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Addictionally irrational

Go to the National Institute on Drug Abuse (NIDA) website right now and you’ll see brains. Pictures, graphics, scans — a colorful display. You’ll also see a photo of Nora Volkow, NIDA’s director, whose “work has been instrumental in demonstrating that drug addiction is a disease of the human brain.” This would be all well and good, if pictures (or any other representation or analysis) of what’s going on in a drug user’s brain actually demonstrated that addiction is a brain disease. But they don’t. How it is that “we have come to believe” this irrational notion, that it has become the accepted truth among both lay people and professional orthodoxy, is simply mind-boggling to me.

As Stanton Peele has pointed out again and again, including today on his Psychology Today blog, the brain disease model of addiction defies both common sense and a reasonable interpretation of scientific research:

The chronic brain disease model doesn’t explain the most fundamental things about addiction, like how the vast majority of people overcome it without treatment, that there are no measurable biological means to determine whether and when people are addicted and when they are not, nor is there any treatment that addresses the supposed dopamine-based nature of addiction. In fact, the best science and therapy both point towards an entirely opposite, real-world way of defining “recovery.”

Meanwhile, as the idea of addiction as a brain disease is imbedded in our culture, we simply get more and more examples of brain diseases as more and more things are understood as addictions, and as we spread the idea further and thinner than any possibly scientific explanation can be spread.

This idea is not an expression of science. It is, instead, a cultural myth, one that the best and the brightest are obligated to endorse to be recognized as mainstream thinkers.

Don’t get me wrong — I’m all for learning as much as possible about the physiological and neurological aspects of addiction, and of all other realms of human experience for that matter. Of course brains (our organism/physiology in general) are absolutely foundational to all that we experience. A baseball bat to the head is all the evidence needed to establish that fact. But how, pray tell, does the plainly evident and obvious fact that all human experience is grounded and reflected in wonderfully complex and interesting ways in the brain and body lead to the notion that so many of our life problems are therefore fundamentally diseases of the brain? Imagine Nora Volkow’s perfect scenario, that after years of research we have finally and perfectly mapped all the changes that happen in the brain over the complete course of drug use and addiction. Imagine that brain scan technology could yield perfect scans and that we understood and interpreted the images perfectly. To my mind that still wouldn’t lend a shred of evidence to the notion that addiction is a brain disease.

A quick thought experiment: You are hooked up to this hypothetical machine (a super scanner) which can perfectly record all changes in your body’s and brain’s physiology, demonstrating with perfect accuracy every deviation from healthy homeostasis. You are put in room. In through the door on the far end walks a tiger. Your body and brain begin to go haywire. Hormones and neurotransmitters are sloshing around and completely transform your state of existence from one of total health and relaxation to one of total stress. The super scanner perfectly records every change and quickly prints out a recipe for a drug that will re-balance your system, with minimal side effects. While your state of stress and imbalance is clearly and dramatically grounded and reflected in your physiology, isn’t it a bit shortsighted to think of your problem solely or even primarily in those terms? If someone were to drop a cage on the tiger, your physiology would quickly and naturally move back to homeostasis without any need for a drug or any other physiological intervention. Your problem was primarily the presence of the tiger, not the changes in your brain that the presence of the tiger inspired. The solution–i.e. the appropriate intervention–to the problem was primarily social and behavioral, not physiological. In fact, the information provided by the super scanner, interesting as it might be, was completely irrelevant in terms of the practical solution to the problem.

Drug use and abuse changes what’s going on in the brain. Yes. Everything we do and everything that happens to us changes what goes on in the brain. Yes. Therefore, deviations from healthy, homeostatic brain and body states are best thought of as diseases of the brain? Not so fast Dr. Volkow. Studying objective brain changes is one of many perspectives that are worthy of consideration, focus, and scrutiny. Taken together with subjective, relational, behavioral, social, and cultural perspectives, we might yet arrive at a truly comprehensive, rational, integral approach to helping those seeking health and well-being.

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Misunderstanding addiction: The beat goes on…

Stanton Peele
Back in May I wrote a post titled Understanding Addiction, throughout which I bemoaned the fact that the National Institutes of Health (NIH) — one of the most powerful voices on matters of health and well-being in our society — continues to perpetuate the misunderstanding that “Addiction is a chronic relapsing brain disease.” Taking a partial truth and stretching it — so that it seems far more significant than it actually is — is the modus operandi of huksters in every sphere, and it’s becoming an all-too-familiar gambit of mental health “experts” these days. Shockingly, my blog posts don’t seem to be helping matters much. Stanton Peele, however, continues to be a lonesome but powerful voice of reason, calling out to those of us with ears to listen. Earlier this month, Peele reminded us on his blog that the NIH’s own alcoholism experts (within The National Institute on Alcohol Abuse and Alcohol) recently concluded the following:

1. 20 years after onset of alcohol dependence, about three-fourths of individuals are in full recovery; more than half of those who have fully recovered drink at low-risk levels without symptoms of alcohol dependence.
2. About 75 percent of persons who recover from alcohol dependence do so without seeking any kind of help, including specialty alcohol (rehab) programs and AA. Only 13 percent of people with alcohol dependence ever receive specialty alcohol treatment.

