Are we doing enough to tackle the rising cases of alcohol

addiction in the UK?

Abstract
Addiction has always been a point of controversy, particularly in regards to whether it is a
disease or a choice. Some argue that addiction is a choice because individuals have complete
control over their behaviour and decisions, such as in this case the decision to drink alcohol
or use drugs. However, over recent years, there have been significant advances in the Brain
Disease Model of Addiction (BDMA) that demonstrate distinctly recurring neurobiological
circuits as well as both physiological and cognitive changes in the brain, all of which
contribute to the compulsive, drug-taking behaviour of addicts.1 Recognising addiction as a
disease has profoundly positive consequences. This is because it can reduce the stigma
around the topic, leading to increased access to treatment and increased funding for research
on addiction, which can lead to the development of more successful treatments.

This is more needed than ever in light of the COVID-19 pandemic (March 2020-December
2021). The pandemic has had a profound impact on the cases of alcohol addiction and it has
resulted in notably increased levels of drinking and increased cases of relapse in UK adults.2
Budget cuts to drug and alcohol treatment services in 2013 means that NHS services are
likely to be unable to tackle the rising cases of addiction from the pandemic. Considering
addiction as a disease, this paper explores the Brain Disease Model of Addiction and the
effect of the COVID-19 pandemic on drinking habits within the UK. Moreover, this paper
examines the effect of rehabilitation on the brain and evaluates the treatment options offered
by the NHS, concluding that the quality and type of treatment provided by the NHS must be
improved, by increasing funding to further finance the resources necessary to support the
rising cases of alcohol addiction in the UK.

Methodology
Once I had come up with a topic, I began gathering sources and conducting research to come
up with a final project title. Addiction was a topic that interested me but I was keen to explore
it in the context of both healthcare and biology. I discovered key sources of information
online that narrowed my project focus to the surge in alcohol dependence cases after the
COVID-19 lockdown and its estimated potential cost to the NHS.

Online academic papers published in scientific journals as well as news articles from medical
and scientific websites were my key sources over the course of the dissertation. This meant
that the internet was a valuable tool, allowing me to find highly useful information from

1
Koob, George F, and Nora D Volkow. “Neurobiology of addiction: a neurocircuitry analysis.” The lancet. Psychiatry vol. 3,8
(2016)
2
Forward Trust: National Survey reports a surge in alcohol and gambling problems during the pandemic. Forward Trust {Website} 2021
<https://www.forwardtrust.org.uk/news-story/national-survey-reports-a-surge-in-alcohol-and-gambling-problems-during-the-pandemic/> Accessed
19/01/23
generally respected sources, such as the Royal College of Psychiatrists or the National Centre
for Biotechnology Information.

After extensive research on both the biological and medical side of addiction, I outlined three
sections to cover in my dissertation. For my first section, I would describe the Brain Disease
Model of addiction and the key changes that occurred in the brain as addiction develops. I
decided that this would be an important section as the understanding of addiction as a disease,
particularly a disease of the brain, has profound implications on how addiction is viewed by
the general public, which in turn impacts both the funding and research dedicated to
supporting addicts. My second section would then discuss the effect of the COVID-19
lockdowns on drinking habits, and explain why exactly addiction cases are rising in the UK.
My third section would then focus on the recovery, outlining the role of the brain in
rehabilitation and the treatments offered by the NHS.

Literature Review
Using the internet, I gathered a wide range of sources to deepen my understanding of
addiction and the NHS in order to provide a valid and conclusive judgement when evaluating
the rehabilitation treatments offered by the NHS. My sources included scientific and medical
journals, blogs and websites. Many of the studies that I referenced I had initially found from
the National Library of Biotechnology Information, a website approved and run by the U.S
government. The website is highly credible and provided me with reliable and accessible
information. I utilised a range of papers from scientific journals, such as the New England
Journal of Medicine. As the papers that I used are aimed for academics of the related field, I
concluded that the information provided would be reliable, as the papers have been published
from credible journals. Moreover, I also gathered information directly from the NHS website,
which as the publicly funded health system of the UK, provided me with reliable, accessible
and comprehensive information on addiction.

I also used national surveys and data from relevant charities such as the Forward Trust and
Alcohol Change UK, as well as graphs and statistics from the Organisation of National
Statistics (ONS), the recognised statistical institute of the UK. The charities that I used as
sources were those that aim to reduce alcohol misuse or support people suffering from drug
and alcohol addiction. This means that the purpose of these sources is to educate and raise
awareness on the issue of addiction. As a result, I took into consideration the possibility that
the information provided by charities such as Alcohol Change UK may be biassed and
potentially exaggerate the data to raise more awareness. As a result, I made sure to balance
the data I used from the non-profit websites with data from the ONS, which is neutral as its
purpose is to inform.
Main Findings

