to facilitate that recovery.