Addiction isn't a brain disease

Disease model gadfly Sally Satel has a piece in Slate challenging addiction’s status as a brain disease. It even has an Aldous Huxley reference!

Satel and her co-author criticize the disease model by blowing it up into a reefer madness caricature and then disproving their caricature by pointing out that the addiction does not have complete control of the addict.

They go on to express fear that it lets addicts off the hook, disempower addicts, will reduce healthy stigma, and dismiss brain imagery studies, not on the basis of the studies themselves, rather because the gullible public tends to believe just about anything prefaced with the statement, “brain scans indicate…”:

As a psychiatrist who treats heroin addicts and a psychologist long interested in the philosophical meaning of disease, we have chafed at the “brain disease” rhetoric [emphasis added] since it was first promulgated by NIDA in 1995. Granted, the rationale behind it is well-intentioned. Nevertheless, we believe that the brain disease concept is bad for the public’s mental health literacy.

Characterizing addiction as a brain disease misappropriates language more properly used to describe conditions such as multiple sclerosis or schizophrenia—afflictions that are neither brought on by sufferers themselves nor modifiable by their desire to be well. Also, the brain disease rhetoric is fatalistic, implying that users can never fully free themselves of their drug or alcohol problems. Finally, and most important, it threatens to obscure the vast role personal agency plays in perpetuating the cycle of use and relapse to drugs and alcohol.

It is true that a cocaine addict in the throes of a days-long binge or a junkie doubled over in misery from withdrawal can’t reasonably be expected to get up and walk away.

Yet addicts rarely spend all of their time in the throes of an intense neurochemical siege. In the days between binges, cocaine addicts make many decisions that have nothing to do with drug-seeking. Should they try to find a different job? Kick that freeloading cousin off their couch for good? Register for food stamps? Most of the patients one of us treats hold jobs while pursuing their heroin habits.

In other words, there is room for other choices. These addicts could go to a Narcotics Anonymous meeting, enter treatment if they have private insurance, or register at a public clinic if they don’t. Self-governance, in fact, is key to the most promising treatments for addiction. For example, relapse prevention therapy helps patients identify cues—often people, places, and things—that reliably trigger a burst of desire to use. Patients rehearse strategies for avoiding the cues if they possibly can and managing the craving when they cannot. In drug courts (a jail-diversion treatment program for nonviolent drug offenders), offenders are sanctioned for continued drug use (perhaps a night or two in jail) and rewarded for cooperation with the program. The judge holds the person, not his brain, accountable for setbacks and progress.

The brave new world of brain scanning figures prominently in the new disease rhetoric. During imaging experiments in which an addict is shown drug paraphernalia, the reward centers in his brain light up like a Christmas tree. It’s easy to be misled into believing that these colorful images prove that the addict is helpless to change his behavior. In a powerful experiment, Deena Weisberg, a doctoral candidate at Yale University, and her colleagues presented nonexperts with flawed explanations for psychological phenomena. They were adept at spotting the errors—until, that is, these explanations were accompanied by “Brain scans indicate … ” With those three words, Weisberg’s participants suddenly found the flawed explanations compelling. Yet in truth, at least at this stage of the technology, we rarely learn as much by visualizing addicts’ brains than by asking them what they are experiencing and what they desire.

Telling the public that addiction is a “chronic and relapsing brain disease” suggests that an addict’s disembodied brain holds the secrets to understanding and helping him. It implies that medication is necessary and that interventions must be applied directly at the level of the brain. But that’s not how people recover. For actress Jamie Lee Curtis, for example, quitting painkillers was a spiritual matter. When she appeared on Larry King Live recently, the guest host asked her, “What made you get clean?” She responded, “Well, you know what, that turning point was a—was really a moment between me and God. I never went to treatment. I walked into the door of a 12-step program and I have not walked out since.”

Finally, dare we ask: Why is stigma bad? It is surely unfortunate if it keeps people from getting help (although we believe the real issue is not embarrassment but fear of a breach of confidentiality). The push to destigmatize overlooks the healthy role that shame can play, by motivating many otherwise reluctant people to seek treatment in the first place and jolting others into quitting before they spiral down too far.

Satel has written some columns that I’ve liked and linked to. (here and here) I don’t think she’s an awful person or anything, but she’s got a world view that informs her opinion. (She’s a fellow at AEI.)