These conclusions, based on the largest study of people’s life histories of alcohol use ever conducted (43,000 people), completely undercut the accepted wisdom that addiction (to alcohol, at the very least) is a “relapsing brain disease,” and they also bring into sharp relief the utter ineffectiveness of the most commonly utilized treatment programs. Beyond this study, the accepted wisdom regarding addiction also fails the tests of sound reasoning, common sense, and an honest appraisal of existing evidence — a case that Peele has been persuasively making for decades. And yet when Americans want the best available information and recommendations about addiction to alcohol and other drugs, we’re told by Dr. Drew, HBO, and the NIH that addicts have a relapsing brain disease, that they can never learn to moderate their drug use, and that their incurable diseases can be most effectively treated by checking into rehab and attending twelve-step meetings. Is it any wonder why our best efforts to help people with drug problems are so ineffective?

Sadly, if we instead look to the most renowned non-government authority on matters of mental health, the American Psychiatric Association, we’ll find only further confusion. In another blog post, Peele describes the APA’s latest attempts to redefine the concept of addiction for the latest version of the Diagnostic and Statistical Manual, DSM-5. Peele was an advisor for the substance abuse disorders section of the current version of the DSM, DSM-IV, so he understands the process well. The upshot is that the DSM-5 Substance-Related Disorders Work Group, chaired by University of Pennsylvania psychiatrist Charles O’Brien, is proposing some major changes, including ditching the term “dependence” in favor of “addiction” (a term not used in the DSM-IV to describe substance abuse problems). Beyond that, the group also wants to create a whole new category–Behavioral Addiction–to refer to pathological gambling. The rationale behind designating only pathological gambling as an addiction (but not pathological sex-having or video game playing or anything else) is that, according to O’Brien, “substantive research” indicates that “pathological gambling and substance-use disorders are very similar in the way they affect the brain and neurological reward system.” Peele, as he’s done his entire career, clearly shows the fallaciousness of O’Brien’s reasoning, which suffers from the same confusions and category errors that have been holding our understanding of addiction (and mental health, more broadly) hostage for decades:

O’Brien’s statement represents a rear-guard effort to frame addiction as a brain disease. There is, indeed, imaging research on the ways various drugs affect the brain. But that’s not the key to addiction. I designed and administer an addiction treatment program, and I can assure you that not one person is sent to our program—or any other program—because of a PET scan. People enter rehab because of regular, habitual screwups connected to substance use—compulsive involvement and continued use of a drug (or other involvements) despite chronic harm.

Indeed, as O’Brien points out, powerful experiences like gambling impact the same “neurological reward system” that drugs do. But so do many other rewarding activities. If there is some such higher level “neurological reward system,” then it can’t be said to exclude anything, from sex to food to gambling to video games.

Nor is O’Brien correct in suggesting that cocaine, nicotine, alcohol, and marijuana follow the same neurological pathways in the brain. Each substance has a very different chemical profile, including the timing of effects and the rewards people derive.

And if gambling affects the same brain reward system as substances, as O’Brien claims, why is it a “behavioral” addiction and not simply an addiction? DSM-5 further muddies understanding of addiction in its handling of two other non-drug appetites—“hypersexuality” and “binge-eating.” Neither is regarded as an addiction. Is this because they do not follow the same “neural reward pathways” as drugs and gambling? Binge-drinking can bring on addiction, but not binge-eating? How come? And is gambling really more neurologically, or intensely, rewarding than sex?

The problem with the DSM-5 approach is in viewing the nature of addiction as a characteristic of specific substances (now with the addition of a single activity). But think about obsessive-compulsive disorder (OCD): People are not diagnosed based on the specific habit they repeat—be it hand-washing or checking locked doors. They are diagnosed with OCD because of how life-disruptive and compulsive the habit is. Similarly, addictive disorders are about how badly a habit harms a person’s life. Whether people use OxyContin or alcohol, people aren’t addicted unless they experience a range of disruptive problems—no matter how addictive the same drug may be for others.

Unfortunately, misunderstanding and misinformation are becoming part and parcel in health education across-the-board in our society. As with our political system, the agencies and organizations responsible for informing the public about matters of health and well-being have been way too corrupted by special interest groups (particularly) and the profit motive (more generally). Moving toward a sensible, fact-based, integral understanding of health requires that we critically appraise and analyze all information that comes to us, not only from the media, but also from the “leading experts” themselves. I have no doubt that the vast majority of individuals working at the NIH, the APA, as well as the countless mental health professionals across the country serving people in need, have only the best of intentions and want above all else to make a positive difference in the world. The same can be said of the members of the United States Congress, but a system can become corrupt, broken, and ultimately ineffective (even destructive) despite the good intentions of most individuals within the system. Our current way of understanding and treating addiction — like the broader “war on drugs” we’ve been impotently waging for years — just isn’t cutting it. Stanton Peele may not have all the answers, but his approach makes a lot of sense to me.

