The wires this week were not so much humming as soaring in full operatic splendour over the vexed subject of whether addiction is a brain disease (hereafter BDMA or Brain Disease Model of Addiction). It was sparked by a very interesting development in the addictions field, akin to the split among academics, clinicians and public health officials over safer nicotine products.
A fissure has opened between those who subscribe to the BDMA and those who believe that the phenomenon of addiction is far more complex than such a reductionist conclusion allows. While the American psychologist Stanton Peele has been challenging the BDMA for years, he has often been a lone figure in an addictions landscape where the BDMA has become the orthodoxy, promoted vigorously by the multi-million-dollar US addictions industry and by such august bodies as the US National Institute on Drug Abuse, a federal agency which funds more addiction research than any other institution on the planet.
But now, a more formal challenge has been established through the creation of an Addiction Theory Network (ATN) which launched this year in England. Leading lights of the ATN include UK Professors Nick Heather and David Best, both with long track records in addiction research and Marc Lewis, an American neuroscientist and development psychologist who has written an excellent book, The Biology of Desire: Why Addiction Is Not a disease.
OK. So straight off the bat my colours are nailed to the mast. I’m writing a blog here, not a book, so I cannot go into all the twists and turns of this debate and I’m not any sort of ‘ologist’ either, but I do have some observations on the issue.
The notion that over-indulgence in a psychotropic substance could be labelled as a disease goes back to the 18th century and the Age of Enlightenment and Reason which also saw an epidemic of chronic gin drinking in London. The thought emerged among the medics of the days, that no reasonable person would let themselves get into such a mess, so they must be ill in some way, perhaps a disease of the will that prevented them from controlling their behaviour. Through the next century, the idea morphed into a full-blown theory of addiction or inebriety as it was then known where it was felt that people who were addicted to alcohol (and opium) were indeed suffering from a disease of the will and for some the cure meant forced treatment. During the same period, a formalised medical profession emerged whose members eagerly sought medical specialisms they could call their own. Not only was inebriety or addiction one such burgeoning area, but the phenomenon allowed doctors to have it both ways. They claimed the disease could only be treated by experts, but then somehow if the treatment failed, it was the fault of the patient for not being strong-willed enough – a neat trick which I think eventually led in part to the notion of addiction as a ‘chronic relapsing disease’ which of course required more medical intervention.
Addiction as a disease was embraced by the founders of Alcoholics Anonymous in the 1930s. There was no actual clinical evidence to support the idea, but it was (and remains) a useful therapeutic trope acting as a counter to the idea that addiction was a blameworthy ‘vicious indulgence’ or in modern parlance, ‘a lifestyle choice’. I heard about this phrase being used by a local councillor in conversation with a drug service manager trying to make the case for spending on treatment. ‘Why should we fund a lifestyle choice?’ the councillor said. For those battling with an alcohol or drug problem with all the attendant guilt and shame, belief that their condition is no different from somebody with cancer or diabetes helps assuage some of the bad feeling. The problem remains though that disease does not respond to the exercise of willpower, a major tenet of the 12-step philosophy of AA and similar peer support groups.
So if addiction is not a disease like Alzheimer’s or multiple sclerosis, what is it? Marc Lewis and others like Professor Carl Hart and Maia Szalavitz, who writes from lived experience. explore the notion of learned behaviour to explain addiction, the way the brain adapts to external circumstances, and I find this quite compelling. At the risk of gross over-simplification, the theory goes something like this.
The brain learns and adapts. If it didn’t, we would never learn how to speak, play a musical instrument or write blogs. To enable this learning process, the brain makes new neural connections which proliferate as the skill develops. However, this process can take place in far less positive circumstances. If a person is growing up in an abusive, dangerous environment, their personal or social circumstances may dictate they discover alcohol or drugs as an effective coping mechanism to help isolate them from trauma. In those circumstances, the brain starts make new connections about the ‘benefit’ of booze and drugs. At the same time, these internal connections are being mirrored in the external world; the person disconnects with family and friends and makes new connections, a whole new social circle of those in a similar position. At its most extreme, the person may join the ranks of the street homeless, relying on a drug dealer network and living a very dangerous existence. But as chaotic as it might seem, it does offers a level of stability and certainty that might have been entirely absent from childhood.
Part of the BDMA argument is that the brain is ‘hijacked’ by drugs. And it is true that, with heroin for example, the brain’s natural painkiller chemicals or endorphins are replaced by the morphine molecules. But detoxifying the brain to allow the endorphins to flow back is not that difficult. Detoxification is not a cure for heroin addiction: as Charlie Parker said, ‘They can get the drug out of your body, but not out of your mind’. That’s the tricky bit because to give up heroin means not just giving up the drug, but giving up that routine, circle of friends, that level of stability and certainty. Yet people can and do permanently recover despite another BDMA mantra that addiction is a ‘chronic, relapsing disease’. Yes, people may well relapse if they are forced into treatment by the courts or family or if the personal circumstances which drove them to addiction in the first place are unresolved. But many people ‘mature out’ of addiction without any treatment interventions because they have had enough of yet another night in the cells, or because they have found a new relationship and what happens then is that a whole new set of connections are made. The brain adapts to these new more positive circumstances, responds to the external changes and grows new connections. The stronger and more sustainable those internal and external connections are, the less chance of relapse. The central message for me is that the opposite of addiction is not abstinence but connection.
By the way, another dimension to this whole question which I think also transcends simple biology is the comforting, grounding role of ritual in our lives. In the context of drug use, that’s everything from the whole process of preparing heroin for injection, to boiling up coffee in a stove pot to passing round a joint and snapping that cellophane on a packet of cigarettes and handing them around. But that’s for another time.
And just a postscript on this, the following quote comes from the ATN launch article in the latest issue of Addiction Research Theory – and sounds like a relevant read across to the debate about safer nicotine products, “It should go without saying that the debate about whether or not addiction is best seen as a chronic, relapsing brain disease should eventually be decided, or at least strongly influenced, by evidence and reasoned debate. Tactics used by supporters of the BDMA are sometimes inimical to this aspiration. It does no good to avoid proper scientific debate by claiming that the issue has already been decided or by implying that raising doubts about the validity of the BDMA is always irresponsible and inevitably dangerous to the health and welfare of persons labelled as addicts”.
Christmas in coming. If you leave out some booze and carrots, Santa might bring you one or even all of these: