Something remarkable happens when we experience a craving for a drink and then take one. We lift the glass to our lips and swallow and then get an immediate sense of ease and comfort; the extraordinary thing about this is that the sensation is immediate. It takes several minutes for any alcohol swallowed to be absorbed in the stomach and then carried through the blood to our brain, yet we get the “aaahhh!” sensation immediately… so it can’t possibly be alcohol that has causes this, yet the sensation is definitely there. We aren’t particularly aware of this but our brain actively encourages us to drink by releasing a motivating chemical called “dopamine”. Dopamine gives us that wordless and nagging sense of wanting or longing for a drink and when we do drink then our brain abruptly stops releasing it; the urging has done its job and is no longer needed. The tension of the nagging insistence suddenly stops and this is what gives us that strong wave of relief we get when we take our first drink.
Our brain is enormously sophisticated but at a cellular level its operation is remarkably simple. Nerve cells, or “neurons” are connected to each other and pass signals from one cell to the next. Each cell is shaped like a tree, with roots at one end, a trunk, and branches at the other. Brains cells connect to each other root-tip to branch tip where there is a tiny gap called a synapse. A signal is passed from one cell to the next when a chemical called a neurotransmitter is ejected from the branch-tip side of one neuron and received on the root-tip side of another. When the neurotransmitter is received then an electrical charge pulses through the trunk to the branch tips of the cell where it causes neurotransmitters to be expelled from the tips to the next cells. The huge complexity of the brain comes from three elements; the brain has roughly a hundred billion brain cells, each neuron is connected on average to seven thousand others, and there are over two hundred different chemicals that work as neurotransmitters. Precisely what signal is propagated through the brain depends not only on the cells that it connects to but also the particular neurotransmitter that is passed. So the number of possible pathways through any given part of the brain is of truly astronomical proportions, and pathways behave differently depending on the neurotransmitter passed.
Proper functioning of the brain requires that neurotransmitters are reliably passed from one neuron to the next and alcohol interferes with this. Once the correct passage of a neurotransmitter is disturbed then this has consequences for all subsequent neurons in the path, so any disruption at all has far-reaching consequences.
The reward system performs several specific tasks within the brain and the neurotransmitter that activates these is dopamine. Whenever we experience something particularly good we feel joy, delight or excitement and the reward system records this. It releases dopamine down one nerve pathway which makes the brain remember the current circumstances and surroundings. This becomes a reference memory and these reference circumstances are known as ‘triggers’. The next time the circumstances of the trigger are encountered then dopamine is activated in another pathway and this pathway creates a feeling of wanting or longing-for: a craving. Finally, if we secure the object of the trigger then the dopamine release is suddenly stopped and we experience this as immediate relief. Dopamine is responsible for all of these actions relating to wanting or longing for something but it also has other roles in the brain and significantly it enhances memory fixation. When we drink then alcohol is absorbed into the bloodstream and soon some of that passes through the blood-brain barrier where it artificially causes the release of dopamine and another neurotransmitter called serotonin. When we drink significantly then we feel happy, carefree and sociable but this is not caused by alcohol; this change in mood comes from the serotonin that has been released. But this happiness has another effect. The reward system recognises that we are enjoying ourselves and it creates a trigger for the circumstances: “that was good, do it again” and the elevated dopamine level imprints this message strongly. Whenever we drink a significant amount then this always causes dopamine and serotonin to be released, so the reward system creates and then strongly remembers a new trigger every single time we drink a significant amount in a new circumstance.
The triggers of the reward system, once established, remain in place forever. This is a feature of how the brain works: what has become known cannot become unknown. Once a trigger has been formed then it can never be removed and neither can its associated motivating urge. But while the components of a trigger become permanent on formation they are not entirely fixed: the trigger can’t be removed but its vigour can be changed.
