The addicted brain

Rehabilitation the winning move, not incarceration

Singapore is a major destination for the importation and trans-shipment of hard drugs. Unfortunately, hard drugs are only getting cheaper, it was revealed in Parliament recently.

That's the bad news.

But there's good news too.

It is a little-known fact that 80 per cent of drug addicts who do seek help are able to kick the habit, according to the National Addictions Management Service.

Singapore argues that its tough drug laws have kept its streets largely drug-free. Be that as it may, we should be looking for new ways of rehabilitation, not repeated incarceration, to deal with the problem of drug addiction.


There might well be new ways, given that much knowledge has been accumulated over the past two decades about how drug addiction is rooted in the brain's very biology.

If this means that addiction may become a medically treatable condition, perhaps we can even look forward to a day when drug policy will be treatment-based rather than punishment-based.

It is now known that chronic drug use - which is repeated abuse over long periods of time - causes the brain's very structure to change physically.

This concerns especially those regions of the brain responsible for the voluntary restraint of one's compulsions and actions. This, then, is the biological reason why the addict's capacity for personal control becomes impaired.

The way addictive drugs do so is by affecting the brain at the gene level. In this way, protein synthesis in the brain is altered. Since brain cells or neurons are protein-based, this impact at the gene level leads to changes in the brain's physical circuitry and, thus, its functioning. The altered brain structure and function then lead to the altered behaviours seen in addiction.

For decades, experts conceived of drug addiction as physical dependence on the drug concerned.

This was because when the addict abstained, he developed withdrawal symptoms which were disabling and even fatal. This was regarded as proof that addiction arose from the abuser's motivation to avoid the effects of withdrawal.

This meant, it was thought, that he had become physically dependent on the drug. So it was believed that the trauma of withdrawal was the basis of addiction.

Yet, if this were the case, why would some addicts willingly go cold turkey, suffer through withdrawal and then stay drug-free for years, only to start all over again? This suggests that the addicted brain may actually continue to stay addicted.

But why or how?

Brain science has now shown that drug addiction arises when the brain's reward and decision-making circuitry becomes physically and functionally altered through chronic exposure to an addictive drug.

The physical and functional changes in the brain cause the addict to crave the drug more and more, even as his brain circuitry for impulse control becomes progressively impaired.

In short, the addicted brain shows increased craving as well as impaired impulse control.

What all this means is that addiction has a neurobiological basis. So it is, in reality, a neurological problem, for which medical remedies might work, just as an infection can be treated with antibiotics.

Now, if chronic drug use causes physical changes in the brain - genetically, structurally and chemically - and affects how it functions, we must revisit the question of whether drug addiction is voluntary, which is perhaps an implicit assumption behind drug-law enforcement.

Genes that make some of us more prone to be addicted to smoking or drinking have been identified.

It is likely that there are also genes that similarly render some people more likely to take up the drug habit.

This may not excuse the initial wilful act of taking drugs, but more recent studies tell us that, over time, the repetitive act of taking drugs becomes transformed into involuntary and finally compulsive drug use.

So, while addiction may start with a person choosing drugs, by the time his addiction is chronic, it is dysfunctional brain tissue that is driving his behaviour.

This is akin to the situation where cardiac muscles weakened by hypertension, say, cause the heart to fail to pump blood around efficiently. If heart failure is caused by these weak heart muscles, then drug addiction may also be construed to be a medical issue in which "weakened" brain tissue is the underlying cause of the behavioural problem.

While initiation of drug addiction may well be voluntarily "impulsive", neuroscience now suggests that in the maintenance stage of the habit, it has become an involuntary "compulsive" disorder.

If so, drug addiction may best be seen not as either voluntary or involuntary but semi-voluntary, say, so that in a court of law, the addict might be found not guilty, but culpable nevertheless.

If so, he need not be jailed, so long as he acknowledges personal responsibility for his drug habit and agrees to be treated.

This matters because it is widely believed, but in error, that drug abuse treatment is not effective. It deserves to be much more widely known that drug addiction is a treatable condition.

Of course, not all modes of treatment - medication, counselling and other related rehabilitative services - work equally well for every addict. And, of course, no single treatment is the best one for each and every addict.

Instead, programmes must be tailored for the individual. But one thing all good programmes have in common is that they assiduously monitor the addict's progress over the long term.

Instead of incarcerating them, the courts could mandate that addicts be put in such programmes.

One exemplar for Singapore to consider is the special "therapeutic court", which is also called the "drug treatment court" in the United States, of which there are about 2,800 all over the country.

These were set up based on the premise that imprisonment alone cannot break the addict's cycle of drug abuse and repeat crimes to support the habit.

These courts mandate a year-long programme of intensive treatment for addicts, instead of a jail sentence for drug possession. They also work as a one-stop court to deal with any other legal problems the addict may have, such as alimony and child support.

The recidivism rates for addicts dealt with in such courts are better than in normal courts. And with 80 per cent of drug addicts in Singapore who seek help in kicking the habit actually succeeding in doing so, this legal innovation deserves to be emulated.

Instead of handing out jail sentences, the courts here can look to the new neuroscience of addiction which offers a biological rationale for judges to mandate that drug addicts seek medical help instead. This could be a winning move all round.

•This is the third of a six-part series on new science on the brain. Next week: The traumatised brain

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A version of this article appeared in the print edition of The Straits Times on August 01, 2015, with the headline Rehabilitation the winning move, not incarceration. Subscribe