Why Addiction is NOT a Brain Disease

Addiction to substances (e.g., booze, drugs, cigarettes) and behaviors (e.g., eating, sex, gambling) is an enormous problem, seriously affecting something like 40% of individuals in the Western world. Attempts to define addiction in concrete scientific terms have been highly controversial and are becoming increasingly politicized. What IS addiction? We as scientists need to know what it is, if we are to have any hope of helping to alleviate it.

There are three main definitional categories for addiction: a disease, a matter of choice, and self-medication. There is some overlap among these meta-models, but each has unique implications for treatment, from the level of government policy to that of available options for individual sufferers.

The dominant party line in the U.S. and Canada is that addiction is a brain disease. For example, according to the National Institute on Drug Abuse (NIDA), “Addiction is defined as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences.” In this post, I want to challenge that idea based on our knowledge of normal brain change and development.

Why many professionals define addiction as a disease.

The idea that addiction is a type of disease or disorder has a lot of adherents. This should not be surprising, as the loudest and strongest voices in the definitional wars come from the medical community. Doctors rely on categories to understand people’s problems, even problems of the mind. Every mental and emotional problem fits a medical label, from borderline personality disorder to autism to depression to addiction. These conditions are described as tightly as possible, and listed in the DSM (Diagnostic and Statistical Manual of Mental Disorders) and the ICD (International Classification of Diseases) for anyone to read.

I won’t try to summarize all the terms and concepts used to define addiction as a disease, but Steven Hyman, M.D., previous director of NIMH and Provost of Harvard University, does a good job of it. His argument, which reflects the view of the medical community more generally (e.g., NIMH, NIDA, the American Medical Association), is that addiction is a condition that changes the way the brain works, just like diabetes changes the way the pancreas works. Nora Volkow M.D. (the director of NIDA) agrees. Going back to the NIDA site, “Brain-imaging studies from drug-addicted individuals show physical changes in areas of the brain that are critical for judgment, decisionmaking, learning and memory, and behavior control.” Specifically, the dopamine system is altered so that only the substance of choice is capable of triggering dopamine release to the nucleus accumbens (NAC), also referred to as the ventral striatum, while other potential rewards do so less and less. The NAC is responsible for goal-directed behaviour and for the motivation to pursue goals.

Different theories propose different roles for dopamine in the NAC. For some, dopamine means pleasure. If only drugs or alcohol can give you pleasure, then of course you will continue to take them. For others, dopamine means attraction. Berridge’s theory (which has a great deal of empirical support) claims that cues related to the object of addiction become “sensitized,” so they greatly increase dopamine and therefore attraction — which turns to craving when the goal is not immediately available. But pretty much all the major theories agree that dopamine metabolism is altered by addiction, and that’s why it counts as a disease. The brain is part of the body, after all.

What’s wrong with this definition?

It’s accurate in some ways. It accounts for the neurobiology of addiction better than the “choice” model and other contenders. It explains the helplessness addicts feel: they are in the grip of a disease, and so they can’t get better by themselves. It also helps alleviate guilt, shame, and blame, and it gets people on track to seek treatment. Moreover, addiction is indeed like a disease, and a good metaphor and a good model may not be so different.

What it doesn’t explain is spontaneous recovery. True, you get spontaneous recovery with medical diseases…but not very often, especially with serious ones. Yet many if not most addicts get better by themselves, without medically prescribed treatment, without going to AA or NA, and often after leaving inadequate treatment programs and getting more creative with their personal issues. For example, alcoholics (which can be defined in various ways) recover “naturally” (independent of treatment) at a rate of 50-80% depending on your choice of statistics (but see this link for a good example). For many of these individuals, recovery is best described as a developmental process — a change in their motivation to obtain the substance of choice, a change in their capacity to control their thoughts and feelings, and/or a change in contextual (e.g., social, economic) factors that get them to work hard at overcoming their addiction. In fact, most people beat addiction by working really hard at it. If only we could say the same about medical diseases!

The problem with the disease model from a brain’s-eye view.

According to a standard undergraduate text: “Although we tend to think of regions of the brain as having fixed functions, the brain is plastic: neural tissue has the capacity to adapt to the world by changing how its functions are organized…the connections among neurons in a given functional system are constantly changing in response to experience (Kolb, B., & Whishaw, I.Q. [2011] An introduction to brain and behaviour. New York: Worth). To get a bit more specific, every experience that has potent emotional content changes the NAC and its uptake of dopamine. Yet we wouldn’t want to call the excitement you get from the love of your life, or your fifth visit to Paris, a disease. The NAC is highly plastic. It has to be, so that we can pursue different rewards as we develop, right through childhood to the rest of the lifespan. In fact, each highly rewarding experience builds its own network of synapses in and around the NAC, and that network sends a signal to the midbrain: I’m anticipating x, so send up some dopamine, right now! That’s the case with romantic love, Paris, and heroin. During and after each of these experiences, that network of synapses gets strengthened: so the “specialization” of dopamine uptake is further increased. London just doesn’t do it for you anymore. It’s got to be Paris. Pot, wine, music…they don’t turn your crank so much; but cocaine sure does. Physical changes in the brain are its only way to learn, to remember, and to develop. But we wouldn’t want to call learning a disease.

So how well does the disease model fit the phenomenon of addiction? How do we know which urges, attractions, and desires are to be labeled “disease” and which are to be considered aspects of normal brain functioning? There would have to be a line in the sand somewhere. Not just the amount of dopamine released, not just the degree of specificity in what you find rewarding: these are continuous variables. They don’t lend themselves to two (qualitatively) different states: disease and non-disease.

In my view, addiction (whether to drugs, food, gambling, or whatever) doesn’t fit a specific physiological category. Rather, I see addiction as an extreme form of normality, if one can say such a thing. Perhaps more precisely: an extreme form of learning. No doubt addiction is a frightening, often horrible, state to endure, whether in oneself or in one’s loved ones. But that doesn’t make it a disease.

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111 Responses to Why Addiction is NOT a Brain Disease

  1. Thank you for this perspective – I really enjoyed the post.
    I wonder if genetic predispositions also have something to do with the perception of addiction as disease. Does heritability equate with disease in some way?

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    • Marc Lewis says:

      Hi Kelly,

      The heritability issue also gets complicated — and political. The disease camp wants to say that genetic links provide further support for the notion of addiction as a disease. Many diseases are in fact genetically linked, including some “brain diseases” like Alzheimer’s.

      But the research suggests that genetic predispositions to addiction, which aren’t very strong to begin with, all revolve around personality traits — especially impulsivity. So, to me, that doesn’t clear things up. Sure, personality, which is partly heritable, is associated with addiction proneness. But character traits are nothing like, say, the tendency for increased plaque deposits! For one thing, they are far more complex in origin.

      In other words, heritability doesn’t spell disease, unless you really want to see it that way to begin with.

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      • Mechelle says:

        I agree and believe the AA and NA convince them they are “helpless” and the cycle continues. I have been sober 17 years and simply made the choice because it was best for me for many reasons, and rejected the rhetoric in the meetings, although I respect it works for some. I found a few different things worked for me. I currently have a son, who at 19 has been to treatment for drugs 7 times and again,is out and the consequences just keep getting worse, he is handsome, intelligent and has lost scholarship, friends, car, respect and yet in spite of it all..the nightmare continues for 4 years now. Have been to all different sorts of mental health professionals, depression diagnosis, ptsd, adhd, oppositional and have considered Ibogaine treatment and if financially can manage it, will try that, because looks like jail or death. Each time he gets within days of a normal life, he blows it. It is beyond any kind of understanding, he was never aware when I struggled with my alcoholism. I believe I didn everything textbook to get him the help he needs, but the system failed me and judicial system grooms them for failure.

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    • Elizabet says:

      Dear Dr. Lewis:
      I need to tell you that your theory of addiction NOT being a brain disease is completely wrong, unsupported, and detrimental. To those of us who have suffered from addiciton, Dr. Alan Leschner’s Theory of Addiciton as a Brain Disease, rings true in every aspect of his findings. At first using drugs is voluntary. But then chemicals in the drugs hijack our brains natural chemicals and we then need (become addicted) to the drug’s chemicals to function. And most certainly our thinking, decision making, behavior, and emotional maturity, are affected by drug use, as well as our health. We need cognitive, behavioral, and social change, as well as healthcare to undue the damage caused by drugs. The only respite is complete abstinence from drugs for a chance for our “normal chemicals” produced by our body, to once again take over. We can then get on with living, with an education, with relationships, and spirituality, and hope to return to living “normally” without the use of drugs. Addiction is and will always be a BRAIN DISEASE.

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  2. Peter Sheath says:

    Hi Marc
    Excellent blog, do you remember a conversation we had (one amongst many) about mental illness? I was positing the idea that maybe mental illness was very similar to addiction, being more aligned with an extreme form of normality or learning. Well I’ve just finished an excellent book by Darian Leader, a Lacanian psychoanalist, who talks about the very same thing.
    He describes hallucinations, delusions, and mood disturbances as being kind of defence mechanisms, unconsciously created to deal with trauma. Delusions and hallucinations nearly always have some kind of, albeit tenuous, rational explanation and will often respond to reason. It raises the question are mental health problems really problems or are they, in some way, mental health solutions?
    He describes the present way we treat mental illness, mainly revolving around medication, as not be particularly helpful in the long term as it prevents the person finding resilience, new coping mechanisms and new identities.
    As you know I have worked in mental health for many years and have never really been happy with the treatment on offer. It has always seemed very barbaric and, from an eatrogenic perspective, unsustainable. I am becoming more and more convinced that addiction-psychoses-neuroses-phobias, exist as a continuum of basically the same issue, human beings remarkable abilities to learn from experiences.

