Your brain on alcohol
A new understanding of how alcohol alters brain chemistry
may transform treatment of the disease
By Susan Brink
U.S. News & World Report, May 7, 2001
Ask any alcoholic trying to take it just one day at a time, and he'll
tell you that compulsive drinking is a disease–period. That's what
the Big Book said, after all, the groundbreaking tome by Alcoholics
Anonymous that came out way back in 1939. And that's what just about
everyone has believed ever since.
But hold on. Technology, not for the first time, is forcing doctors and
therapists to see things in a new light. With the aid of sophisticated
new imaging techniques, scientists can look inside the brains of
alcoholics at the very moment they're being tempted by thoughts of
cold beers, crisp martinis, or fully ripened cabernet francs. The
new science shows just how alcohol can rewire the circuitry of the
brain, eroding its ability to feel pleasure and act wisely, and replacing
it with a locus for intense craving and destructive behavior.
"Alcoholism is a disease that interferes with home life, work, interpersonal
relationships, and eventually with health," says James West, medical
director emeritus of the Betty Ford Center in Rancho Mirage, Calif. "It's
biological, but it's also psychosocial."
The picture is a scary. But the good news is that it's changing the way
doctors and specialists are thinking about the treatment of alcoholism.
Until recently, largely believing they had nothing to offer, physicians
have left such treatment to counselors, recovering drinkers, and
clergy. The result has been a hodgepodge of therapies, some with
good results, others merely good intentions.
Now doctors are weighing in–big time. The most promising area of research
is the new drugs that target specific areas of the brain to help
ease the craving for liquor. One such drug–the first of its kind–has
shown promise in quelling the terrible yen for a drink. Naltrexone
has been approved by the Food and Drug Administration and is available
by prescription. Two more drugs that also may ease craving are being
tested in clinical trials.
But even proponents of pharmaceutical treatment say drugs aren't the
whole answer. Most alcoholics will still need counseling or 12-step
programs to help confront the harm they may have caused or the growing
up they need to do. Yet just as Prozac got general practitioners
interested in depression, anticraving drugs might get more physicians
involved in alcoholism treatment. Says Keith Humphreys, a psychologist
and addiction researcher at Stanford University: "Doctors want
to be able to do something medically."
Brain pain.
The new brain-imaging technology will be the key to determining how much,
and how effectively, doctors can help. Some 14 million people in
the United States are alcoholics or abuse alcohol. They are skid-row
bums and lace-curtain drunks, senseless rebels and charming rogues.
They chill Louis Roederer Cristal champagne in silver buckets and
swill Budweiser from plastic cups. They tell themselves they are
not alcoholics because they never drink before 5 p.m., or because
they make it to work every day, or because dinner is always on the
table on time.
But their excuses can't overcome the damage they do. Inga fell down a
flight of stairs with her infant in her arms. Mark had five wives,
and five divorces. Betty polished off a pint of vodka, then carpooled
fourth graders from soccer practice. Jeffrey committed strong-armed
robbery. April, once shy, took off her clothes and danced for money.
Martha threatened her husband with a carving knife. Paula slipped
into the kitchen during dinner parties to swill down the last drops
of wine left in dirty goblets. All are recovering alcoholics and
they are ashamed of these recollections.
For active alcoholics, drinking trumps reason. It distorts judgment.
It severs the connection between behavior and consequence. It lays
waste to marriages, friendships, and careers. It leaves children
stranded. For alcoholics, love and logic can't hold a candle to liquor.
And the damage is not limited to others. Over time, addiction becomes
an enervating trial for the drinker. "I would always drink out
of glasses that were opaque so my husband couldn't tell what I was
drinking," says Jackie Clarke, sober for 16 years. "I would
put vodka in my wine because wine seemed more acceptable. I was always
thinking about what I was going to drink, when I was going to drink,
hiding bottles so my husband wouldn't know how much I drank. It was
exhausting."
Just where alcohol abuse crosses the line into addiction remains blurry.
John Schwarzlose, president of the Betty Ford Center, has his own
simple criterion: An alcohol abuser might get stopped once while
driving under the influence, and the experience will be mortifying–and
sobering. For an alcoholic, how- ever, the embar- rassment is not
enough. "Two or more DUIs–that is an alcoholic," says Schwarzlose.
But it is often a mean- ingless distinction to family members, loved
ones, and employers. They know that excessive drinking can ruin lives
through betrayal, broken promises, lost jobs, car accidents, and
a host of other personal tragedies.
Pure pleasure.
Alcoholism is a disease that can start with a first drink. With that
drink, one fork in the road appears, leading some to a future of
alcoholism and others to a lifetime of enjoyable, moderate drinking.
The brains of people genetically predisposed to alcoholism may be
unable to naturally produce adequate dopamine–one of the brain chemicals
that make us feel pleasure. For them, the first drink is a hit of
dopamine, and of pleasure, they haven't felt as strongly before.
And then, it's love at first tipple. "The first time I got drunk,
I was 11 years old," says Clarke, of Falls Church, Va. "I
was babysitting with a girlfriend. We broke into her father's liquor
cabinet, and then we had a food fight. I never had so much fun in
my life."