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Understanding addiction

It seems reasonable to assume that if you want to know about a given topic, a good place to start is by checking out what the leading experts in the field have to say about it. For instance, if you google the word “addiction,” you pretty quickly are led to HBO’s Addiction Project site, which contains loads of information backed by such heavy-weights as the Robert Wood Johnson Foundation, the National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA). So what is addiction, according to the leading experts?

Addiction is a chronic relapsing brain disease. Brain imaging shows that addiction severely alters brain areas critical to decision-making, learning and memory, and behavior control, which may help to explain the compulsive and destructive behaviors of addiction.

Ah yes, the brain. The three pound hunk of tofu that is the ultimate source of all problems and all answers. (Deep, prolonged sigh.) Of course it’s true that any human behavior or experience can be understood in terms of neurobiology and brain states, and it’s also pretty clear that this understanding is valuable and worth pursuing. But it simply doesn’t follow—in theory or in practice—that therefore dysfunctional behaviors and experiences are neurobiological diseases. In our everyday lives, we take for granted that human life is complicated and plays out on many levels. And long before “neuroplasticity” became a buzz word, we already knew that what we do, how we use our attention, and how we relate to one another affects the quality of our lives (and the structure and function of our bodies/brains).

I worked on a chemical dependency unit in a psychiatric hospital for several years, and I’m fairly certain that most of the professional staff would accept information provided by NIDA (and most everything on the HBO site) uncritically, as I’m sure it fits seamlessly with what they learned in graduate school. But young people tend to question everything, and the patients I worked with were anywhere from 12 to 18 years old. Part of my job was to lead educational discussion groups with these kids several times a week. I also accompanied them to Alcoholics Anonymous and Narcotics Anonymous meetings several times a week. These kids constantly questioned staff members about all the contradictions they perceived between AA’s philosophy, the treatment center’s information packets, and their own life experiences. For the most part, the contradictions the kids brought up were crushed by the weight of authority, not cleared up by reasoned argument and explanation. I was quite often in the awkward position of covering for and/or attempting to recast the many misconceptions served up daily and repeatedly to patients, some of whom were desperate for accurate information. The kids (who were almost all cigarette smokers) would inevitably point out things like: “Nicotine is super addictive, right? Well, I personally know several people who quit smoking on their own, without any treatment centers or twelve step groups. So, why is everybody here telling me I can’t stop getting high on my own, that I’m powerless over the ‘disease of addiction’?”

As Stanton Peele (one of the few clear-thinking “leading experts” on addiction I’ve come across) has been pointing out for decades, addiction is and has always been politically and socially defined as much as it has been scientifically defined. Peele covers this ground thoroughly in his recent article The Fluid Concept of Smoking Addiction:

The neurobiological model of addiction is static. It is built on the difficulty – often stated as the near impossibility – of quitting or moderation. The model does not attempt to explain how (or, more accurately, why) people cease addictions – even though such cessation is more typical than not with every type drug. The neurobiological model really has nothing to say about why smokers quit (as a majority do), for example due to the pleading of a spouse or a child. In the terms of the model, cessation is unexpected, unexplained, unpredictable, and simply falls beyond its purview or boundaries.

I used an Integral Health framework to help my patients make sense of their substance abuse problems. In practice, our entire staff operated under the integral premise, i.e. that we must address every conceivable dimension of the patient’s life if we hope to make the most effective impact. Some patients, especially those who were heavy opiate users, were given (non-narcotic) drugs to deal with their withdrawal symptoms. Other than that, there was little about the treatment program that had anything to do with directly impacting brain chemistry. We helped patients become more aware of their thought patterns. We taught them healthy coping strategies to deal with the challenging situations and emotions that would inevitably continue to crop up in their lives. We brought their families in for counseling sessions. We contacted teachers, probation officers, judges—anyone who would be working with these kids once they were discharged back into their respective communities—and developed detailed aftercare plans. We covered all the bases, because we knew that substance abuse problems both develop and are potentially resolved in a multidimensional, bio-psycho-sociocultural context. Surely, most thoughtful people (including the folks at NIDA) know this to be true, and yet the “leading experts” continue to present their oversimplified, disingenuous “brain disease” model to the public (complete with brain scan images that often signify very little, and the obligatory lip-service footnote containing the term “biopsychosocial”). I confess, I’m not entirely sure why this is the case. I suspect it has something to do with how government and academic institutions secure their funds. The more influence the pharmaceutical industry has on research and policy processes, the more traction the brain disease model seems to get. And, of course, the public eats up (literally, in the case of pills) easy answers and quick-fix remedies that require as little life-style change and psychological work as possible.

So, although it may seem reasonable to rely on the opinions of leading experts in a given field, this doesn’t always hold true when it comes to the field of mental health. Integral and integrative understandings of addiction and other problems do exist, but they haven’t yet had the appeal and/or financial backing required to capture the imagination of either the leading experts or the general public.

On the bright side, I’m sure all this will change once I click the “Publish” button and everyone on the internet reads this blog post!