What Causes Addiction?

An archaic, though surprisingly prevalent and longstanding conceptualization of addiction involves deficits of moral fiber and character. The main text of Alcoholics Anonymous (2001), originally published in 1939, was avant-garde in making claims for its population such as:

If a mere code of morals or a better philosophy of life were sufficient to overcome alcoholism, many of us would have recovered long ago. But we found that such codes and philosophies did not save us, no matter how much we tried. We could wish to be moral, we could wish to be philosophically comforted, in fact, we could will these things in all our might, but the needed power wasn’t there (Wilson, 2002, p. 62).

Scientific research continues to support this claim and undermine the less compassionate deficit in morality or will power conceptualization. This piece will provide an evidence-based explanation for a complex and multifaceted subject: the disease of addiction, and will examine some of the biological, psychological, and social components to the etiologies of addiction.

Addiction Etiology: Background

A common way to gather information about a client initially is a psychosocial assessment, which is conducted by a trained licensed clinician (Sommers-Flanagan, J. & Sommers-Flanagan, R., 2017). This assessment provides the groundwork for generating a diagnosis from the American Psychological Association’s Diagnostic Statistical Manual (2013), which can help provide collateral information to others providing care for the patient, sometimes be a component of billing insurance, examines problematic symptoms that tend to cluster together, and provide insight into other possibly co-occurring disorders (comorbidity). For instance, according to Killeen et al. (2015), PTSD has been found to be highly comorbid with substance use disorders. This comorbidity is compounded by even higher rates of relapse as well as developing additional mental health issues. Both conditions exacerbate one another. Comorbidity considerations can help guide more successful treatment, especially with those individuals in comorbid populations who are susceptible to specific risks.
The information generated through this assessment is then used to guide treatment planning and case formulation. Though this assessment can gather a lot of important information, it does not fully explain all the cultural influences and experiences of the client as an individual, hence part of the rationale why ideally a clinician conducts this assessment at the beginning of session in a natural way while also beginning the process of therapy, which includes building rapport and modeling secure attachment (Sommers-Flanagan, J. & Sommers-Flanagan, R., 2017). The consideration of all these, often interconnected factors, and in some cases, many more, are important aspects to consider when beginning to understand and formulate treatment for someone with a substance use disorder.

Etiology: Biological Components

The question of whether addiction is due to biological or environmental factors is especially relevant to substance abuse disorders. There are a number of ways that the disease of addiction has explanations related to the biology of the individual which include, but are not limited to, genetics, organic mental illness, and dysregulated brain chemistry.
Genetic Predisposition
There are a number of correlations related to genes and substance use outcomes. For instance, certain genes have been linked to a higher propensity toward increased use of certain substances, most commonly alcohol. According to Daly (2012), “These genes are involved in alcohol metabolism and affected individuals have high alcohol tolerance which leads to excessive alcohol intake to achieve intoxication” (p. 62). Also, there have been recent discoveries of other genes involved in nerve cell modulation within the neurochemical systems related to abuse of specific substances. Some of these genes influence the gamma-aminobutyric acid (GABA) systems (alcohol/sedatives), endogenous opiate system (opioids, heroin) and cannabinoid system (marijuana) (Daly, 2012).
Genetic influences are supported by the higher prevalence of substance abuse in family members. According to the American Psychiatric Association (2013), “Alcohol use disorder runs in families, with 40% to 60% of the variance of risk explained by genetic influences,” (p. 494) increasing with closeness to relatives, genetic closeness, and severity of the substance related issues with those relatives. Moreover, “A three- to fourfold increase in risk has been observed in children of individuals with alcohol use disorder, even when these children were given up for adoption at birth and raised by adoptive parents who did not have the disorder” (p. 494).
Also, higher rates of alcoholism exist between monozygotic twins when compared to dizygotic twins (American Psychiatric Association, 2013). Though there are non-biological reasons to account for this familial influence, research with twins of both genders supports that there is a genetic link. Seglem, Waaktaar, Ask, and Torgersen (2016) conducted a longitudinal study with twins to research more about environmental and genetic predispositions’ effects on alcohol consumption in adolescence to young adulthood, while also looking at sex differences. The study found that females tended to consume more alcohol during the middle adolescence, whereas males consumed more in young adulthood. The study also found that, while environment played the biggest role, and a large determinant of environment was attributable to sex differences, there was also a moderate genetic correlation, supporting previous research.
A notable example of a genetic proclivity on a population level can be seen when looking at Chinese consumption of alcohol. The earliest records of alcohol consumption are credited to China. Theorists hypothesize that prolonged exposure to alcohol and its toxic effects have caused a shift within this gene pool and evolution among Chinese individuals, which accounts for why they develop a glow, or flushed face, when drinking; it is a mutation that results in an avoidance of imbibing copious amounts of alcohol, leading to lower rates of alcohol abuse among ethnic Chinese. Conversely, this theory may provide strong evidence for the high rates of alcoholism within Native American populations due to the more recent introduction of alcohol and thus greater sensitivity to exposure to ethanol. This is related to specific genes responsible for enzymes that process the alcohol (Poludasu, Godi, & Gurram, 2015).

