Why Quitting is So Hard: Understanding Addiction

Dr. Avery: Quitting is really hard. You're going against what's happened to your brain. You're going against whatever mental health struggles you're in. You're going against whatever environment you're in. That makes it very hard to do a different behavior. And so it takes a lot of intention and work often to curb a addictive behavior.

Courtney: Welcome to Health Matters, your dose of the latest in health and wellness from NewYork-Presbyterian. I'm Courtney Allison.

This season on Health Matters, we're covering your health from A to Z, asking our experts to break down the health topics and wellness trends we're all curious about. Today, we're at Q for quitting.

It can be difficult to talk about addiction. In this episode, we talk with Dr. Jonathan Avery, an addiction psychiatrist at NewYork-Presbyterian and Weill Cornell Medicine, to better understand what's happening in our brains when we're addicted to a behavior like online gambling or to a substance like alcohol and why it can be so hard to quit. As he explains the importance of reducing stigma around addiction, Dr. Avery shares thoughtful ways to support those who may be struggling, and the therapies and treatments that can lead to a successful long-term recovery.

Dr. Avery, thank you so much for joining us today.

Dr. Avery:  Hey, Courtney. Thanks for having me.

Courtney: It's such a pleasure to have you here on the show, a fellow podcaster. I'm very excited for our conversation. Something that struck me when I was listening to some of your episodes, you've said that thriving doesn't mean the absence of loss or struggle, but finding a way forward through it. Could you elaborate on that? What does it mean to thrive with addiction?

Dr. Avery: Traditionally, we think of addiction as something that you have and that you overcome or something that other people have and they overcome. And I think when we create these narratives about overcoming addiction or thinking of it as something in the past, we miss that it really is all around us. And so I think to really address and understand addiction, you have to recognize it in each of us. As a large part because of the stigma of addiction, we really don't look at it in ourself or others, and I think that creates a lot of trouble.

Courtney: I appreciate what you're sharing because I think whether we're struggling with it ourselves or have family members or loved ones, it is really out there.

Dr. Avery: It's tens of millions of people that struggle with classic substance use disorders, things like alcohol and cannabis and increasingly more behavioral addictions like gambling and gaming and sex addiction. But there are probably more than even that. I mean, I'm addicted to my phone right now, and we all go through these phases in our life where different things grab our attention, hijack our dopamine. And, and so I do really believe that it's in all of us, and we all have to monitor our behaviors.

Courtney: What exactly is addiction?

Dr. Avery: Addiction is complicated, and it's not just one thing. There are a spectrum of behaviors and neurobiologic processes. There's genetics and social determinants of, of health, spiritual factors. But at its core, in the most simplest form, addiction is the chronic use or compulsive engagement with a substance or behavior despite negative consequences. And this is often driven by impaired regulation of reward, stress, executive function systems. But I think even more importantly, addiction is often a response to pain, to disconnection, to trauma, unmet needs. I think when we simplify addiction to just being about a substance, like everyone who gets exposed to acceptance gets addicted, that's not true. If we make it just about the brain and genetics, that also doesn't encompass how addiction develops because some people have the genetics, they have a vulnerable brain, and they use and they don't get stuck. It's often that vulnerable brain plus exposure to the substance plus different factors in their life, including mental health and trauma, a difficult living situation, access to substances, availability. So there's a lot that goes into this behavior that we call addiction.

Courtney: So understanding there's many different factors, and it's not just what's happening in the brain. What is happening in the brain when it comes to addiction? What does it have to do with dopamine, our reward pathways, things like that?

Dr. Avery: So we initially thought addiction was all about dopamine, and that's still partly true, and, and the reward pathways in the brain where you use something, you get this big dopamine spike, and then with time, you start to get this dopamine spike about acquiring the substance. And so your reward system is driven to use. But we've learned over time that so many other neurocircuits and processes from the parts of the brain that remember, the parts of the brain in the frontal cortex that are involved with decision-making and putting the brakes on behavior all the way throughout the body, in fact, too, is, is impacted by substances. The other thing that drives substance use forward is that when you use a substance chronically, you get withdrawal states when you remove it. So it's both the hijacking and then when you remove it, how terrible you feel in your body and brain when that's taken away. And some substances have very wicked withdrawal states that make it very hard to stop.

Courtney: Can you walk us through some of the common addictions we all might encounter? I mean, you mentioned before your phone. That's very relatable.

Dr. Avery: Well, as a father of 3 young kids, I'm especially interested in how social media and online and YouTube and all these other things are addictive. But the classic addictions we think of are these substance use disorders. And the main thing we treat in addiction is alcohol still. Like, as much as marijuana and the youth vaping and opioids are in the press, if you're gonna get stuck on any substance, it's alcohol. But we're in the opiate epidemic, the fentanyl opiate epidemic especially, where we have a lot of contaminated drug supply around the country that's impacting and causing people to lose a lot of lives and become addicted. And then there are behavioral addictions, not just social media, but the ones we've studied the most are gambling, gaming, and sex addiction. And you would think they act differently on the brain than the substances, but they actually act very similarly, and we treat them very similarly in addiction.

