Understanding Addiction: A Guide for Clinicians and Concerned ReadersThe War in the Brain: Decoding the Science of Addiction

OliveHealth
Oct 17
3 min read

by Dr. Ed Fuentes

Addiction is often misunderstood as a simple lack of willpower, but the science tells a different, more complex story. At its core, addiction is a biopsychosocial illness where biological, psychological, and environmental factors intersect.

The highlighted root of this struggle: the hijacking of the brain's pleasure/reward pathway, specifically the nucleus accumbens.

Normal pleasure (like food or connection) boosts the reward system by $100% to 150%
Addictive substances flood this system with dopamine, spiking the reward level by $200% to over $1000% or more, creating an overwhelming reward.

This explosive reward signal is closely tied to memory and emotion, making cravings intense and long-lasting. Critically, it bypasses the prefrontal cortex—the part of the brain responsible for rational thought and planning. For the person struggling, it truly becomes a "war in the brain" where the primal urge overrides logic.

The Four Pillars of Intervention: What Works in Primary Care

The good news is that evidence-based interventions are highly effective, especially when initiated in a primary care setting. The presentation outlined a powerful four-step approach for healthcare providers:

Reflect Findings: Present evaluation results (labs, legal issues, social consequences) in a nonjudgmental and factual way.

Educate: Frame addiction as a treatable chronic illness, similar to diabetes or hypertension.

Advice: Recommend a next step, whether that's psychosocial support or medication.

Follow Up: Take ownership of the patient’s long-term management; specialist referrals are only for absolutely necessary cases.

Essential Behavioral Therapies:

Cognitive Behavioral Therapy (CBT): A structured approach to unpack automatic thoughts and behaviors, offering alternatives to using substances.
Motivational Interviewing (MI): Excellent for patients who are ambivalent or in early stages of change. It helps patients articulate their own reasons to change, capitalizing on even the smallest motivation.
Mutual Help Groups (e.g., AA): The most accessible, widespread, and evidence-based treatment component available globally.

Alcohol Use Disorder (AUD): Strategic Pharmacotherapy

When treating AUD, pharmacotherapy is essential, and the choice of medication should align with the patient's primary challenge and treatment goals (abstinence vs. reduction).

Medication	Mechanism	Best for...	Key Consideration
Naltrexone	Blocks opioid receptors, reducing the reward from drinking.	Patients driven by the craving for intoxication/reward. Goal: Reducing heavy drinking.	Monitor liver function tests (LFTs).
Acamprosate	Reduces protracted withdrawal symptoms (anxiety, insomnia, restlessness).	Patients driven by the need to avoid withdrawal and maintain long-term abstinence.	Difficult 3x daily dosing; relies on kidney function.

A Critical Warning: The danger of modern concoctions blending alcohol with high-dose caffeine (e.g., five shots of espresso). The stimulant masks alcohol's sedative effects, allowing the user to consume lethal amounts before becoming too tired to continue.

Opioid Use Disorder (OUD): The Power of Medication-Assisted Treatment (MAT)

The opioid epidemic taught a difficult lesson: the majority of people who developed OUD were initially taking prescriptions exactly as directed—a tragic iatrogenic problem.

Today, MAT is the standard of care for OUD:

Buprenorphine (BUP): The preferred first-line treatment. As a partial agonist, it cuts cravings while offering a ceiling effect, meaning the risk of respiratory collapse and overdose is minimal, making it safe for office-based prescribing.

Methadone: A full agonist that must be administered through a highly structured Opioid Treatment Program (OTP). Best for patients who thrive in a structured environment.

Naltrexone: An antagonist that blocks all opioid effects. Best for patients who want absolutely no opioid sensation, but must be initiated only after the patient is opioid-free.

Beyond Alcohol and Opioids: Stimulants and Cannabis

Stimulants

In a troubling trend, stimulants are often mixed with fentanyl today. Treatment relies primarily on Contingency Management (CM), which uses immediate rewards (vouchers, small prizes) for negative urine screens. While there are no FDA-approved medications, prescribing bupropion or topiramate for a comorbid condition (e.g., depression) may offer additional benefit.

Cannabis

Modern cannabis has a much higher concentration of THC. Crucially, the number one reason people use cannabis is often to relieve cannabis withdrawal symptoms. This highlights that many users are caught in a cycle of use and withdrawal, which can be addressed through motivational interviewing and behavioral therapy.

The Role of the Family and Community

Finally, the presentation stressed the critical role of the patient's support system. If a patient is unmotivated, family members can:

Support sobriety: Provide rides to meetings, encourage healthy activities.
Discontinue support for use: Stop providing money or resources that will directly fund substance use.
Seek their own support: Family members need their own therapeutic resources (perhaps through an addiction specialist) to reduce their burden and manage the situation effectively.