Addiction as a brain disease revised: why it still matters, and the need for consilience PMC Rorcha Seguros

Second, though cravings are unpleasant, experiencing them seems to fall very far short of any kind of mental illness or pathology. Subpersonal over-valuation of drugs plus intense cravings are not sufficient for the person to suffer from a defect of rationality. Nor are they sufficient for the person to suffer from a sufficiently serious impairment of agency or of their ability to pursue a worthwhile life. The neuroadaptations characteristic of addiction are longlasting; it is for this reason that the Alcoholics Anonymous slogan “once an alcoholic, always an alcoholic” has more than a grain of truth to it. Yet plainly the former heavy drinker or drug taker who has been abstinent for many years need not be suffering from any impairment (though she may have a vulnerability to suffering an impairment). All by itself, this fact shows that the neuropsychological dysfunction underlying addiction is not sufficient for disease.

We argue that when considering addiction as a disease, the lens of neurobiology is valuable to use. We agree that critiques of neuroscience are warranted and that critical thinking is essential to avoid deterministic language and scientific overreach. It thus seems that, rather than negating a rationale for a disease view of addiction, the important implication of the polygenic nature of addiction risk is a very different one.

Is a View of Addiction as a Brain Disease Deterministic?

It warns that denial harms treatment access and calls for integrated, multidisciplinary research on recovery. Hazardous (risky) substance use refers to quantitative levels of consumption that increase an individual’s risk for adverse health consequences. Clinically, alcohol consumption that exceeds guidelines for moderate drinking has been used to prompt brief interventions or referral for specialist care 112. More recently, a reduction in these quantitative levels has been validated as treatment endpoints 113. Among high-risk individuals, a subgroup will meet criteria for SUD and, among those who have an SUD, a further subgroup would be considered to be addicted to the drug. However, the boundary for addiction is intentionally blurred to reflect that the dividing line for defining addiction within the category of SUD remains an open empirical question.

Viewpoints: is addiction a disease?

Records of opium use date back nearly 6000 years (Booth, 1996); beer brewing dates back even further. In these conditions, there was no selective pressure for human beings to develop a specific self-control mechanism with regard to these substances. For instance, Murphy and Stich (2000) have hypothesized that depression might sometimes result from an overly (but not pathologically) sensitive relative status detector.

Lessons from genetics

Finally, such work should ultimately be codified in both the DSM and ICD systems to demarcate clearly where the attribution of addiction belongs within the clinical nosology, and to foster greater clarity and specificity in scientific discourse. The concept of compulsivity in addiction is analyzed, differentiating it from the compulsive behaviors seen in OCD. The authors acknowledge that substance use is influenced by environmental contingencies, but also emphasize that addiction systematically increases the probability of maladaptive choices, even with available alternatives.

Social networking and mental health: looking beyond frequency of use and towards mechanisms of action

Not all individuals consuming substances at hazardous levels have an SUD, but a subgroup do. At the severe end of the spectrum, these domains converge (heavy consumption, numerous symptoms, the unambiguous presence of addiction), but at low severity, the overlap is more modest. The exact mapping of addiction onto SUD is an open empirical question, warranting systematic study among scientists, clinicians, and patients with lived experience. No less important will be future research situating our definition of SUD using more objective indicators (e.g., 55, 120), brain-based and otherwise, and more precisely in relation to clinical needs 121.

Both «addiction as a disease of choice» and «addiction as a brain disease» are presented as complementary perspectives. The brain disease model recognizes that addiction profoundly compromises choice faculties but doesn’t negate free will. Thus, as originally pointed out by McLellan and colleagues, most of the criticisms of addiction as a disease could equally be applied to other medical conditions. This type of criticism could also be applied to other psychiatric disorders, and that has indeed been the case historically. Few, if any healthcare professionals continue to maintain that schizophrenia, rather than being a disease, is a normal response to societal conditions. Why, then, do people continue to question if addiction is a disease, but not whether schizophrenia, major depressive disorder or post-traumatic stress disorder are diseases?

Their proposal builds upon Nesse and Williams (1995) suggestion that depression may be an adaptive response to a fall in, or a failure to gain, status. Treatment was focused not primarily on improving the health and well-being of people who use drugs but on controlling the “contagion” of a “social disease” in “special” populations seen as vulnerable by virtue of social class, race, age, or sex. Each of these European countries has progressed toward harm reduction within important limits.

• It originates from within the scientific community itself, and asserts that this conceptualization is neither supported by data, nor helpful for people with substance use problems 4,5,6,7,8.
• On the systemic account, developed by Cummins (1975), it is not the role that something played in evolutionary history that gives it its function; rather, it is the role it (or its homologs) actually plays in a system.
• Shortcomings of clinical nosology reflect difficulties in drawing hard lines and underscore the fuzziness of the one drawn regarding addiction.
• Changes in brain function and structure in addiction exert a powerful probabilistic influence over a person’s behavior, but one that is highly multifactorial, variable, and thus stochastic.

Scientists are studying how addiction changes the brain to understand why people struggle with choosing healthy things over harmful things. Critics argue that preserved ability to make advantageous choices refutes the idea of compulsion. It involves inflexible, drug-focused behavior, insensitive to negative consequences, which while not universal in addiction cases, is a key clinical symptom. This doesn’t mean complete lack of choice, only a significant shift in choice probabilities toward maladaptive behaviors, even when better choices are available. Addiction involves a disease of choice preferences, where the brain’s reward system is disrupted and choice capacity impaired, not destroyed. Classifying addiction as a disease does not narrow the opportunities for healing; it expands them.

Support to KES was provided by the Intramural Research Program of the NIH-NIDA (National Institute on Drug Abuse). DOJ acknowledges that there may be large impacts related to Federal taxes and research and development investment for the pharmaceutical industry, among other things. DOJ is specifically Top 5 Advantages of Staying in a Sober Living House soliciting comments on the economic impact of this proposed rule. DOJ will revise this section at the final rule stage if warranted after consideration of any comments addiction as a brain disease revised: why it still matters, and the need for consilience pmc received. Behind me the camera picked up vague shapes in a dark, messy living room—watching it afterward, I thought I looked like a resident in some unlit chamber of hell, compared to the bright faces in the studio in Toronto. But the real problem was that one of the three other guests was an MD, a psychiatrist, named Peter Selby—a guy who does both research and clinical work at a psychiatric/addiction institute in Toronto, called the Centre for Addiction and Mental Health.

• We agree that critiques of neuroscience are warranted and that critical thinking is essential to avoid deterministic language and scientific overreach.
• Accordingly, we do not maintain that a chronic relapsing course is a defining feature of SUD.
• The most promising of these is harm reduction, a 50-year-old social movement mounted against repressive drug policies.
• Rather, there is significant evidence that addiction is a complex cultural, social, and psychological phenomenon, as much as it is a biological phenomenon.

The hope is that mechanistic insights will help bring forward new treatments, by identifying candidate targets for them, by pointing to treatment-responsive biomarkers, or both. Developing innovative treatments is essential to address unmet treatment needs, in particular in stimulant and cannabis addiction, where no approved medications are currently available. Although the task to develop novel treatments is challenging, promising candidates await evaluation. A particular opportunity for imaging-based research is related to the complex and heterogeneous nature of addictive disorders. Imaging-based biomarkers hold the promise of allowing this complexity to be deconstructed into specific functional domains, as proposed by the RDoC initiative and its application to addiction.

The authors outlined an agenda closely related to that put forward by Leshner, but with a more clinical focus. Their conclusion was that addiction should be insured, treated, and evaluated like other diseases. This paper, too, has been exceptionally influential by academic standards, as witnessed by its ~3000 citations to date. What may be less appreciated among scientists is that its impact in the real world of addiction treatment has remained more limited, with large numbers of patients still not receiving evidence-based treatments. Close to a quarter of a century ago, then director of the US National Institute on Drug Abuse Alan Leshner famously asserted that “addiction is a brain disease”, articulated a set of implications of this position, and outlined an agenda for realizing its promise 1. A subsequent 2000 paper by McLellan et al. 2 examined whether data justify distinguishing addiction from other conditions for which a disease label is rarely questioned, such as diabetes, hypertension or asthma.