Terrance R Reeves, MD
When I practiced as a Vascular Surgeon, I treated an extremely complex disease. More often than not by the time I saw a patient with a vascular problem, the disease was fairly advanced. Earlier intervention could have prevented the problem from getting so bad, but people tend to put off change until severe symptoms force the issue. A sudden clot or a blockage in a blood vessel can force the issue. Complex interactions lead to severe symptoms that cry out for something to be done. Clots are removed, blockages are opened, a substitute artery may be used. Whatever it takes for flow to be restored. Relief! Recovery is finally possible. After the intervention (surgery), instructions are given to the patient with the hope of avoiding another episode. Enough time is needed to allow vessel linings to remodel normally and for active living to resume. If the patient is diligent in following suggestions, there is enough time for normal healing to occur so there is much less chance of a recurrence. Less diligence means less time to heal, and more disease will surface sooner rather than later.
A similar pathway is often followed with addiction treatment. Symptoms eventually crescendo into some unacceptable situation demanding relief. Actions are taken and medicines are used hoping to replace a drug or block it. (Today we call this medication assisted treatment, MAT.) Following initial measures that provide some relief, suggestions are also given and also variably followed. With diligence, healing has a chance. Less diligence means here we go again. Adequate time is needed after flow is restored for a new artery to heal and reshape properly. Similarly, time is also needed after sobriety is restored for a new life to heal and reshape.
If different diseases could be ranked on a complexity scale, addiction would score much higher than vascular disease in my book, and I have treated a lot of both of these diseases. What is more complex, an artery or the brain? A diseased, changed and maladaptive brain leads to the symptoms we call addiction. The changes in the brain leading to these symptoms go far beyond the oft quoted dopamine problem given in standard neurobiology lectures. The brain is designed for flexibility and efficiency. The flexibility allows adaptation and learning. Efficiency allows the brain to do many different things at once. We remember what helped us be fed, watered, safe, secure, and content- what helped us be “ok” and we repeat them. They become automatic. This flexibility and efficiency of the brain are coopted and misdirected in addiction due to the powerful “ok” signals that drugs can produce. It is remembered and hard wired to make it efficient. Automatic. Once this maladaptation happens, the brain becomes incapable of its main purpose- to be “ok”. How do we fix the “ok” part of the brain? Where is it?
“OK” starts in the midbrain and frontal cortex of the brain. These are areas where emotions arise, consideration of a situation takes place, and choices are made. These areas are physically and chemically changed in addiction. Areas of the brain that once allowed rational thinking and reasoned behaviors are not working correctly. In the survival hierarchy of importance in the brain, drugs now hold a status on par with water and air. The frontal cortex contains what has been called the “executive functioning center” of the brain. Just the name of this area tells how important it must be. This is like the Boss’s Office. What happens at work if the boss doesn’t show up for days, weeks or years? The frontal cortex, or “Boss” that normally promotes moderation, paying attention, creativity and other human things is AWOL. A previously harmonious workplace, the brain, becomes chaotic, inflexible, and inefficient.
Flexibility and efficiency of the brain are possible because of neuroplasticity. This is the process the brain uses to learn, adapt, shape itself, organize, and grow. Neruoplasticity allows an unwired newborn brain to become 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 brain wiring. 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. I assure you, this is hard science. Some would call these things spiritual or mindful practices. Others would use behavioral or biological definitions. They are all correct and necessary to change the brain. Establishing practices and living in an environment that promote these things leads to physical and chemical changes in the brain that can restore harmony and flexibility.
You get the picture. Addiction is very complex. We have grossly underestimated the complexity of this disease for a long time. This has led to “fixes” based on expediency and cost rather than what is really needed for “flow” to be restored. Yep, it takes time. Unfortunately, more time than today’s payer driven treatment industry typically can provide or allow. We must collectively work to change this system which seems to be managed by payers rather than best practices. Only by standing together and collectively and loudly insisting on ethical, evidence based treatment that is supported by science will those of us involved in the treatment industry be able to change the system into one designed to change the brain rather than to calm it down or medicate it into complacency.