Section 1
The definition for addiction often varies. The National Health Service (NHS) defines
addiction as ‘not having control over doing, taking, or using something to the point where it
could be harmful to (the addict)’’.3 This definition groups drug addiction with compulsive
behaviours not involving substances such as gambling, internet usage and shopping. The
definition used by the National Institute of Drug Abuse narrows down drug addiction to “ a
chronic relapsing disorder characterised by compulsive drug seeking and use despite adverse
consequences’’.4 The American Medical Association outright defines addiction as a disease,
“as a treatable, chronic medical disease”.5 This definition also does not distinguish between
substance addiction and behavioural addiction, which perhaps reflects the stark similarities
between the two, save for the physiological indicators and actual substance abuse present in
drug addiction.6

As a result, in this paper, I will use the definition of addiction as described by the American
Medical Association, as it is general and strongly linked to the Brain Disease Model of
Addiction (BDMA), which I will be discussing in this section.

Addiction is characterised as a neurological disorder according to the BDMA. This is because

drugs of abuse, i.e. alcohol, operate by exploiting and altering the brain’s mesolimbic
dopamine pathway, which eventually leads to dependence on and compulsive use of the drug,
not for renewed pleasure but to stave off symptoms of withdrawal.7

The brain’s reward circuit

The brain’s reward circuit, located in the limbic system, involves a set of structures that
regulate an individual’s ability to feel pleasure. The reward circuit can be activated through
natural behaviours such as exercise and sex, but also through consumption of addictive drugs.

In the reward circuit, the neurotransmitter dopamine is released by dopaminergic neurones

and consequently received by proteins called dopamine receptors in the process of synaptic
transmission.8 When encountering a reward, the presynaptic cell releases a larger amount of
the neurotransmitter, causing a sharp increase in dopamine which results in heightened levels
of dopamine in the brain. This signals to the brain that the action causing the release of
3
The National Health Service: Addiction: what is it?. National Health Service {Website} 2018,
<https://www.nhs.uk/live-well/addiction-support/addiction-what-is-it> Accessed 12/11/22
4
NIDA. "Drug Misuse and Addiction." National Institute on Drug Abuse , 13 Jul. 2020,
<https://nida.nih.gov/publications/drugs-brains-behavior-science-addiction/drug-misuse-addiction> Accessed 12 Nov. 2022.
5
AMA “What is the definition of Addiction?” American Medical Association 15th Sept 2019
<https://www.asam.org/quality-care/definition-of-addiction> Accessed 11/01/23
6
Alavi, Seyyed Salman et al. “Behavioral Addiction versus Substance Addiction: Correspondence of Psychiatric and
Psychological Views.” International journal of preventive medicine vol. 3,4 (2012): 290-4.
7
Neuroscience: Addiction and the brain, Youtube, uploaded by Carleton University, 4th Jan 2019.
<https://www.youtube.com/watch?v=3ndOL0G-YRg>
8
The Reward Circuit: How the brain responds to natural rewards and drugs, uploaded by the National Institute of Drug Abuse,
18 Nov,2014, <https://www.youtube.com/watch?v=DMcmrP-BWGk&t=104s>
dopamine and the consequent feeling of euphoria is important and should therefore be
remembered and repeated.

This is how beneficial behaviours such as eating, socialising and sex are reinforced in the
brain. The euphoric feeling is subsequently associated with the action responsible for it, as
well as any environmental cues present.9 This mechanism also occurs with addictive drugs.
When there is repeated exposure to the drug, dopamine neurones begin releasing dopamine in
anticipation of the reward, triggered by cues, as well as in response to the reward itself. This
drug-induced release of dopamine leads to neuroplastic changes associated with learning and
memory. Consequently, environmental and internal stimuli may come to trigger a conditioned
release of dopamine, predicting the delivery of the reward, contributing to a strong craving
for the drug.10

3 stages of addiction

George F Koob and Nora D Volkow (2010,2016)11 conceptualised addiction as a cycle

composed of 3 stages with distinct recurring neurobiological circuits:
1) Binge and Intoxication
2) Withdrawal and Negative Affect
3) Preoccupation and Anticipation

Binge and Intoxication

The initial consumption of the addictive drug causes the consumer to feel a sense of euphoria
far greater than the feeling caused by any naturally rewarding behaviour such as eating,
exercise or sex. The exact cause of this euphoric feeling has not yet been determined, but it is
believed it results from the combined release of dopamine and endorphins, the body’s natural
opioids. The drug targets the ventral tegmental area (VTA) of the brain, which causes the
release of dopamine into the nucleus accumbens.12 The association of this feeling of euphoria
with the action of taking the drug, as well as with environmental and internal cues, is believed
to underlie the imminent drug-seeking behaviour, which eventually leads to drug-seeking
becoming a habitual, automatic behaviour, i.e a compulsion. 13