Biological Links with Mental Illness

Other biologically related causes of addiction are theories relating to mental illness. The high comorbidity of substance use disorders and other mental health issues confirms this. According to the American Psychological Association (2013),
High vulnerability is associated with preexisting schizophrenia or bipolar disorder, as
well as impulsivity (producing enhanced rates of all substance use disorders and
gambling disorder), and a high risk specifically for alcohol use disorder is associated with
a low level of response (low sensitivity) to alcohol. A number of gene variations may
account for low response to alcohol or modulate the dopamine reward systems; it is
important to note, however, that any one gene variation is like to explain only 1% to 2%
of the risk for these disorders (p. 494).
Organically occurring mental illnesses such as depression, anxiety, and even schizophrenia may increase someone’s chances of using substances to self medicate. This is because certain drugs act on neurotransmitters where deficits may be present. Using a substance such as a stimulant or even alcohol may temporarily relieve symptoms of depression. Likewise, anxiety can show immediate reduction through the use of alcohol, benzodiazepines, cannabis, etc. due to the neurological effects these drugs exert on parts of the brain such as the GABA receptors. Individuals with schizophrenia are more likely than not to abuse nicotine products, which is supported by the nuanced effects of the substance on the nonnormative neural circuitry of these individuals compared to a brain with normative brain chemistry (American Psychological Association, 2013). “In individuals with current tobacco use disorder, the prevalence of current alcohol, drug, anxiety, depressive, bipolar, and personality disorders range from 22% to 32%. Nicotine-dependent smokers are 2.7-8.1 times more likely to have these disorders than nondependent smokers, never-smokers, or ex-smokers” (American Psychological Association, 2013, p. 574).
These substances then continue to rewire the neural circuitry of the brain with prolonged use. For example,
Many young people begin losing control of substance use because of insomnia, an early
symptom in many psychiatric disorders like depression, anxiety, and bipolar disorder.
Young adults often use the effects of substances to counter unpleasant symptoms:

• stimulants to fight depression
• alcohol and narcotics to counter anxiety or over-excitability
• marijuana to help with sleep and poor anger control (Daly, 2012, p.
  62).

  Usually, the earlier conditioning of this kind begins, the worse the prognosis affecting treatment outcomes.“The earlier in adolescence it begins, the higher the risk that it will persist into a disabling disorder in adulthood” (Daly, 2012, p. 55).