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    • Marc Lewis says:

      Hi Peter!

      Those ideas are so provocative. Was that from before or after the curry? I’ve generally thought, like you, that mental illness is an extreme form of personality development. Yes, like addiction. But two things come to mind.

      First, it’s probably sensible to divide the obviously organically “caused” problems, like Alzheimer’s, from things like depression or anxiety disorder, which are very often reactions to nasty life events. That division roughly parallels the division between physical and psychological addiction — only roughly, though, since the physiology of physical addiction is more consequence than cause.

      Second, I’m often on-side with your conviction that mental disorders, certainly including addiction, are pretty much all the result of learning — learning gone bad, I sometimes call it. Then you get into issues like “is all learning adaptive in some sense”? Well, sure, in a way. And issues like “addiction as self-medication,” which implies that it really IS adaptive… but only for a while.

      Maybe it’s best to think of these learning trajectories as falling into attractors — ie., self-reinforcing habits that acquire their own causation. In other words, you might have learned to be addicted, or depressed, or paranoid, for good reasons, so to speak. But now it’s just a big fat synaptic feedback cycle, sucking up it’s daily supply of neuromodulators. So it’s no longer a “response” to environmental nastiness, as much as it’s a response to its own history.

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      • Elizabeth says:

        Addiction is a Brain Disease

        By ALAN I. LESHNER, MD

        A core concept evolving with scientific advances over the past decade is that drug addiction is a brain disease that develops over time as a result of the initially voluntary behavior of using drugs. (Drugs include alcohol.)

        The consequence is virtually uncontrollable compulsive drug craving, seeking, and use that interferes with, if not destroys, an individual’s functioning in the family and in society. This medical condition demands formal treatment.
        We now know in great detail the brain mechanisms through which drugs acutely modify mood, memory, perception, and emotional states.
        Using drugs repeatedly over time changes brain structure and function in fundamental and long-lasting ways that can persist long after the individual stops using them.
        Addiction comes about through an array of neuro-adaptive changes and the lying down and strengthening of new memory connections in various circuits in the brain.

        The Highjacked Brain
        We do not yet know all the relevant mechanisms, but the evidence suggests that those long-lasting brain changes are responsible for the distortions of cognitive and emotional functioning that characterize addicts, particularly including the compulsion to use drugs that is the essence of addiction.

        It is as if drugs have highjacked the brain’s natural motivational control circuits, resulting in drug use becoming the sole, or at least the top, motivational priority for the individual.

        Thus, the majority of the biomedical community now considers addiction, in its essence, to be a brain disease.

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  3. I’m a compulsive overeater. I have been obese since childhood. I am nearly 56 years old. Compulsive eating and obesity have devastated my life. If you were to compare a PET scan of my brain with that of a non-addict, you would see a quiet pool in my VTA. Dr. Volkow has shown this, as you say. Pleasure that is non-potable is very rare in my life. I continue to battle my brain — addiction coupled with depression and social anxiety — every day.

    Spontaneous omission? Maybe. But does that mean that the devastation to dopamine and serotonin receptors reverses itself? There is an AA term — “dry drunk” — that describes the person who is abstinent but sour, angry, showing signs of addiction except for being drunk. What kind of image would a PET scan show of that brain?

    AA, NA and other 12-step programs don’t work for everyone, nor are they FOR everyone. But very few of those spontaneous recoveries go on to drink a glass of wine at Sunday dinner without craving more unless they have wills of titanium. There are people who are like that, of course — strong-willed, single-minded — but not many.

    Your dopamine-driven examples of love may also be the explanation of obsessive love, the kind that drives people to stalk and/or endanger the object of their adoration. Learning and excitement can be as much about chocolate cake or a line of coke as they are about algebra or Paris.

    There is plenty of cutting edge science against your reasoning and I’ll leave it to the researchers to argue that with you. As an addict, however, I find your reasoning faulty and I suspect the motive of the psychiatric community that benefits from emphasizing talk therapy over other approaches to addiction. I’ve had great therapists and they have saved my life. But not one of them helped me cope with food. A 12-step program does that, as well as embracing brain-amping foods and activities (see such books as Pam Peeke, MD’s THE HUNGER FIX or Susan Albers, Psy.D’s 50 WAYS TO SOOTHE YOURSELF WITHOUT FOOD).

    I have written before that the disease of addiction in not my fault, but it IS my responsibility. Please remember that spontaneous recovery does not necessarily mean neural pathways are not damaged or that one is no longer addicted. It simply means the individual has forced him/herself not to engage.

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    • Marc Lewis says:

      Wow! So thoughtful and honest and intelligent. And so much to respond to. Let me just take a crack at a few things.

      Re the dry drunk. I’ve become familiar with the concept through a heated and mostly very productive debate on my home blog. Please see the last two or three posts and especially the comment dialogue following them, on http://www.memoirsofanaddictedbrain.com/blog/

      So I think you are suggesting that spontaneous recovery is necessarily? often? what leads to the dry drunk phenomenon? Why would you say that? If you check out the tone and content of comments by the recovered addicts on my blog, you’ll see no such correlation. The message I’m mainly getting is the opposite. Programs like AA and NA (though they can do a lot of good for SOME people in SOME circumstances) may be more likely to lead to dry-drunk status. Because you’re stuck, with your addictive personality, your addictive cravings, that hair-trigger cascade of neural events waiting to happen, yet you have this monolithic “NO” that races to the anterior cingulate in time to deflect the addictive act itself….And a lot of people get that — that rigid NO facing off with the crystallized addiction stuff — through attending meeting after meeting, building up the wall of NOs reinforced by others, and, according to some, being very stuck by the likelihood that your own compatriots will turn against you if you either drink/drug sporadically or else if you even start talking about the underlying stuff, the trauma, the context, the ambivalence….

      Sorry: hugely run-on sentence there. But I just don’t see the connection between “spontaneous recovery” and that state of stuckness you describe. What would the dry drunk brain look like? you ask. Great question! Maybe frequent high activation of dorsal ACC and lateral PFC, especially left, maybe left-ventrolateral. Because you are very keyed in to “reappraisal” at every step. More than that (sheer speculation obviously), maybe unusually low synchrony across distal regions, maybe low delta or theta, or maybe low coupling between theta and other frequencies, such as gamma, because you can’t think and feel at the same time. Maybe high synchrony within hemispheres, but not across, and between close but not distal regions…. Like the brain of a young child?!

      I think that most brands of recovery, spontaneous or not, leave most of the old synaptic highways in place. But once recovered you’ve developed new ones, energized them with high motivation supporting concrete goals — so the ventral striatum can be your friend, not just your enemy. And you’ve developed a couple of choice strategies, like DIVERT the ruminative cascade as soon as it gets started, so you won’t sit on the fence, imagining, and finally succumb to ego depletion because you couldn’t stop thinking about it.

      I don’t think I’m wrong, of course, but if I am, it’s not for the reasons you suggest. I have no personal investment in any type of therapy, including talk therapy, and not much love for standard psychiatric approaches to anything. I was seriously psychologically (and often physically) addicted to opiates/narcotics, for years, from roughly age 23 to 30 — catalogued in my book, Memoirs of an Addicted Brain.

      Yes, addiction really sucks, but I believe that different people get better in different ways. The resounding message I get from my blog community is that one size does not fit all and diversity is key when thinking about paths to recovery. I’ll vote for anything that works for anyone.

      Lastly, it’s not just the reward circuitry that is (probably permanently) altered by addiction. The whole brain is different. Especially all that personality structure we’ve built up — the meaningfulness of it all, of succumbing to it, and/or fighting it and/or repressing it, all those synaptic connections that have been carved out over many years, in places like the orbitofrontal cortex, a primary substrate of emotional appraisal and closely connected to the ventral striatum. Those habits of thinking, feeling, appraising, valuing — are a big part of the addiction. But habits of thinking, feeling, appraising and valuing can also be configured by religious fanaticism or, say, by falling in love, or by having kids. None of which are thought of as diseases!

      Thanks for making me think and feel more about this stuff…and for your honesty and your clear and thoughtful perspective.

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    • Patrick ONeill says:

      I am a former alcoholic that frequently has a glass of wine with dinner without suffering cravings or any consequences.

      I’m not a “dry drunk” – in fact I’m quite happy. AA and 12 step programs were worse than a waste of time for me, and I’m not sure I can tell you how I got better.

      Because I don’t really know – all I know is that I reached the point where I absolutely had to and so I did somehow.

      I do know, from personal experience, that while the AA / 12 step model seems to be the prevailing wisdom it is, for me, both false and harmful.

      Particularly telling people that they are “always” addicts – just sober or “recovering” ones, and there is no such thing as actually not being an addict any more.

      It just ain’t true.

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      • Jim Cox says:

        Interesting. Harvard’s Grant study followed a cohort of men from their sophomore year in college until their 90s. A few of them were alcoholics, which afforded an opportunity to see the natural history of alcoholism over the lifespan. As reported by George Vaillant, all or almost all of former alcoholics in the Grant study, even ones who had returned to social drinking for a few years, eventually became abstinent.
        I don’t know what it means, however. I did know an alcoholic in graduate school who returned to social drinking who is now abstinent – or nearly so. A six-pack to him, once a half-day’s supply, is now a year’s supply of beer.

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        • Marc Lewis says:

          Well, my dad is becoming more and more abstinent (though he was never a drunk), but he says it’s because it makes him pee too often. Perfectly understandable, given that he’s 85. I can see myself going the same way….

