Aditi Sridhar
While Euphoria, directed by Sam Levinson, has gained popularity for its glamorous portrayal of adolescent problems, there is truth underlying each of its narratives. As an integral character of the show, Rue Bennet's story is no different. In episode five of the second season, viewers are privy to a turbulent battle between Rue and her loved ones as they confront her relapse with oxycontin, an opioid. At the height of her withdrawal, there is a vulnerable scene that features the seventeen-year-old girl attempting to intimidate her mother, Leslie, after being caught for using drugs. Although the entire encounter is agonising, a specific accusation from Leslie to Rue is arguably the most excruciating: "You're not a good person, Rue" (Levison S., 2022). This statement sets the stage for an important debate concerning the extent of individuals' control over their addiction; is it a result of a series of selfish choices or a vicious inescapable cycle over which they have no control? Through a neuroscientific lens, this article will attempt to answer this question and thus conclude whether Rue was in control of her addiction or the victim of a disease.
The initial experience with an opioid is euphoric. When it enters the body, the opiate binds with mu-opioid receptors, on the surface of "opiate-sensitive neurons" (Kosten & George, 2002). Generally, these neurons are responsible for the rewarding feeling we receive from fundamental life processes, motivating survival (Gardner, 2011). However, when manipulated by such addictive narcotics, the brain is almost tricked into believing that ingesting the drug is a vital function. The mesolimbic reward circuit is triggered by the opioid and releases dopamine into the nucleus accumbens, signalled by the ventral tegmental area (Kosten & George, 2002). Dopamine-release provides feelings of pleasure, reward and motivation (Olguin, Guzman, et al., 2016). Thus, while individuals initially experience a high, they become tolerant to it with repeated use (Kakko, 2019).
Opioid tolerance is the need to increase the drug dosage at every subsequent intake to experience the same high (Kosten & George, 2002). With repeated subjection, the opioid receptors become decreasingly sensitive to stimulation, and the brain releases excess dopamine to counteract this effect (Kosten & George, 2002). The brain starts needing opioids to function normally. This stage is termed as opioid-dependence. Individuals face adverse physiological and psychological reactions without the drug, termed as withdrawal syndrome (Mistry, Bawor et al., 2014). Levinson skillfully portrays Rue’s withdrawal through emotional changes marked by her violent emotions and manipulative stance and physical symptoms of diarrhoea, palpitations, sweating, and yawning (Huecker, 2022).
Considering that opioids are self-administered, it is natural to wonder why individuals might subject themselves to such an experience. Thus, some researchers doubt the compulsivity of opiate addiction, mentioning that most individuals who are clinically diagnosed with addiction attain untreated sobriety by the age of thirty (Heyman, 2013). Thus, a positive correlation between quitting and choice is drawn, explicitly disapproving of the habit being considered a chronic disease (Heyman, 2013, Branch, 2011).
Functionally, opiates alter the structure of the ventral tegmental area through neuroplasticity (Langlois & Nugent, 2017). These changes are maladaptive, increasing the vulnerability for opioid dependence (Dacher & Nugent, 2011). However, critics of the disease model of addiction state that all chronic experiences alter synaptic plasticity translating to changed behaviour. Thus, no fundamental neurological quality indicates that opiate addiction is a disease (Branch, 2011). Instead, it should be viewed as the result of a series of myopic choices with individuals failing to consider the long-term consequences of temporarily satiating their immediate craving (Heyman, 2013).
This argument climaxes at the wasted investment on rehabilitation centers as individuals achieve sobriety via globally optimal choices driven by societal demands, without professional treatment (Branch, 2011). Since most addicts quit on their own, the changes in neuroplasticity must not be as binding as previously assumed (Heyman, 2013). Though this argument takes a perfectly logical stance, it is fundamentally unsound.
The claim that addiction to opiates is a consequence of poor decisions dismisses the formative neurological changes. Prolonged usage of opiates impairs decision making due to a damaged frontal cortex (Koob, 2015). This refutes the premise that individuals can make the 'right' decision to simply snap out of their addiction. The statement that most individuals choose sobriety at thirty is statistically erroneous, as it probably focuses on the general population rather than the clinical one (Heilig et al., 2021). Diagnostic unreliabilities have created room for misdiagnosing severe opioid addiction in only mildly addicted individuals. Less than 30% of those with a severe opioid addiction experience stable sobriety, refuting the ease with which individuals can choose to abstain from drugs (Heilig et al., 2021).
Even assuming that the clinical population was being considered, waiting for an individual to hit thirty and escape their addiction is still detrimental, since the mortality rate of those with opioid addiction is significantly greater than the general population (Heilig et al., 2021). Several environmental, sociological, and genetic risk factors contribute to opioid usage. For instance, at the age of fourteen, Rue was on the verge of losing her father to cancer when she took her first drug. Adolescents, due to increased stress, are vulnerable to developing addiction disorders of an already sensitive developing brain (Mistry et al., 2014). It would be unfair to write such individuals off as irresponsible and bar them from seeking effective treatment. While it is true that opioid dependence might begin with one wrong decision, it is naive to assume that all such individuals were completely healthy when making that first choice.
Those severely addicted to opioids experience an affective three-pointed vicious cycle whose stages are "the intoxication stage, withdrawal affect, and anticipation stage" (Koob, 2016). The basal ganglia control the intoxication stage where the individual experiences anxiety without the drug. Withdrawal affect is characterised by the deteriorating function of the reward system and an excess release of cortisol leading to stress (Kakko, 2019, Kosten & George, 2002). The anticipation stage features maladaptive decision making and behavioural inhibition, driving craving (Kakko, 2019, Mistry et al., 2014).
There is an apparent impairment of emotion regulation from the above neurological evidence. This explains Rue's behaviour during her withdrawal, desperately craving the drug, and unable to inhibit her behaviour or make rational decisions as a result. Rue wasn't looking at the bigger picture, not because she didn't want to or because it was difficult, but because she could not. Her brain had been so altered and diseased by neuroplastic changes facilitated by opiates that it was no longer healthy. Her mother's claim that Rue was hurting herself and the people she loved because she was not a good person is refuted by the neurobiological changes of the brain. There is sufficient evidence corroborating that a psychologically vulnerable brain typically makes the first choice to try drugs. Rue was subjected to a life-altering trauma, which led to a dependence on external substances to cope with her emotional pain. She was left unable to make choices and ended up in an almost-fatal situation. Thus, like most individuals addicted to opioids, Rue was also the victim of chronic disease.
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