Debating whether addiction is a ‘brain disease’ gets in the way of making progress

The New York Times ran an article this week, Rethinking Addiction as a Chronic Brain Disease, that dives into the endless debate about which framework we should use to understand addiction: brain disease, society failure, personal choice, or environmental context. Conversations like these are interesting and seductive, pushing up against ideas of agency and motivation and self-determination, or lack thereof.

I’ve specifically avoided writing about ‘What is addiction?’ because even though I have theories and opinions and think it’s a fascinating debate, I think the debate itself distracts us from more effective policy making.

Intellectuals, activists, and entrepreneurs love moments when a field is stuck in an old, entrenched model and then a new framework comes along, changes how the problem is understood and there’s rapid progress. It’s fun! And deeply satisfying. But addiction has already long been understood as a societal problem (hence prohibition) and a personal choice problem (hence jail, shame), before the brain disease model came along. There have been decades of research that fall under and across all of these models of addiction and there will continue to be. Unfortunately, there is no wide open unresearched space here waiting to be unlocked, if we just look at things differently. 

Yes yes, it’s all a rich tapestry.

The Times article appears to have been spurred by this academic paper which argues that the context of the drug user’s behavior should be placed at the center of our understanding: 

“From this perspective, addiction is neither the individual's moral failing nor an internal uncontrollable urge but rather is the result of environmental contingencies that reinforce the behavior.”

The paper makes plenty of valid points and the model seems fine, in the sense that it basically boils down to saying that addiction has a lot of factors and arguing for more emphasis on context and environment, which everyone has long agreed is important in addiction recovery.

But here’s where the intellectual catnip of an intriguing debate starts to get a little dangerous. From the Times article:

“I don’t think it helps to tell people they are chronically diseased and therefore incapable of change. Then what hope do we have?” said Kirsten E. Smith, an assistant professor of psychiatry and behavioral sciences at Johns Hopkins School of Medicine and a co-author of the paper, published in the journal Psychopharmacology. 

I don’t want to hold Dr. Smith too tightly to this one quote, but there’s a common frustration expressed here which I think leads in unhelpful directions.  

First, there are a TON of chronic diseases that have ongoing behavioral inputs– heart disease, Alzheimer’s disease, diabetes, osteoporosis, depression, etc. Identifying something as a chronic disease doesn’t mean that behavior change isn’t helpful or important.

Secondly, whether science understands addiction as a ‘chronic disease’ is a different issue from how we treat people with addiction. We don’t want to be answering a scientific question like ‘is this a chronic disease?’ based on a worry that it will make patients feel bad if we say yes. And, in fact, for many people the chronic disease framework liberates them from paralyzing shame that prevents recovery.

Thirdly, to the question ‘Then what hope do we have?’ – as with all chronic diseases, the hope we have is that we can cure the disease!  The field of addiction is the only major disease area where expectations are so low that experts and advocates don’t talk about trying to find a cure.

OK, but is it a “chronic brain disease” or not?

When a debate revolves around how to define a word, that’s probably a sign that it’s becoming a dead end. The debate about whether AI systems will achieve artificial general intelligence (AGI) is like this– everyone disagrees about what “AGI” actually means and you could argue that definition infinitely OR you can focus on what specific abilities AI does or doesn’t have, which will teach you a lot more about what’s going on.

But let’s look at ‘brain disease’ for a second and then get back to why we shouldn’t have.

Addiction clearly happens in the brain– our decision making happens there and our cravings happen there and our reward systems are there.  For most people the phrase ‘brain disease’ implies that there’s some damage happening to the brain. While drug use can cause damage to the brain, addiction itself is more like a self-reinforcing dysfunction in the brain that damages a person’s desires and priorities. And yes, it causes changes to brain patterns and structures as it self-reinforces. Maybe you should call addiction a ‘chronic brain disease’ or maybe you could call it a ‘priority disorder’ or a ‘brain-based decision dysfunction’ or a ‘craving disorder’ or something else. I don’t think the name matters that much because I don’t think the distinction drives much of the science and policy decision making and I don’t think it changes things much for patient treatment outcomes.

