LOLLIE: Welcome back to Let’s Talk Drugs, where we take a close look at drug research so we can all be armed with facts. Let’s Talk Drugs is presented by ProjectKnow.com (that’s project k-n-o-w dot com), a website dedicated to providing digestible explanations for the complex world of drug and alcohol abuse. If you or someone you care about is struggling with substance abuse, call 1-888-287-0471 to reach out to our dedicated treatment support specialists for help in starting the recovery journey.
My name is Lollie, and in this series I want to take on a topic that can seem intimidating: the brain. More specifically, how drugs affect the brain. I’m sure many of us have heard that drugs can damage the brain, but why is it so few of us have heard exactly how they cause damage? Well, it’s time for you to know. This series will explore all the crazy ways that drugs affect the brain, from the mysteries surrounding psychedelics to why opioids can kill you in an instant.
In the last episode we discussed the baffling nature of marijuana and psychedelics with Dr. Ben Romoli. For this final episode, we circled back with Dr. Scott Salomone to talk about what is actually happening when a person develops an addiction and what the possibility of recovery from substance abuse is. Can your brain ever recover full function? Let’s find out…
How do Drugs Change Your Brain?
LOLLIE: At this point we know that drugs work by affecting our system of neurotransmitters, whether by imitating a neurotransmitter, increasing the release of a neurotransmitter, or locking a neurotransmitter in the gap between cells (aka the synapse). Some drugs have alternative methods of action, like marijuana, but for the most part drugs of abuse use these 3 basic mechanisms to exert their effects.
So, what happens when a person abuses a drug? Well, as a person is abusing a drug, they may start to find that the same dose doesn’t have the same effect anymore, especially if they are dosing frequently. They may start to need higher and higher doses in order to get the same desired high. This is called building up a tolerance, and it is one of the official diagnostic symptoms of a substance use disorder.
Neurotransmitters and Addiction
LOLLIE: Okay, so tolerance is when you need more and more, increasing doses, of a drug in order to get the same effects because your brain has changed itself to adjust to the level that you’ve been using, correct?
LOLLIE: And then dependence is when essentially you’ve been using it so frequently, or in such high doses, that, because of all these changes that have happened, because of this tolerance that has built up, you now basically need the drug in order to feel normal. So, you’re not even taking it necessarily to get high anymore, you’re kind of taking it just to feel… to basically avoid withdrawal.
SCOTT: Yeah, our brains are really good at establishing a norm for ourselves, and so whenever you’re taking these substances regularly your brain kind of incorporates that as its new normal.
LOLLIE: So essentially what’s happening is your brain is adjusting to this new level of normal that includes drugs as part of the “normal.” As you adjust to higher and higher doses, your body gets used to that and it kind of realigns your center of normality, in a sense. So now your new normal is heavily dosed up on drugs. What happens then is that when you don’t do drugs (when you finally start to either detox or somebody can’t find drugs to use), the normal is not met. We’re falling below what our brain is used to, and that induces withdrawal effects.
Adjusting your level of normality to include drugs is essentially known as dependence. Dependence is basically when you need drugs in order to avoid withdrawal. Withdrawal effects are sort of this backlash of not using the drug when you’re finally adjusted to it, and they result from the way that drugs work. So, if a drug has been increasing activity in the brain, withdrawal effects tend to reflect a lower level of activity in the brain. Whereas if a drug has consistently been decreasing the level of activity, or slowing the level of activity, in the brain, the withdrawal effects will reflect an increase in activity (like a higher body temperature, higher heart rate, in some extreme cases, seizures, which can be deadly). This is why certain drugs have a withdrawal period that can be extremely life-threatening, in a way.
LOLLIE: Okay, so when someone is dependent on a drug, meaning physically dependent- because psychological dependence is different, it’s kind of when you think you need a drug to feel normal, but actually, physically, biologically, you do not.
LOLLIE: But a physical dependence is where your body and your brain are so used to this drug that they need it to feel normal so when you do not take the drug you get withdrawal effects, which… what are withdrawal effects?
SCOTT: What happens is your brain has established its new norm, right? And it’s used to having that drug, and when it doesn’t have that drug anymore that’s when you start to feel withdrawal because it’s not getting a signal that your brain is used to.
LOLLIE: I want to take a moment really quick to clarify the difference between dependence and addiction. What many people tend to refer to as “addiction” is actually a dependence, and that can include physical and psychological dependence. Dependence means that you need the drug in order to feel normal, as we just went over. Addiction is actually a completely separate definition, and it encompasses a set of behaviors surrounding drug use.
The definition for an addiction actually comes from the Diagnostic and Statistical Manual (DSM), which psychologists/psychiatrists use to diagnose disorders. The actual term in the DSM for addiction is a substance use disorder. What it encompasses is a set of 11 criteria- so there are 11 different points about this disorder that are used to diagnose whether or not someone has an addiction or a substance use disorder.
- If you meet 2 to 3 of the criteria, then you have a mild substance use disorder.