A single fact or detail is stored in the brain in a group of connected neurons. These groups of connected neurons behave in one respect like a muscle in that just as a muscle gets stronger and faster with exercise so does a group of neurons that fire together. Neurons that work in groups like this are called neural pathways and the more often a neural pathway is traversed then the faster and firmer it becomes. New triggers get formed whenever we meet a new circumstance that we enjoy, but if we meet a circumstance that is already a known trigger then the neurons encapsulating that trigger are activated and it becomes stronger and faster: the more often we access a trigger the faster and firmer it becomes. Triggers that are accessed frequently become lightning fast and are found before other triggers related to similar circumstance. But not only does a regularly exercised trigger become quicker it also gains vigour and when it does that it releases more dopamine. The more often we drink in response to a particular trigger then the more powerful the intensity of the craving sensation becomes. But there is something else that makes a trigger function more powerfully, and that is closeness.
Evolution made the reward system impart urgency to doing things that benefit survival. However, something beneficial like a food that is available now might not be found again for some time, so the reward system encourages us to take advantage of the opportunity while it is present; but it also encourages us do so efficiently. If for example there is a bird in the middle of a field of fruiting berry bushes then there are berries all around it. There is good food in every direction but it would be inefficient in terms of energy use for the bird to pick berries randomly from all corners of the field. So the reward system evolved to use energy efficiently by encouraging the bird to take the closest ones first. The motivating urge launched by a trigger is stronger when its subject is closer than when the subject is more distant. In terms of alcohol this means that a craving to drink is far more powerful when we are close to the triggering circumstance. But it also means that if we begin drinking in a location where alcohol is freely available then we experience another craving for a drink as soon as we have finished our first one. Once we have started drinking in a place where alcohol is available then our reward system demands that we continue. This encourages us to drink more and to drink for longer than we intended when we first arrived at the location.
Every new circumstance in which we drink forms a new trigger and our brain constantly scans incoming information looking for triggering circumstances that have been met before. Directly seeing or smelling the subject of a trigger will make that trigger fire, but triggers are by no means limited to this direct identification. A flying bird may not be able to see the actual berries on a bush but it can see that the bush is of a type that bears good fruit. And the bird may be so far away that it can’t even see the bush but it can see the terrain that bushes of this type grow. The bird forms triggers for the berries, bushes of the correct form and for the terrain that supports this type of bush and we do exactly the same with alcohol. Yes, we form a trigger to drink whenever we see or smell alcohol but we also form a trigger for a place at which we’ve drunk previously and we also form triggers for the roads that lead to that place. Over an extended period we accumulate hundreds and hundreds of triggers that urge us to drink. The cravings brought on by these triggers grow stronger each time we act on them and they grow stronger as we draw closer to the trigger’s location. But the reward system can be fooled regarding closeness. The reward system evolved before the existence of pictures, photographs, television etc. and it evolved before our human ability to visualise and imagine. To the reward system all of these things are recognised as real. It cannot distinguish between a glass containing alcohol and a picture of a glass containing alcohol; both cause cravings to be launched. Photographs of alcohol and images of people drinking will bring on cravings and even imagining these things will cause the related triggers to fire. We can bring powerful cravings on ourselves by simply daydreaming about drinking.
Whether or not drinking becomes compulsive rather than chosen depends on the vigour that the drinking triggers acquire. The intensity of a craving is determined by how close we are to the circumstances of the trigger and also by the number of times that this trigger has been successful in delivering alcohol. The more often we drink in response to the craving initiated by a trigger then the more powerful that trigger becomes: the next craving we get from it will be stronger. The reward system encourages us to drink more and it encourages us to drink more often, and if this continues then the triggers strengthen without limit and we become addicted. But everybody has this reward system, so how come that everyone that ever has a drink doesn’t become alcoholic?
Triggers exist to encourage some behaviours and discourage others, but a single subject can have multiple triggers for different circumstances. For example, we might have two triggers for lemons; we may feel the urge squeeze some lemon juice over fried food, but we would recoil strongly from the suggestion we should eat a whole one. Just like the example of the lemon most people have some triggers that encourage them to drink and other triggers that urge them not to. It is the balance of these competing triggers that (most often) prevents them from drinking unwisely. Normal drinkers have triggers motivating against drinking too much and they have triggers motivating against drinking at the wrong times. They have triggers linked to the discomforts of drinking too much; hangovers, vomiting, and loss of control, and they have triggers relating to the unwanted consequences of drinking; failing to meet important obligations, doing things that are regretted or shameful and so on. But these alcohol-avoiding triggers do not form properly in alcoholics and the absence of these commits us to a catastrophic trajectory.