And yes, even ‘drug-influenced brain-based disordered decision making’ is still affected by environment, motivation, psychology, etc– someone with an addiction does not fully separate from these other factors, as the Times article and the academic paper emphasize. We already know that you can have societies like Singapore with virtually no drug use if you are willing to implement extreme punishment and blanket surveillance to strongly shift people’s motivations. 

Don’t be seduced by the Rorschach test

What is the one true meaning of ‘addiction’?

While I don’t think that what we call addiction matters very much, I do think that the debate around this question matters, in the sense that focusing on these questions prevents progress in how the public tackles addiction.  When the public and policymakers get drawn into philosophical debates about whether addiction is a disease or a choice or the fault of society, we drift away from the questions that really make a difference: which strategies work, which have the best evidence, and which are the most promising to invest in for the future?  

The most effective public health intervention for alcohol abuse and for smoking is raising taxes– is that intervention an example of recognizing that personal choice is key to addiction because people will choose to use a drug less if it costs more?  Or is it an example of taking away personal choice by making the drug too expensive to access?  Or is it better understood as a change to the environmental context of availability?  The answer is… it doesn’t matter! It works and we should do as much of it as the public will tolerate up to the point where it generates black markets. And we should pursue other strategies, like better medications at the same time.

Addiction is so personal and so painful and so layered that debates about drug policy become a Rorschach Test for everyone’s pet theory or personal experience of what addiction ‘really is’ and this leads to policies that are driven more by emotional attachments to solutions (drug war vs harm reduction) than by efficacy.

The best part of Times article comes near the end, when our friend and member of our CASPR scientific advisory board, Keith Humphreys, says this:

“People want to relieve themselves of the burden of the mixed emotions they feel towards their loved one, but that’s the burden inherent in the condition,” said Keith Humphreys, a psychologist and an addiction expert at Stanford University. That is in part why, he said, it’s easier for people to see addiction in absolutist terms — as a choice or a disease.

We have to pull focus back to the research and efficacy– what works and what doesn’t, what’s politically feasible and what’s not.

Focus on effective and scalable solutions

I believe the debates around addiction now are where the debates about obesity were five years ago. There are a wide range of intersecting medical, social, and environmental factors that contribute to obesity and there are infinite ways of framing and debating the problem. The obesity conversation revolved around the same questions– personal responsibility, environment, shame, psychology, and whether ‘disease’ was an appropriate or helpful label.  Now we have medicines like Wegovy and Zepbound that don’t answer any of those questions. But they do turn down the desire for food, and that is extending the lifespan and healthspan of millions of people.  

The same is possible for addiction– we can create medicines, and GLP-1s may be the first step– that reduce the craving and desire for substances. These medicines will work in the brain but whether that means they are solving a ‘brain disease’ will start to feel irrelevant. Once there are really good solutions of any type, philosophy matters less to everyone and stigma fades. Our proposal of GRACE: GLP-1 based OUD harm reduction and treatment includes offering financial incentives for taking GLP-1 doses, combining both a brain medicine approach and a decision-influencing approach (it’s a simplified and less controversial version of contingency management).

More broadly, we believe that resources should be directed to the areas that show the highest potential for impact. We have argued that addiction medicine development is dramatically underfunded relative to the scale of the disease and the scientific opportunity for rapid progress. Currently, the federal government spends about $44 billion every year on drug enforcement, about $4.5 billion on treatment programs, and only about $2.2B for NIDA and NIAAA to research the science of addiction, develop new treatments, and test the efficacy of medical and non-medical interventions. This funding ratio is backwards and it’s why our outcomes have gone backwards as the opioid and stimulant crisis has worsened.

We should be approaching the challenge of addiction in society by looking for strategies that can scale, examining the ROI of different research opportunities, and demanding brutal honesty about which interventions really work.