- If you meet 4 to 5 of the criteria, then you have a moderate substance use disorder.
- If you meet 6 to 7 (or more) of the criteria, then you have a severe substance use disorder.
Addiction is a set of behaviors, but dependence is the actual in-the-body part of addiction. Somebody can be dependent on a drug without actually having an addiction (and that happens a lot with prescription opioids, people end up dependent on these drugs to feel normal but they’re not necessarily doing everything they can to seek out this drug). A general rule of thumb you can use for addiction is: is a person seeking out this substance despite negative life consequences? Part of the definition of addiction also includes tolerance and withdrawal.
I’m not trying to get too complicated with this, but just remember that addiction is a set of behaviors and dependence is the actual in your body, in your brain part of addiction. Again, somebody could be dependent without being addicted. Somebody could also have a substance use disorder, or be addicted, but not necessarily be dependent on a drug. They can go one without the other, but they do tend to happen coincidentally hand-in-hand. They tend to develop together. But, that’s an important distinction to be made when we’re talking about addiction and dependence, especially with substance abuse: that dependence is the actual in the brain [effects], addiction is the set of behaviors surrounding drug use.
I also think it’s important to acknowledge a particular form of damage that can occur in substance abusers, and that is to the prefrontal cortex (PFC) of the brain. If you take your finger and put it on your forehead, right behind that is your prefrontal cortex- this very frontal part of your brain. It is our most recently evolved part of our brain, and it’s actually kind of what distinguishes humans from animals. We have this large prefrontal cortex that controls our executive functioning, meaning it controls our self-control, our ability to make judgements and create plans of action, and to attribute importance to certain things.
When somebody abuses drugs, over a long period of time the PFC incurs changes, or damage, that can impair a person’s ability to make judgements about their own actions, or about the use of drugs, for example.1 This damage happens at a cellular level, it’s not just this theoretical damage that could maybe harm somebody- it’s a real, tangible change that occurs in people who suffer from long-term addiction.1 This, in turn, can affect that person’s ability to create a plan of action to get sober, or to enact that plan of action to get sober. So, addiction doesn’t only affect these behaviors and our reward pathway, it actually affects our ability to get better after addiction, which is where professional help comes in.
Adjusting back down to a sober baseline takes a lot of work and it takes a lot of time. This especially depends on the substance being abused. Some have longer withdrawal periods, longer periods of time for adjusting back to “normal,” and other ones have much shorter spans. Adjusting back to sobriety can be extremely uncomfortable, it can be life-threatening, but it is important nonetheless because you need to train your brain all over again. Somebody who has abused drugs for a long time has essentially trained their brain to get used to drugs; to get used to this high level (or low level) of stimulation; to get used to this adjusted normal that includes drugs. You need to retrain your brain back to a sober baseline.
This takes a lot of time. It’s not going to be easy for everyone. But, it’s incredibly worth it because once you get back down to this baseline it kind of gets a little bit easier to work on all these other skills you need to maintain sobriety in the long run.
Can Your Brain Recover from Drugs?
Lollie: What is the possibility of recovery from addiction, especially in terms of changes in the brain?
SCOTT: In the same way that you were able to train your brain to need this substance, there are many things we can do to help train the brain to no longer need it. The term is “plasticity,” and it means that these connections can change throughout your lifetime. There are many different ways that we do this. Therapy is a great option, and that allows you to work and use your own thoughts to actually create changes in those pathways, and create different pathways for how your brain manages different types of information.
LOLLIE: In recovery treatment, a therapist can help you develop skills that will work to retrain your brain. When you work with a therapist, you’re not just working on childhood trauma and everything like that, you’re working on real-world, current skills that you need in order to avoid relapse. These can be anywhere from recognizing and avoiding situations that could lead to relapse, to knowing what to do when you are faced with severe cravings or a relapse possible scenario.
For example, if somebody you used to use with comes over and brings drugs and is like, “Hey, you want any?” You need to have a plan of action for that, and a therapist can help you identify what works for you in that moment (because everybody is going to be different). For some people it is going to be easy to just say, “No, I don’t want to do that.” For other people, their biology, the way their addiction has developed, makes it extremely difficult to say no.
Relapse is a very real possibility. In fact, the rates are between 40% and 60%, which is similar to other types of health-related problems like diabetes and high blood pressure. We need to have skills that are developed with a professional in order form new habits, in order to fight old habits, and in order to just find a new way to live an abstinent lifestyle.
The possibility of recovery is very real. In fact, with sustained abstinence your brain can recover almost full function with most substances. So, there’s no waste in even trying. The more you work on staying abstinent- even if you relapse, going back and trying again, and re-developing your skills, and strengthening other skills- this is what will actually prepare you for long-term recovery. No matter how many tries it takes, just going back and re-trying will consistently strengthen your skills, and will consistently recreate better habits in your day-to-day life.
For some people, therapy alone won’t do the trick, so they need a little something extra to help them manage cravings throughout this period of recovery, and that’s where medication comes in.