The reward system encourages us to do some things but it discourages us from doing some others and how it handles conflicting triggers is central to how addiction forms. If I stand on a hilltop where I can see a long way and I also overlook a large lake or sea then I will get a strong sense of calm: I have put myself close to plenty of water (vital to our survival), I am above the surroundings (therefore safer from predators) and I can see a long way (also, safer from predators). However, if that same hilltop I stand on is a cliff edge then a different trigger will fire and the others will not. The risk of falling is present, and fear is induced to motivate me to move away. Even though I am still in that elevated position where I can see water and I can see a long way I do not experience any sense of calm; I only experience the fear. This is because the trigger to make me step back from the edge is stronger than the triggers saying “here is good”, and when triggers compete then the most powerful one prevails. We don’t simply feel the effects of the more powerful trigger above those of the weaker triggers, the motivating urges from those other triggers are completely dismissed. But if competing triggers have similar strength then the triggers that discourage harmful behaviours prevail over triggers promoting beneficial behaviours. The evolutionary origin of this preference is quite simple: it is better to miss even the finest of feasts rather than to risk being caught by a predator. However, the extent to which we prefer triggers discouraging harmful actions over triggers encouraging beneficial actions is not entirely fixed across all society; it varies from individual to individual. Some people place higher importance on the triggers encouraging avoidance of danger than they do on the triggers encouraging beneficial behaviours and these people tend to be more timid. On the other hand those that place less importance on the harm-avoiding triggers tend to be more adventurous. Individuals that prefer risk avoidance assign greater strength to the triggers discouraging potentially harmful behaviours, whereas individuals that are more inquisitive, independent or adventurous assign greater strength to the triggers associated with beneficial outcomes. Most addicts are in this second group. We assign much greater strength to drinking triggers than we do to drink-avoiding triggers and this has a profound effect on our drinking behaviour because when triggers compete in us it is far less likely that a drink-avoiding trigger will ever prevail over a drink seeking trigger. But there is another characteristic that can prevent some people from forming alcohol-avoiding triggers at all.
Just as a trigger gains power depending on its closeness a similar thing happens in relation to closeness in time: we are attracted to partaking of something beneficial now rather than coming back for it later. The evolutionary origin of this is obvious: take the food now because it might not still be there when we come back. But what if the reward (or penalty) later would be larger than the reward (or penalty) now? How we behave under this circumstance is famously demonstrated by “the Marshmallow Test”:- Put a marshmallow in front of a child, tell them that they can have a second one if they can wait ten minutes without eating the first one, and then leave them alone. Some children will resist the urge to eat the single marshmallow knowing that there will be two later, but some will not. The key attribute demonstrated here is that the children who don’t wait the ten minutes devalue the extra benefit of another marshmallow over time far more aggressively than the others. These children favour a result now far more strongly than a result later and people having this internal preference form far fewer alcohol-avoiding triggers than everyone else. The extra benefit is still considered valuable for these people, but if that advantage is significantly in the future then it is disregarded in favour of the immediate opportunity. But it isn’t only advantageous things that get discounted over time this way, disadvantageous ones do as well. In terms of drink-avoiding triggers this means that for people greatly preferring something now over something later the later penalty of a hangover is diminished to the point that it isn’t significant enough to form an alcohol-avoiding trigger. People that are highly motivated by “now” rather than “later” form far fewer alcohol-avoiding triggers because the adverse consequences, though they may be severe, are most often encountered significantly after drinking rather than at the same time or very close to it.
