How Well Do We Understand Addiction?

Overdose deaths involving opioids have spiked dramatically in recent years. What goes on in the human brain helps explain why.

In a session with National Press Foundation fellows, Dr. Petros Levounis outlined the drivers of the current opioid epidemic, detailed how the brain is affected by addiction and summarized the best evidence on various treatment strategies.

“The opioids crisis is the perfect storm of three major sources,” said Levounis, chair of the Department of Psychiatry at the Rutgers New Jersey Medical School. These sources are:

  • A medical mistake in the form of a 1980 letter that erroneously suggested that patients treated with narcotics would not be at risk of becoming addicted.
  • A pharmaceutical industry that capitalized on this medical mistake and overprescribed narcotics.
  • A series of neurobiological responses that result in addiction.

How can journalists help their audience understand the neurobiology?

Levounis recommended describing addiction as a war between two parts of the brain: the frontal lobe, which is responsible for executive function, and the pleasure-reward pathway, which is the more primitive section of the brain. Addiction effectively shuts down of the frontal lobe and hijacks the pleasure reward pathway. The frontal lobe acts as the “voice of reason,” Levounis said; once it is out of the picture, there is no mechanism to prevent substance abuse.

Levounis noted that the anatomy of the brain contributes to making recovery especially hard because the pleasure-reward pathway is sandwiched between the parts of the brain that control memory and emotion. Once a person’s pleasure-reward pathway has been hijacked, it is very difficult to stop using drugs and very easy to relapse. Levounis compared the process to learning to ride a bike.

What should journalists know about how neurobiology affects treatment? Levounis said a physician’s job when treating addiction is two-fold. First, he or she must “cool down the engine.” This means using medication to mitigate the damage that was done to the hijacked pleasure-reward pathways. The second step is to “beef up” the frontal lobes through psychotherapy and counseling.

Past treatment strategies included psychoanalysis – “a disaster,” according to Levounis – and aggressive “boot camp” approaches to handling addiction; they also proved ineffective. Currently, physicians employ a three-pronged treatment approach of mutual help, including 12-step programs, motivational interviewing and medication.

There are also a number of forward-thinking strategies that journalists should be on the lookout for. Levounis pointed to mindfulness – a heightened awareness of thoughts, feelings and existence – as one emerging trend. He also mentioned psychodynamics as a form of treatment that may be used more often, highlighting data from a study that showed those who self-identify as “mostly-straight” were more likely to report substance use disorders than respondents who characterized themselves as completely heterosexual or homosexual. According to Levounis, this suggests that taking a Freudian approach and unpacking sexuality could be most useful for patients grappling with their sexuality.


This program is funded by the American Society of Addiction Medicine, California Health Care Foundation, American Medical Association, National Institute on Alcohol Abuse and Alcoholism, National Institute on Drug Abuse and Caron Treatment Centers. NPF is solely responsible for the content.

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