Why Do Alcoholics and Other Drug Addicts Go Far “Down” Before Recovery (If They Do Recover)
To someone not addicted to alcohol or other drugs it is mystifying why an alcoholic or other drug addict would suffer so much pain and continue drinking and using. Domestic strife, job loss, economic ruin, illness, injuries, legal problems, jail, even prison and yet the behavior continues. What does it take? Why does it go on so long?
We tend to know addiction as producing pleasurable states that become increasingly motivating and then producing a craving as the body reacts to absence of the drug commonly called withdrawal. That view of addiction as a pleasure center issue is a long held understanding and certainly part of the equation. As the transition from heavy, repeated use to this later stage evolves, there are factors that are used to “excuse” heavy use and early stage consequences that are probably familiar to the casual observer.
Social acceptance is a factor that encourages continuing use even though evidence is mounting of the dangers for certain users. Although we have demonstrated elsewhere that 30% of Americans do not use alcohol, and only 16% use cannabis recreationally, alcohol use, and increasingly cannabis use, are socially acceptable and even encouraged. These drugs are supposedly a way to unwind and be more effective in social situations. It is widely believed that using a substance is an acceptable way to improve mood or to feel better both physically and mentally. As social drinking and use begins to result in difficult consequences for the abuser and addict, these factors encourage continued use despite the evidence, even if early and not yet frequent, that they are slipping into abuse and addictive behavior.
It is also the case that many people who abuse alcohol and drugs are doing so associated with severe stress and/or other behavioral health issues. According to the Substance Abuse and Mental Health Services Administration , more than one in four adults living with serious mental health problems also has a substance use problem. Substance use problems occur more frequently with certain mental health problems including depression, anxiety, schizophrenia, and personality disorder.
Mental health problems and substance use disorders sometimes co-occur due to several factors. Certain individuals with a mental health problem may misuse these substances as a form of self-medication. In some cases mental health and substance use disorders share underlying causes such as changes in brain composition, genetic vulnerabilities, and early exposure to stress or trauma. We cannot overstate how adverse events as children and as adults result in mental health and substance abuse issues. In these instances the where with all to begin recovery is a much more complicated transition as the issues are multiple and interactive.
As the discipline neuroscience has advanced and focused in part on addiction a more complex understanding has emerged. In “Neuroscience: The Brain in Addiction and Recovery” posted on the website for the National Institutes for Alcohol Abuse and Alcoholism the authors use lay language to describe what we know today. They note that alcohol not only creates pleasurable reactions but also produces chemical imbalances in several specific areas and functions in the brain. Chronic, heavy drinking can impact brain regions involved in motivation, memory, decision-making, impulse control, attention, sleep regulation, and other cognitive functions. Once dependence and addiction develop and progress these changes can make it harder to stop drinking without assistance. Yes, dependence from the pleasure centers develops and later in the cycle creates withdrawal when absent, but changes to the brain from repeated use limit the normal, cognitive functions that might mediate a decision to stop in the face of all that pain.
Although we might focus on the intransigent case of long term abuse despite consequences, not all people have such a long and difficult period of active use. In a 2017 study, “Identifying “Hitting Bottom” among Individuals with Alcohol Problems: Development and Evaluation of the Noteworthy Aspects of Drinking Important to Recovery (NADIR)” posted on PubMed, the authors point out that “hitting bottom” is not a monolithic experience; each individual may experience their own tipping point if at all. They note that “This tipping point is often conceptualized in-part as a culmination of alcohol-related problems; however, this tipping point of hitting bottom may be different for each individual. One individual may perceive his or her drinking as hitting bottom after losing his or her job, spouse, and home, whereas another individual’s hitting bottom may consist of experiencing serious physical problems such as liver disease. Hitting bottom is a term used to describe a multidimensional, individualized construct that can range from a “high bottom” to a “low bottom”. One can substitute drugs for alcohol in that quote.
In some respects our neuroscience colleagues are parsing sophisticated, scientific language around things that are intuitive for many of us observing the behaviors of our friends with a substance use issue. One significant contribution is to note actual changes in brain chemistry. Historically we knew of “wet brain’ syndrome where someone who abused alcohol and other drugs for too long a period of time became mentally incapacitated. We now know that this physical phenomenon does not occur with one last ingestion of a substance that reaches a critical mass of toxicity. Rather, these brain changes occur over time, sometimes faster and sometimes slower, dependent on the physical make up of an individual. The significant contribution is knowing that one reason people with substance use disorder tolerate increasing levels of distress is that they are becoming less capable of mounting those intellectual tools and defenses that they need to make the changes that are required for recovery.
We have a friend who often says that most alcoholics and addicts don’t see the light; rather they feel the heat. People who find recovery often do so after some traumatic and dramatic event. This moment of fear, disruption, crisis forces a moment in which recovery seems like the best or perhaps the only option despite all their previous arguments to the contrary. From this beginning they may find a life without alcohol and drugs that they will come to cherish. We now know that the longer the individual may go with their using the more difficult it will be if and when that time comes.
Gene Gilchrist
September 2025