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      • Marc Lewis says:

        I very much agree with you. Check out my personal blog for some intelligent debate on this issue. But I think most people who are not card-carrying 12-steppers recognize that a return to social drinking is common and is perfectly fine. I’ve cited the stats elsewhere. And this is part of the larger issue of “harm reduction” — but maybe that’s a misnomer, because as you so convincingly point out, harm is not only reduced, it’s gone!

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      • Kasia Kamieniarz says:

        Good to know we (I mean me and my husband who is a sexaholic) are not alone…12 steps are REALLY not for him, and no for me as a co-addicted person. I feel in it like in a sect. of course we can understand that there are many people find it helpful but we need proffesional help based on science not on a religion.

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    • Cynthia says:

      I’m very similar to you in age and circumstance surrounding compulsive eating. Perhaps a requirement of anyone commenting on addiction should be that they themselves suffer from the affliction. Unless someone has lived it, I believe it’s very difficult to understand. I don’t really care if it’s defined as a disease or any other descriptor. I only want permanent relief.

      My life is shaped by many multiple experiences of losing a great amount of weight and then, no matter how hard I tried, gained the weight back. That’s where I am now. Highest weight of my life… and just a year ago was at a normal weight.

      Each weight loss experience is followed by equal weight gain, and more… followed by belief that the next new program will be the answer. And it always is… for awhile.

      “The Craving Brain” book has been the most logical explanation of my inability to control my craving. Addiction is a complicated issue and solving it is more than just staying away from whatever substance gives you that “aaaahhh” feeling. The fact that I could lose so much weight fairly easily but then gain it back no matter how I tried to stop binging tells me there is more at work than we realize.

      Maybe joining diet programs can work for the average overweight person. But after doing every weight loss program out there, and inpatient treatment, OA, counseling, etc., the motivation to continue always wanes, as the desire to overeat increases.

      Even with counselors who claim to work with eating disorders, most don’t understand the dopamine-seratonin connection. Everything I try works for awhile. It’s as if my body chemistry is always trying to override what I’m doing, to get it back to its “normal.”

      It isn’t normal for an intelligent, accomplished, successful person to be so out of control that they can’t stop eating until they’re stuffed, even when they don’t want to.

      Now that I’m back at my highest weight again, I have nowhere to turn. I’ve tried everything. Now I don’t have the motivation to try anything because I’ve failed every single time. I don’t want to relive the pain of regaining weight. It’s embarrassing and painful. I know it’s unhealthy. It’s also embarrassing and painful to be where I am. I’m trapped.

      Now I read this article after searching the internet for answers, and I hear that my problem is just “extreme normal.” My logical brain tells me different. Our scientific community is supposed to be so advanced… yet they can’t even agree on whether I have something that needs to be cured.

      So I’m damned by society for being obese and unhealthy, but no solution is truly offered, besides blaming me. Is it any wonder people give up?

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  4. Aid Jaffe says:

    Nice summary and critique. I’ve always seen addiction as a syndrome lying across a continuum. Your definition as “an extreme form of normality” relates to one specific end of that continuum, but many of those who spontaneously recover likely lie somewhere in the middle. IMO

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    • Marc Lewis says:

      Well, okay, maybe….but it’s still a continuum. Still not quite sure what you mean. Do you mean that the “extreme” end of the continuum features those with less likelihood of spontaneous recovery? That’s probably true. The poor souls with many missing teeth, whose only CV is a criminal record? The “disease camp” would like to draw our attention to how very ABnormal those folks are. But there would be that line in the sand again, which would make it hard to explain garden-variety (ex) addicts like me.

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  5. Gabriel says:

    I think the best “disease model” of addiction is to think that its a very severe side effect of a toxic substance. You can get intoxicated by many substances but only a few alters brain function in such a way that the person gets “sick”. The consequence is that in addition to dopamine, many neurotransmitters and brain systems are involved.

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    • Marc Lewis says:

      True, there’s the toxicity of the substance itself. But that’s a separate issue, in my mind. You can be horrifically addicted to gambling, or porn, or (some say) computer games. In which case, you still get tons of dopamine, just by virtue of the attraction itself. But all that dopamine is coming from your very own midbrain!

      The “extra” dopamine you get from, say, meth or coke, is like icing on an already dangerous cake.

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      • Kasia Kamieniarz says:

        well..but maybe if we stop definig behaviour addictions as a disease there will be no chance to get help from the public health service? so it’s useful in some ways…

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  6. Janis says:

    Quick question — if we’re going to look at this as a medical thing, or at least as a behavior that has a history and a capacity that developed in our species for some reason, then it becomes a matter of asking what benefit there was to creatures to become addicted. You’ve tried to analogize it to learning as a positive force that increased a species’ health that’s somehow gone haywire. I don’t think this is really helpful.

    To look at it another way: were there any homo habilis addicts? Were there any Neanderthal addicts? What might they have been addicted to? Was there ANYTHING in their environment that humans could conceivably have gotten addicted to? Were they technologically able to create anything powerful and concentrated enough to create addiction? Probably not. Even sex didn’t have that capacity, just because they probably lived in such relatively small communities that even had one of them had sex with every possible candidate they knew, that might have translated to about fifteen people.

    I can’t shake the feeling that addiction is an instance of humans encountering things that are outside of the magnitude of things that we evolved to handle. They encourage us to operate “out of spec” in a way. Some people, like me, dislike very heavy calorie-laden foods and so I tend to react to operating “out of spec” in that way by simply ignoring the stimulus. Others such as the previous commenter Frances react differently when confronted with a super-stimulus like that and it causes them dire problems.

    We all evolved to deal with certain stimuli: for food, for sex, for confrontation, for communication, for stockpiling. Nowdays, because we are a technological species, we have begun creating things (substances, pastimes) that stimulate these appetites in ways that we were never designed to handle. Whether it’s deep-fried Snickers bars, gonzo porn, first-person shooters, Twitter, or credit cards, some people will react by filtering out a stimulus their brains aren’t equipped to handle in currently available enormous quantities, and some people will react by pursuing the stimulus even more.

    I repeat: we are operating “out of spec.” THAT is addiction. No one gets addicted to coca leaves. They get addicted to cocaine.

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    • Marc Lewis says:

      If that’s a quick question, I’d hate to see a long one. I couldn’t agree with you both LESS AND MORE!

      My disagreement is as follows. Not all biological patterns, habits, species-specific traits or trends have to have evolved because they’re adaptive. Stephen Jay Gould argues strenuously against this “adaptationist” perspective, for example, by demonstrating that pink flamingoes are NOT pink in order to blend in with the sunset (camouflage). They’re pink because they eat a lot of shellfish or shrimps or something. Traits evolve for all kinds of reasons. My favorite example is back-aches. Almost everyone I know over the age of 45 has back problems. Does that mean that back-aches are adaptive? Of course not. They are byproducts of having an upright spine — which certainly is adaptive. I often think of depression in the same way. A miserable byproduct of liking or loving people that eventually ditch us.

      By this line of reasoning, addiction is a byproduct of something more fundamental that clearly is adaptive: having a brain function (housed in the nucleus accumbens/ventral striatum — a very old region) that charges us with the motivation to pursue short-term goals and connects with a motor generation system (the dorsal striatum) that directs our behavior toward those goals. So Homo Habilis was probably not an addict, but he sure did go for a lunch of tasty ribs or maybe just low-hanging fruit — a primal dessert. See http://www.memoirsofanaddictedbrain.com/connect/is-homo-habilis-enjoying-his-lunch/ for a cute picture. Thus, goal anticipation and pursuit are highly adaptive. But goal anticipation equals craving when the goal is out of reach. And even that craving state was probably adaptive for H. Habilis, as it led him up over the next hill to find more meat or more fruit. Yet we recognize “craving” as a fundamental symptom of addiction. My point: that doesn’t mean that addiction itself was EVER adaptive.

      But I AGREE with you that addiction, the phenomenon, is all about substances and activities that are “out of spec” — experiences that are too pleasureful or exciting, that overwhelm us, that we are not equipped to handle, all of which you portray beautifully. That observation seems not only astute but also “right” at the gut level. Heroin, cocaine, gambling, porn….these are all highly attractive and are the result of technological achievement. But wait a minute. Some people, like a previous commenter, Frances, whom you also cited, are simply addicted to food. And it doesn’t have to be deep-fried Snickers. Some cells in the orbitofrontal cortex have an unlearned response to sweetness. Sugar is a primary reinforcer. So, you don’t need high-tech stuff to be addicted to…..it just makes the addiction all the more likely, more intense, and maybe that much harder to quit.

      If I were to try to reconcile what I agree with and what I don’t agree with in your comment, I’d say….I’m saying…. Technological evolution is an extension of social evolution which is an extension of biological evolution. (A few very smart people have argued this, though I can’t remember any of their names at the moment.) So of course we refine coca leaves and extract opium from poppies and wire up a lot of flashing lights when we build casinos, and make poker chips very attractive looking….and some single-malt scotch is just so tasty AND it gets you drunk.

      Whatever we were ever attracted to, during our evolutionary past, goes through immense cultural and technological upgrading. (Except maybe sex, which was probably hard to improve on.) So we’ve gone from “mere” rewards (which we craved 2 million years ago) to super-rewards. That just facilitates addiction; it doesn’t cause it.

      What causes addiction is the self-perpetuating nature of a brain design that sensitizes us to cues predicting reward, motivates us to go after that reward, then finds a way to acquire it, enjoy it, and want more of it. Plus a few other brain features that favor delay discounting (I want it now!), reappraisal, rumination, and other cognitive-affective goodies.