Withdrawal and Negative Effect

9
NIDA. "Drugs and the Brain." National Institute on Drug Abuse, 22 Mar. 2022,
<https://nida.nih.gov/publications/drugs-brains-behavior-science-addiction/drugs-brain> Accessed 18 Nov. 2022.
10
Volkow, Nora D. and Koob, George F. and McLellan, A. Thomas. “Neurobiologic Advances from the Brain Disease Model of
Addiction” New England Journal of Medicine vol 374,4 (2016)
11
Koob, George F, and Nora D Volkow. “Neurobiology of addiction: a neurocircuitry analysis.” The lancet. Psychiatry vol. 3,8
(2016)
12
Neuroscience: Addiction and the brain, Youtube, uploaded by Carleton University, 4th Jan 2019.
<https://www.youtube.com/watch?v=3ndOL0G-YRg>
13
Koob, George F, and Nora D Volkow. “Neurobiology of addiction: a neurocircuitry analysis.” The lancet. Psychiatry vol. 3,8
(2016)
Research14 has found that in chronic drug users, drug consumption triggers much smaller
increases in dopamine than in people who do not have an addiction. Consequently, the
consistent drug-induced release of dopamine causes the brain’s reward system of the addicted
individual to become much less sensitive to stimulation by rewards. The overactivation and
consequent desensitisation of the brain’s reward system means that people with addiction are
never able to achieve the same level of euphoria that they had experienced during the initial
consumption of the drug.

Similarly, the desensitisation of the reward circuit means that the brain no longer responds
appropriately to natural rewards, e.g food, sex and socialising. This causes a decrease in
motivation to activities that were once previously stimulating, such as relationships.
Therefore, when the individual is not high, the dopamine signalling in the brain is lower than
the set point, which provokes the onset of depressive and negative feelings.

Repeated exposure to drugs of abuse leads to changes in a group of midbrain structures called
the extended amygdala. These systems start to release stress hormones, which “gives rise to
the highly dysphoric phase of drug addiction”.15 This stage occurs when the effect of the drug
has worn off, or during withdrawal. As a result, the drug is no longer consumed to feel
pleasure, but to temporarily escape the adverse feelings and symptoms of withdrawal.

Preoccupation and Anticipation

Chronic drug use leads to the compromise of structures in the frontal lobe, resulting
particularly in dysfunction of the prefrontal cortex, the region of the brain responsible for
cognitive control functions, most importantly in this case, impulse inhibition. Furthermore, a
2018 study16 conducted in Indiana University used Magnetic Resonance Imaging (MRI)
scans to reveal that in the brains of people with alcohol abuse disorders, there is a decrease in
level of glutamate, (the most abundant excitatory neurotransmitter in our brain and nervous
system), when exposed to cues, i.e photos associated with drinking.

This demonstrates that environmental cues modulate glutamate levels in the brain. As a
result, the impaired signalling of both dopamine and glutamate significantly weakens impulse
inhibition, explaining why addicts struggle so much to refrain from their impulse to drink or
take drugs despite expressing a sincere desire to stay sober.

Consequently, addiction can very easily be considered a brain disease due to the
overwhelming amount of evidence demonstrating the effect of drugs on key structures in the
frontal lobe and on the brain’s reward circuit. These structures that become compromised as a
result of drug abuse are responsible for the cognitive control functions resulting in impulse
control, when in relation to addicts, usually referred to as ‘willpower’ or ‘self-control’. These

14
Volkow, N., Tomasi, D., Wang, GJ. et al. “Stimulant-induced dopamine increases are markedly blunted in active cocaine
abusers.” Mol Psychiatry 19, 1037–1043 (2014).
15
Volkow, Nora D. and Koob, George F. and McLellan, A. Thomas. “Neurobiologic Advances from the Brain Disease Model of
Addiction” New England Journal of Medicine vol 374,4 (2016)
Cheng, Hu et al. “Effects of Alcohol Cues on MRS Glutamate Levels in the Anterior Cingulate.” Alcohol and alcoholism
16

(Oxford, Oxfordshire) vol. 53,3 (2018): 209-215.

advances now tie the characteristic atypical, impulsive and almost uncontrollable behaviours
of addicts to neurobiology. The desensitisation of the brain’s reward circuit leading to
withdrawal symptoms and the dysregulation of key brain regions are steps further in
understanding the science behind addiction.

Nowadays, although the Disease Model of Addiction is largely accepted, it is worth noting
that this model remains a point of dispute, with some psychologists taking a different
approach. For example, the neuroscientist Marc Lewis, who has tackled addiction himself,
has argued against the disease model, proposing that addiction is a behavioural problem,
something that is learned, not a disease.17 Similarly, the psychologist Jeffery Schaler argued
at the start of the century that addiction is a choice and to say otherwise is simply ‘’clinical
folklore’’ and discourages addicts from taking responsibility for their actions18.

Despite this, the significance of defining addiction as a brain disease is evident when we
consider the implications this has on society, ranging from the societal attitudes towards
addiction to the funding of rehabilitation treatments.

