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Addiction and the Brain: What I Learned from Carlton Erickson

By Daniel Jordan

I was at an addiction conference yesterday in beautiful Nanaimo, British Columbia sponsored by our friends over at Edgewood, a private drug treatment center located on Vancouver Island. The keynote speaker of the conference was Dr. Carlton Erickson, Ph.D., Professor of Pharmacology, and director of the Addiction Science Research and Education Center in the College of Pharmacy at the University of Texas at Austin. Dr. Erickson, a research scientist, has been studying the effects of alcohol on the brain for over 40 years and he did a commendable job of trying to summarize all of his knowledge in a 3-hour presentation.

Here’s what I learned from Dr. Erickson:

Lesson One: Addiction is a “Brain Disease”

It’s not surprising that a neuroscientist would suggest that addiction is a brain disease but Dr. Erickson does make a compelling argument by comparing chemical dependence to several other diseases such as Type 2 Diabetes, hypertention, Parkinson’s Disease, and Attention Deficit Hyperactivity Disorder (see page 11 of Erickson’s book, The Science of Addiction ).  The presentation included some very colourful, scientific images of the brain and it’s good to know the latest in addiction research on the brain and the exact brain area that is affected in the chemically dependent person, the mesolimbic domamine system.

At Sunshine Coast Health Center, we have found that clients love the psychoeducation classes on the brain since, for the first time, many can start to understand why they have the thoughts, feelings, and behaviours normally experienced with a dependence to drugs or alcohol. With this  biological, rather than a moral, explanation clients begin to question their attachment to detrimental emotions such as guilt and shame.

Lesson Two: Our Terminology Needs Fixing

More than the scientific presentation showing how addiction impacts the brain, I was particularly fascinated by Dr. Erickson’s claim that many of the the words, or terminology, that the general public and the treatment field use to describe drinking and drugging are leading to continued prejudice and discrimination in North American culture. This stigmatizing, Dr. Erickson argues, is a big part of why governments are not providing adequate funding for addiction research, prevention, and education.

“Addiction” is a Vague Term

The term “addiction,” for example, has been used for way too many behaviours and things including but not limited to cell phones, television, work, food, sex, exercise, oil, shoes, “crackberries,” etc.  As a result, Dr.  Erickson suggests that “addiction” is an imprecise, unscientific term. The term addiction is now used in popular vocabulary as a way to describe something desired such as “I love the Oprah Show so much I think I’m addicted to it.” Obviously, the negative impact of watching too much Oprah and smoking copious amounts of crack cocaine cannot compare. The use of “addiction” to describe America’s over-reliance on foreign oil shows how far the term has been adopted beyond its original intended use.

Another problem with the term “addiction” is due to the umbrella-like nature of the term which fails to distinguish between conscious drug abuse and pathalogical chemical dependence (see Lesson Three below).

Alcoholics Anonymous has Broadened the Term “Alcoholism”

Alcoholism is another term that should be replaced due, unintentionally, to its popular use at Alcoholics Anonymous meetings. If you have ever attended AA or watched a video such as Clean & Sober (starring Michael Keaton) you will have witnessed participants starting off their testimonials with the words, “Hi, my name is ____ and I’m an alcoholic.” The truth is, suggests Dr. Erickson, many of these people standing up are problem drinkers and not necessarily dependent on alcohol since joining AA is open to any problem drinker seeking to get better.

 “Abuse” is a Perjorative Term and Should be Retired

In his book, The Science of Addiction, Dr. Erickson calls the term “abuse” the number 1 myth that prevails in the treatment field or in the minds of the public. The word abuse * is an inappropriate term for several reasons, such as:

  1. the term being used, for centuries, as a morally sinful act such as child abuse, sexual abuse, spousal abuse
  2. the implication that alcohol, an object, is being abused by someone just like a child is being abused by someone (a preferred term in Europe is misuse)
  3. the use of the term substance abuse does not distinguish between voluntary use (“misuse”) and uncontrolled use (“dependence”) similar to the generalized use of the term “addiction” 

By continuing to refer to people as drug, alcohol, or substance abusers, according to Bill White *, “misstates the nature of their condition and calls for their social rejection, sequestration, and punishment.”

More myths can be found at the the University of Texas website

(*) Note: See page 4 of “The rhetoric of recovery advocacy: An essay on the power of language,” written by WIlliam White.

To summarize, Dr. Erickson idetifies the terms “addiction,” “alcoholism,” and “substance abuse” as sloppy and stigmatizing because they do not distinguish between intentional, voluntary use of drugs or alcohol (“abuse”) and the impaired control over drug use (“dependence”).

Lesson Three: Drug Misuse and Dependence are Two Different Conditions

I have always understood that someone who “abuses” drugs or alcohol is not necessarily chemically dependent but Dr. Erickson really drove the point home by making several important distinctions.