      I’m reluctant to say this — because it’s trite and cliched and logically flawed or at least distorted — but “nature and nurture” rings a bell here.

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  8. Theresa says:

    I really appreciate your expert point of view, and I offer a rebuttal to your point about spontaneous recovery.
    1. addiction can be looked as a spectrum disorder or illness. There are those whose symptoms aren’t so grave, and their disease responds to treatment.
    2. As for treatment, though I am not a medical professional, aren’t some conditions improved, or even reversed by life style choices? Heart disease, diabetes are examples that come to mind.
    3. Maybe the operational definition of Disease need to be relooked at?

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    • Marc Lewis says:

      Hi Theresa. I’m not exactly sure what you’re rebutting, but I’m all ears. If addiction is a spectrum disorder, does that mean that all addictions should be considered “diseases”, but there’s a lot of difference within that category, and only the less severe ones may be subject to spontaneous recovery? Again, there’s the issue of “where do you draw the line?”

      Your second point is provocative. You are saying that “real” diseases can go away due to lifestyle choices. True enough. Maybe I spoke too quickly when I minimized spontaneous recovery for medical diseases. But lifestyle changes can affect so many things: being greedy or needy, being sexually attractive to others, getting pregnant, saving for your future, voting Republican… So the fact that diseases are also profoundly affected by lifestyle changes doesn’t seem to improve the argument that addiction is a disease.

      Still, it’s interesting that the diseases you mention are fundamentally “developmental” . It makes sense to compare these diseases most closely with addiction. And I agree with you that the definition of “disease” can well use some updating. I think that’s currently happening in medical circles, e.g., in regard to cancer.

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  9. John Egan says:

    Very interesting. But are you conflating complusivity, addiction, overconsumption and binging? I know the lines between these are messy, but I think there are distinctions.

    I’ve always found problematic the conflation of addiction with gambling, for example. Addiction implies consuming something that metabolizes in a way that creates/triggers more consumption–even when the deliterious impacts are clear.

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    • Marc Lewis says:

      There are so many definitions of addiction: “behavioral addictions” like gambling are recognized as addictions by lots of professionals. There’s even a journal devoted entirely to behavioral addictions. So I don’t agree that substances have to be the goal.

      It’s true that gambling epitomizes compulsive behavior, but compulsive behavior is often considered a characteristic of addiction. So….I don’t see the problem.

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  11. Hal says:

    I am surprised that you do not mention the very illuminating Conditioned Opponent Process Theory of Addiction, formulated by Shep Siegel (refining earlier opponent process theories by Solomon & Corbett). In the 1990s there was a lot of very sophisticated thinking about the connections between learning and addiction, building on some striking experimental evidence.

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    • Marc Lewis says:

      You are right that component process theories could help my argument, because they frame addiction as the result of psychological (e.g., learning) rather than medical mechanisms.

      For those not familiar with such accounts, opponent process (or “dual-process”) models highlight the tension between two systems with different functions: for example, a reward-seeking or impulsive system that does battle with a self-regulation or future-oriented system — sometimes described as a horse/rider relationship. Some researchers have started to flesh out such models in neural terms (e.g., a paper in press in Clinical Psychological Science by Wiers, Gladwin, Hofmann & Ridderinkhof). But there is still a long way to go…

      My only hesitation is that I think this type of model has to fit with observable neurobiological processes really well, before it can play in the same ring as disease models based on brain change. I’m sure that will happen eventually.

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  12. I have a friend that was opiate addicted for many years. After about five years, she realized opiate addiction was not a good idea and tried methadone. That eliminated the good feeling from opiates but was addictive itself. She then moved to Suboxone -same problem. She finally tried an experimental treatment involving receptor blocking- it worked; she also lost the craving for cigarettes. It seems to me that there are at least two dimensions to addiction; the physical and the psychological. Successful treatment for the latter does not eliminate the ‘craving’ syndrome, some treatment for that seems required. In the case of many alchoholics (me, for instance). There is little or no physical aspect to the addiction so quitting is primarily a psychological factor and AA seems to show that. Thus a fully addicted person would seem to have a mental disorder, + possible psychological aspects, + a physiological condition. For example: clinical depression, derived feelings of inadequacy, self medication, addiction.

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    • Marc Lewis says:

      It’s very useful to distinguish the physical and psychological aspects of addition, as you do here. But I think you mix things up a bit.

      By finding a receptor-blocking agent, I’d say your friend overcame her psychological addiction. I’d say the physical addiction disappeared on its own, as it often does once you’ve beat the psychological addiction. Just because the change in her drug use (including tobacco) was initiated by a drug does not mean she targeted the physical addiction. Psychological changes (e.g., in impulse, compulsion, self-control) are underpinned by the same brain, the same “wetware”, as physiological changes. I think that it’s only useful to talk about “physical addiction” with respect to tolerance and especially withdrawal symptoms.

      Moreover, it’s the psychological addiction that is so much harder to beat, so much more insidious, because it can nail you a week, a month, or ten years after you’ve quit — whereas withdrawal usually only lasts a few weeks. I think you agree with that in your comment, but I’m not quite sure.

      You seem to connect craving with physical addiction. But I’ve always seen it as purely psychological (though the torment can be enhanced by withdrawal symptoms). When I was taking opiates — and I was very much a psychological addict, in that I could not control my impulses — I’d have to fight off intense cravings weeks after I was “clean” physically and withdrawal symptoms were long gone. That’s typical of opiate addicts. The connections between drug/alcohol cues and activation patterns in the amygdala, ventral striatum, and ventral tegmental area (all involved in emotional associations and motivation to pursue goals) simply do not go away in a few weeks. They may never go away.

      In a nutshell, the addict’s greatest enemy is the mind, not the body.

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      • Mark says:

        Wonderful blog, and I’m sure all recover[ed, ing] addicts out there are grateful for the information. I’m clean for one year, on March 29th, from a 6 year addiction to Oxycontin, which eventually came to shooting it and heroin.
        I just wanted to opine on my experience of physical withdrawals, in regards to its role in addiction.

        I feel that physical withdrawal pain was incomparably severe. I always assumed that it was something huge in every addiction – drugs and alcohol, at least.

        While I’d openly admit that I utilized the drug to the full extent of its ability to psychologically compensate for my severely diminished reality, the physical pain of withdrawals was an absolute force that established that reality as an…irrefutable certainty. Locked me in.

        Do you not feel that physical withdrawal in and of itself is a major factor of addiction? At the very least in the case of addictive drugs? I understand that addiction is now an umbrella term that includes many things besides drugs or alcohol, but for drugs and alcohol, I’d always assumed that everyone was “bound” as much by the purely physical compulsion as well as their psychological compulsion.

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        • Marc Lewis says:

          Hi Mark,
          I am no longer participating in this blog, but I hope this reaches you. Yes, I certainly agree that withdrawal is one factor that distinguishes some addictions from others. But it’s complicated! Opiates produce the most severe withdrawal symptoms — but opiates may also get to receptor sites the are hugely important for a sense of wellbeing. So that makes a certain kind of sense: don’t mess with the molecular network that helps you to feel fundamentally ok.

          But other drugs have no withdrawal symptoms — e.g., coke and meth. After a couple of days of resting up, even rather severe users can feel very little cost — physically. And yet these drugs remain highly addictive psychologically. So the two modalities are really not in synch.

          I’ve recently been discussing differences among various addictions on my home blog, http://www.memoirsofanaddictedbrain.com/. Please come visit us there.

          And congrats on one year clean. Oxycodone is a real bitch! (I’ve been there)

          Cheers,
          Marc

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  13. Delane Roberts says:

    The argument relies on an all or nothing assumption about who is an addict or what is considered to be addiction – or when addiction rises to the level of a “disease.”

    I certainly agree that people who are considered addicts often recover by themselves, and it is reasonable to question if they ever had a disease. Very possibly, the definitions of “addiction” and “addict” are too broad.

    However, there are many people who are undeniably addicted, addicts, and diseased. They may not be the majority of people labeled as addicts, but they suffer extreme withdrawal symptoms, are rarely able to meaningfully or permanently reduce their dependence, and are profoundly disabled because of it.

    This subset of dependent people at least qualify as diseased, don’t they?

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    • Marc Lewis says:

      I don’t agree. Even that severe subset don’t have to be labeled “diseased”. Sure, physical withdrawal symptoms comprise a physiological backlash to a chemical imbalance (self-imposed). If you want to call that a disease state, well, go ahead, but it only lasts a few weeks. The severe dependency you note can be quite divorced from withdrawal symptoms. For one thing, it very often outlasts them (see my last comment). More to the point, people can be severely dependent on an abusive spouse, on porn, on sweet foods, on a whole host of things that have nothing to do with physiological withdrawal symptoms. That would make it a psychological condition.

      I’m trying to argue that severe dependency is learned, it’s reinforced, it’s self-augmenting, it’s really nasty, and yes, we can point to its neural substrates. But it is still a psychological condition, and it can be overcome through psychological interventions, including CBT, mindfulness training, changes in self-concept, or interpersonal changes (like falling in love).

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  14. George McKee says:

    I think you’re getting caught up in an artificial distinction, and then being distracted away from it. What happens in the brain/mind in addiction is important to understand regardless of whether you call it a “disease” or call it some other kind of disorder or syndrome. “A rose by any other name would smell as sweet”.

