The Saturday morning after St. Patrick’s Day, 22 patients are locked up in a nondescript detox facility on the outskirts of a Midwestern suburb. A couple of the men and women checked themselves in; a few more arrived in a police car; the rest were brought here by a worried friend, partner, or parent.
A trio of volunteers from a local chapter of Alcoholics Anonymous has just arrived to hold a meeting. Those willing to join the circle recite the Serenity Prayer, listen to someone read “How it Works” from AA’s 575-page Big Book, and share their stories. (In accordance with AA’s promise of anonymity, the names of the participants have been changed.)
Robert is 19. He started drinking daily when he was 12. At 17, he left his belt-wielding father to crash with friends. He started blackout drinking a year ago to stave off sleeplessness, and then quickly turned to cheap speed when the alarm went off. After a nine-day binge smoking methamphetamine, he tried to commit suicide.
Anita is 36. Her blackout drinking began over a decade ago. She left her “latest abusive boyfriend” a week after Valentine’s Day. Diagnosed as bipolar, she usually washes down prescription drugs like clonazepam with high-octane vodka. At 10:30 a.m. on St. Patrick’s Day she was pulled over for drunk driving.
Theo is 52, but looks 20 years older. He’s been in and out of treatment a dozen times, has sometimes stayed sober for months at a time, and can quote from the Big Book like a preacher cites Scripture. He was picked up by police after passing out under a highway overpass.
Go to any detox facility, rehab center, or substance-abuse support-group meeting in the United States, and you’ll hear similar tales. A 2013 survey conducted by the National Institute on Drug Abuse indicated that an estimated 22.7 million Americans needed treatment for problems related to drugs or alcohol. The institute also determined that the “total overall costs of substance abuse in the United States, including productivity and health- and crime-related costs, exceed $600 billion annually.”
Today, as the nation’s opiate epidemic makes headlines and policy makers grapple with the question of whether to legalize marijuana, academics from a variety of disciplines are trying to understand addiction and find successful treatments for people like Robert, Anita, and Theo. Last summer, for instance, neuroscientists at the University of Texas at Austin conducted experiments on mice that led them to conclude that a medicine already approved by the FDA to treat high blood pressure could eventually help erase the unconscious memories and cues that can lead recovering addicts to relapse. Scholars like Carl Hart, a professor of psychology at Columbia University, and the Princeton economists Angus Deaton and Anne Case are conducting increasingly sophisticated data-driven studies to determine how a person’s race, class, and age can predict risky behavior.
But even as new insights emerge from both the physical and social sciences, a longstanding argument over whether or not addiction is a disease prevents researchers from identifying effective treatment strategies. The “disease model” remains dominant among medical researchers as well as in the treatment community. But it is not universally embraced, and some researchers think it gets in the way of fresh ideas about how to help people.
“We don’t have very good science yet,” says Sheigla Murphy, a medical sociologist and director of the Center for Substance Abuse Studies at the Institute for Scientific Analysis, in San Francisco, “and a lot of that has to do with issues of conceptualization and politics.”
The lack of consensus was palpable at a conference on addiction last October at Gustavus Adolphus College, in St. Peter, Minn. There, 11 panelists from various academic disciplines — including neuroscience, psychology, philosophy, physiology, and sociology — spoke to a crowd of 2,500 students, educators, concerned citizens, and health-care professionals.
Researchers and treatment providers “don’t come together as often as you might think,” said Peg O’Connor, chair of the conference and a philosophy professor at Gustavus Adolphus. But those who came to the two-day event looking for innovative, multidisciplinary solutions to a growing crisis probably went home wanting. Before the first morning session was over, it was clear that the accepted wisdom regarding substance abuse and the brain is still largely a matter of debate.
Rhetorical fireworks went off immediately after the conference’s inaugural presentation, given by the Nobel Prize-winning neuropsychiatrist Eric Kandel. A professor at Columbia University and director of its Kavli Institute for Brain Science, Kandel described his research on memory disorders, mental illness, and addiction, including studies on mice that show nicotine use can lead to cocaine abuse. Marc Lewis, a neuroscientist and professor of developmental psychology at Radboud University, in the Netherlands, kicked off the day’s first round table by challenging Kandel’s implicit contention that addiction is a disease.
Lewis’s argument, outlined in his 2015 book, The Biology of Desire: Why Addiction is Not a Disease (PublicAffairs), is that dependence on substances and other behavioral patterns are learned via the “neural circuitry of desire,” and do not result in permanent, irreversible changes to the brain.