In the beginning of the 20th century doctors viewed addiction as a moral failure, a choice
made by people who lack the willpower to combat their addiction. However, it is now well
understood that the complex combination of biological, genetic, psychological, behavioural
and environmental factors all contribute to causing varying degrees of vulnerability to
addiction. Furthermore, the physiological changes that occur within the body (such as
discussed in the 3 stages of addiction) provide undeniable evidence for addiction being a
“treatable, chronic medical disease involving complex interactions among brain circuits,
genetics, the environment, and an individual’s life experiences”19.

17
Jenny Valentish : “Why addiction isn’t a disease, but a result of ‘deep learning’ “ The Age {Website} 2015
<https://www.theage.com.au/national/why-addiction-isnt-a-disease-marc-lewis-seo-here-20150810-givho9.html>
Accessed 11/01/23
18
Jeffery A. Schaler “Addiction is a choice” The Psychiatrist Times. vol. 19, 10 (2002)
19
AMA “What is the definition of Addiction?” American Medical Association 15th Sept 2019
<https://www.asam.org/quality-care/definition-of-addiction> Accessed 11/01/23
Section 2
Attitudes towards alcohol have invariably changed over the past century, with average
alcohol consumption rising and falling repeatedly. Data showed that alcohol intake had
started to steadily decline since reaching a peak during the mid 2000s.20

Prior to the pandemic, average alcohol consumption was decreasing in the UK, with the
proportion of adults drinking alcohol on a weekly basis in England falling from 52% in 2015
to 48% in 2019. The adults in the age demographic 55-74 were the most likely to report
drinking alcohol weekly, 58%, compared to 30% of the younger generation aged 16-24,
demonstrating that the younger generation may be consuming less alcohol than in the past.
Furthermore, there has been a notable increase in the proportion of non-drinkers (16+) in the
UK population, increasing from 17% in 2015 to 20% in 2019.21 This demonstrates that in
2019, alcohol consumption in the UK appeared to be on a downward trajectory, particularly
evident in how people aged 16-24 were consuming less alcohol on average than older age
groups.

However, between March of 2020 and December of 202122, The UK government introduced,
then relaxed, and later reintroduced a series of lockdown measures and restrictions aimed at
minimising the spread of COVID-19 and at preventing the NHS from being overwhelmed.
The impact of the three lockdowns on alcohol consumption in the UK has been devastating.

The results of a national survey conducted by YouGov indicated elevated levels of excessive
drinking and relapse a year into the pandemic. The data concluded that as many as 20% of
UK adults may be drinking more due to the three lockdowns. Furthermore, 17% of survey
respondents believed that they were experiencing further stress and problems as a result of
their increased drinking, related to work, sleep, relationships and even physical withdrawal
symptoms. Of the respondents who had identified as being in recovery from addiction prior
to the pandemic, 37% reported a relapse of their addictive behaviour a year into the
coronavirus lockdowns and restrictions. Both of these results demonstrate the sustained high
in drinking habits from the survey conducted in May of 2020.23 Finally, out of the adults that
were surveyed who had identified a cause for concern with their addictive behaviour, 36%
believed that they would require support to tackle the problems that they were experiencing,

20
Alcohol Change UK: Drinking Trends in the UK. Alcohol Change UK {Website} 2019
<https://alcoholchange.org.uk/alcohol-facts/fact-sheets/drinking-trends-in-the-uk> Accessed:18/01/23
21
Drink Aware: Alcohol Consumption UK. Drink Aware {Website} 2021,
<https://www.drinkaware.co.uk/research/alcohol-facts-and-data/alcohol-consumption-uk#:~:text=Adults%20aged
%20between%2055%20and,decreased%20from%2052%25%20in%202015> Accessed:18/01/23
22
Institute for Government: Timeline of UK Government coronavirus lockdowns and restrictions. Institute for
Government {Website} 2022
<https://www.instituteforgovernment.org.uk/data-visualisation/timeline-coronavirus-lockdowns> Accessed
18/01/23
23
Forward Trust: National Survey reports a surge in alcohol and gambling problems during the pandemic.
Forward Trust {Website} 2021
<https://www.forwardtrust.org.uk/news-story/national-survey-reports-a-surge-in-alcohol-and-gambling-problems-d
uring-the-pandemic/> Accessed 19/01/23
equating to 930,000 adults in the UK population, a surge of 24% from the survey conducted
in 2020.24

These results undoubtedly support concerns regarding the impact of the pandemic on the
cases of alcohol addiction in the UK, and the associated deterioration of mental health. It
should also be noted that a significant portion of the population reported a decrease or no
change in their drinking habits during the pandemic. People who drank little to a moderate
amount of alcohol before the pandemic tended to drink less during lockdown, whereas those
that were already heavy drinkers reported that their drinking problem had exacerbated over
lockdown. 25

Why did people drink more during the lockdown?

