Hans Breiter, director of the Warren Wright Adolescent Center and professor of psychiatry and behavioral sciences at Northwestern Medicine, pioneered functional MRI and quantitative anatomic imaging for psychiatry and cognitive science. This work allowed him to localize the reward-aversion system in humans using brain imaging, producing unambiguous evidence for the model of human addiction as a brain disease. He is one of the few neuroscientists to have discovered laws in emotion neuroscience, and how that system malfunctions in substance abuse and addiction. For this interview, he shared aspects of his latest research and his views about where his field is headed next.
What has your work and that of the Warren Wright Adolescent Center at Northwestern uncovered about the causes of and solutions for addiction in general and adolescent addiction in particular?
At the Warren Wright Adolescent Center, we’re focused very much on dissecting the working pieces of the reward-aversion system, their connection to memory systems, and their underpinning of decision-making. We’re trying to understand the full range of abnormalities under addiction, and how this differs across different drugs and contexts. People start out with a certain amount of resilience and susceptibility, and then you have initial exposure, adaptation to repeated use, and ultimately dependence. There is always some reason why people start to use drugs. In some cases, drugs may help reduce anxiety and/or depression. Alternately, some kids have impulse control issues or need for strong positive experience. With repeated use, one sees development of craving, habit formation, and tolerance — so you take more of it over time. It is all about how repetitive short-term rewards, tolerance, restrictions to your portfolio of preference and changes to your sense of potential harm interact in you as an individual.
With the rise of the opioid crisis, are we in a startling new era for addiction?
There’s always something new on the horizon. Cocaine was around a long time, but with the development of crack as a cheap, easy-to-make formulation, it became much more accessible. And now with very cheap formulations of heroin and synthetics, such as fentanyl, we’re seeing an opiate crisis with more OD deaths per year than there were in the entire Vietnam war. It comes in waves, but now there is also an increasing sophistication by drug suppliers to stay one step ahead of researchers, regulators, and health care providers. There is a mix of potential approaches we could be using to reduce the carnage, but there appears to be no political or philanthropic will to empirically attack the problem, or do the nuanced science needed at this point. I’ve been doing addiction research since the early 1990s, and yet, I couldn’t protect one of my kids. One of my own children just had a major OD requiring Naloxone to save his life. It’s so insidious, it goes underneath or around any firewall you as a parent try to put up against it.
What does your research show about the seeming variability in people’s ability to resist addiction?
Addiction is complex, like the human mind and the brain that mediates it is complex. How one person might best resist addiction is likely to be quite distinct from another. Let’s get into some details here: our research has shown that addiction isn’t just about the function of the brain. These compounds change the structure of the brain, too. There’s a retuning and rewiring which likely has its own set of resilience and susceptibility factors. Research exists clearly showing that there are genetic factors, and, in parallel, that some compounds seem to have a higher capture rate. You might have resilience about one type of compound and susceptibility toward another. There’s also this thing we have a poor understanding about, called the transfer function, where people substitute one habit for another. People can stop smoking, they can get treatment, but then they start to eat and gain weight. It’s not by accident that whenever you go to a center where people are getting treated for opiates, many of them smoke tobacco.
Are there any new therapies on the horizon for breaking the cycle of addiction?
One modality that I find exciting is called transcranial magnetic stimulation (TMS), wherein a pulse of magnetization hits the circuits and turns them off for a moment. It can be quite focal. It induces adaption of the circuits that have been affected and may lead to new synapse formation. That may be a route forward for helping to shift somebody out of a negative cycle of dependence. I’ve also been more and more impressed with the 12-step method, which is ancient, as methods go, and has become connected to ideas of mindfulness. I believe it will be important to understand the neuroscience of mindfulness and use techniques such as TMS to facilitate mindfulness-type processes with addiction treatment. I think this could become a very powerful approach.
Are there any new psychiatric drugs that seem promising?
I have moved away, myself, from psychopharmacology and any thought of a magic drug curing a mental illness or addiction in the complex human mind. There’s an emerging consensus among a number of hard-core neuroscientists that neuropsychopharmacology may need to be rethought. And that circuit-based treatments like TMS along with mindfulness may be the better primary approach at this time. Ultimately, it may be that all three are going to be needed; that there’s going to have to be a multidimensional approach to addiction and psychiatric care in general. Keep in mind, when you just do mindfulness approaches to addiction, such as a 12-step program, it takes a long time for the brain to adapt. I have very little faith that somebody is not going to relapse until I see them being sober and actively talking about recovery, and making amends, for two or three years. In my opinion, the idea that one drug would do this is delusional. Psychiatry has taken us down a rabbit hole and needs a radical restructuring, including development of a model of the mind in mathematics to guide addiction neuroscience and pharmacology. Absent this, psychiatry is the headless horseman, terrorizing the countryside every night looking for its head.