Courtney: What do all these have in common? What does gambling have in common with alcohol, cannabis, screens?

Dr. Avery: The striking thing about these behavior addictions is that they are neurotoxic in the same way these substances are. You see the same changes in the brain.

Courtney: Wow.

Dr. Avery: And you see a similar set of behaviors that evolve around these things as well. The striking thing about gambling is, one, it lights up the brain, sometimes even more than substances. It does something to our reward pathway, and that is really remarkable. And then you can even get withdrawal states when you stop gambling. You can feel physically unwell from not gambling when you have a severe gambling disorder.

Courtney: And how is the new availability, accessibility of gambling, betting on smartphones, how has that impacted people?

Dr. Avery: The phone. The phone is such a troublemaker, you know? The phone has really increased the availability of a lot of these behavior addictions. We wouldn't give our kids vodka at age 10, but we have them on social media at that age. They have availability to see difficult sexual content at that age. And then the sports betting has just taken over, especially young male culture, where if you watch any sports game these days, you watch the game and you see all the betting odds, and it's become what kids talk about. And the phone makes it easy to gamble and wager. And then for the developing brain, all these behaviors, all the substances and all the behaviors may especially be more engaging and especially harder to put the brakes on as the brain keeps developing until 25.

Courtney: Are there any surprising things that someone might be addicted to? I think I saw validation could be an addiction. That surprised me a little.

Dr. Avery: Yeah, there's love addiction. There's food addictions. Even though some of these things may not sort of light up the brain in the same way, different behaviors are helpful to think about in an addiction lens because of a lot of the things we do that we'd rather not be doing. If we applied some of these addiction principles, we could help moderate those things. Be careful not to eat junk food when you're hungry, angry, lonely, tired, for example. Things we're telling people is to be mindful of those states around substances, to not doomscroll after a long day at work, but try to do something healthier. So some of these addiction principles can apply to a bunch of these things.

Courtney: That's really helpful. Could you say more about that? So being aware of your state, hungry, angry, lonely, did you say?

Dr. Avery: Hungry, angry, lonely, tired, HALTS, and then we always say, and sometimes bored. These are the triggers for substance use. When you're either trying to be absent or trying to moderate, you don't wanna be chasing feeling states. If you're gonna have a healthy relationship to something, you wanna be doing it intentionally and because you're enjoying it, not because you're trying to get rid of a feeling.

Courtney: What are some signs that you might be teetering into that harm category?

Dr. Avery: It often happens subtly, which makes it hard to recognize. But once it starts getting in the way of things you value and starts to impact your function, that's when we think you start veering into addiction.

Courtney: So say you're noticing that. What's the first step to try to manage it?

Dr. Avery: The first step is to raise your hand. There are more treatments and help than ever. Sometimes people feel when they raise their hand, there's only one option, which is to quit substances entirely, go to 12-step work, but that's not the case. There's different therapies, different groups. There's online options. There's in-person options. And then the biggest sea change in the last 10 to 15 years in addiction psychiatry and medicine is there are actually medications that can help with what you're self-medicating, but also help with craving towards substances and behaviors. We've had great meds for alcohol use, some which help you drink less, some which help you maintain abstinence. If you struggle with opiates, the gold standard is to be on medications that either replace or block your opiate system and really improve outcomes. And then there's other meds that help with craving for marijuana and cocaine and good meds that help you stop smoking cigarettes or vaping nicotine. Just ask your doctor. If you have a kid that's struggling, ask the pediatrician.

Courtney: Is there potential for GLP-1s to help with addiction? What are the studies showing?

Dr. Avery: Yeah, it's very promising. The weight loss on them have been tremendous, obviously, and their role in chronic medical conditions has been notable. And there's studies, including pretty solid, larger studies now showing that the GLP-1s help curb drinking and binging on drinking and helping people enter recovery states. But there might also be promise for even some of these behavioral addictions like gambling. There's a lot more that I think is gonna come out in the next couple years, but there's some real promise there.

Courtney: That's really exciting to hear. And so when it comes to addiction, can people get better?

Dr. Avery: People get better. That's the thing. Most people get better. There's a real large community of people who have gotten better, but you gotta raise your hand. I think part of what makes it scary for people to raise their hand is they feel like their initial step is to go to rehab and be completely abstinent. But in fact, a lot of people can recover with moderation. A lot of people can recover without going to intensive treatment. And I think one contributor to stigma is that those people that recover in nontraditional ways or non-12 step ways often don't have the space to share their story. Because addiction is so secret and stigmatized, people often don't have the vision of themselves in recovery in their head just because they haven't seen it in others.

