Substance use disorders result from changes in the brain that can occur with repeated use of alcohol or drugs. The most severe expression of the disorder, addiction, is associated with changes in the function of brain circuits involved in pleasure [the reward system], learning, stress, decision making, and self-control. Every substance has
slightly different effects on the brain, but all addictive drugs, including alcohol, opioids, and cocaine, produce a pleasurable surge of the neurotransmitter dopamine in a region of the brain called the basal ganglia; neurotransmitters are chemicals that transmit messages between nerve cells. This area is responsible for controlling reward and our ability to learn based on rewards. As substance use increases, these circuits adapt. They scale back their sensitivity to
dopamine, leading to a reduction in a substance’s ability to produce euphoria or the “high” that comes from using it. This is known as tolerance, and it reflects the way that the brain maintains balance and adjusts to a “new normal”—the frequent presence of the substance. However, as a result, users often increase the amount of the substance they take so that they can reach the level of high they are used to. These same circuits control our ability to take pleasure from ordinary rewards
like food, sex, and social interaction, and when they are disrupted by substance use, the rest of life can feel less and less enjoyable to the user when they are not using the substance. Repeated use of a substance “trains” the brain to associate the rewarding high with other cues in the person’s life, such as friends they drink or do drugs with, places where they use substances, and paraphernalia that accompany substance-taking. As these cues become increasingly associated with the
substance, the person may find it more and more difficult not to think about using, because so many things in life are reminders of the substance. Changes to two other brain areas, the extended amygdala and the prefrontal cortex, help explain why stopping use can be so difficult for someone with a severe substance use disorder. The extended amygdala controls our responses to stress. If dopamine bursts in the reward circuitry in the basal ganglia are like a carrot that
lures the brain toward rewards, bursts of stress neurotransmitters in the extended amygdala are like a painful stick that pushes the brain to escape unpleasant situations. Together, they control the spontaneous drives to seek pleasure and avoid pain and compel a person to action. In substance use disorders, however, the balance between these drives shifts over time. Increasingly, people feel emotional or physical distress whenever they are not taking the substance. This distress, known as
withdrawal, can become hard to bear, motivating users to escape it at all costs. As a substance use disorder deepens in intensity, substance use is the only thing that produces relief from the bad feelings associated with withdrawal. And like a vicious cycle, relief is purchased at the cost of a deepening disorder and increased distress when not using. The person no longer takes the substance to “get high” but instead to avoid feeling low. Other priorities, including job, family, and
hobbies that once produced pleasure have trouble competing with this cycle. Healthy adults are usually able to control their impulses when necessary, because these impulses are balanced by the judgment and decision-making circuits of the prefrontal cortex. Unfortunately, these prefrontal circuits are also disrupted in substance use disorders. The result is a reduced ability to control the powerful impulses toward alcohol or drug use despite awareness that stopping is in the person’s best
long-term interest. This explains why substance use disorders are said to involve compromised self-control. It is not a complete loss of autonomy—addicted individuals are still accountable for their actions—but they are much less able to override the powerful drive to seek relief from withdrawal provided by alcohol or drugs. At every turn, people with addictions who try to quit find their resolve challenged. Even if they can resist drug or alcohol use for a while, at some point the
constant craving triggered by the many cues in their life may erode their resolve, resulting in a return to substance use, or relapse. Review the full text for The Neurobiology of Substance Use, Misuse, and Addiction – 2016 [PDF | 6.0 MB]
Defining Positive And Negative Reinforcement
Addiction is a complex process. What drives people to use illicit substances or alcohol in destructive ways? What makes someone keep using despite things spiraling out of control? There are several underlying motives that encourage substance misuse. Can we use the word encourage? Maybe motivate? Regardless, one motivating factor could be the “high” one feels when they use a substance. The pursuit of pleasure. But what happens when the high is no longer achieved? What keeps them going? There are two phenomenon that are in play that can help explain: positive and negative reinforcement.
The repetition of a habit based off a relationship with a stimuli, is known as reinforcement. Reinforcement can be either classified as positive or negative. That does not equate to “good or bad” as one may think. Both reinforcement types increase drug usage in this context. Reinforcement is usually facilitated by an external stimuli or some sort of trigger, by adding to the desired effect, or removing of an aversive stimuli. The key result of any “reinforcement”, is that it maintains the behavior, in the case of addiction, the drug using process, regardless of it being positive or negative reinforcement. We will explore the difference.
For example, someone who needs to achieve higher grades in school, who studies better while using a certain drug, may continue to be reinforced to use it, as the drug use helps them study longer, and results in better grades. Alternatively, someone battling depression may discover that using a drug may provide enough relief to temporarily soothe their low or sad mood, and depending on the substance, continues using it. In the first example, adding the drug leads to [positive] better grades and reinforces further drug usage. In the later example, using the drug removes [negative] the aversive situation, depression, which reinforces further drug usage. Both result in maintaining or increasing drug usage.
So, lets look at this construct further.