Neurological components

An explanation of the biological reasoning behind brain chemistry driving substance abuse can be seen through the dopamine seeking system deficit model, and it helps to explain continued use. When looking at the dynamics of brain chemistry, specific substances (opioids, cocaine, alcohol, marijuana, etc.) mimic and create high production of naturally occurring chemicals in the brain such as dopamine, GABA, serotonin. These substances generate an overabundance of these chemicals.
Just as drugs produce intense euphoria, they also produce much larger surges of dopamine, powerfully reinforcing the connection between consumption of the drug, the resulting pleasure, and all the external cues linked to the experience. Large surges of dopamine “teach” the brain to seek drugs at the expense of other, healthier goals and activities (NIH: National Institute on Drug Abuse, 2018, para 16).
Then, in the interest of maintaining balance within the neural networks, the brain begins to stop creating these chemicals that the drugs are producing an excessive amount of. Once this cycle is repeated, when drugs are not present to flood the brain, the disruption of the brain no longer producing these chemicals (usually dopamine-euphoria) produces unpleasant effects. The individual’s urge to use changes from positive reinforcement (euphoria) to negative reinforcement (dysphoria). “Thus dopamine contributes to addiction…through its differentiated roles in reinforcement, motivation, and self-regulation, referred to here as the ‘dopamine motive system’, which, if compromised, can result in increased, habitual and inflexible responding.” (Volkow, Wise, & Baler, 2017, p. 741).
This addiction framework is conceptualized by Koob, Arends, & Le Moel (2014) under the framework of “binge/intoxication, withdrawal/negative affect, and preoccupation/anticipation.” The binge/intoxication stage largely involves the basal ganglia. The withdrawal/negative affect is mostly involving the extended amygdala. The preoccupation/anticipation (‘craving’) stage involves key elements of the prefrontal cortex which mediates executive function, which controls the ability to “organize thoughts and activities, prioritize tasks, manage time and make decisions” (p. 52). Koob and colleagues say in addiction two opposing systems in the prefrontal cortex act to “engage habit systems,” which they call the Go system, and conversely “to inhibit them,” which they label the Stop system. “The result of the interactions between these two systems produces the well-known impulsivity associated with the addiction process, both during the initiation of drug intake and relapse” (p. 59).

Psychological Components

Though one may be genetically predisposed to have higher incidences of substance abuse based on biological factors he or she may have no control over, explaining addiction through only a biological lens would be overly deterministic as the biological etiology of addiction is only a piece of the puzzle. Without psychological, social, and cultural factors that cause one to use particular substances at certain ages and rates, substance use and abuse could not happen. For example, adolescents are more affected by brain wiring of substances. One of the biggest reasons for adolescent substance use is that the prefrontal cortex is less developed and not able to make higher level decisions (Daly, 2012). Adolescents respond more physiologically to the rewarding effects of drugs, while they are less responsive to the adverse effects (Carroll, & Smethells, 2015,). but cultural and psychological factors such account for whether the adolescent is exposed to substances. In American culture “…young adults are widely acknowledged to comprise the highest age group for substance abuse…” (Daly, 2012, p. 55).

Learning Theory

B.F. Skinner developed the concept of operant conditioning. Skinner is known for using rats to develop this theory, and rats have been used to study substance abuse as well. Central to his theory of operant conditioning are positive reinforcement and negative reinforcement. In Skinner’s theory of operant conditioning, essentially, with a drug-naive rat, positive reinforcement accounts for the act of the rat consuming the substance and feeling under the effects of the substance. Important in drug addiction is when this shifts from positive reinforcement to negative reinforcement. Negative reinforcement is when the rat will need to take the drug to avoid the adverse consequence of feeling dysphoria or aversion as the result of prolonged positive reinforcement (Koob et al, 2014).

Dynamic/Analytic Theories

An alternative explanation to only viewing observed behavior would be to psychodynamically infer that people use drugs to intentionally and unintentionally change the way they feel. According to Koob et al. (2014), “The focus of this approach is on developmental difficulties, emotional disturbances, structural (ego) factors, personality organization, and the building of the ‘self.”’ (p. 9). Khantzian’s self-medication hypothesis states that individuals, “take drugs as a means to cope with painful and threatening emotions” (Koob et al, 2014, p. 9). This theory goes on to state that the drug of abuse will often be complementary to the undesired affective state the individual is attempting to escape. This would not be problematic if the drugs did not have adverse consequences, namely dependence and then the collateral physical, emotional, behavioral side effects that ensue.
A different theory to partially explain problematic substance abuse is that addiction is being used to meet self-object needs. Kohut’s theory says people who did not have validation as children use objects like drugs to complete their sense of self when “archaic needs are unable to be transferred into self-esteem, solid ambitions and goals…. In this sense the ‘selfobject’ function of drug use is used as a replacement for a defective self-structure” (Smith, 2007, p. 17) A specific example of this from Miller (2002) who writes about a hypodermic needle as a transitional object for individuals who were very neglected/abused by parents as children. The addicted individual seemed to be able to find some form of unconditional safety and comfort from a needle almost as a breast substitute. In a situation with better parenting, the relationship to the needle might not be defined in the same way.