Only 1 in 9 people who drink continues the path to alcoholism. Those
who do succumb are disproportionately related to alcoholics; an estimated
50 percent to 60 percent of those who become alcoholics have a genetic
predisposition. "My father was an alcoholic," says Mark
Abel, 50, in treatment for alcoholism at Operation Par Village in
Largo, Fla. "He worked hard and he drank hard." But environment
plays a significant role, too. "When I was a kid, I used to
get my dad beers," recalls Abel. "I'd get the first couple
of sips on the way back from the refrigerator. I loved the taste."
That's because alcohol heads to the mind's seat of emotion and pleasure,
called the nucleus accumbens, which also houses gratification of
hunger, thirst, and sex. There, like other addictive drugs, it increases
the concentration of dopamine, a pleasure-causing chemical, in the
brain's reward circuits. But recent research shows that alcohol also
opens the floodgates on other feel-good chemicals, including serotonin.
It disturbs levels of glutamate, which can make people feel high,
and then it interferes with other chemicals that can make people
feel tired. Enoch Gordis, director of the National Institute on Alcohol
Abuse and Alcoholism, calls alcohol "the most widespread and
damaging substance we have in society."
Once excessive drinking begins, the new research shows, alcohol begins
resculpting the brain regardless of family history. "In even
nonsusceptible individuals, chronic use may create addiction," says
psychiatrist Raymond Anton, scientific director of the Charleston
Alcohol Research Center at the Medical University of South Carolina.
People who binge several times a week–five or more drinks in a day
for a man, four or more for a woman, according to the National Institute
on Alcohol Abuse and Alcoholism–are clearly at risk, and they can
also suffer other consequences like impaired concentration, slowed
reflexes, disrupted sleep, and high blood pressure. There's no evidence,
however, that moderate drinking–two drinks a day for men, one drink
for women–alters brain chemistry.
Want becomes need.
People often start down the road to alcoholism in their teens or 20s.
But stress later in life–a divorce in their 30s, a job loss in the
40s, the death of a loved one anytime–can also push a life off course.
At this point, the amygdala, the part of the brain that helps the
body respond to stress, may be calmed by alcohol. But though these
drinkers may start later in life, heavy drinking likely causes similar
brain alterations. Barbara Halsey, 47, didn't begin to drink heavily
until she divorced in her early 30s. At first, it was for the relief
and fun of partying. Pretty soon, she was drinking almost every night. "I'd
stay out late. I found myself losing jobs," she says. However
it starts, heavy drinking eventually robs alcohol of its value as
a brain treat. Want becomes need. The drinker needs ever more alcohol
to provide the same high until, eventually, the high is gone. "There
was a time in my life when chemicals did something for me. And then
one magical day, they stopped," says Jay Ehrlich, who has been
sober for 16 years. "And I spent an inordinate amount of time
trying to cross back over and get it back."
At this point, recent brain-imaging studies show, the primitive nucleus
accumbens, with its hunger for pleasure, may ultimately not be the
main player. New pathways have been formed, adapted to function in
alcohol's service. Now, researchers believe, the frontal cortex,
the brain's executive branch responsible for decisions and memory,
holds a mere memory of pleasure, as insistent as the original pleasure,
and demands another drink. Alcohol may also put its stamp on areas
of the frontal cortex involved in judgment and impulse control.
From the frontal cortex, it's a short hop to the basal ganglia, the brain
center that when wired differently makes obsessive-compulsive people
continually wash their hands or avoid stepping on cracks. The latest
results from laboratory-animal studies suggest that alcoholism may
use the same neural pathways that lead to compulsive behaviors. The
brain then demands more and more alcohol, regardless of reason and
consequences. "In the end, I'd drink by myself. I'd hide beer
in the closets, under the porch of the house. It wasn't fun anymore.
It went from a luxury to a must," says Michael Small, 40, of
Zephyrhills, Fla., who drank for more than 20 years before entering
treatment.
Some people summon the will to stop from within. "What shocks people
is that the vast majority of people who recover from alcoholism never
sought any treatment at all," says Stanford's Humphreys. But a lot
of people can't quit on their own. The ability to stop is as individual
as each person's internal motivation. Ehrlich, for instance, had spent
much of his adulthood drinking and using drugs while he lived the high
life of a rock-and-roll promoter. He tried quitting on his own, tossing
pills and bottles into a casket at an elaborate
"wake" for his addictions. Finally, he went to the Betty Ford
Center for treatment.
Banishing the pink elephant.
About half a million people each year make a similar decision, seeking
a treatment slot at Betty Ford, the Hazelden Foundation, Par Village,
Delancey Street in San Francisco, and a host of other inpatient and
outpatient treatment centers. Up to a million more get in touch with
Alcoholics Anonymous. For the most impaired, the first step is to
get weaned from alcohol. This is the time when patients can become
leg-jiggling, arm-scratching, face-touching, whirling dervishes of
inattention, seeing the
"pink elephants" of lore. They can have tremors, hallucinations–even
seizures. The brain has grown accustomed to an artificial balance between
chemicals that cause excitation and those that cause inhibition. Sudden
withdrawal of alcohol alters the balance in favor of excitation. Valium
can help, but it, too, is addictive. Some nonaddictive anticonvulsants,
like carbamazepine, divalproex, and gabapentin, can also ease the passage.
