There is a huge societal stigma associated with addiction. Many people view addiction as a sign of weakness or lack of willpower. But we now have a whole new understanding of addiction and its management. The following points will be covered briefly in this blog:
- What is addiction?
- What forms of addiction occur?
- How common is addiction?
- What are the predisposing factors to addiction?
- What is the pathophysiology of addiction?
- What are some pathways to addiction control?
- How can Lifestyle Medicine impact addictions?
What is addiction?
“Addiction is a chronic or lifelong condition that involves compulsive seeking and taking of a substance or performing an activity despite negative or harmful consequences.” It is considered a brain disorder because it involves functional changes to brain circuits involved in reward, stress, and self-control. 1
What forms of addiction occur?
Two types of addiction are recognised – substance addiction (substance use disorders – SUD), and behavioural addictions. SUDs include alcohol, caffeine, nicotine, marijuana, hallucinogens, hypnotics, sedatives, anxiolytics, inhalants, opioids, and stimulants.
Behavioural addictions can include work, gambling, eating, exercising, dieting, shopping, sex, pornography, video gaming, and screen-viewing, to name some of the more common behaviours involved.
How common is addiction in South Africa?
The most common addiction is smoking. According to the 2021 Global Adult Tobacco Survey SA, 29,4% of South African adults currently use tobacco, with almost 3 times more men than women smoking. 2 Up to 32,5% of South African adults are problem drinkers or at risk of developing an alcohol problem. 3 The average global prevalence of food addiction is 20%. 4 Fifteen per cent of South Africans suffer from drug addiction in one form or another. Between 6-8% of men in South Africa will become addicted to pornography at some point, most commonly between the ages of 15-30 years.5
What are some predisposing factors to addiction?
- Genetic factors are responsible for 40-60%. If you have a sibling or parent with a SUD, the risk of addiction is greater.
- Mental health conditions, such as depression, post-traumatic stress disorder (PTSD) and bipolar disorder, increase the risk by 50%.
- Environmental factors, such as access to substances, peer usage, and prescription of addictive substances.
- Adverse childhood experiences may play a role.
What is the pathophysiology of addiction?
Addictive behaviour results from disruptions in the normal controls within the brain. The basal ganglia contribute to positive motivation, including feelings of pleasure from healthy activities. They are also involved in forming habits and routines. This represents what is called the “reward circuit”. However, overuse of this circuit by addictive behaviours or substances produces early euphoria. But with repeated exposures, its sensitivity is diminished, needing ever more “hits” to satisfy. The extended amygdala is responsible for unpleasant withdrawal feelings, motivating more addictive behaviours or substances. “The prefrontal cortex powers the ability to think, plan, solve problems, make decisions, and exert self-control over impulses.” 6 It was once thought that dopamine surges directly produced euphoria, but it is now believed that it has more to do with getting us to repeat pleasurable activities. Dopamine enhances neural connectivity, enabling easier repetition of the activity.
Nevertheless, PET scans show dopamine receptors lighting up when exposed to addictive behaviours and substances. With repeated exposure, these receptors become less responsive. This explains why increasing doses of stimulants are needed. It can take many months for those receptors to return to their normal status after rehabilitation.
Cues in our environment become linked to activities or substances. Exposure to those cues triggers uncontrollable cravings. Smokers struggling with quitting often identify cues, such as drinking coffee or alcohol, talking on the phone, sitting in a favourite chair, or driving in traffic. During rehabilitation, it is important to identify the cues and consciously avoid or manage them until the habit is broken. With addiction to ultra-processed foods, shopping when one is hungry, standing in a queue among all those snacks, or a stressful event, are all cues to satisfy the craving. 6,7
What are some pathways to addiction recovery?
The most widely recognised is the 12-step programme of Alcoholics Anonymous, developed in 1935 by two recovering alcoholics, Bill Wilson and Dr Bob Smith.8 Over the last 90 years, millions of people globally have been helped to recovery through this programme. Its success is based on peer support, acknowledging one’s inability to overcome through willpower alone, regular mentoring, acceptance, honesty, openness, and living with purpose. The greatest sense of purpose comes from helping others break their addiction.
