Why Change People, Places, and Things in Early Recovery?

Alcoholics Anonymous has a popular adage that those in recovery from addiction should change "people, places, and things” in order to maintain sobriety. While many people have heard this slogan, not as many are familiar with the neuroscience behind it. Why should people in early recovery avoid the things they previously associated with their substance use? It's not just about "resisting temptation"; instead, it’s all about conditioning.

How the Brain Processes Reward

The brain is fascinatingly sophisticated. One of its more complex functions is to take notice of those stimuli that trigger reward (or the release of particular neurotransmitters in the mesolimbic dopaminergic pathway responsible for wanting and liking; Berridge & Kringelbach, 2015). The amygdala and hippocampus are implicated in the creation of emotional memories that record which stimuli are associated with the experience of reward and pleasure (Koob, 2009; Simpkins & Simpkins, 2013). For example, eating activates the brain’s reward system, so the brain learns that tasty food is associated with positive experiences. Once an association is made between a stimulus and reward, the individual is motivated to pursue that stimulus again (e.g., to eat again in the future).

In the same way, using a drug of abuse (e.g., cocaine) stimulates the reward system, yet the activation is more powerful than any natural stimuli, such as food or sex. Therefore, the brain quickly learns that the drug leads to euphoric or pleasurable feelings, and the individual is motivated to seek out and use the drug again in the future. An association is made between the drug and reward (and stored as an emotional memory), and this process is called conditioning.

What is Conditioning?

Simply put, conditioning occurs when the brain learns to associate specific stimuli with the experience of reward. One outcome of the process of conditioning is that the brain begins to anticipate reward in the presence of those things that have been consistently paired with the stimulus (called reward cues; Arias-Carron et al., 2020).

For example, if an individual consistently drinks alcohol in a particular chair in the living room, the brain begins to anticipate the euphoric feelings associated with drinking upon seeing the living room chair. The individual may even feel a hint of reward (triggered by dopamine release) when he or she enters the living room and sees the chair, even though no alcohol has been consumed. A pairing has taken place between the living room chair and the euphoric effects of alcohol, and the brain has learned this association. This is the process of conditioning, and the chair has become a conditioned stimulus signaling to the brain that a reward is coming. Although there is nothing neurobiologically rewarding about the sight of a living room chair in and of itself, since it has been continuously paired with drinking, the brain responds to the chair with a heightened sense of anticipation for reward.

In the same way, numerous sights, sounds, smells, and objects that are routinely paired with drug use become conditioned stimuli and trigger the brain’s anticipation of reward. These conditioned stimuli or reward cues can be extremely diverse, including all contextual and environmental features that have been repeatedly associated with drug use (Volkow & Morales, 2015), such as a medicine cabinet, spoon, lighter, cash, street sign, particular corner of a neighborhood, time of day, a certain scent, or a myriad of other sensory input.

Cues and Cravings

In light of the process of conditioning, when a person stumbles upon a reward cue (e.g., a syringe in a doctor's office), the brain begins to anticipate reward. The emotional memories created and stored by the amygdala and hippocampus are recalled, and the brain knows that this stimulus routinely precedes feelings of euphoria. The reward system is activated in anticipation, and this can lead to strong urges for the drug and cravings to use (Koob et al., 1998).

This means that, even in the absence of the drug itself, if a person is exposed to stimuli that have been repeatedly paired with drug use, it can trigger a small release of dopamine in the reward pathway as the brain expects the forthcoming reward (Volkow & Morales, 2015). The activation of reward circuitry due to a conditioned stimulus is responsible for cravings for the drug and increased motivation to seek out and use the drug (Volkow & Morales, 2015). These cravings can be extremely challenging and frustrating for individuals in recovery from addiction.

Yet, rather than a cause for shame, it is important to recognize cravings for what they are: a predictable neural response to a conditioned stimulus. Cravings do not represent an individual's lack of desire to be clean and sober, a loss of willpower, or weakening commitment to recovery. Instead, they are part of a sophisticated brain system that is wired to learn, anticipate, and seek rewards.

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Why All of This Matters

Given what we know about the brain, one of the best things an individual can do in early recovery is to avoid those stimuli that were previously associated with substance use (namely, “people, places, and things”). This will prevent the conditioned stimuli from activating the brain’s reward circuitry in anticipation of reward. However, not all conditioned stimuli are avoidable; individuals in recovery still have to function in the world and may be exposed to sights, sounds, and smells that were previously paired with drug use.

In those instances, it is important to have a plan for how to manage cravings. Coping strategies, such as meditation, spiritual practices, calling a sponsor, walking in nature, journaling, finding a healthy distraction, positive self-talk, social support, attending a 12-step meeting, and mindfulness-based urge surfing (picturing the craving like a wave that will eventually crest and fall), can be helpful (Bowen et al., 2011). These coping strategies should be identified and practiced routinely, so individuals are prepared when urges and cravings emerge.

In sum, changing “people, places, and things” in early recovery is a simple adage to explain complex brain functioning. Maintaining sustained recovery from addiction is challenging, yet the more that individuals become informed about how the brain operates, the more prepared they are to face the challenge with tools for success.