Frequently accessed neural pathways become firmer and faster and over time we increase the power of the triggers that we drink in response to. But if our personal characteristics undervalue the repulsing “don’t drink now” triggers then when we come to an occasion where we are triggered to both drink and to avoid drink then the weaker trigger is almost always the drink-avoiding trigger and it is dismissed. When this happens we strengthen the trigger that encourages drinking because it was successful but we also weaken the trigger that discourages drinking because this trigger failed to deliver its objective. People that strongly favour “now” over “later” systematically strengthen drinking triggers while also weakening drink-avoiding triggers. Over time the drink-avoiding triggers become so feeble that they are almost never more potent than a drinking trigger; so motivation from the reward system to avoid drinking only rarely occurs. This bias towards favouring drinking triggers over drink-avoiding triggers becomes more marked as we continue to drink and a similar bias develops in our memory.
One of the changes that occur when we drink is that alcohol artificially increases the release of the neurotransmitters serotonin and dopamine. The elevated serotonin release makes us feel less stressed, lifts our mood and makes us more socially engaged. Dopamine is the principal agent in the formation of triggers and the motivating cravings but it has an additional function: in enhances memory fixation. When both serotonin and dopamine are raised then we feel like we are having a good time and we remember having fun more firmly. But enhancing the memories of drinking being an enjoyable experience isn’t the only distortion; the opposite happens to memories of occasions when drinking had bad outcomes. Memories associated with negative emotions are forgotten more quickly than those associated with positive emotions; this is known as “Fading Affect Bias”. Not only do memories of good times while drinking get amplified, our memories of drinking that had bad outcomes get diminished.
Failing to remember the bad experiences of drinking as strongly as the good experiences means that our recall of alcohol is unfaithful and what we remember is not how it was. When we think of drinking then our first memory is always of good and happy times, never bad ones, and in the same way that our reward system becomes hopelessly biased in favour of drinking then so does our memory. “Drinking is good” and “drinking is fun” become the things we know more confidently than anything else and any memory that drinking is bad is a murmur by comparison.
Normal drinkers build strong triggers and memories relating to bad drinking experiences, but we don’t. We don’t build many alcohol-deterring triggers, and we only have weak memories of bad experiences. This inability to properly recognise the downsides of drinking means that we are still encouraged to drink when others would refrain. For example alcoholics will drink with complete disregard to the fact that a severe hangover will follow because our reward system does not have the trigger that encourages us to avoid this outcome. We are aware that we are drinking enough to get a hangover, but when this thought arrives (if it arrives at all) it comes only as simple information; it has no accompanying motivating urge to refrain, stop or slow down. We do not have a trigger that prompts “that’s enough now” we only have a pale memory that says drinking a lot ends with hangovers. What we do feel however is a strong compulsion to have another drink and to have another drink right now.
Not only are we encouraged to drink too much we also drink at inappropriate times like before important meetings, at work, or on other occasions where sobriety is expected. Again, this is because we receive no motivating repulse from doing so. In alcoholics the urge to seek out alcohol is very strong, and the impulse to avoid it is barely, if ever, present. So we are always motivated to drink and we are almost never presented with the motivation to desist. We even drink in ways that contradict our own standards of sensible behaviour, and we do this because in the moment our mind always urges us to drink, it never encourages us to stop. For example, we will drink before driving and picking up children. We know this is an extremely dangerous and foolish thing to do and we would condemn this behaviour in others but in the time that precedes picking up the children our mind presents no objection to drinking. In fact the opposite happens; our mind still encourages us to seek out and secure drink regardless of what we are going to do later. We are rewarded with a large dopamine surge on taking that first drink and once we have begun drinking then our brain never says “stop, that’s enough!” but instead insists “there’s time for one more”.
