John Stossel, ABC’s world-class sneerer, has decided to apply his considerable powers of sneering to the notion that drug addiction is a “brain disease.” [Partial transcript here.] His story is absurdly tendentious and dismissive, and all right-thinking people who study drug abuse are properly up in arms over it.
In my view, “brain disease” idea has been wildly oversold, especially by Alan Leshner, the former Director of the National Institute on Drug Abuse and current President of the American Association for the Advancement of Science.
Scientifically, it’s not (yet) the case that the diagnosis of addiction is, or can be, made on the basis of brain imaging. Morally, it’s not the case that calling something a “brain disease” implies either that the only, or best, way to deal with the situation is medical treatment or that the resulting behavior is involuntary and therefore not (1) subject to modification by circumstances or (2) morally chargeable to the person involved.
But let’s not throw the baby out with the bathwater. It seems absurd to deny that someone who doesn’t feel normal except when he has an opiate in his bloodstream, or who can’t stop thinking about cigarettes when he tries to quit smoking, has something wrong with him, and the problem surely resides in his brain, rather than his pancreas. What’s wrong with calling that condition a “brain disease,” then?
The whole “brain disease” debate seems to me about as useful as the “tastes great” — “less filling” controversy, but it has the power to do some damage in the real world. (The latest nonsense is the suggestion from some bioethicists that if addiction is a brain disease it may not be possible to obtain valid consent to research from people in its grip; that’s a complete non sequitur, but that won’t keep some Institutional Review Boards from acting on it.)
Below are some of my thoughts on this, which will appear in somewhat edited form in a forthcoming issue of the journal Addiction as a response to a very good essay on the subject by Wayne Hall et al. entitled “Addiction, Neuroscience, and Ethics.”
IS ADDICTION A “BRAIN DISEASE”?
The behavior of some people with respect to intoxicants and stimulants of various kinds seems problematic to them: they self-administer those chemicals in ways that (in Thomas C. Schelling’s formulation) “are deprecated in prospect and predictably regretted in retrospect.”
Some but not all of those who complain about their own drug-taking seek professional help or engage in other organized practices in an attempt to get their behavior back under control. Those attempts are notoriously difficult and uncertain of success, at least in part because of the ambivalence of the people with problem drug habits, who despise their habits but love their drugs. Even after apparent success, marked by periods of abstinence from, or moderation in, drug-taking, relapse is common, in part to the persistence of craving, especially cue-conditioned craving.
Other people have similar behavior patterns and do not regret them (or do not consciously regret them, or do not admit to regretting them), but complaints come from those around them (families and employers, for example).
For lack of a more precise term, call these unwanted patterns of drug-taking “substance-related disorders,” or “addictions.” (Or perhaps the clinical terms “substance abuse”and “substance dependence” are more appropriate for the common comparatively transient forms of these problems, and “addiction” should be reserved for the less common persistent cases.)
Since these problems are behavioral, presumably they are related to states and functions of the brains of those engaging in them. (Though if they were related instead, as some aspects of some drug problems seem to be, to changes in their livers, it is hard to see why that should matter from a moral or policy viewpoint.) Those states are atypical, more or less persistent, involuntary (in the sense that they cannot be wished out of existence by those affected by them), and unwanted.
Since any atypical, persistent, involuntary, and unwanted state or function of any tissue or organ can reasonably be called a “disease,” the language is not strained if we call substance-related disorders “diseases,” and since the states in question are states of the brain it is reasonable to call them “brain diseases.”
On the other hand, the language would also accommodate calling them “bad habits,” which your mother warned you were hard to break, and which also must somehow relate to states and functions of your brain. Nothing said above is specific to bad habits about chemicals, and we now know that it is quite possible to be addicted to gambling, for example. Progress in documenting the neuronal changes that embody addictions may eventually help us learn how to diagnose, treat, and even prevent them, though so far the impact of brain-imaging studies on practically useful knowledge has been more sizzle than steak.
But calling a bad habit a brain disease, or even demonstrating the brain states that constitute a bad habit, does not change its moral status or prescribe what to do about it in policy terms. The recognition that some bad habits are so terribly hard to break that they ought to be called “addictions” does make a moral difference; the less (currently) voluntary a behavior pattern is, the less justifiable it is to punish people for being subject to it.
Nevertheless, contingency management can still be, and in fact often is, among the best ways of reducing the frequency of the unwanted behavior in the presence of the established habit and its associated cravings, and eventually of reshaping the response pattern itself. Contingency management takes advantage of the fact that even after the craving to use drugs becomes involuntary, actually using on any given occasion remains responsive to the conditions and consequences of doing so.
Those moral and practical inferences depend on the relative involuntariness of the condition, not on its embodiment in the brain. Thus the policy and moral implications of the “brain disease” idea are much smaller than they first appear. After all, learning is embodied in brain changes; that does not mean that findings from receptor studies or brain imaging research ought to begin to dictate educational practice or policy.