    Considering more carefully, you should ask if there are other biomedical phenomena that have similar properties to the aspects of addiction that make you reluctant to call addiction a disease. I can think of three, and one of them you hold up as a good example of a disease: allergies, Type 2 diabetes, and cancer.

    These diseases also have genetic propensities, are enhanced by environmental exposures, can be controlled by willful behavior, and sometimes undergo spontaneous remission. What these all have in common is that they are disorders of adaptive regulation, where the dynamical behavior of the system can range from amplification to damping under the delicate influence of a control factor, or perhaps many interacting control factors, based on chemical signals (hormones, neurotransmitters) that are simultaneously being created and removed at different rates, and receptors that can be occupied, blocked, and cleared at various rates.

    Now, untangling control networks is extremely difficult, and there is no silver bullet to force them back into good behavior (a silver sledgehammer will sometimes work, but may do more damage than it repairs). But arguing about whether the malfunctioning system is properly called a “disease” only helps if you’re stuck in some primitive notion of disease like requiring Koch’s postulates to be satisfied. Given modern medicine’s checkbox-based diagnostic and treatment methodology, it’s expedient to simply accept that if it’s treatable, it’s a disease, and get on with the real work of trying to understand what’s actually going on.

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    • Marc Lewis says:

      This is a very thoughtful argument, but I think I can still resist it!

      At its most fundamental level, addiction is a condition of wanting something very badly and not being able to control the wanting or the pursuit of it. Now look at the words I used here: “wanting”, “control,” “stop,” and “pursuit” — these words describe psychological or intentional states, not body states. Along the same lines, you say those three diseases — cancer, Type 2 diabetes, and allergies — can be controlled by willful behavior (i.e., by intention). I don’t think so. At least with regard to cancer and allergy, you can control the likelihood of contracting it, but once you “get it” you can’t rid yourself of it through acts of will.

      You make many excellent points: these diseases develop, as does addiction — so they’re very different from, say, cholera, which you either have or don’t have. Ok, so we narrow the range of conditions we’re comparing….but that doesn’t cross the gulf between what’s intentional and what’s not. You correctly say that all of the above are dysfunctions in adaptive self-regulation. Yes! But we know that cognitive self-regulation is radically different from self-regulation as a physiological process (as in temperature control). You go on to say that both kinds of conditions are affected by neurochemicals, hormones, receptor availability, etc, but so is everything we sense, feel, think, and do! I’m not going the route of mind-body dualism. It’s just that we need to distinguish what’s cognitive and what’s not.

      So on to your last point. Indeed, the definition of disease is rapidly evolving within medicine, and to the extent that some diseases are truly developmental, we at least have a tighter analogy with addiction. So what does it matter whether we call addiction a disease or not? We have to call it something!

      I think it matters because of this issue of intentionality. Having “met” hundreds of (mostly ex) addicts through my other blog, I keep getting hit over the head with the importance of how addicts see their addiction. 12-step programs like AA and NA define addiction as a disease, so the way you deal with it is through a static form of treatment (going to meetings for the rest of your life), and you are made to believe that you will NEVER be free of it — so you have to spend the rest of your life controlling a hideous disease. Not a pleasant prospect. Moreover, the will is almost anathema to recovery in the 12-step world. They often refer to it as “willfulness” and it makes things worse, not better. Members are strongly advised to give up their sense of intention, control, will, etc, and submit to a higher power.

      Now the success rate of AA/NA type programs is actually not very impressive (see summaries in Stanton Peele’s work or the Orange Papers site — http://www.orange-papers.org/), especially when these rates are compared to the net effects of “rational” recovery programs, mindfulness, and treatment-independent “spontaneous” recovery. These latter approaches, in contrast to AA/NA, rely on a sense that one’s efforts do matter, and the addict’s creativity and resolve are strongly encouraged, not dismissed.

      In my view, these correlations — between a definition, an approach to recovery, and outcome statistics — are reason enough to challenge the implications of addiction as a disease.

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  16. aidel says:

    This is an interesting post but I disagree. Recently I read about some research that reached the opposite conclusion. (That addiction is a disease, observable on scans, and definitely with a genetic component.) I wish I could supply you with a reference but I can’t remember exactly where I read it (but I can tell you it WASN’T in Huffington Post or Psychology Today — it was respectable scientific research). I would like to see more evidence for your argument. If addiction and/or mental illness are not diseases, are we going to be forced back to models such as hysteria?

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    • Marc Lewis says:

      I don’t think we have to go backward, say to hysteria (or even worse: it’s all my mother’s fault). Rather, I want us to go forward: from the DEFAULT assumption that mental or emotional states we don’t approve of are “de facto” diseases. I think we can do better.

      Those scans you refer to will never tell you whether something is a disease or not. They just tell you about brain activity… They might even tell you that something is “abnormal”… Well London cab drivers have an abnormally large hippocampus — a brain part that is crucial for long-term memory. That goes with having a tremendous grasp of the geography of London; it does not suggest a disease.

      Whether something is a disease or not….that’s definitional, it’s conceptual, it has to make sense. I don’t think we should accept it as a default assumption. To me that’s lazy thinking.

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  19. Joe S says:

    Aren’t the processes that govern wanting physical processes? We’ve inherited the reference to psychological processes from a time before we could measure physical activity within the brain. I think this distinction is very important because it helps explain why it is so hard to will addiction away. Some people say well it’s just a psychological problem, get over it it’s all in your head (psychosomatic).

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    • Marc Lewis says:

      Yes, indeed, they are physical processes. But that covers all psychological activities and trajectories. Every nuance of thought and feeling has a physical analogue, or, if you prefer, correlate, or substrate, or….you name it… in the brain. Not sure what that has to do with “disease” versus, say, learning.

      In roughly 50-100 years, that mapping may be subtle enough to articulate physical brain processes at the level that, say, novelists or biographers articulate psychological processes. (Read Updike lately? — maybe 300 years). Until then, we have to be content with two levels of analysis.

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  22. Krishna says:

    Interesting take on addiction, although I have to agree with some of the commenters here and find fault with this argument. I always thought of disease as a pathological state that doesn’t allow for normal functioning of human functions.

    So Yes there is no question that addiction is a disease. Yes irregular users of drugs of abuse can recover without any medical intervention. But that is not case in heavy users and this condition is the one being called a disease. Yes I agree with you that a distinction should be made between these two situations. But to remove the title of disease for addiction or addictive disorders will affect these patients not just psychologically but also from a public health policy stand point.

    On a completely unrelated note, I am a biochemist working on the cannabinoid system and my research work mostly involves understanding their signaling pathways inorder to help us develop novel drug treatments for pain, obesity etc. Of course addictive disorders could also be a therapeutic indication for these drugs that would be developed from our research, but a number of colleagues have stated their concern over why we spend so much money for addiction research when it could simply be avoided by individuals’ self control? Well because it is a disease that although started out to be under their control is not anymore and therefore our duty as healthcare professionals to provide them the care they need. This, I believe, should include terming a condition that is out of their will as a Disease.

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    • Marc Lewis says:

      I’m not sure how to debate with you. Once you say ” there is no question that addiction is a disease” there is nowhere else to go. You distinguish between light use and heavy use of substances, looking for the line in the sand between non-disease and disease. That works as a metaphor…sometimes. But it breaks down. Is compulsive gambling a disease? Is pedophelia a disease?

      You end your comment by defining whatever cannot be controlled as a disease. But this is not logical. Sexual attraction can often not be controlled — even when it’s healthy and normal. That does not make it a disease. Maybe by noncontrol you mean the expression of unwanted desires in behaviors…but again, it’s hard to find the logic. People will cheat on their wives because they could not (?) did not (?) control the desire-action connection. Is cheating a disease?

      I do agree with you that public health policy can benefit from the disease labeling trend. And that is a plus. But the power base of public health/policy consists almost entirely of physicians and ensurers! And government funding follows the path of least resistance. I just don’t see how that helps us get closer to a scientific analysis.

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    • James Morris says:

      As a public health professional, and someone who has ‘recovered’ from alcohol dependency, I see disease model thinking as one of the biggest challenges to the ‘public health’ task of reducing overall alcohol harm. This applies even if addiction was or is a diesease.

      Essentially, most people who have alcohol-related problems are not dependent, or certainly not ‘alcoholics’ who can never drink again. In England (UK), around 24% of adults have an alcohol use disorder (i.e drink in a way that is actually or potentially harming their health). However up to only 4% of adults have some level of dependence, with only around 1% having severe dependency that is usually equated with ‘alcoholism’/disease model thinking.

      The big challenge to public health is to help the 20% of alcohol misusers without dependecny to recognise they are at-risk or may be experiencing problems. However most will believe that because they are not ‘alcoholic’(dependent), they therefore don’t have a problem or are not at risk.

      So regardless of whether disease model thinking is right or helps those with addiction, overall it presents a big challenge to the public health task of reducing the overall burden of alcohol misuse.

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  23. Molyneux1000 says:

    I feel you need to define what you mean by ‘recovery’ when you refer to individuals who have recovered from their addiction.

    Is recovery going from dependent drinking to social drinking, as many try but fail to achieve (white knuckle sobriety, more often than not leading to relapse); or is recovery going from dependency to maintaining abstinence? I feel the disease model helps me to explain to my patients why abstinence is most likely the only viable option.

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    • Marc Lewis says:

      Actually many with alcohol dependency problems do recover fully and continue social drinking. Please see my comment below for further references, but for now check out the recovery stats for a period of just one year:

      http://www.niaaa.nih.gov/news-events/news-releases/2001-2002-survey-finds-many-recover-alcoholism-researchers-identify

      Some have to abstain completely, some not, so of course the definition of recovery is complex and controversial.