Our problem with alcohol begins and escalates in the reward system in this sequence:-
We drink alcohol which causes the brain to release dopamine and serotonin. The serotonin makes us enjoy the experience of drinking and a trigger is formed. We create another trigger every time we drink under new circumstances. When we encounter the circumstances of an existing trigger then a craving is launched to encourage us to drink. Triggers strengthen every time we drink in response to the craving which makes the next craving to come from that trigger more powerful. We continue to crave alcohol for as long we remain somewhere where alcohol is nearby. The dopamine released in response to drinking also enhances fixation of the memory that this experience was good. But we do not often form counterbalancing alcohol-avoiding triggers, nor do we often form strong memories of occasions of when drinking was unpleasant, damaging or dangerous. In the absence of triggers and memories that encourage avoidance or moderation we drink more, and we drink more often. As we drink over an extended period we accumulate more and more new triggers and our existing triggers grow in strength. Over time the motivating urge to drink grows without limit until it is both incessant and compelling while the triggers to avoid drink are progressively weakened. Eventually the compulsion to drink overwhelms all other motivations and desires.
This is the process by which our addiction forms but we have no idea at all that this is happening to us. All of the changes described here occur in the reward system and this is a part of the brain that we can’t see into; we have no awareness at all of what is going on in there. We don’t know when triggers form or when they are activated and we have no idea of the strength they have gained. Our only awareness is of a sudden, wordless and urgent demand to drink but we have no direct knowledge of why we are experiencing this.
The power of the reward system to direct our behaviour cannot be over-stated. Humans stand apart from the rest of the animal realm because of our higher mental functions. Humans have a highly developed sense of self, a remarkable ability to discover and invent solutions to problems, logical thinking and judgement (the means to weigh the pros and cons of any situation). These higher functions require relevant information to be found, compared, chosen and then brought into our awareness for us to consider and this requires a huge computational effort. But the reward system requires none of this and it operates up to a million times faster than our conscious thinking. Not only is the reward system a lot faster it also operates entirely independently and our higher functions are oblivious to its operation. This means that the reward system motivates us to do something before our conscious mind has even recognised that there’s anything to respond to. For example, we will have jumped back in shock before we are consciously aware of a snake crawling through the grass. We react through our reward system and we respond through our conscious thinking and reaction always comes before a considered response. When a drinking trigger is fired we feel a craving before we are even consciously aware that alcohol may be near; we are quite literally directed to have a drink before we’ve even thought about it.
The reward system is enormously motivating and for most animals it is the principal mechanism driving their behaviour. A bird does not stop and ponder what it will have for lunch or where, it lacks that ability, yet it feeds successfully throughout its life. The reward system will motivate an animal to behave in ways that protect and prolong its life and it is enormously compelling, and if it weren’t then the animal would die younger. Directing behaviour is the entire purpose of the reward system, so of course it is a powerful motivator. But there are two characteristics in particular that can tip the reward system into a runaway condition. These are; greatly favouring the benefit of something over its disadvantages, and greatly favouring something now over something later. People having both of these characteristics are susceptible to addiction, and these characteristics are very familiar to us: we want more, and we want more now. This is quite literally written into our DNA. In us the reward system becomes destructively associated with the acquisition of alcohol, but we don’t know this has happened. We also have no idea that over a period of time the forces invoked by the reward system have become incredibly powerful. Our behaviour becomes driven by feelings that are involuntary, insistent and beyond our direct control, and they come before any considered thought. They come first, we can’t ignore them, we can’t turn them off and we can’t negotiate with them. They are impervious to reason and both precede and defy logic. These are the forces that drive our addiction; they are primal, compelling and unrelenting.
A person with a worsening alcohol problem is completely unaware of the changes in their brain relating to finding and consuming alcohol. To us everything about our drinking seems normal… everything that is except the way that others are starting to talk about it. As our addiction progresses we sense no change in ourselves but perceive the problem to be “in the eye of the beholder”. This is the truth for us as we genuinely perceive no problem because our mind insists that “alcohol is good!” despite what other people tell us.
The onlooker watching someone become steadily more and more regularly drunk sees a problem, but we see none. This is caused by the different perceptions. The onlooker is seeing us from an untainted viewpoint; their memories and triggers associated with alcohol are balanced. To them too much alcohol is bad. But to us, alcohol is good, and more alcohol is also good… and we are completely baffled as to why other people don’t see it the same way.