Surveys conducted by Drink Aware discovered that the most common reasons for the
increasing drinking during lockdown were:
1) Having more free time available (52%)
2) Having less structure to their day (50%)
3) To help with stress or anxiety (37%)
4) To relieve boredom (36%) 26

The stress and anxiety experienced by the majority of the UK population could very well be
correlated to direct financial consequences of the pandemic, as over ¼ of the workplace were
furloughed at the start of lockdown. 27 This meant that worries related to housing costs and
the economy were ever more prevalent.

Furthermore, the impact of the pandemic on loneliness and social isolation has also been
correlated with the worsening mental health of many people over lockdown. Cross-sectional
results from the COVID-19 Psychological Well-being study concluded that rates of loneliness
during the initial phase of lockdown were high. This is because quarantine or any form of
social isolation proves a challenge for individuals to face as it is incongruent with the social
nature of humans. Lack of social engagement results in a range of harmful psychological
reactions, one of which being loneliness. The study also demonstrated that rates of loneliness
were more prevalent in individuals aged 18-24, indicating that young people are
disproportionately affected by social isolation. 28

24
Forward Trust: Impact of lockdown on recovery. Forward Trust {Website} 2021
<https://www.forwardtrust.org.uk/news-story/national-survey-reports-a-surge-in-alcohol-and-gambling-problems-during-the-pan
demic/> Accessed 19/01/23
25
University of Sheffield: Shift in alcohol consumption during the pandemic could lead to thousands of extra deaths in England.
University of Sheffield {Website} 2022
<https://www.sheffield.ac.uk/scharr/research/themes/alpol/alcohol-group-publications#England%20reports> Accessed 19/01/23
26
Emma Caterall: Who has been drinking more than normal throughout Covid-19 restrictions? Drink Aware {Website} 2020
<https://www.drinkaware.co.uk/news/who-has-been-drinking-more-than-normal-throughout-covid-19-restrictions#_ftn2>
Accessed 19/01/23
27
Office of National Statistics: An overview of workers who were furloughed in the UK. Office for National Statistics {Website}
2021
<https://www.ons.gov.uk/employmentandlabourmarket/peopleinwork/employmentandemployeetypes/articles/anoverviewofwork
erswhowerefurloughedintheuk/october2021>
28
Jenny M. Groarke et al: Loneliness in the UK during the COVID-19 pandemic: Cross-sectional results from the COVID-19
Psychological Wellbeing Study. PLoS ONE 15(9): e0239698. <https://doi.org/10.1371/journal.pone.0239698> Accessed
25/01/23
Section 3
Funding issues and the effect of rising cases on the NHS
Since 2013, there have been drastic budget cuts to publicly funded drug and alcohol services.

Figure 1: Rates of drug misuse deaths increased in 202129

A BBC analysis estimated that £162 million had been cut from treatment services from
2013-2018. This lack of funding means that people struggling with addiction are unable to
get the help and support they need, with phone calls to drug treatment hotlines going
unanswered. 30

Furthermore, Figure 1 above from the Office of National Statistics (ONS) indicates that the
rates of drug misuse deaths in England and Wales have increased since the start of the
century, with a sustained surge in deaths since 2013. This suggests a negative correlation
between the cut to funding for treatment services and deaths related to drug misuse, which
certainly implies that more funding is urgently needed.

The effect of the budget cuts on drug and alcohol treatment services means that addiction
services are undoubtedly ill-equipped to tackle the surge in alcohol addiction cases resulting
from the pandemic. The Royal College of Psychiatrists have called for a multi-million pound
boost to addiction services in order to deal with the increasing number of people drinking at a
higher risk due to the pandemic.31
29
Office of National Statistics: Deaths related to drug poisoning in England and Wales: 2021 registrations. Office for National
Statistics {Website} 2021
<https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoison
inginenglandandwales/2021registrations> Accessed 23/01/23
30
David Rhodes: Drug and Alcohol services cut by £162 million as deaths increase. BBC {Website} 2018
<https://www.bbc.co.uk/news/uk-england-44039996> Accessed 23/01/23
31
The Royal College of Psychiatrists: Addiction services not equipped to treat the 8 million people drinking at high risk during
pandemic, warns Royal College. The Royal College of Psychiatrists {Website} 2020
It has been estimated that the rising cases of alcohol addiction may eventually have a
profound effect on the NHS. This is because the increase in alcohol consumption over the
lockdown will have a sustained impact in the future, likely leading to an increased number of
hospital admissions, additional cases of alcohol-related disease such as liver cirrhosis, and
premature deaths related to drug misuse, as outlined in Fig. 1.
A report by the University of Sheffield examined how hospital admissions and deaths related
to alcohol consumption may increase over the next 20 years. It was estimated that with the
worst-case scenario, there will be almost 100,000 additional hospitalisations and over 25,000
additional deaths, with an estimated expense of £5.2 million to the NHS. Moreover,
researchers from the Institute of Alcohol studies and specialists from HealthLumen projected
that if alcohol consumption did not return to pre-pandemic patterns, there will be almost
150,000 further cases of alcohol-related disease, e.g liver cirrhosis and breast cancer and
1,000 additional premature deaths, which is projected to cost NHS £1.2 billion. 32

This paints a worrying picture for the future of the NHS, especially considering its current
state, already under enormous pressure from the backlogs of operations and appointments
since the pandemic.