Other established methods of treatment include medical therapy, cognitive-behavioural therapy, contingency management (using rewards as positive reinforcement), motivational enhancement therapy, and family therapy (to enhance social support). These are best provided by practitioners qualified in addiction rehabilitation.
How can Lifestyle Medicine prevent or manage addictive behaviour?
Each of the 6 pillars of Lifestyle Medicine has a role to play in the prevention and management of addictive behaviours. Lifestyle Medicine views people as a whole. It brings harmony into our lives in the physical, mental, social, and spiritual spheres. It also recognises the social determinants of health, which are so important in understanding patients and their health challenges. It treats people with respect and dignity.
Pillar 1: Minimising harmful substances and behaviours is the obvious intervention. Genetics predisposes some people to alcoholism. Abstinence prevents that consequence. Replacing addictive behaviours with healthful activities or substances is vital. Some people merely replace one addiction with another. Seek to understand the underlying factors leading to addictive behaviour in a particular individual, and address those specifically.
Pillar 2: Ensure restful and restorative sleep. Fatigue reduces the functioning of the prefrontal cortex, which is involved in choice and rational thinking. Lack of sleep also increases the craving for ultra-processed foods.
Pillar 3: Eat a predominantly whole food plant-forward diet, rich in fibre, phytonutrients, antioxidants, vitamins and minerals. Ultra-processed foods are high in sugar, salt, and saturated fats, which in their own right are addictive. Many addictive drugs and behaviours reduce the desire for healthy foods, resulting in malnutrition and ill-health.
Pillar 4: Manage stress in positive ways. Many people turn to substance abuse to escape challenging life situations – failing relationships, joblessness, financial stress, health issues, etc. Professional help may be needed through Psychologists or Social Workers. Mindfulness and Positive Psychology can provide tools to manage stress. Finding purpose in our lives through spiritual activities and connecting with a higher power has been the key to many people finding freedom from addiction.
Pillar 5: Physical activity boosts endorphins, reduces anxiety and depression, and improves health and well-being. It also helps us sleep better, think better, and function better – all necessary in managing addiction disorder.
Pillar 6: Social connection is vital to a sense of purpose, acceptance, forgiveness, affirmation, and intimacy. Families were designed to be supportive. Reaching out to a supportive community is key to most successful rehabilitation programmes.
Lifestyle Medicine practitioners are best suited to lead the intervention in collaboration with other health care practitioners.
Dr Dave Glass
MBChB, FCOG(SA), DipIBLM,
Chairperson of SALMA,
VP for AfLMC, and WLMO ExCom member
References:
- Goldstein RZ, Volkow ND. Dysfunction of the prefrontal cortex in addiction: neuroimaging findings and clinical implications. Nat Rev Neurosci. 2011;12(11):652-669. doi:10.1038/nrn3119
- https://health.gov.za/wp-content/uploads/2022/05/Global-Adult-Tobacco-Survey-GATS-SA_FS-Populated__28-April-2022.pdf
- https://www.issup.net/knowledge-share/resources/2021-02/demand-alcohol-south-africa-during-national-lockdown
- https://olympicbehavioralhealth.com/rehab-blog/food-addiction/
- https://rehabhelper.co.za/pornography-addiction-rehab/#:~:text=Pornography%20addiction%20is%20a%20growing%20concern%20in,relationships%2C%20or%20hobbies%20due%20to%20pornography%20use
- https://nida.nih.gov/publications/drugs-brains-behavior-science-addiction/references
- https://my.clevelandclinic.org/health/diseases/6407-addiction
- Chawla, Nishtha; Sarkar, Siddharth; Sagar, Rajesh. The Meeting of Bill and Bob: Helping the Cause of Countless Alcoholics. Journal of Mental Health and Human Behaviour 22(1):p 72-73, Jan–Jun 2017. | DOI: 10.4103/jmhhb.jmhhb_12_17