Withdrawal is the relatively easy part, generally lasting three days
or less. Dealing with the ongoing verbal dual between the devil on
one shoulder and the angel on the other is the hard part. The brain
has been reprogrammed to compulsively want a drink, and hundreds
of individual thoughts or actions can trigger the craving–a walk
past the neighborhood tavern or even seeing a beer commercial.
Subconscious desires.
Craving can haunt recovering alcoholics even in sleep. "I had a
dream last night that my friend met me at the airport with a huge glass
of champagne," says Monica, 40-ish, tall, slim, and regal, who is
checking out after 28 days at the Betty Ford Center. Such dreams are
an indication that craving never rests. "Dreams are drives that
call out for satisfaction," says Brian Johnson, a Boston psychoanalyst
who specializes in addiction treatment.
Mark George, along with Anton, at the Medical University of South Carolina
has done some of the first brain imaging showing the power that the
mere thought of a drink can have on a recovering alcoholic's brain.
He put alcoholics and nonalcoholics inside an MRI, then showed them
photographs of martinis, beer bottles, or glasses of wine. They were
also shown pictures of soft drinks and coffee, and a third set of
neutral images. In alcoholics, the frontal cortex lights up with
desire at the alcohol images.
Drugs can help dampen that desire, although no one knows exactly how.
An early drug called Antabuse, now little used, made patients sick
when they took a drink but didn't kill the craving. Naltrexone appears
to. Originally used to counteract opiates like heroin, it might work
by blocking a pleasurable surge of natural opiates released in the
brain by an image or thought of alcohol. The drug may have worked
for Scott Campagna, 23, of Atlanta, who participated in an ongoing
trial. Campagna says he binges about twice a week–seven or eight
beers and two or three hard drinks. "I feel I could quit or
cut back if I wanted to,"
he says. He believes he got the drug, not a placebo, because he thought
less about drinking the week he took it.
Another substance, acamprosate, has shown promising results in Europe.
And ondansetron was found to reduce drinking and increase days of
abstinence in clinical trials. Yet for now, alcoholism treatment
centers are reluctant to prescribe drugs. At the Betty Ford Center,
for example, counselors might sometimes suggest naltrexone to fight
cravings if follow-up contact shows that a patient has repeatedly
relapsed. But the drug is not used during the stay there. Helping
heavy drinkers cut back may not be enough to treat actual alcoholics,
say counselors. Most experts think moderate drinking is not an option
for a true alcoholic.
Talk therapies.
Experts are betting that new generations of drugs will work best when
combined with counseling and group therapy. These talking therapies,
researchers believe, help the brain learn to compensate for the damage
done, just as rehabilitation helps a stroke victim's brain relearn
speech or movement. Many alcoholics must relearn how to accept responsibility
for themselves and how to behave toward others. Almost all group
programs incorporate the 12 steps of AA, which help people just starting
their recovery get support from veterans of the struggle.
A large-scale study in 1997 that tested three kinds of treatments–cognitive
therapy, motivational therapy, and group AA meetings–found that roughly
half the patients in each group reduced their drinking or avoided
heavy drinking. (Some centers, such as Betty Ford, have success rates
of more than 60 percent.) Other chronic diseases, such as diabetes
and asthma, have similar relapse rates after medical treatment, according
to a study published last fall in the Journal of the American Medical
Association. A setback isn't cause to give up. "There is no,
I repeat no, treatment [for alcoholism] that is finished at the end
of a residential stay," says A. Thomas McLellan, author of the
JAMA study. "There aren't cures here."
Treatment experts say patients and families should be skeptical of programs
that promise much higher success rates–say 80 percent or more. Experts
also caution against programs that forbid drugs of any sort, even
such nonaddictive medications as some antidepressants, which can
help some alcoholics.
No matter how much scientists learn about the brain changes behind alcoholism,
much of the work of recovery still will fall to patients. And so
will the rewards. "When I was drinking, my life was a roller
coaster, and when I was first sober, I thought sobriety would be
a dull, flat line," says Clarke. Yet since she stopped drinking,
she has lived in Hawaii for a year, traveled to sunny climes with
friends, and painted desert scenes in California and cherry blossoms
in Virginia. "Now, instead of just daydreaming, drunk on the
couch, about wonderful things I would do, I do wonderful things."
U.S. News spoke to dozens of alcoholics. Some agreed to be fully identified,
others by their first names only. For those who requested confidentiality,
fictional names are used.
Treatment.
For a list of programs as well as a discussion of approaches, visit The American Society
of Addiction Medicine
Find a comprehensive listing of support
groups for alcoholics and their families.
Track down a nearby Alcoholics
Anonymous meeting.
Questions. For answers to questions such
as how to tell if you are an alcoholic