Rehabilitation, the brain and the NHS

Addiction is certainly a treatable disease. Although relapse is commonplace, it can be
considered a part of the recovery process, which is long and difficult, hence why addiction is
referred to as a ‘chronic’ disease. The potentiality for an addict to recover is evident when
reviewing the impact of rehabilitation treatment on the brain, in particular when reviewing
the role of neuroplasticity.

What is neuroplasticity?
Neuroplasticity refers to our brain’s ability to change its structure and function as a result of
life experiences, repeated behaviours, thoughts and emotions. 33 Neural pathways refers to
connections between neurons in the brain and they are formed based on the behaviours that
we perform. If a certain behaviour is performed more frequently, the number of connections
within a specific neural pathway is increased. In repeated behaviours, neurones in that
specific neural pathway are more active and communicate much more frequently, which
strengthens their connections with other neurons. This facilitates communication and
consequently makes it much easier for us to perform that behaviour, resulting in the

<https://www.rcpsych.ac.uk/news-and-features/latest-news/detail/2020/09/14/addiction-services-not-equipped-to-treat-the-8-mill
ion-people-drinking-at-high-risk-during-pandemic-warns-royal-college> Accessed 23/01/23

32
University of Sheffield: Shift in alcohol consumption during the pandemic could lead to thousands of extra deaths in England.
University of Sheffield {Website} 2022
<https://www.sheffield.ac.uk/scharr/research/themes/alpol/alcohol-group-publications#England%20reports> Accessed 19/01/23
33
Terry Hurley: Neuroplasticity and its role in Addiction and Recovery. English Mountain {Website} 2022
<https://englishmountain.com/neuroplasticity-addiction-recovery/#:~:text=The%20Role%20of%20Neuroplasticity%20in%20Addi
ction%20Recovery&text=When%20a%20person%20in%20recovery,new%20pathway%20strengthens%20through%20neuropla
sticity.> Accessed 25/01/23
formation of habits. 34 This process occurs in the brain of addicts, where regular consumption
of a drug becomes a habitual behaviour, becoming easier to carry out and much harder to
stop.

As discussed in Section 1, chronic drug use causes desensitisation of the brain’s reward
system and dysregulation of key brain regions that are responsible for cognitive control
functions such as impulse control. This results in withdrawal symptoms and eventual
dependence on the drug, paired with the compulsive, drug-seeking behaviour of addicts.
Consequently, neuroplasticity contributes to the onset of addiction as it leads to more
habitual, and eventually more compulsive drug consumption, resulting in the learning of
maladaptive patterns of behaviour.

However, neuroplasticity also plays a crucial role in addiction recovery. Rehabilitation

treatment aims to reverse these changes in the brain caused by chronic drug use, in which the
process of neuroplasticity plays a key role. Rehab treatment can promote the growth of new
neural connections and create new neural pathways by encouraging people in recovery to
replace the harmful habit of drug consumption into positive habits such as exercise or
volunteering.

The impact of cognitive behavioural therapy (CBT) also works hand in hand with
neuroplasticity. Behavioural therapies such as CBT and contingency management encourage
individuals to relearn healthy patterns of behaviour, so as the new positive habit is
consistently repeated, the new neural pathway continues to strengthen. Consequently, while
the individual in recovery is abstaining from drugs, the neural pathways that contributed to
the habit of drug use are weakened since they are not being reinforced. 35

34
Danielle Riley: Understanding Neural Pathways and Behaviour Change. The Soulful Psych {Blog} 2018
<https://thesoulfulpsych.com.au/understanding-neural-pathways-and-behaviour-change/> Accessed 25/01/23
35
Maria Mavrikaki: Brain plasticity in drug addiction: Burden and benefit. Harvard Health {Website} 2020
<https://www.health.harvard.edu/blog/brain-plasticity-in-drug-addiction-burden-and-benefit-2020062620479> Accessed
26/01/23
Changes in the brain during and after addiction
Several brain scan studies have demonstrated a significant difference in the brain of an
addict as compared to the brain of a healthy person, i.e a person who is not suffering from an
addiction. In particular, some of these scans have been able to capture the brain in recovery
from an addiction.

Figure 2: Images illustrating the density of dopamine transporters in the brain of a healthy person, of a meth user
36
after one month of abstinence, and of a meth user after 14 months of abstinence.

