The Pulse: In Early Recovery, A Vulnerable Brain

Mar 16, 2017

Neurotransmitters involved in substance abuse, plus the location of the frontal cortex.
Credit National Institute on Drug Abuse

Early recovery from addiction is a delicate, difficult period. It’s a time when drug users are most at risk of relapsing or overdosing. But scientists are learning more about the biology of early recovery and how people with substance abuse problems can survive it.

Stephanie is in early recovery from heroin addiction. She's been sober about six months. (We're not using her last name to protect her privacy.) She’s nearly 30 years old. She’s been living in this sober house for a few months now. She’s one of tens of thousands of Rhode Islanders who have sought treatment for opioid addiction, according to the state’s department of behavioral health. Before August 3rd- that’s her sobriety date – Stephanie lived a routine similar to many addicts’: wake up, try to find the money for the day’s supply of drugs.

“It was a full time job. I would go shoplift the most expensive pants I could possibly fit into a small area. Then I would have to go find somebody with an ID to go back to the store to return the stuff," Stephanie says. She'd ask someone she found on the street, just by driving up and down, "'Hey, you want to make 10 quick bucks?' Then I would sell the gift card, to get the cash. Then that was the morning.”

She’d use the drugs. “Then that would be gone. Then I’d need to go shoplift again in the afternoon. It was a full time job. It was literally exhausting.”

Now her days look different. She’s looking for work. Going to doctor’s appointments. Dealing with some of the legal fallout from shoplifting to support her addiction. And–she’s experiencing her feelings, instead of numbing them.

“How am I so overwhelmed inside when I don’t even know what my day consists of?  Certain things take me twice as long," Stephanie worries. "There’s something going on where I’m feeling completely overwhelmed but I’m really not.”

So why does Stephanie feel overwhelmed and anxious?

“What’s happening is there’ve been these changes in a lot of areas of the brain," says Bob Swift, a professor of psychiatry and human behavior at Brown University and chief of mental health at the Providence VA medical Center.

Swift says one area of the brain that addiction damages is the frontal cortex. “The area that helps you control is weakened. And people will have trouble making decisions, have trouble controlling their emotions.”

That difficulty controlling impulses and dealing with emotions puts addicts at risk of relapsing. And most will, according to the National Institute on Drug Abuse. It’s especially tough in early recovery.

“So you’re left with this brain that has adapted to the presence of the drug and really needs the drug in order to function," says Swift. "And you take that drug away and so the brain really does not function normally.”

The urge to just feel normal keeps addicts using, or sometimes leads to relapse. There’s also the fear of withdrawal. That’s the period right after someone stops using when the brain is aching for the drug and the body is sick. Some of those symptoms can be smoothed with medication. But Swift says even after the acute phase of withdrawal, maybe a week or so.

“There’s a period for all drugs of kind of what we call protracted withdrawal, which is a kind of state of the brain that is outside of equilibrium, [when addicts] still don’t feel right.”

In addition to the weakening of the frontal cortex, that part of the brain that helps you control impulses and make decisions, there’s another part that’s out of whack in early recovery.  A chemical called dopamine - that’s a neurotransmitter associated with pleasure and reward - has been depleted. So it’s hard to feel happy doing normal, everyday things. Here’s how Butler Hospital addiction psychiatrist Dr. Kevin Baill explains it:

Essentially when individuals get addicted to illicit substances they’re trying to manage their dopamine system and increase the output of dopamine. But the dose that normally happens in life is at a small level and when someone is using heroin intravenously they’re sort of bombing that system or hacking that system and supernatural amounts of dopamine are flooding the system," Baill says.

Baill says that makes the brain less sensitive to dopamine. So that when you stop using drugs, the normal amount of dopamine your brain produces just doesn’t cut it. That’s why Baill recommends most of his opioid addiction patients go on medication to help stabilize that dopamine system. But even with that treatment, the brain in early recovery is still vulnerable. Years of drug use change pathways in the brain, like a sled that travels the same downhill path again and again.

“And so over time it becomes sort of a well-worn groove neurologically and a harder lift to not get someone to go down that chute.”

Stephanie’s housemate Celeste, is also trying not to go down that chute. We won’t use her last name either. She has been sober for a few months. She’s in her mid-twenties. And Celeste says another challenge of being in early recovery is simply having a lot of time on your hands, time she used to spend using drugs or planning how to get them.

“When you first get sober you don’t know what to do with yourself. You don’t know how to act," Celeste reflects. "I’ve been using since I was 17.”

Celeste says that during her active addiction to heroin, she lost connections with friends, lost jobs. Now she must rebuild those connections and recover what’s been lost.

“It’s like you start over again. You have to do everything new all over again. And it sucks. I hate that beginning phase. It’s like you start a new job and you learn everything again.”

Both Celeste and Stephanie’s brains are learning again. The more effort they put into staying sober, says Butler psychiatrist Baill, the better their brains will heal.

“Hopefully, a person is normalizing themselves physiologically in terms of taking better care of their body, having a more balanced diet, sleeping more regularly, making amends with family, going to meetings, going to counseling," says Baill. "And all of those things would be associated with some increase in frontal lobe activity.”

VA psychiatrist Bob Swift says the brain can repair itself. But addicts need support in the meantime.

“Having a social support network of people who are not using drugs - a group of people who are abstinent or working on their recovery - can be a very strong help to remaining in recovery.”

Swift says a network like this can almost perform the function of the frontal cortex – helping addicts control impulses, deal with emotions, and perhaps even begin to feel pleasure and connection again. But Swift acknowledges early recovery takes more than having a sober network. Someone in early recovery is often looking at a whole new way of living.

“Getting through that early period is really hard,: Swift says.  "I have immense respect for people who have that struggle and make it through or don’t.”