Kandel countered that neural imaging shows definitively that addiction causes physical changes in the brain, and that because of those changes, a certain percentage of people simply can’t stop their self-destructive behavior. Just because social factors contribute to the condition and can help mitigate its symptoms — as is true with depression and schizophrenia — doesn’t mean addiction isn’t a disease. When Lewis pushed back, arguing that the brain changes all the time, Kandel became exasperated. “I think we need a course in biology before we go any further, to be honest with you,” he said.
Their quarrel over terminology picked up again during the second panel discussion, with a back-and-forth over whether or not hard, epidemiological evidence should be filtered through more subjective data on individual experience and difference. “Of course [those things] matter, because we tackle different problems,” Kandel snapped. “But ultimately I should be able to replicate your findings and you should be able to replicate my findings, otherwise it’s not science, it’s bullshit.”
“I knew something like ‘if it’s not science it’s bullshit’ was coming,” remembers Sheigla Murphy, who was also on the panel. Different definitions of addiction guide everyone’s research, she said. “Our knowledge construction is predicated on how we understand these concepts and how we define terms, so people get very emotional.”
The panelists at the conference expressed a range of opinions about the disease model. Though their views did not break down entirely along disciplinary lines, the social scientists tended to be the most wary of the label. On the one hand, nearly everyone ceded, it’s an established fact that addiction alters dopamine receptors in the brain and can affect how the limbic system functions. There’s also compelling research that some drugs, such as naltrexone for opiate abusers, can help curb certain cravings, which suggests that dependence is at root a biological phenomenon.
Still, a slim majority of the panelists, including Murphy, did not want to emphasize the word “disease,” because it implies that chemical dependence is primarily a function of pathology, when in fact environmental factors (dysfunction at home, stress at work), learned behavioral patterns (binge drinking, for instance), and economic disparities have been shown to play a significant causal role. Clearly, the debate was not just semantic.
The disagreement over terms is rooted in the 1930s and 40s, when AA came of age and provided a life raft for chronic alcoholics, many of whom had been doomed to suffer crippling isolation, institutionalization, and early death. By positing that alcoholics are powerless against their affliction, suffering from an “allergy of the body and obsession of the mind,” the authors of AA’s Big Book, first published in 1939, helped reduce the stigma of addiction. And since no reliable medical protocol was available to provide long-term relief, the group’s charter members encouraged fellow alcoholics to abstain completely, create a fellowship, and help each other work through 12 steps, which promised a cleansing spiritual experience.
The program was far from perfect, but it did provide relief for many of those silently suffering and saved jobs, families, and lives. In the 75 years since, the 12 steps, in one form or another, have endured as a go-to for treating not just alcoholism but also narcotics dependence, compulsive gambling, and sex addiction. Seven out of 10 drug-treatment facilities rely on the model. And chances are good that if a general practitioner encounters a patient with substance-abuse issues that don’t require inpatient treatment, he’ll recommend a 12-step meeting.
One of the earliest and most compelling critics of AA is Stanton Peele, a psychologist and writer who has been challenging its disease-based model since the mid-70s, when the organization was still an emerging cultural force. Peele argues that AA’s methodology, steeped in spiritual rhetoric, is unscientific, predicated on the notion that only by acknowledging their “powerlessness” over alcohol and accepting a “higher power” can an addict find salvation. He’s also quick to point out, along with other critics of the 12-step model, that traditional treatment programs, which generally rely on it, have a depressingly low success rate.
Peele believes that instead of adapting the disempowering language of disease (which he says is itself stigmatizing), addicts should embrace their failings and pursue mindfulness techniques, not to find a cure but to ease anxiety and consider how their history, environmental influences, and personal relationships inform their habits, good and bad.
Michael V. Pantalon, a senior research scientist at the Yale School of Medicine and co-founder of the Center for Progressive Recovery, is agnostic regarding the use of the word “disease.” He does agree, though, that a one-size-fits-all approach to addiction is not necessary or effective, and points out that a number of scientifically proven approaches already exist that can be applied separately or in some combination, including cognitive behavioral therapy, motivational enhancement therapy, and medications. His frustration is that not enough people on the front lines of treatment are offering these alternatives to the AA approach.
One reason the “disease model” remains dominant is that the National Institutes of Health — as well as the American Medical Association and the American Society of Addiction Medicine — believe that the use of the term is scientifically accurate and still helps eliminate stigma. Nora Volkow, director of the National Institute on Drug Abuse (which is part of NIH), frequently evangelizes about the subject, drawing evidence from brain scans. Those show, she has argued on The Huffington Post, “physical changes in areas of the brain that are critical to judgment, decision making, learning and memory, and behavior control.”