Figure 2 shows three brain scans: the scan on the left showing the brain of a healthy person,
the scan in the middle of a meth user after a period of 1 month abstinence, and the scan on
the right of a meth user after 14 months of abstinence. The three scans highlight dopamine
receptors, with areas of high density indicated in red.

As discussed in section 1, chronic drug use causes the brain’s reward system of an addicted
individual to become much less sensitive to stimulation. This is what results in the decreased
density of dopamine receptors in the brain of consistent drug users, as demonstrated in the
brain scan of the user after 1 month of abstinence, which shows severely reduced levels of
receptors. It should be noted that other drugs, including alcohol, have the same effect on the
brain. Most strikingly, the second and third scans illustrate neuroplasticity in effect and thus
the brain’s ability to recover after a long period of abstinence from drugs.

Treatment options offered by the NHS

Typically, the first step for an addict is to make an appointment with a general practitioner
(GP), where the patient and doctor can discuss the different options available. This
appointment would also allow the GP to assess the patient’s drinking habits, using tests such
as the Alcohol Use Disorders Identification Test, (AUDIT) a widely used screening test
which was originally developed by the World Health Organisation (WHO), then modified for
use in the UK. The AUDIT consists of 10 questions, such as “How often during the last year
have you had a feeling of guilt or remorse after drinking?” and the answer is recorded on a

36
NIDA. "Treatment and Recovery." National Institute on Drug Abuse {Website}, 22 Mar. 2022,
<https://nida.nih.gov/publications/drugs-brains-behavior-science-addiction/drugs-brain> Accessed 18 Nov. 2022.
scoring system from 0-4, with 4 being the most frequent or recent. The tally of the score for
each answer allows both the patient and doctor to assess the degree of dependence, with a
score of 20 or more indicating a possible addiction.37

Afterwards, if GPs deem the patient suitable, they can refer them for counselling which
consists of talking therapies such as CBT. Although CBT has been found to be an effective
form of treatment 38, waiting times for individual counselling sessions are usually long and it
can sometimes take up to 2 months before treatment begins. The waiting period for
counselling treatments frequently serves as a barrier for those seeking treatment as prolonged
periods of waiting can lead to people giving up on the recovery process, only to continue
drinking. 39 For more complex addictions GPs can refer the patient to specialist services.

Other publicly funded treatments options include medically assisted detox and prescription of
medical drugs to aid the process of sobriety. For alcoholics there are 2 main types of
medicines prescribed by the NHS to help recovery:
1) Medicines, often anti-anxiety medication, used to treat symptoms of alcohol
withdrawal. The most commonly prescribed of these medicines is chlordiazepoxide,
known as librium. This medication is prescribed in reducing doses over a shorter time
frame.
2) Medicines that reduce urges to drink, such as acamprosate and naltrexone. These
drugs help the patient overcome their impulses to drink, and are often taken in
conjunction with counselling or post-detoxification. They are given at a fixed dose for
a period of 6-12 months.40

Medically assisted detox is a treatment method that tends to be required for people who have
experienced an extended period of heavy drinking. Detoxification from harmful drugs such as
alcohol can be dangerous and may even prove fatal if attempted alone, so this process is often
supported by a doctor or nurse to allow the patient to gradually and safely cut down on their
drinking, and it can be assisted with medicines like those mentioned above. 41

The NHS could also refer patients to private residential rehabilitation programmes as a last
resort due to their fees, which may be subsidised by the government.

37
NHS: Alcohol Misuse. National Health Service, {Website} October 2022 <https://www.nhs.uk/conditions/alcohol-misuse/>
Accessed 30/01/23
38
McHugh, R Kathryn et al. “Cognitive behavioural therapy for substance use disorders.” The Psychiatric clinics of North
America vol. 33,3 <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2897895/>
39
Redko, Cristina et al. “Waiting Time as a Barrier to Treatment Entry: Perceptions of Substance Users.” Journal of drug issues
vol. 36,4 (2006)
<https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2396562/#:~:text=The%20waiting%20period%20(including%20being,%2C%20
%26%20Hayes%2C%201998)>
40
NHS: Alcohol Misuse. National Health Service, {Website} October 2022 <https://www.nhs.uk/conditions/alcohol-misuse/>
Accessed 30/01/23
41
NHS: Alcohol Misuse. National Health Service, {Website} October 2022 <https://www.nhs.uk/conditions/alcohol-misuse/>
Accessed 30/01/23
Evaluation of NHS treatments

People suffering from alcohol addiction or dependency tend to present with comorbidities
and usually suffer from depression and anxiety as well. The counselling services offered by
the NHS utilise talking therapies such as CBT that intend to combat the depression and
anxiety typically serving as root causes for addiction.