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      • James Morris says:

        There is also a comprehensive review of the research up to 1980 in a book called ‘Controlled Drinking’ (Heather, Robinson). They have since published ‘Problem drinking’ which updates this to a large degree.

        I’ve also documented my own experience or returning to ‘social’ or problem-free drinking after past dependence on the blog https://thinkingaboutdrinking.wordpress.com/

        One thing is clear is that its not very everyone. The severity of dependence appears a significant indicator in that those who reached more severe/physical depedence seem less likely to achieve controlled/social drinking. A long period of abstinance and improved life circumstances are also crucial in many cases it would appear.

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  24. E says:

    Ok, addiction is not a disease or an illness, it is an “extreme form of normality or learning”. So what, if anything, do we do about this “extreme form of whatever-it-is-ness”?

    When I started reading this article I thought, good, someone will now present a different view of addiction and suggest a new approach to treating it. Like you I struggle with the idea of addiction as illness because illness leaves little room for free will. But having read the piece by Steven Hyman, linked to in your article, I prefer his view that the brain is multi-redundant and while addiction damages the parts of the brain dealing with motivation, the patient can with the right support and treatment encourage other parts of the brain to take over and re-assert control. Rather like what happens when a stroke victim learns to walk again.

    Which is probably not so far from your own treatment model although I expect you phrase it rather differently but it seems that you have had to argue yourself round in a circle to get there. I would also challenge your assertion that 50 – 80% of alcoholics make a spontaneous recovery, where exactly did that figure come from?

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    • Marc Lewis says:

      The brain is indeed “multi-redundant”….but so what? What I find most contentious is your statement that addiction “damages” the parts of the brain concerned with motivation. (by the way, you say that came from Hyman, but I just searched for the term “damage” in the interview with Hyman linked in my post. Got zero hits. Maybe he says it elsewhere?)

      Anyway, what on earth do you mean by “damage”? Synaptic growth, synaptic pruning, retraction of dendritic spines, and changes in gene expression are not damage. They are the mechanisms by which the brain learns. Sure, take vast amounts of alcohol or methamphetamine and you’ll damage something. But most addictions do nothing of the sort. Certainly there is zero evidence that behavioral addictions (e.g., gambling, sex, eating disorders) “damage” anything — yet there is a great deal of similarity in the profile of onset and maintenance, recovery and relapse issues, etc, etc, between substance addiction and behavioral addiction.

      As to alcohol recovery stats, check out the research. Go to the link in my post, or better yet, look at the results of the biggest study of alcohol dependence ever conducted. I’ll refer you to a summary comment — http://www.psychologytoday.com/blog/addiction-in-society/201010/what-percentages-people-in-recovery-are-treated-and-untreated — that links to the NIAAA website (part of NIH) and thence to many other references. I didn’t make it up.

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  25. Joe S says:

    Isn’t it possible that, once advaced far enough, addiction becomes irreversible? The reason we see spontaneous remission is because most cases turn around for some reason before they reach the point of no return. Those that die after being addicted for a long time may have reached a point of no return. Indeed, case histories indicate some poor souls just can’t seem to stop despite severe degredation. Wouldn’t we call this irreversible condition a disease?
    Since there is evidence that drugs ramp up the circuitry of motivation for drugs and ramp down the circuitry of cognitive control should we still call addiction a choice?
    What if specific changes to these circuits were found to be caused only by drugs of abuse?
    In my opinion addiction is not a ‘true’ choice but hasn’t yet been proven a ‘true’ disease.
    Finally, since there is no ‘treament’ proven to be effective we need much more effort devoted to describing the features of spontaneous remission like the link you provided to Klingemann’s paper but I’ve found following up on the research in this area quite difficult. Perhaps someone can steer me in the right direction.

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    • Marc Lewis says:

      Indeed there often seems to be a point of no return. But you can’t define it or predict it (as you could with, say pancreatic cancer). You can only see it in hindsight. In other words, it’s never really irreversible except in a tautological way — it’s irreversible once it reaches a point of no return. True, some people die from addiction. To say it’s irreversible when they die — well I think that’s a weak argument. The same would apply to walking across a busy street in rush hour in New York.

      In any case, I agree with you in general. Addictive behavior is neither a true choice nor a true disease. It has some elements of both, and that’s why it’s so damn difficult to pin down. As you say, we need to look really closely at spontaneous recovery. There are a lot of clues hidden there.

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      • Joe S says:

        So it’s not truly a choice and it’s not truly a disease. We can agree then addiction is a disordered state with features of opponent processes, learned behavior, excessive drive and (it seems) cognitive impairment. Since all the models don’t quite fit the findings then it must be in a class by itself. At certain times and in certain settings addicts can control their use. At other times and other settings they go out of control. It’s not truly involuntary and not truly voluntary. It is certain, addicts are sick people.
        I get hung up on the definitons of psychological and physical dependence. Both are caused by brain systems that can be measured at least in part. Both drive one to use and as you say and I have experienced the psychological seems to be stronger and much harder to overcome. In my experience, my will was useless in overcoming my addiction.
        I think the disease and choice models should be scrapped and argued against vociferously. The disease model gives too many an excuse to cling to. The choice model diminishes the severity of addiction and allows people to ‘kick the addicts to the curb’. There should be a movement to define addiction properly, in it’s own category. I thank you for your efforts in this area.

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        • Marc Lewis says:

          Joe, you and I fundamentally agree. I would endorse all your points, above, except one. You state clearly that addiction is in a class of its own, and definitions based on “disease” or “choice” fall short of explaining it. But then you say ” It is certain, addicts are sick people.” I’m going to assume that the spirit of Nora Volkow temporarily inhabited your body for that sentence.

          Otherwise, yes, a class of its own. But we’ll get there. The more we learn about the brain, the closer we get. We begin to appreciate mechanisms like sensitization, switching of control from one system to another, developmental processes like “kindling” and so forth — all based on the growth of neuro knowledge.

          As for the distinction between physical and psychological dependence, I’ve touched on this in various places and in my book. But the nutshell version is this: physical dependence is caused by changing the set-point of specific neural systems. They get used to a high quantity of opioid molecules, for example, and then they rebound (sometimes called “antireward”) when that quantity goes back to normal. Physical dependence is relatively short-lived. However, psychological dependence is caused by changes in many systems, probably under the control of the ventral striatum (nucleus accumbens) that connect various representations to goals or anticipated rewards. Psychological addiction depends on long-term changes in synaptic networks, and is thus comparable to normal learning and memory. Psychological addiction brings changes in the meaning or value we attach not only to stimuli but to the contexts in which we encounter them. This, to me, is where addiction deserves scrutiny as a singular phenomenon — a class of its own.

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          • Joe S says:

            Yeah, Nora and I have a thing going on. She’s done some fantastic research but seems to go ‘off the resevation’ when she draws conclusions beyond what her experiments can support. Much like BF Skinner in “Beyond Freedom and Dignity”. But, I still think addicts are very sick. What else can one say about someone who wakes up in the middle of the night terrified and can’t calm down until he gets a fix?
            I’m trying to understand Berridge’s incentive sensitivation theory which has experimental support but seems inconclusive. Berridge states that drugs of abuse cause withdrawal states, ramp up incentive and cause cognitive dysfunction whereas normal stimulants ie food, sex, social interaction ‘may’ ramp up incentive but probably don’t cause withdrawal states and certainly don’t cause cognitive dysfunction. I think he’s wrong about withdrawl states. Certainly hunger, lonliness and unrequited ‘love’ look like withdral states. That leaves us with cognitive dysfunction as the only difference between drugs of abuse and ‘healthy’ reinforcers. I think that permanent cognitive deficits are rare and even when they are severe, the power to overcome the drug incentive can be restored.
            Setting, context and a host of ‘triggers’ are so important. One drives by the liquor store and the urge to pull in and buy a bottle can be overpowering. Why does the brain operate this way?
            Will we see medical advances that can ‘cure’ addiction in our lifetime?

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  26. Ericka says:

    I am a recovering alcoholic and have not had a drink in 16 years. You might call my recovery spontaneous, I was almost dead when I got to the hospital. After several weeks in the hospital, some in the medical ward and some in the in house detox and addiction treatment ward I did not drink again. I did go to AA for a while, but no longer do.

    My take on this whole thing is that addiction may be a spectrum, I had never thought of it that way. I have always thought there may be two kinds. One inherited and one acquired. But, to put it in the context you are speaking of, maybe on one end it could be acquired and up through the inherited.

    My parents were both alcoholics. When I took my first full drink, at a very young age ~12, I was already addicted (although as a younger kid an occasional sip of beer was allowed from the grownups). As soon as the effects wore off I wanted another drink. Until I quit I always wanted another drink. Of course when I was younger I could not always get this, but as I got older I could, and drank almost every day of my life from about 18 years old until I was 29 years old.

    This feeling has been reported in many of the other addicts I have known. Not all of them, but many. The others I believe may be like you and able to drop the habit very quickly because it is more habit, at least at first. (I am not saying there is no physical or psychological addiction there, just a different one) Those like me, I believe, might have a different brain chemistry or structure from birth. Maybe the drugs or alcohol change the physical and chemical responses in the brain, like the dopamine or serotonin, more quickly and permanently in people like me than in the others. I wonder if someone like myself would present differently in an fMRI than the others and non-addicts?

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    • Marc Lewis says:

      These are really interesting points, Ericka. Thank you for your honesty and your insights. The spectrum idea feels right to me. I’m not sure how to define it or demarcate it, but does seem to capture a lot of the phenomenon.