To start this important discussion, Dr. Erickson made reference to DSM-IV critieria and pointed out to the audience that abuse of drugs or alcohol needs to show a maladaptive pattern of drug use leading to impairment or distress presenting as one or more of the following in a 12-month period:

  1. recurrent use leading to failure to fulfill major obligations
  2. recurrent use which is physically hazardous
  3. recurrent drug-related legal problems
  4. continued use despite social or interpersonal problems

On the other hand, dependence on drugs or alcohol needs to show a maladaptive pattern of use leading to impairment or distress, presenting as three or more of the following in a 12-month period:

  1. tolerance to the drug’s actions
  2. withdrawal
  3. drug is used more than intended
  4. there is an inability to control drug use
  5. effort is expended to obtain the drug
  6. important activities are replaced by drug use
  7. drug use continues despite knowledge of a persistent physical or psychological problem

Source: Adapted from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition – Text Revision, 2000.

If you have just one or two symptoms, it is not dependence. For example, you may think you are dependent on coffee but it is unlikely that your caffeine use has led to anything beyond symptoms one and two in the list above.

However, the implication of making a clear distinction between the two conditions has one clearly controversial implication that has been hotly debated in the treatment field: “abusers,” unlike people that are dependent, can go back to moderate or controlled drinking (see pg. 17 of the Science of Addiction) *.

(*) Source: Wallitzer, K.S., & Connors, G.J. (1999). Treating problem drinking. Alcohol Research & Health, 23, 138-143.

How treatment providers like Sunshine Coast Health Center make the distinction between clients who are pathalogically dependent and those that are merely voluntary misusers is another matter. Clearly, however, this information needs to be handled, if at all, with clients. It does, however, explain why many addiction professionals claim that there is a cure for addiction since, in their research or clinical experience, they may have been working with “abusers” rather than truly chemically dependent individuals.

Lesson Four: Some Drugs are More Addictive Than Others

Dr. Erickson calls the likelihood that a person will become dependent on a drug its “dependence liability.” Some drugs have a dependence liability while others do not. The criteria for dependence liability is how it acts on the mesolimbic dopamine system. Caffeine, antidepressants, and newer anti-seizure medications do not have dependence liability. However, some drugs do and the following chart shows that a certain percentage of people (depending on the drug) will become dependent *:

Drug / Percentage of People Who Become Dependent

Nicotine – 32%, Heroin – 23%, Cocaine – 17%, Alcohol – 15%, Stimulants – 11%, Cannabis – 9%, Sedatives – 9%, Psychedelics – 5%, Inhalants – 4%.

Source: Anthony, J.C., Warner, L.A., & Kessler, R.C., (1994). Comparative epidemiology of dependence on tobacco, alcohol, controlled substances, and inhalants: Basic findings from the national comorbidity survey. Experimental & Clinical Psychopharmacology, 2, 244-268.

Lesson Five: There are Different Types of Alcohol Dependence

Dr. Erickson presented compelling research showing that some types of alcohol dependence occur early in life while other types occur late in life:

  1. Early Onset – some adolescents are at higher risk for alcohol dependence, especially when they drink at an early age
  2. “Instant” Onset – some people become “instantly addicted” to alcohol or cocaine with the first use of the drug, that they “feel normal” for the first time in their lives.
  3. Late Onset – after age 25 for some, or geriatric age for others.
  4. Absence of Onset – just like some people eat a lot and never get fat, some people can misuse drugs or alcohol forever and never become dependent.

In this way, alcohol dependence is not onlike other diseases that have different onsets such as diabetes, leukemia, and heart disease. Dr. Erickson did point out, however, that more research is needed to confirm these findings.

Conclusion

Regardless of whether you were a professional who advocates a harm reduction or abstinence-based approach, Dr. Erickson’s presentation had some good news and some bad news. With his clear support for research validity, however, one thing that the treatment field should not do is dismiss his work out of hand. Kudos to Edgewood for presenting Dr. Erickson, an addiction professional who is clearly an advocate for change.

For More Information

For those interested in learning more about addiction and the brain, Dr. Erickson recommends the following websites:

University of Texas Addiction Science and Research Center

National Institute on Drug Abuse (NIDA)

National Institute on Alcohol Abuse and Alcoholism (NIAAA)

Join Together Online

Faces & Voices of Recovery

Brain SPECT Imaging (Daniel Amen, MD)

NIH/NLM Publications

For those that want to learn more about this important topic, pick up a copy of The Science of Addiction: From Neurobiology to Treatment.  I have since found a criticism of this book by Harvard University psychiatrist Edward J. Khantzian, M.D. and it’s worth a look for those interested in the polarization in the field of addiction between psychiatry and addiction medicine.

About the Author

Daniel Jordan is the General Manager of Sunshine Coast Health Center and hopes that these postings will help  take away some of the mystery often associated with addiction and its treatment.

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