Neuroscience education for people living with addiction

Addiction is one of the most prevalent and deadly forms of psychopathology worldwide.1,2 Substance use contributes to the death of 1 in 5 individuals and incurs costs of more than $45 billion annually in Canada alone.3,4 This mental illness transcends socioeconomic, geographic, cultural, gender, and age boundaries, affecting people from all walks of life. In Canada, opioid-related deaths are rising at an alarming rate, with approximately 22 fatalities each day, predominantly in Alberta, British Columbia, and Ontario. Lifetime rates of alcohol use disorder among adults range from 15% to 20%, and cocaine has become the most commonly used illicit drug in the country.5 Although more than half of those struggling with cocaine addiction seek treatment, the prevalence of this addiction has not diminished over time,6 largely because of the lack of approved medications for its treatment.7 Additionally, nearly two-thirds of Canadians participate in gambling, with 1.6% of past-year gamblers at moderate to severe risk of developing a gambling disorder. Importantly, there is high comorbidity between substance use disorders and gambling disorders,8 just as there is co-occurrence of multiple types of substance use. Despite the development of a continuum of care at the community and provincial levels, the situation continues to grow more dire.

New and innovative approaches that can make immediate differences are urgently needed. One strategy to support harm reduction practices and long-term recovery might be to empower people living with addiction with knowledge about how their brain architecture develops, functions, and changes with substance use and recovery. While evidence for this approach is preliminary at this point, this editorial argues that further evidence should be generated to identify whether this strategy should be pursued as an additional treatment option.

Addiction as a brain disorder

Addiction can be defined as a behavioural syndrome, characterized by compulsive drug seeking, drug use despite harmful consequences, and repeated relapses, even after long periods of abstinence. In the mid-1990s, the former director of the National Institute on Drug Abuse (NIDA), Dr. Alan Leshner, conceptualized addiction as a brain disease, such that long-lasting brain changes are responsible for the distortions of cognitive and emotional functioning that occurs in people with addiction. 9 This viewpoint not only catalyzed funding to guide research efforts toward a better understanding of the neurobiology of addiction, but also identified addiction as a neurobiological, organic illness requiring prevention and treatment rather than a moral failing or a social problem requiring interdiction and law enforcement. A well-cited study conceptualized addiction as a chronic brain disease, with very similar rates of adherence to treatment as 3 other chronic illnesses: type 1 diabetes mellitus, hypertension, and asthma. Specifically, outcome studies indicate that 30%–50% of adults with type 1 diabetes and 50%–70% of patients with hypertension or asthma will experience a recurrence of symptoms each year to the point where they require additional medical attention to re-establish symptom remission.10 Similarly, 1-year postdischarge follow-up studies from participation in Alcoholics Anonymous treatment programs indicate that 40%–60% of abstinent discharged patients relapsed to alcohol use.10,11 Thus, over the last 30 years, neurobiological research has identified addiction as defined by the American Society for Addiction Medicine: “a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences.”12

Notably, the conceptualization of addiction as a brain disorder has also received criticism from the scientific community. Some have suggested that the conceptualization of addiction as a brain disease is not based on evidence from imaging studies in the way that Huntington disease or Parkinson disease, for example, can be easily identified with structural and functional neuroimaging.13 However, neuroimaging studies have shown that neurobiological function in people with addiction differs markedly from that in healthy individuals, and these effect sizes are comparable to those with conditions like Huntington disease or Parkinson disease.14 Furthermore, these criteria would exclude other psychiatric conditions like schizophrenia or major depressive disorder that do not currently have observable structural brain biomarkers for disease severity or progression. Currently, the main objective of imaging in addiction research is not for diagnosis, but to improve our understanding of mechanisms that underlie it with the view to bringing forward new treatments, identifying treatment-responsive biomarkers, or both.15

The conceptualization of addiction as a brain disorder has also been criticized for promoting social injustice by eliminating the role of psychosocial factors.13 However, it is important to consider that stress, trauma, poverty, discrimination, and socioeconomic status influence the development of brain architecture, which sets the stage for how individuals cope with subsequent life stressors.16,17 Indeed, MRI scans of 7350 White and 1786 Black children aged 9 and 10 years found that stressors such as economic hardship and systemic racism contributed to Black children having decreased grey matter volume in the amygdala, hippocampus, and prefrontal cortex.18 The influence of discrimination and poverty on the development of addiction is not inconsistent with the idea that addiction manifests in the brain, as these are factors that strongly influence brain development and how the brain responds to future stressors16 and that, in turn, can influence an individual’s coping strategies. Thus, the contemporary view of addiction as a brain disorder does not deny the influence of social, environmental, developmental, or socioeconomic factors, but proposes that the brain is modified by those factors, which then influences future responses.