      Yes, your history would place you at one end of the spectrum. But I don’t know if this means “inherited” exactly. There is some recent work in epigenetics that suggests that parents’ experience can change the way their offspring react to stimuli — outside of the child’s learning. And, there’s also the issue of damage in utero. That doesn’t mean “inherited” in the traditional sense. I mean, there is no genetic cluster for addiction per se.

      Nevertheless, you sure did go over that cliff quickly and you stayed there for a very long time. This reminds me of “Straight Life — the Story of Art Pepper.” After his first shot of heroin, he immediately said: this is for me — this is what I need. These kinds of reactions are still mysterious to me, and you’re right that my own history would probably place me closer to the other end of the spectrum.

      These are important things to consider and discuss, and they demonstrate why we need detailed information both from science and from personal experience in order to find answers.

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  27. Leon D says:

    Hi Marc,
    I enjoyed the article. I didn’t read all the comments – there are quite a few – but I still think you’re missing some critical points. I don’t have the technical chops to really debate it with you, but have you seen Dr. Kevin McCauley’s documentary Pleasure Unwoven?

    It seems to explain a very strong, well-researched argument as to why addiction is a disease, and he explains it far better than I ever could. Here’s a link to some short snippets of the documentary Dr McCauley has posted on Youtube (approx. 25 minutes in total):

    http://www.youtube.com/watch?v=ekDFv7TTZ4I

    What do you think?

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    • Marc Lewis says:

      Hi Leon,
      I watched this clip, but clearly I would have it investigate McCauley’s work in much more detail to have anything meaningful to say about it. In the clip, he really just says that it’s absolutely crucial to uncover the mechanism by which addiction works as a disease. He says that current explanations of HOW addiction can be a disease are not very helpful. I sure agree with that.

      But here’s an initial thought. McCauley seems to say that addiction is a disease RATHER than a choice, as if those were the only two possibilities. And the way he talks about choice is somewhat distorted. Even adherents of the “choice” model recognize that no one chooses addiction — rather, people choose to take drugs or whatever. There’s a difference. But I don’t like the “choice” model anyways, for lots of reasons. One is that the “choice” camp rejects neuroscience-based explanations of addiction — as if choice occurs somewhere other than the brain. We understand so little about how the brain makes choices, that calling addiction a choice really just pushes the mystery back one level, from a concrete behavioral pattern to a general cognitive phenomenon. I think I’m going to deal with this issue in my next post. Stay tuned.

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  28. Dave says:

    Hi Marc

    Interesting article. However, I was hoping that you would be able to clarify some points for me, please? You talk of spontaneous recovery and then in a later sentence indicate that addicts work hard at overcoming their addiction, surely this is a contradiction? I have difficulty conceptualising working hard towards recovery as spontaneous recovery. This doesn’t seem like spontaneous recovery but self-motivated recovery as opposed to a medically prescribed treatment.

    Additionally, there was no mention of what the recovery criteria is. Is it total abstinence or recovering the ability to consume a substance in moderation without further relapse into disinhibited substance use? One could argue that total abstinence is not, in fact, complete recovery but rather remission from an enduring pathology. Similarly, a diabetic patient may be self-motivated to make dietary modifications which obviate the need for pharmacological prophylaxis. This person has not, in any real sense, spontaneously recovered from diabetes but has engaged in self-motivated and purposive behavioural modifications to control their symptoms.

    Best

    Dave

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    • Marc Lewis says:

      Hi Dave.
      You’re right that “spontaneous recovery” is a misleading phrase. You don’t just wake up one day unaddicted. It truly does involve effort, usually a great deal of effort. But I think the term remains useful in that it captures the idea of recovery as a natural process, in my view a developmental process. I think addiction develops over time, but so does recovery. Once we get to the notion of development, “spontaneous” and “effortful” don’t seem so far apart. Watch a toddler acquire language for a perfect example. Toddlers put a lot of effort into mastering language, but of course language development is natural and thus, in a sense, spontaneous.

      As to criteria for recovery, this is a huge debate. I like your point that complete abstinence might be considered an incomplete recovery. A parallel might be a diabetic who abstains entirely from sugar. Doesn’t sound quite healthy. Similarly, if you can’t pick up a glass of wine at a party, then you are certainly behaving in relation to your addiction, past or present, and that suggests that the recovery is not complete.

      AAers have no trouble with that conclusion. They generally believe that once an addict always an addict. I don’t see it that way, and for me, being able to take substances that are socially appropriate, at levels that are socially appropriate, without harming the self or others, would serve as a good definition of recovery. Many agree with this view, including Stanton Peele. Check him out if you haven’t already.

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  29. Pingback: Addiction Treatment Forum | Blog: Why Addiction is NOT a Brain Disease

  30. Rich ZT says:

    I am curious about how other people including doctors would classify my behavior. Am I an addict or am I not?

    A brief history of my life. I was raised in a family of Jehovah’s Witnesses. My father was physically violent with us when we were young. My next door neighbor who was a young teen at the time sexually molested me during this time as well. My mother found out about my fathers temper and separated from him which led to him divorcing her. My mother got custody of us and we lived with our grandparents for a long time. I choose to not visit my father because I couldn’t stand to be around him. This all happened before I was seven years old.

    I have always been very introspective. I have an exceptional memory for the most part. I remember the majority of my life from about the age of three and I have memories of events that would have happened just shortly before I turned two. For the majority of my life I had issues with feeling like an outsider. I never really felt wanted by my mother after she got divorced. I am the only one of my siblings that my parents planned to have. This feeling got worse when I turned my back on her religion. To this day I am the only one of my siblings to openly deny her religion even though only one of my siblings still practices it. I know that I am not my mothers favorite child since she told me when I was in my early 20′s that one of my brothers was her favorite. My feelings of isolation increased in high school when I was put into our schools gifted program. Also I have never been a religious person. I have never naturally felt a connection to a higher power or felt any type of faith in something outside of myself.

    When I was 19 I used marijuana twice. The first time was out of curiosity. I didn’t like parts of the experience. I found myself being overly anxious and nervous. The second time I found the experience to be enjoyable but something about my behavior seemed to bother my friends which led me to feel that the drug was not for me. During this time I tried shrooms, dramamine, and some other drugs that I don’t know the names for. I didn’t find any of the drugs to be compelling in the slightest and didn’t feel the need to continue with them. I didn’t do illegal drugs for over 11 years.

    In my early 20′s I started to become a bit more comfortable with who I am and found that I was able to make peace with most of my life. I still felt like an outsider but I was more comfortable with being me. During this time I really began to study spirituality. I was fascinated by religious experiences that people had and I really liked to study morality.

    Just before I was 31 I tried marijuana again. My experience was totally different now. I didn’t feel anxious or nervous. I felt a kind of peace and tranquility coupled with a level of introspection that was deep even for me. I also found I could sleep comfortably if I used it before I went to bed. I have always tossed and turned in my sleep and would normally fully wake up several times a night. With marijuana I found I would sleep deeply and wake up feeling very refreshed the next day. Also I don’t crave it when I don’t have it. When I had a bad tooth infection I found that I could use it for pain relief and I didn’t have to worry about feeling that I needed it when I wasn’t able to smoke. When I was 18 I had my wisdom teeth removed and was given a large prescription of vicodin. To this day I don’t like opiates because I crave them if I use them as prescribed. Currently I use marijuana daily before I go to bed. I don’t like to use it through out the day. I prefer to be sober most of the time. Occasionally I will use it when I have a day off of work and have nothing else to really do. These days are very rare normally only once every couple of months. I do not ever use it before or during work. I don’t smoke it as I prefer to use a vaporizer or to consume it in food.

    My other drug that I use is Psilocybe Cubensis mushrooms. I tried them again when I was 32. When I tried them when I was 19 they seemed a bit odd and not really interesting. I saw some minor hallucinations and laughed about things that weren’t really funny. My experience was very different as an adult. Part of this I can say is because I had a very different mindset going into the experience. As and adult I found that the drug bordered on what I would say is a religious type experience. The first time I used them in my 30′s I had a very negative type trip. I had to confront a lot of issues that I thought I had resolved but apparently hadn’t. I have always had a bit of an issue with loneliness and slight depression. I have had an issue with anti depressants making me flighty and interfering with my ability to focus on things for more than a few minutes at a time. The first shroom trip in my 30′s made me confront some truths about myself. I wasn’t lonely because other people didn’t care about me. It was my own behaviors that were causing me to feel that way. I spent about 6 hours getting hit with what I would describe as very uncomfortable and even painful truths. I couldn’t deceive myself while I was on this drug. Afterwords I felt better about myself and I noticed some personality changes. I was more open to other people and less stand offish. I dealt with loneliness better and felt less down about life in general.

    Several months later I tried shrooms again. This time I had what I would say is the strongest life changing experience of my life. I have no words to completely describe what I experienced. I felt the presence of universal love. It was not part of me. It was outside of my existence. It was not an emotion or an idea but instead it was love as a complete state of being. This love that I touched cared for me more than I cared for myself. I could only touch it for brief moments of time and when I did it was like existing in a state of pure bliss. I almost cried at the simplicity of it all. I saw the Hindu god Ganesha look at me through the walls of my living room and there are no words to describe what I felt. It was like all of the world was connected in a single point of love or compassion or something so immense that it just can’t be explained. I was not tripping alone this time and my friend noticed that our experience was coming in waves of normality slowing turning into the tripping state and then returning to normality over about a 45 minute period. Our waves were in sync with each other and I felt a connection with my friend that was very spiritual. This lasted for many hours. Since that trip I have not felt depressed or lonely since that experience. I have a feeling of peace that is hard to explain without using religious terms. I am still agnostic and rationally I understand that the experience was just chemicals messing with how my brain functions. But the experience itself was simply the most powerful experience of my life. I use shrooms once to twice a year on average and I always have strong spiritual experiences on them. I have never had a spiritual experience in regular day to day life while I am sober.

