As a vascular surgeon, I learned to care for an extremely complex disease. More often than not by the time I saw a patient with a vascular problem, the disease was fairly advanced. A clot or a blockage in a vessel was causing severe symptoms that needed treatment. Complex interactions between inflamed vessel linings and body reactions culminate in symptoms that must be addressed. Clots are removed, blockages are repaired, or a substitute artery is used. Relief is provided and recovery can now begin. After the repair, aftercare instructions are given to the patient in the hope of avoiding recurrent episodes, but the suggestions may not be faithfully followed.
Many people are more willing to have a surgical repair of the problem once symptoms can no longer be ignored than to adhere to a longer process addressing diet, stress or lifestyle. A timely and expedient bypass graft has saved the day, but it has done nothing for the underlying disease of atherosclerosis that led to the problem. Medicines are used to help recovery and prevention, and they do help. Patients are better than they were before treatment with these medicines, but not as well as they could be if they followed suggestions. The disease process is relentless and progressive.
We follow this same pathway with addiction treatment. Symptoms eventually crescendo into some unacceptable situation demanding stabilization. Actions are taken and medicines are used, in the hope of replacing a substance or blocking it. Today we call this medication-assisted treatment (MAT). We have named the use of medicines for addiction as if this use is unique in disease treatment. Later, aftercare suggestions are given, and variably followed. MAT improves the complications and ramifications of addiction, similar to what a vascular graft does for vascular disease. These are beneficial treatments, and no one is suggesting they not be used. Worse problems are averted, and function improves. New bandages are placed on the underlying disease, giving hope that it will not happen again. The disease still smolders, however.
What exactly is this disease of addiction that we are acutely treating? An excellent review of this brain disease was provided in a 2016 article in the New England Journal of Medicine by Volkow et al., called “Neurobiologic Advances From the Brain Disease Model of Addiction.” The article underscores the complexity of the disease of addiction, a complexity matching or exceeding that of vascular disease. Changes in the brain leading to the symptoms of the disease go far beyond the oft-quoted dopamine problem given in standard neurobiology lectures.
The article describes important areas of the midbrain and frontal cortex that are affected. Many areas of the brain that once allowed rational thinking and reasoned behaviors are changed. The same survival part of the brain that mandates breathing and drinking water has now elevated a substance to being just as important as air and water. “Flow” in the brain progresses unimpeded from bottom up, acting as a gas pedal to the part of the brain that makes us human: the cortex.
The frontal cortex contains what has been called the executive functioning center of the brain, with the name alone suggesting its roles and importance. While motivation, or “gas,” is flowing toward the cortex, the balancing flow from the cortex back down is “blocked.” All gas and no brake. No steering, either. The frontal cortex that normally promotes moderation, attunement, creativity and other human things has become impotent. Structural changes in wiring occur. Chemical changes, such as an altered glutamate system in specific areas of control, are present. Decisions are now made by a brain with imbalanced wiring and chemistry. The journal article goes into much more detail, but ultimately harmonious brain balance has become chaotic.
You get the picture. Addiction is very complex, and our underestimation of this complexity has led to answers that are partial or temporary. Today’s treatments are helpful and have benefits, but they often are inadequate to address the disease process. MAT and a few weeks of treatment are to addiction what an acute repair is to vascular disease. Things are better, but real problems remain.
In order to treat this complex brain disease successfully, the brain must be changed. The brain wires itself using a process called neuroplasticity. Needed connections form in response to the environment. Neuroplasticity is how an unwired newborn becomes a musician or a teacher. It is also how this same musician or teacher later dies of an overdose. Treatment must use methods to harness this natural process of neuroplasticity in order to rewire the brain again, restoring health and harmony.
Practices that actively seek the things lost in addiction will strengthen wiring in areas of brain that have been short-circuited by addiction. Practices that restore awareness, reason, discovery, connection and choice actually change the brain. Some would call these spiritual or mindful practices. Others would use behavioral or biological definitions. They are all correct, and they are necessary to change the brain.
MAT is spoken of today almost as a holy grail for addiction treatment. This is not because it restores a normal brain, but rather because it is affordable and expedient and provides relief just like a bypass for vascular disease. Yes, we should use these things. They decrease loss of life and complications. They are only Band-Aids, though, for the underlying disease process. We must not be lulled into believing that these medicines are the answer. Addiction is far too complex.