To do good work, I cannot be too fixated on any one viewpoint or way of thinking. People are complicated, issues are varied, and being helpful requires different mental models, different ways of thinking about problems.
For addiction and recovery in particular, there are several mental models I use frequently. They are useful for making sense of what is happening, and for thinking about how to be helpful. This is the first post in a four-part series that will explore some of the different models that I commonly rely on.
About 4% of US adults have a non-alcohol substance use disorder, and that number rises to ~17% with alcohol included. About 25% of the US population will have a substance use problem at some time in their lifetime. In short: problematic substance use is not rare. This is an issue that touches all of us.
I think of substance use disorders as an extreme form of human behavior, but behavior that all of us engage in. Not all of us drink heavily to cope, but all of us engage in behaviors to check out– scrolling our phones, eating too much, lying to ourselves. In other words, even if you are not someone who struggles with substance use directly, the patterns of behavior that drive substance abuse are universally human, and we can all relate.
Part one, today, is focused most strongly on the medical model:
Addiction is a chronic, relapsing-remitting medical condition
There are many illnesses that follow this pattern, including asthma, inflammatory bowel disease, and multiple sclerosis. Chronic, relapsing-remitting means a few things specifically: 1) they do not go away. 2) they go through periods where the disease is bad, and causes lots of symptoms, and 3) they also go through periods where the disease is in remission, and is not really bothering anyone. Many require ongoing medical therapy, and that treatment keeps the symptoms at bay.
The goal of any of these conditions is to make the flare-ups, or the relapses as short a possible (a day is better than a week, a week is better than a month, a month is better than a year), as infrequent as possible (once a week is better than daily, once a year is better than once a month– ideally never) and as little damaging as possible. Asthma kills people, but most people with asthma have no symptoms at all, or flare ups are treated with a change in medications.
Chronic conditions are almost all managed through a combination of medical therapy and behavioral change. For example, many chronic conditions require changes in diet and close attention to sleep. You would never tell somebody with diabetes to fix blood sugar without taking insulin, but we know that even with insulin, huge amounts of soda are going to lead to difficulty managing blood sugar.
All of these things are present in addiction as well. Medications are extraordinarily helpful, but are not adequate by themselves. At the same time, behavioral change alone is rarely enough to treat a substance disorder. The relapse rate to opiate use after medically supervised detox, without the use of ongoing medication, is 80-90%. It is the combination of lifestyle management and medication that leads to the best outcomes.
By definition, chronic conditions are managed over time. We all want a one-time intervention that will fix our problem but chronic conditions don’t work that way. Instead, they require sustained, long term effort to treat, and the outcome tends to be the result of thousands of small decisions over time, rather than one dramatic choice.
Tolerance, Dependence, and Addiction
These are three related concepts that are often treated as the same thing, but are distinct ideas.
Tolerance occurs when a substance becomes less effective over time, requiring a larger dose to produce the same effect. This happens with many substances and medications, from caffeine to opioids. Tolerance is simply a biological adaptation. By itself, it does not indicate addiction. Instead, it is the observation that escalating doses are required to achieve the same physiological effect.
Dependence occurs when the body adapts to the presence of a substance and expects it to be there. If the substance is stopped abruptly, withdrawal symptoms occur. Withdrawal cannot happen without dependence. Dependence can develop with many medications, including antidepressants, opioids, and even caffeine. Like tolerance, dependence is a physiological state, not a diagnosis of addiction. Moreover, dependence and withdrawal does not signal addiction.
Addiction is characterized by compulsive use despite harm, loss of control, craving, and continued use despite negative consequences. While addiction often includes tolerance and dependence. It is fundamentally a pattern of behavior rather than simply a biological adaptation. It also exists on a spectrum, rather than being present or absent. Many of us engage in compulsive behaviors despite harm that we would like to change (think: sedentary lifestyle), we might even say we’re addicted to the couch, to Netflix, or to driving.
A simple way to think about this is that tolerance and dependence are physiologic responses to repeated exposure, while addiction is a disorder characterized by compulsive use and impaired control. Tolerance and dependence are often mistaken for addiction, creating unnecessary fear and stigma.
Limbic Activation
The limbic system is the part of the brain heavily involved in emotion, motivation, reward, memory, and threat detection. It is useful to think of it as the part of the brain that is primarily concerned with survival. Its job is not to make us happy, wise, or fulfilled, but to keep us alive.
The limbic system is fast, powerful, and not always particularly sophisticated. It is constantly asking questions like: Is this safe? Is this dangerous? What should I move toward? What should I move away from?
When the limbic system becomes highly activated, our behavior changes. We become more reactive, more impulsive, and more focused on immediate relief. Long-term planning, reflection, and self-control become more difficult, and are not really the point of the limbic system. Anyone who has ever been extremely anxious, angry, exhausted, or frightened has experienced this– in those moments, our ability to think clearly diminishes.
Addiction can be understood as a chronic state of limbic activation. People often begin using substances because they provide rapid relief from anxiety, fear, loneliness, shame, emotional pain, or stress. The substance temporarily quiets the alarm system. For a brief period, things feel safe again– but that relief is temporary, limited by the half-life of the chemical.
Over time, the brain learns that the substance is the solution to the alarm. The moment distress appears, the limbic system begins demanding the familiar solution. This can happen long before conscious thought enters the picture. Someone may find themselves craving alcohol, opioids, nicotine, or cannabis without fully understanding why. In real life, this might mean driving past the liquor store, a picture of a place that is strongly associated with drug use, or seeing drugs used in a movie. Often, the craving is simply the brain's attempt to resolve a state of activation.
This framework is helpful because it shifts the question. Instead of asking, "Why is this person making bad choices?" we begin asking, "What is activating their alarm system?" or “What was the trigger to the limbic system?”
Sometimes the answer is obvious: trauma, grief, conflict, financial stress, chronic pain, or mental illness. Sometimes it is surprisingly mundane: lack of sleep, hunger, social isolation, overwork, or chronic uncertainty. Whatever the source, the more activated the limbic system becomes, the harder it is to access the parts of ourselves responsible for reflection, judgment, and restraint.
Many recovery tools can be understood through this lens. Medications, exercise, good sleep, strong social connections, meditation, and time in nature all reduce limbic activation. Therapy often helps by identifying the sources of activation and developing healthier responses to them.
From this perspective, recovery is not learning to say no to a substance, it is learning how to create a nervous system that spends less time in a state of alarm. The calmer and safer the brain feels, the less urgent the need becomes to seek relief through chemicals.
Addiction is what happens when the brain becomes convinced that a substance is necessary for safety. Recovery is the gradual process of teaching the brain that safety can be found elsewhere.
Every disease attacks a specific part of the body. A heart attack attacks the coronary arteries, multiple sclerosis attacks the myelin sheath of the nerve cells, and type 1 diabetes attacks the beta-islet cells of the pancreas. Addiction attacks the soul.
While the medical model is a useful framework for looking at the problem, it is not adequate on its own, particularly when it comes to understanding the human nature of addiction, and the lived experience. fMRI scans are powerful tools, but they do not really help us make sense of our choices. In the post next week, I’ll explore more of what allows substance abuse to take root.
Love,
Doc
This post was based on a quote from Pema Chodron, The essence of bravery is to live without self deception.
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