Another criticism of the brain disorder model is that by providing neurobiological explanations of mental health problems, one might increase stigma rather than reduce it.19 For example, while neurobiological or genetic explanations in mental health reduce blame and moralistic perceptions, they increase the perception of dangerousness, the perception that individuals are less likely to recover, and the desire for greater social distance.19 While this implication is troubling, it assumes that the brain and behaviour are immutable. Thus, psychiatric neuroscience should be communicated in the context of neuroplasticity (i.e., the brain changes), as brain disease is not static in essence.

Why provide education on the neuroscience of addiction?

Although there is general consensus that altered brain structure and function underpin addictive disorders, treatment providers working in addictions rarely incorporate neuroscience-informed approaches into their treatment programming or clinical practices. Furthermore, as our understanding of the neuroscience of addiction increases and provides more implications for practice, 20–22 few treatment providers and clinicians are incorporating neuroscience-informed interventions into routine practice.23 For example, cognitive deficits associated with substance use disorder can last 3–6 months beyond discontinuation of drug use.24,25 This can have a potential negative impact on treatment adherence and retention, in addition to craving, relapse, and quality of life after treatment. Furthermore, it has been reported that performance on cognitive assessments (e.g., MicroCog test battery) was a consistent predictor of treatment retention, and performance on decision-making tasks (e.g., Iowa and Cambridge gambling tasks) was a consistent predictor of relapse.22 However, cognitive assessments and cognitive training (as done for concussions, dementias, and schizophrenia) are rarely used in clinical practice for the treatment of substance use disorder.

Achieving treatment success might occur with better education on the neurobiology of addiction for people living with addiction, their caregivers, and the communities in which they live. With enhanced understanding of how addictions are a consequence of basic neurobiological principles, we may in turn enhance empathy for those with this brain disorder. This knowledge might also empower individuals in their recovery and help them identify personalized treatment strategies based on their experiences rather than generic treatment strategies. Furthermore, increased knowledge of how their brains function may lead to better adherence and willingness to participate in brain and cognition recovery programs. For example, a pilot study delivered a neuroscience-informed psychoeducational program for people with addiction to promote awareness of their brain function (metacognition) in the main cognitive domains affected by drug and alcohol use.26 This approach led to increased awareness and engagement in the brain and cognition recovery process. 26 To date, no other trial has directly assessed whether neuroscience education has measurably improved clinical outcomes among people living with addiction.

Other education-related interventions that have demonstrated some effectiveness in reducing substance use include mindfulness-based and cognitive behavioural relapse-prevention approaches.27,28 For example, a study of 286 individuals who recently completed substance use treatment programming were randomized to 8 weekly group sessions of mindfulness, cognitive behavioural relapse prevention, or treatment as usual.27 Targeted mindfulness practices supported long-term outcomes by reducing heavy drinking days and drug use, and delayed time to relapse.27 Similarly, a mindfulness-based relapse-prevention intervention reduced craving over a 12-month period among individuals with posttraumatic stress disorder.28 In another study, acceptance and commitment therapy for chronic pain and mindfulness-based relapse prevention for opioid misuse were used as a combined intervention in half of the participants recruited through a United States Department of Veterans Affairs co-occurring disorders clinic, while the other half were randomized to treatment as usual.29 This intervention taught individuals to pay attention to how they respond to pain and drug cravings and to make room for negative feelings and sensations without engaging in harmful strategies to control them. Assignment to the integrated intervention group was associated with less opioid misuse and lower pain interference scores than treatment as usual at 6-month follow-up.29 Connecting individuals undergoing outpatient addiction treatment to primary care practitioners improved health care engagement beyond that typically reported at 6 months after treatment. This had lasting improvement (up to 5 yr) in health care use patterns.30 In another community health intervention, community-based education focused on increased overdose education and naloxone distribution, safer opioid prescribing practices, and communication campaigns to mitigate stigma and drive demand for evidence-based interventions, but resulted in no change in overdose deaths from any drug.31 However, when analyzed for opioid overdoses, a study demonstrated that the community health intervention was associated with a reduction in deaths,31 while another study, conducted in the context of the COVID-19 pandemic and fentanyl-related overdose epidemic, showed no reduction in deaths from opioid overdose.32 Notably, the community health interventions did not include mindfulness, care-seeking, or neuroscience education. Thus, the type of intervention appears to be critical. Education-based interventions have been used in other fields, such as diabetes management and HIV/AIDS treatment education, with educational guidelines and patient-focused information having demonstrated success in improving outcomes. Importantly, NIDA’s research fellowship program INVEST supports addiction research on evidence-based substance use interventions and the education of clinicians in the implementation of these interventions.33 Additionally, Integrative Management of Chronic Pain and Opioid Use Disorder for Whole Recovery (IMPOWR) is a research program launched by the National Institutes of Health HEAL (Helping to End Addiction Long-term) Initiative that supports patient-centred research. Thus, there are emerging initiatives to improve neuroscience-based education approaches in the treatment of addiction.