William Cope Moyers, vice president of public affairs and community relations at the Hazelden Betty Ford Foundation (which uses the 12-step model) and author of Broken: My Story of Addiction and Redemption, (Penguin, 2006) says he has begun avoiding the term “disease” in his work “because it’s a term that either a lot of people can’t understand or disagree with.” But in the early 2000s, he says, he used to use the term “all the time.” “When I was lobbying for parity in Congress, for example, I always used ‘disease’ because I thought that was the most effective term to describe how an insurance company discriminated against people with addiction,” Moyers explains.
That institutional bias is, in large part, what upsets many social scientists. They’re concerned that precious federal funds are too often pushed toward studies and programming steeped in status-quo assumptions, instead of challenging longstanding treatment paradigms and biases. “The definition of addiction as a disease, endorsed by the medical and scientific communities and most Western governments, may be the most powerful tool for the rehab industry,” Lewis argues in The Biology of Desire.
All of which makes it ironic that in the coming years, a comprehensive $300-million study funded by the NIH, and championed by Nora Volkow, may offer the best hope for eventually resolving the disease debate, one way or the other.
A significant barrier to broader consensus regarding the disease model is a lack of definitive data. Research on chemical dependence is often very narrow in scope and relies on small, unrepresentative samples. The best evidence that addiction is a disease is based on brain imaging of chronic addicts either while they’re using or shortly after. What’s not known is whether or not there are ways to accurately predict if a person with addictive tendencies is about to cross the line from a bad habit to a disease. “Is there a biomarker that tells you that you have a disease? No. Is there a definitive set of circumstances? No,” says Hugh Garavan, a professor of psychiatry at the University of Vermont. “There’s no biological test for it. We don’t have a single medical test.”
Enter the NIH, which is embarking on a 10-year study of the adolescent brain. Coordinated and led by a cross-disciplinary team of scientists at the University of California at San Diego, the national effort will include 19 research institutions and hundreds of faculty members around the country, including Garavan. Their charge over the next two years is to enlist 10,000 healthy children between the ages of 9 and 10, representative of the general population. Researchers will gather the children’s’ answers to a series of cognitive and environmental questionnaires, conduct functional brain imaging on each of them, and then follow their progress. Assuming all goes well, researchers anticipate that the NIH will continue to fund the study and follow the same kids into adulthood.
The large size and long scope of the study are characteristic of a fledgling field called population neuroscience, a term coined by researchers at the Rotman Research Institute at the University of Toronto in 2010. Tomáš Paus, a professor of psychiatry and senior scientist at the institute, wrote an influential book on the subject in 2013. The unprecedented size of the data set, according to NIH, will help answer questions from policy makers about front-burner issues, like the effects of marijuana use on the adolescent brain; whether or not casual drug and alcohol consumption affects the developing mind; if specific substance uses lead to abuse of other drugs; and “how factors (such as prenatal exposure, genetics, head trauma, and demographics) influence the development of substance use and its consequences.”
But it quickly became evident to Volkow and others involved in getting the study off the ground that it has the potential not just to shed light on substance abuse but also to radically affect the way educators, parents, and health-care providers work with children. Researchers will track how various factors — including diet, sleep patterns, gender, race, economic circumstance, air quality, and exercise habits, as well as substance use — correlate with changes in the subjects’ brain scans over the years.
“How cool will it be if we can collect data on 9- and 10-year-olds that will help predict how all young people will function in later life?” asks Garavan. “This is the sort of information that will truly help people parent, and legislate, and educate, and live healthy lives.”
It will also, as a matter of consequence, help determine whether or not addiction is a disease, like diabetes or hypertension, that can be diagnosed and controlled. If a biomarker for addiction exists — “and it might not, given that addiction is not all about the brain,” says Garavan — the neuroimaging may help find it. “Either way, it should help clear up these essential definitional uncertainties and debates.”
Meanwhile, Sheigla Murphy says she would like to see more gatherings like the conference at Gustavus Adolphus, where people from different disciplines can engage in public debate and, ideally, find more opportunities for mutual understanding and compromise. Moyers, as an advocate on the front lines in his role at the Hazelden Betty Ford Foundation, hopes that even when fundamental differences remain, academics, medical professionals, and lawmakers will always keep the Roberts, Anitas, and Theos of the world first and foremost in their minds. “All that really matters is that we strive to get better at what we do by identifying the complexities of this illness, and that we apply proven, some would say evidence-based, approaches to the treatment of it,” Moyers says. After all, “we are the lucky ones. We’re the ones who help people get well, we are the ones who got well. And it is our responsibility to change the terms of the debate for the sake of those who still suffer.”
David Schimke is an independent journalist and the former editor of Utne Reader magazine.