LOLLIE: So, besides therapy, what are other helpful things for somebody in recovery?
SCOTT: One of the biggest things that we use is medication. And actually when used together, therapy and medication at the same time is shown to be the most effective way to treat.
LOLLIE: Than either on their own.
SCOTT: Correct, correct. So with medications we have, it kind of depends on which substance is being used or is causing the addiction, and we tailor our treatment to that.
LOLLIE: So, for example, the opioid epidemic that’s kind of happening right now. We have this drastic increase in deaths, overdose deaths, due to prescription opioid abuse.
LOLLIE: So, what kind of medications are being used to help those people?
LOLLIE: For opiates, we have other types of medications that are available that either replicate the effects of opiates, and some of them have a combined medication that prevents you from overdosing on the same medication by using it in a way that would not be proper.
LOLLIE: What Dr. Salomone is referencing here is that people in recovery from opioid abuse can abuse the medications that they’re prescribed to help them reduce cravings for opioids. These medications include methadone and buprenorphine (brand name Subutex). So the way these work is that they sort of mimic the effects of the previously abused opioids by activating a similar type of opioid receptor in the brain. These carefully monitored doses help to ease withdrawal and cravings, but can have some minor psychoactive effects.
So, they’re less addictive when they’re used as prescribed, but they can be abused: you can use them in a way other than intended, or use them in higher doses, and they will produce these euphoric effects–not to the same extent as opioids of abuse, but they can help the user get high. So, people who abuse these drugs are sort of taking away their progress in recovery.
SCOTT: There are other medications that we can use that block the effects of opioids, and these are used in instances of overdose. So, if somebody takes too much of an opioid, and it causes negative effects on the body, you can block those effects from happening using naloxone.
LOLLIE: Oh, okay, so this is available in pharmacies these days, is it not?
SCOTT: In some places, yes. It’s regulated differently across the country, but in some pharmacies yes, you can get naloxone and have it available if you know somebody that is addicted to opioids, or for the opioids user themselves to have on them so that they can be saved in the event of an overdose.
LOLLIE: Wow, that’s amazing.
SCOTT: Right, and there’s a third type of medication that we can use with opioids that is a combination of an agonist that acts like an opioid, and the antagonist that blocks it. Those combo drugs are great because they prevent the user from overdosing on the drug that they’re using to help them with their addiction.
LOLLIE: Wow, that’s awesome. And those are available in injection form as well?
SCOTT: I believe there are injection forms. There’s oral forms as well.
LOLLIE: Okay, so basically somebody could get this medication to be effective for like a month, or like a big period of time, rather than just taking a daily pill.
SCOTT: That is correct, there are long-release formulas that we can use so a user can come in and get their injections to help them manage their addiction over time.
LOLLIE: That’s amazing. What about for alcoholism? I know there’s some medications kind of being explored right now. There’s a whole lot of stories that are out there about different drugs working for alcoholism. What is out there that we know can be effective?
SCOTT: One of the most useful drugs right now is naltrexone, and it’s a medication to treat people who are having difficulty managing their alcohol use.
LOLLIE: So, it helps reduce cravings?
SCOTT: Yes, that’s its main effect is that is help reduce cravings for alcohol.
LOLLIE: Wow, that’s amazing.
SCOTT: Yeah, absolutely.
LOLLIE: All-in-all, we have numerous treatment options that have high-quality evidence behind their effectiveness. Therapy can help you fight against these prefrontal cortex changes and regain your action planning skills, develop relapse prevention skills, and better understand why you began abusing drugs in the first place, which can help you identify high-risk situations later. Medications can also be prescribed to help manage cravings and prevent continued substance abuse. Used together, therapy and medication provide a well-rounded approach to recovering from addiction.
So, yes. Drugs can change your brain, sometimes even causing functional damage that can change the way you think and plan. But sustained abstinence can allow you to heal these changes and recover normal functioning.
LOLLIE: Drugs are bad, mmkay? (laughs) I think that’s about it.
SCOTT: The main message that I want to share with this is that there is hope for recovery, and we have a huge variety of different ways that we can help someone recover from their addiction. If you catch it, and you help somebody get in touch with the right resources, there’s definitely a path to recovery that’s available.
LOLLIE: Thank you so much, Scott.
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LOLLIE: Ultimately, all drugs classes affect the brain in different ways, causing different consequences (including dependence and addiction), and laying out different paths to recovery. We fully recognize that recovery can mean different things to different people, and we want to hear your story. Reach out to us with #LetsTalkDrugs to share your own journey and ask any questions you have about drugs and recovery.
Our next series will take an in-depth look at the current opioid epidemic. What is fentanyl and why is it killing people who aren’t even using it? Where are these drugs coming from and why are people buying them? Tune in next Monday to find out!
We’re available on iTunes, SoundCloud, and most podcast listening apps, so be sure to subscribe and share so you don’t miss your weekly drug talk. In the meantime, my name is Lollie, and this has been Let’s Talk Drugs.