My viewpoint that a better understanding of one’s brain can contribute to empowerment and better addiction outcomes comes from a recent personal experience teaching neuroscience to people living with addiction. Over the last 2 years, I have volunteered my time at a residential recovery facility as well as an outpatient facility in Calgary, Canada, to teach neuroscience to their clients once a week. For these classes, I provide an overview of concepts that are important for the basic understanding of addiction neuroscience, the first of which being that addiction is a process involving distinct phases, many of which are cyclic in nature, and that the brain changes that occur with some of these processes are readily reversible, whereas other changes are long lasting. I have moved away from teaching from the perspective of a deficit model of disability. Many of the clients have heard repeated messages throughout their lives of the negative impact of drugs on their brains, yet they continue to use. Instead of teaching the deleterious effects of substances on their brains, I teach from the perspective of how the brain changes. How does the brain develop in utero, during childhood, and during adolescence? How do early-life stress exposures influence brain development? How is the brain affected by “good stress” (adaptive) and by “toxic stress” (the effects of allostatic load on the body and brain)? Why are some people susceptible to addiction and others are resilient? How long do changes in the brain from substances last? For example, brain adaptations to tolerance and withdrawal are readily reversible, while habits last much longer or even a lifetime, like riding a bike. Nevertheless, addiction seems very hard to reverse, at least for some people, perhaps due to genetic or environmental factors. How does recovery affect the brain? What are the medicines available to treat various use disorders, and how do they work? Many individuals have co-occurring mental illnesses; therefore, I have found it important to teach about affective and psychotic disorders, and how medications for these are meant to work.

There is an enormous research literature to draw from on the negative effects of substances on the brain, but less on how the brain changes during recovery. As a neuroscientist who focuses on preclinical models of addiction, this teaching experience has changed my perspective on how I run my research program. I now notice there are gaps in the research literature on how long addiction-related brain changes last, how the brain changes with recovery, how the effects of medication-assisted treatment influence the affected neural circuits, and how one can mitigate the effects of early-life adverse events. Answers to these questions are what people living with addiction want to know and are emerging areas of research for my lab. Thus, teaching these classes has also afforded me the opportunity to regularly engage with people with lived experience to help me ask better questions in my research program as well as to provide an opportunity for knowledge mobilization.

The University of Calgary defines transdisciplinary scholarship as research that “is directed towards a complex issue or problem, most often one with a social dimension. Because of the complexity of the issue or problem, it is best addressed by teams of researchers from multiple disciplines. To address the social dimension of the question, transdisciplinary scholarship incorporates knowledges from outside the university, through theoretical or creative approaches to societal issues, and ideally by including societal actors who are implicated in the issue or problem in question.”34 Therefore, this may be a way that preclinical and fundamental neuroscientists can engage in transdisciplinary scholarship through community outreach activities that support people with lived experience.

Conclusion

Ultimately, education is fundamental in dismantling the stigma around addictions. Understanding addiction as a chronic medical condition rather than a moral failing can lead to more people accepting treatment and can ultimately save lives. Importantly, this must be done from the perspective that the brain changes with our experiences, including those that start from gestation through to those that we experience as older adults. Individuals who acquire this awareness about their brains may perceive behavioural interventions as more meaningful and necessary for addiction recovery. Thus, they may become more motivated to participate in the programming and less likely to drop out, which is a challenging part of addiction treatment programs. However, this remains to be tested. Teaching the neurobiology of addiction to people living with addiction provides the opportunity for the instructor to engage in transdisciplinary research, which may highlight new perspectives on understudied areas of research and novel therapeutic strategies.