Where Craving and Self Control Live in the Brain (and Why That Matters)

I’ve been a therapist in an intensive outpatient program for those with substance abuse, mental health diagnoses and HIV for several years. I also used to work in a neuroscience research lab at Duke Medical Center so I geek out on brain stuff more than the average Clinical Social Worker. Last week, preparing a presentation on the brain and addiction, I learned some really interesting things that have already informed my practice.

The oldest parts of the human brain are deep in its center because the brain evolved outward. In this “reptilian” part of our brain lie the Basal Ganglia (BG) - the brain’s pleasure center -- and the amygdala. The BG helps us survive by making experiences that aid our individual and species survival — like eating and sex — pleasurable so we’ll do them again. The amygdala helps us survive by taking a sensory snapshot of what was happening when we experienced emotionally intense things and assigning significance to them (“yikes- bear!” v. “Lasagne good!”) so we can find the good stuff again and avoid the scary stuff. These systems worked to help our hunter gatherer ancestors eat more when food was available to help survive when food was not and also helped know where danger might be near.

The other part of the brain that comes into play is the much newer Pre-frontal Cortex (PFC). Only mammals have this. This is the area that helps us know whether or not we should give into an impulse based on other things we know. Rent is due so I can’t afford a new sofa this week. This part is responsible for our ability to plan, reason, weigh pros and cons, make decisions, regulate our emotions and keep our impulses in check. And yes, parents, this is the part that doesn’t fully develop until about age 25. Speaking of age, for addicts who start abusing alcohol or drugs before that age, addiction’s grasp can be that much stronger and it can impair the PFC’s ability to develop properly leading to weaker impulse control in adulthood.

Did you know meth (what’s on the street today that’s more powerful than 10 years ago and usually laced with fentanyl) releases roughly 2,000 times the amount of dopamine and other pleasure chemicals in the BG than normal? The amygdala then screams we need this to survive and we need to keep doing it. Because we did not evolve with these drugs made in a laboratory, they effectively overload and hijack these pleasure centers. The PFC may be screaming we can’t keep doing this it’s pissing everyone off and we’ll be jobless and homeless soon but the pleasure centers are screaming more loudly. Contrary to societal stigma and what resentful relatives and partners tend to believe, addicts really don’t enjoy the experience of active addiction. It’s confusing, exhausting, demoralizing, and often, like watching a car accident play out right before our eyes, still they feel unable to stop.

OK here’s the cool part. Recovery self help groups and we therapists who work in addiction and recovery spaces have been telling people for decades to talk through triggers, cravings and painful emotions. Now we know that part of why that helps is when we do that, we're taking these unconscious impulses and moving them to an area of the brain that’s more verbal and more conscious where we can experience a measure of control over them. If we look at the brains of recovering addicts, where there is better communication between the BG and the PFC, those individuals are actually less likely to relapse. In a way we can think of the activity of the pleasure centers and the amygdala as like the inner addict voice telling us it’s just one hit- no one will know, etc. These pleasure centers have also hijacked the PFC. Also - again brain science is catching up to what people in recovery have been doing for decades - meditation (and adjacent activities such as spiritual practice and altruism) strengthens the PFC. In fact, since brain pathways that fire together wire together, that’s another piece of very good news for anyone trying to recover from addiction or just bad habits - the more you do the good stuff, the easier it will get as your brain lays down pathways for those healthier habits.

Centuries ago, epileptics were told they were possessed by demons and sometimes cordoned off from mainstream society and denied basic rights like the right to marry. Now we understand epilepsy as a problem of abnormal electrical activity in the brain and treat it with drugs. I’d like to think we are on the same trajectory with treating addiction and wonder if addiction will ever be that treatable and that de-stigmatized. The unexpected promise of the new GLP-1 drugs to reduce cravings for substances of abuse has renewed our hope that this might be possible some day.

Thanks to Stephen Knight, LCDC, Melissa Atlas, LCSW, LCDC, and Facing Addiction in America, the Surgeon General’s Report on Alcohol, Drugs and Health, 2016.