However, a study carried out by the University of York found that 53% of NHS patients
relapsed, expressing symptoms of depression and anxiety within a year after completing Low
Intensity Cognitive Behavioural Therapy (LICBT). They also found that over 70% of the
relapse events occurred within the initial 6 months after treatment. 42 These results indicate
that patients are likely being discharged too early on in the recovery process. As a result,
patients that are still displaying signs of depression towards the end of their treatment have an
increased chance of relapse within the next few months. The importance of continued
monitoring of patient’s well being, along with the need for relapse prevention are evidently
highlighted by this study. This has significant repercussions for patients with addictions, as
these findings illustrate the short-lived impact of NHS provided behavioural therapies.

Another key issue that serves as a barrier to patient recovery is the disjointed coordination of
treatment provided by primary care and specialist substance-misuse services. The budget cuts
mentioned previously (see Funding issues and the effect on the NHS) have meant that
specialist services are no longer available from general practices. Consequently, patients can
no longer be shared between primary care and specialist addiction services, negatively
impacting the effectiveness of addiction management and recovery. This is because patients
requiring prolonged treatment are receiving fragmented care, as there is not enough time,
resources or funding to provide a sole treatment coordinator. 43

How to improve
In order to improve NHS treatments for addiction, I would first recommend more frequent
reviews of the long-term effectiveness of recovery treatments. The talking therapies offered
by the NHS have primarily resulted in short-term, temporary rehabilitation, indicating the
need for a revision of these behavioural therapies. It is clear that there ought to be consistent
modifications to accommodate for the decreasing effectiveness of treatments as services
become increasingly overwhelmed. For example, a recent trial conducted in Doncaster has
highlighted a significant improvement in patient recovery after implementing an updated
version of antidepressant therapy. This modification was based on behavioural activation
therapy, which proposes that engaging in positive, fulfilling activities can improve mental
health and replace the self-destructive behaviours characteristic of those with

42
Shehzad Ali et al: How durable is the effect of low intensity CBT for depression and anxiety?. Science Direct: vol: 94, 1-9
(2017) <https://www.sciencedirect.com/science/article/abs/pii/S0005796717300840>
43
Allie Anderson: Breaking the habit: tackling rising cases of addiction in primary care. Nursing in Practice {Website} 2021
<https://www.nursinginpractice.com/clinical/addiction-and-mental-health/breaking-the-habit-tackling-rising-cases-of-addiction-in-
primary-care/> Accessed 02/02/23
substance-misuse disorders. This therapy is also supported by the principles of neuroplasticity
( see Rehabilitation, the brain and the NHS), conveying an underlying link between
behavioural therapies and the brain.

Secondly, it is evident that the NHS ought to improve coordination of care between primary
care providers and addiction specialists or therapists. This has been largely impacted by the
series of budget cuts to addiction services. Limited communication between primary and
secondary care providers has been shown to result in several detrimental consequences.
These include the patient being left dissatisfied, discontinuity of care and the inefficient use
of already limited resources. 44 However, in order to have coordinated provision of care, there
must be sufficient funding to supply the resources that are needed to appoint a sole treatment
coordinator, or to ensure that addiction specialist doctors are available from general practices.
Furthermore, increased funding is also necessary to decrease the number of patients suffering
from addiction still waiting on treatment and support from counselling services.

Conclusion
This paper concludes that we are not doing enough to support the rising cases of alcohol
addiction in the UK. The limited funding and its impact on the quality of treatment provided,
combined with the surge in cases due to the pandemic, means that NHS services are
undoubtedly unprepared and unequipped to tackle the rising cases of alcohol addiction.

It is evident that the pandemic has had a profound impact on alcohol misuse problems across
the UK. The increased alcohol consumption of many UK adults over the course of the
COVID-19 lockdown will have a sustained impact on NHS services and it has been estimated
that this will cost the NHS £1.2 billion. This accounts for the surge in alcohol-related diseases
if drinking does not return to pre-pandemic patterns. Furthermore, the series of budget cuts
that took place in 2013 to 2018 have had a critical effect on the quality and consistency of
care provided to patients reporting problems with addiction. In addition, the current
counselling treatments offered by NHS services are largely seeing short-term impacts.
Relapse rates after the provision of LICBT have been found to reach 53% 6 months
post-treatment, suggesting either the treatment is ineffective in the long-run or that patients
are being released too soon. Eitherway, both explanations are rooted in the lack of resources
available to update therapy treatments or to extend provision of care.

Moreover, the model of addiction as a neurobiological disease will pave the way for newer,
more efficient treatments for patients. This is because knowing how the brain changes as drug
dependence develops will improve understanding of the complex nature of addiction as well
as its deep-rooted effects on the brain, body and behaviour. Neuroplasticity plays a crucial
part in not only the onset of addiction, but during the recovery process as well. This
demonstrates the overriding role of the brain in addiction and recovery and consequently its
importance in addiction research.

44
P.Vermeir et al. “Communication in Healthcare: a narrative view of the literature and practical recommendations” The
International Journal of Clinical Practice vol: 69, 11 (2015)
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