Courtney: You mentioned how your work focuses on stigma. Why is stigma so dangerous?

Dr. Avery: Well, I saw friends and family struggle with addiction around me growing up, and I noticed that they were treated differently than people that had other health conditions. And intuitively, to me, that never made sense. It was sort of obvious to me that these folks, if they could do better, they would, but they couldn't for complex reasons. And our studies show sort of what I'm describing, that people's attitudes are worse towards those with substance use disorders or addictions than towards any other medical or psychiatric condition. And these attitudes even exist in the places that should be the safest, like among healthcare providers, lawyers, and even our own family. And that's dangerous and problematic because when there's all this stigma all around—saying that you're a moral failing and not acknowledging how we can thrive with addiction—it creates a situation where people feel bad about themselves. It makes them not want to seek help, and it results, I think, in a lot of untreated addiction. I think there's been some improvement. There's actually a number of people here at Cornell working on the stigma of addiction. I do think things are getting better and more people are talking about it and open and honest, but still there's a long way to go. It's still really a hidden condition.

Courtney: Can you talk more about the importance of community and what that looks like in recovery?

Dr. Avery: Substance use and other addictions can be really isolating. People often can feel very alone with it and stigmatized. And one way out is through the therapies and the groups and the meds and then addressing the mental health, but no one recovers alone. And there's all sorts of famous quotes about how the opposite of addiction isn't recovery, but connection. But it's true. You need an extended community. You really benefit often from having other people in recovery in your corner as well, because then you have people you can lean on, people you can be honest with, and people that can be with you through it. And that often results in building a life that's much more meaningful, much more connected, and goes a long way to solving a lot of what sometimes brought about the substance use, this isolation and disconnection.

Courtney: Would you say more about isolation as a risk factor? If raising your hand is an answer, what about for people who don't feel like they can raise their hand to anyone?

Dr. Avery: Because of the stigma, people do often end up isolated with their substance use disorder or behavioral addiction and other conditions that one might have, like depression, anxiety, other mental health conditions. They can often be isolating and are often co-occurring as well. And so if you feel like you can't, I would encourage you to just start anywhere. Go online, talk to someone that you feel like you can trust, and build up that ability to just share it with even one person.

Courtney: Could you say more about how other mental health conditions might overlap with substance use disorders?

Dr. Avery: One of the driving hypotheses around addiction and substance use disorder is the self-medication hypothesis. And part of that recognizes that when you have a substance use disorder, addiction, behavioral addiction, you often have a co-occurring mental health condition, depression, anxiety. The odds ratios are through the roof. It's one of the biggest risk factors for developing addiction is having a mental health condition or having trauma. You can't often address the addiction without addressing those things at the same time, without also treating the mental health and the trauma. And sometimes the addiction becomes the loudest thing in the room, and so you've got to take care of that first, but you can't forget the whys.

Courtney: So if there's someone in your life who's struggling, what could be the most helpful thing you could do for them to support them, and maybe what shouldn't you do as well?

Dr. Avery: People often think they need to scare or punish people into recovery, and I think we have to meet them instead with kindness and understanding. Understand that they're doing this behavior for a reason. It's doing something for them. And to meet them in that space with kindness, to offer resources, and support them as they try to navigate this difficult health condition.

Courtney: And it's not easy to quit, right?

Dr. Avery: Quitting is really hard. You're going against what's happened to your brain. You're going against whatever mental health struggles you're in. You're going against whatever environment you're in. That makes it very hard to do a different behavior. And so it takes a lot of intention and work often to curb a addictive behavior.

Courtney: What could people look forward to if they can get through recovery? What stories do you see of how people thrive?

Dr. Avery: There's so many stories of how people thrive when they stop using substances or doing a problematic behavior. I think part of what happens in the brain is that the thing that's lighting your brain up most are these substances, and you sort of lose all these other passions and interests. And so when you enter recovery and everything sort of gets right-sized, you start to find a lot of joy again in life, in your relationships, in your work. You're physically healthy, which goes a long way. And so the people I see in recovery are some of the happiest, well-adjusted people I see. And also for going through that struggle, you learn a lot. There's a certain wisdom and expertise that comes with having learned to thrive with a substance use disorder that I think we really could all benefit from. It is worth acknowledging that this is a condition that can take us to our knees sometimes and can be really hard, and we do lose lives. If you're stuck, I'd say start anywhere. It's worth the effort.

Courtney: Dr. Avery, thank you so much for joining us today on Health Matters and for this wonderful conversation and helping break stigma and provide strategies for people.

Dr. Avery: Thanks for having me and all the work you're doing.

Courtney: Our many thanks to Dr. Jonathan Avery. I'm Courtney Allison.