Incentives For Drug Use: Positive Reinforcements
There are examples of positive reinforcements that can motivate each person differently. Positive reinforcements in relationship to substance abuse can include:
- Drinking alcohol in order to increase socialization.
- Feeling artistically inspired after taking LSD.
- Feelings of courage while intoxicated.
- Euphoria when taking prescription medications.
- Feeling calm and relaxed when taking sedatives.
- Uninhibited feelings due to alcohol intoxication.
- Feelings of high energy and focus when taking stimulants.
Let’s examine the role of positive reinforcement, or operant conditioning, in the context of addiction. For example, someone who has had a car accident visits the doctor and is prescribed and opioid for their severe pain. The individual is prescribed a certain dosage to help manage and alleviate symptoms for their pain. The relief of pain in their body allows for the individual to feel less stress, gain mobility, and enjoy a better quality of life with reduced pain. Furthermore, the euphoria the individual may feel while taking the drug may become a mood enhancer. This interaction promotes or “reinforces” the use of the opioid.
Motivations For Repeated Chemical Abuse And Positive Reinforcement
Expanding on the above storyline of someone prescribed an opioid to assist in reducing pain, they later discover they have better mood overall and continue to use opioids even after the pain subsides. In this case the use of pain medication to help their overall state of mind and outlook, that they are “happier”—the positive reinforcement of an improved mood can encourage misuse or the consuming of non-prescribed in increased amounts. Obviously, this is dangerous. The pharmacodynamics and mechanisms of action of opioids readily make someone physically dependent in a very short time, around two weeks, even at therapeutic dosages, and more with overzealous amounts. Opioids bind with opioid receptors in the brain which release endorphins and activates the brain’s reward system, with a rush of dopamine which rewards one with a good feeling. Once someone gets the high from the drug, they often develop a cycle of pursuing that high. The physical nature of opioids create changes in the brain quickly, that when one tries to stop, significant psychological and physical discomfort can occur. And once this physical dependence has been achieved, the severe discomfort of withdrawal, is often the trigger leading to a vicious cycle pursuing more opioids, and facilitating addiction. Concurrently, tolerance to the drug can nullify the strength of the effects, as tolerance has occurred once the original dosage of the drug is not enough to get the person high anymore. This is due to sensitization in the brain to the drug. This leaves the individual seeking a higher amount of the same substance, or a stronger similar class of drugs to illicit a high.
That second part of pursuing a drug to avoid or mitigate physical withdrawal leads us to explore the concept of negative reinforcement.
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Incentives For Drug Use: Negative Reinforcement And Addiction
There is still much research being done on negative reinforcement and drug abuse. Negative reinforcement can include someone who abuses a drug and get used to its effects, then stops and feels withdrawal, and now has to continue its usage to avoid the aversive situation. In the case of substance abuse, negative reinforcement can include:
- Using alcohol to remove anxiety in social situations.
- Bad trips while taking acid, causing one to now add benzos to calm the mind.
- Depression when not abusing a drug, that leads to using again to improve mood.
- Inattention and distractibility lessens, as one uses more cocaine.
Motivations For Repeated Chemical Abuse And Negative Reinforcement
Negative reinforcement is an often misunderstood concept. We see the word negative and feel that it has to do with an outcome, something bad happened, or resulted. Well, yes, when using drugs and alcohol within the scope of addiction, it is all negative, but in this context, we speak of the removal of an aversive stimuli or situation that further reinforces using the substance.
Example would be from our first storyline, that an individual first started using opioids for a legitimate pain condition, found the “euphoria” and mood enhancing qualities that came along with it, and now despite resolving the pain condition, continued to use to the point of physical dependency. Now what? Using now is not to really pursue pleasure anymore, it is to escape the pain, to take away, “negate”, the withdrawal. This further promotes, or reinforces, the drug usage. This is negative reinforcement. Removing [negative] the aversive stimuli or situation, by using the drug.
The irony of addiction is how it starts. It often begins by using drugs or alcohol as experimentation, while socializing, or to feel good; the pursuit of pleasure and positive reinforcement. Many times we see progression of a prescribed medicine to treat authentic medical or psychiatric condition, become diverted and used in maladaptive ways. No one knows the full extent of the relationship drugs and alcohol will ultimately have on the mind and body when they are first introduced. It’s a complex interaction of genetics versus “everything else.” There are so many variables and nuances that compound upon one another and can act as risk factors to develop a substance use disorder. So these aforementioned reinforcement models may help us understand a drug’s use progression, based on this conditioning over time, and the relationship with risk factors all placed against the backdrop of the environment. So, whether starting out using for pleasure, and developing tolerance and physical dependence, or beginning with other risk factors such as painful medical or distressing psychological conditions, ultimately, when one continues to use in this vicious cycle to escape the pain, to remove the aversive stimuli, this switches to negative reinforcement.
Fortunately, treatment for substance use disorders can break this vicious cycle. Engaging in treatment is a major step, one that can offer the tools to address the physical and psychological distress that exists with addiction, and start the journey of living a drug free life. There are ways to pursue pleasure and escape from pain, without the path of addiction.
For more information on addiction and treatment options, contact a treatment provider today.