Social/Cultural Components

Prognosis and environmental risks include considerations such as cultural attitudes about alcohol consumption, intoxication, availability, personal experiences, and extremes of stress. Also important may be peer group excessive substance use patterns, amplified beliefs about the beneficial effects of alcohol consumption, as well as poor coping strategies (American Psychological Association, 2013).
Gender: Male bonding/rituals
One might make the argument that consuming alcohol is an inherent part of being male in American society (i.e. drinking a beer, sports, getting dirty). According to Sanders (2011), drinking is a ritual among young men, especially for those lacking power, like teenagers: “Men tend to drink more than women, drink more often, to a higher state of intoxication and have higher rates of abuse as well as dependency” (Sanders, 2011, p. 50). Men have more positive attitudes toward drinking and alcohol than women, who tend to associate more negative consequences such as intoxication, vulnerability, or even illness (Andsager, Austin, & Pinkleton, 2002, Therefore, the social modeling or peer group influences appear to be a significant influence on why American men would have a rate of substance abuse disorder two to five times higher than women (Brady and Randall 1999; Johnson and Glassman 1998; SAMHSA 2008; SAMHSA, OAS 2004; cited in Center for Substance Abuse Treatment). Using drugs is also a male-dominated activity, which is evident when looking at the populations of treatment centers and prisons (Sanders, 2011).

Media influence

Media reinforces substance use by linking it to positive societal role models and qualities. For instance, research about alcohol advertisements has shown them to be targeting young males, making appeals to gender schema and ideologies about male dominance. According to Aronson, Wilson, and Akert, (2013), advertising is replete with gender-specific stereotypes including stereotypes about male alcohol use. Alcohol advertisements often play on themes such as masculine power, entitlement, and control over women (Towns, Parker, & Chase, 2011). Popular media show both pros and cons of substance use, but are more concerned with what is entertaining and is less likely to be over morbid when depicting addiction.

Social Learning Theory

Social Learning Theory is most popularly known from Albert Bandura’s Bobo Doll Study (1961). Social Learning Theory posits that humans learn by observing others around them. This can happen through watching television or movies, or seeing older individuals modeling behavior. This becomes further compounded when a young individual finds a counter culture group that is accepting of him or her. These groups satisfy very basic needs of being accepted, belonging, and finding connection. Counter culture groups, such as gangs, sometimes use substances. Being inducted within these groups or progressing through stages of substance use can sometimes lead to an unrealistically disproportionate amount of substance use, especially among the youth. When bonding with these socially disaffected individuals, it fair to state that healthy coping skills are not being developed as opposed to using substances as a way to mask emotions (Aronson et al., 2016).

Cultural Components

Though culture may be somewhat related to social factors, due to its often overlooked,
yet high influence, it can be considered in its own right. American Psychological Association
(2013), contains a section on Cultural formulation. An example of cultural influence on substance use can be shown by comparing more permissive attitudes toward drinking within Italian and French American families versus more conservative or negative attitudes held by Irish and Protestant American families who paradoxically have higher “…incidences of alcoholism and alcohol-related social, psychological, medical, and legal problems” (Daly, 2012, p. 60). Though the French and Italian consume more alcohol as families on average, they have lower rates of problematic drinking than Irish families who hold negative views on alcohol, but have high rates of problematic drinking.
American culture’s pressure to achieve material success can encourage substance abuse, especially in adolescents, as a means of coping with anxiety or parental expectations. Daly (2012) believes a culture of continual striving encourages dissatisfaction and stress, while at the same time decreasing time spent with those who matter, family and friends.

“Devaluing relationships and over-valuing external material possessions, status, and achievements is a form of ‘misinformation’ that prevails in our culture.” However, “when parents want to value emotional and psychological health and development, they encounter heavy and difficult pressures they must counter” (p. 80).

**John Bowlby’s Attachment Theory is another prominent conceptualization not included in this work

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