    So I am curious about how a professional views my use of drugs… How would this behavior be classified?

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    • Marc Lewis says:

      Not only would I not call you an addict, but your experiences capture a lot of what’s beneficial about taking drugs. Starting with your mushroom trips (psilocybin) , I doubt anyone would call using anything once or twice a year an addiction. As you discovered with opiates, addiction includes craving, and craving leads to regular use — not occasional use. The bigger point is that this drug has clearly beneficial effects for you. It brings you closer to yourself and others and enhances your understanding of your own personality. Natives of the Amazon region have been taking ayahuasca — also a psychedelic — for thousands of years as a form of therapy, similar in many ways to your own use. I don’t see a problem.

      One might argue that your nightly use of marijuana constitutes an addiction. But you take it to help you sleep. You don’t wish to take it to enhance your mood or change your mental or emotional functioning. Sleep is biologically necessary, and good sleep is highly beneficial physically and psychologically. So you, like roughly half the individuals in the Western world, are taking a drug to help optimize a normal psychobiological function. Again, I don’t see a problem.

      Congratulations on finding balance in your life. Few people, including finger-pointers, are that lucky.

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  31. Too simplistic. Dr. Lewis does not wrestle with the mind/brain dilemma – which is part of the issue. He also does not see that their may be a conflict between the limbic system and the prefrontal cortex and that the prefrontal cortex may be the factor in spontaneous recovery.

    A more accurate view is to see addiction as a complex phenomena in which the brain will play a role of varying importance depending on the person and the drugs that are being used. In this article by Dr. Joanna Fowler, she pointed out that brain scans can predict relapse within the next two years: http://archives.drugabuse.gov/pdf/Perspectives/vol3no2/Imaging.pdf – which is really quite amazing.

    In addition, the history of methadone treatment is a major argument for the role of the brain in addiction. See: http://www.westbridge.org/assets/enc%20of%20neuroscience%20-%20methadone.pdf

    Lastly, a more integrated view of addiction and addiction treatment can be found here: http://www.tandfonline.com/doi/abs/10.1080/07347324.2012.635544 Here we argue that it is best understood as a Psychiatric/Mental Health Disorder.

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    • Marc Lewis says:

      Frankly, I don’t know what you’re talking about. You’re trying to convince me that the brain is important to addiction? I’ve been arguing that for a few years now, as I do in the above post. You think I don’t see that addiction is complex? How much detail did you expect me to go into in a blog post? And I failed to discuss the mind/brain problem? There are so many approaches to this problem — dualism, compatibilism, embodied cognition — how could I squeeze a review of these issues in as well?

      It seems you are jumping at the opportunity to say “you’re wrong” without taking the time to listen to what I’m actually saying!

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      • Hi! Thanks for responding. So it sounds like we are in agreement… maybe. Addiction is a brain disease or a complex disorder in which a damaged or dysfunctional brain plays a central component. This kind of integration would be a good place for the whole treatment field to build from.

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        • Marc Lewis says:

          Well, maybe we are in agreement after all, at least partly. I didn’t think so from your initial comment. I agree that addiction is highly complex and that it’s all about what’s going on in the brain. Whether we call that a disease or a dysfunction depends on our societal perspective. From the brain’s perspective, certain goals have assumed higher than usual priority — but in other respects it’s acting as it was designed to act.

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  32. Shawn Kearney says:

    Spontaneous recovery occurs regularly, and this quality is what makes a condition “benign”, who hasn’t had the flu? You can, indeed, die of the flue – as thousands do every year, even in the developed world. But there is no “cure” for the flu after anti-viral drugs are not effective – once you have the flu your destined to either recover spontaneously or die.

    In reality, the majority of treatments for many diseases, if not most diseases, only treat symptoms, not the disease itself – giving the body time to heal itself, as such, these diseases are also “spontaneously healed”.

    If we think of therapies for addicts as treating symptoms, the peripheral circumstances that aggravate addiction, such as self esteem, childhood abuse, stressful lifestyles, etc, such that the chemically dependent mind can find more healthy ways of coping, how is it any different than treating the symptoms of the flu – such as dehydration and fever – such that the body can heal itself?

    We have a pretty good understanding of our immune system and how hydration and maintaining a safe body temperature help prevent death by flu, but we understand much less about how the brain builds new pathways when it is understood that old solutions are ineffective, or distorted. But this does not change the fact that diseases of all variety often work their way out – and it is only the appropriate treatment that is different.

    So the argument that addiction is not a disease on the basis of spontaneous recovery is fundamentally flawed, as many, if not most diseases are so. The only difference is that we undersand better the mechanism by which this happened – and by contrast addicts *appear* to spontaneously recover when in fact there is an underlying mechanism which triggers recovery that we do not yet appreciate.

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    • Marc Lewis says:

      This is a very convincing argument. You show how addiction treatment is much like the treatment of “medical” diseases. I think you score points for analogy on that one. But you also show that many medical diseases disappear spontaneously, through endogenous repair processes, and that “treatment” often just makes room to help the body do what it needs to do.

      So, if I am arguing by analogy that spontaneous recovery in addiction is a reason NOT to classify it as a disease — because spontaneous recovery is quite normal for diseases — then I am in error. I think I buy your argument and put my hands up.

      Only two things left to say: I guess I was drawn to an argument based on spontaneous recovery partly because the addiction treatment monopoly (12-step programs and their alliances with large, funded facilities) insists that you MUST get help or you will NOT get better. That always got under my skin, mostly because it’s just not true. Secondly, I have a dozen other reasons for arguing that addiction is not a disease. I’ll have to rely on those and drop the spontaneous recovery pitch — it’s a dead-end.

      Thank you for that!

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  33. juliette young says:

    Very interesting blog, and I totally concur that addiction is not a disease. I wonder if you have come across The Human Givens, and the theories of Joe Griffin (one of the founders) as to why we become addicted? Their approach to treating addiction is very effective, adhering more towards the Social Learning model of addiction, and couldn’t be further from the 12 Steps model. What you say very much chimes with the HG approach.

    http://www.hgi.org.uk/archive/human-givens.htm

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    • Marc Lewis says:

      No, I don’t know this work. But I’ll certainly look it up. Thanks very much for pointing me (and other readers) in that direction!

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  34. Gina says:

    Very interesting post! Very interesting perspectives! As a very interested party reading such very interesting material I felt the need to pipe up! I, in my 40 years have experienced this topic from many different points of view. Having a degree in Psych with a concentration in Behavioral Studies, I have read and researched the text book theories on both sides. Being a high school special education teacher, I see on a daily basis the early effects and behaviors of “addiction” and try to explain them to best implement a “treatment” program so that a student can find academic and social success. I have battled my own addictions from alcohol to social media to cigarettes. I have battled addiction through an ex husband’s behaviors and I continue to battle the “effects” of addiction through my daughter’s eyes in explaining said ex husband’s behaviors.

    The concept of whether it is a disease or a choice, I would say, truly depends on where one wants to lay blame and on who is going to pick up the tab to fix it. Both sides can produce what would seem to be compelling scientific evidence to provide a definition. Many perspectives have only studied (possibly tested) the theories that they promote. Some have lived through it and speak from first hand experience. My own addictions, easy enough, I decided to stop and therefore I did, hence supporting the choice theory. My ex-husband, never made that decision despite the supports in place, now he is addicted to yet another substance to get off the first one and cries that he has a disease and should be forgiven.

    Am I bitter and biased based on my own personal situation? I am sure. However, it is still my belief that no matter how many brain scans we look at and analyze and how many technical terms we through out and how many counselors we train to say that it is or isn’t a disease, there is an addiction situation that society is attempting to fix, therefore they need to blame someone (or something) for its origins and then need to send some one the bill for each individual case that they address. If it is “diagnosed” as a disease, insurance companies will pick up the tab. The government can claim that there is an “epidemic” and world wide their is great sympathy for those who have this “disease”. However, if it is a choice, then the individual person is accountable for his or her actions, little help is offered, and we have a growing population of addicts making bad choices lending to a number of other societal issues that the taxpayers end up paying for in the end. To be honest, I am not sure I care what the definition and/or diagnostic criteria is for societal reasons, but I beg, for our children’s sake, that those who make the initial choice, admit that denial is more than a river and own up to what has destroyed innocent children’s emotional well being through environmental effects alone. How does one explain to a child that it’s not daddy’s fault (or mommy’s as the case could be) but rather the disease’s fault. I speak of specific drug addiction here and not addiction in the general sense, though I believe that the concept would be the same.

    Difficult as it may be for the addict or the enabler to admit, the definition lies within personal accountability. We all have the option to use the insanity plea to excuse our actions, and in some cases society will buy the explanation, but I am unsure if even if they do, they have actually heard the truth. I am no expert and I don’t claim to be, I can only speak to my observations and own experiences and what is published via others’ research. I believe it boils down to: find an excuse or find a solution.

    Great post Marc, and great comments from everyone. I didn’t write to argue, just felt the need to express an opinion.

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  35. Marc Lewis says:

    You’re quite right: we very much fall into this dichotomous way of thinking — addiction is either a disease or a choice. And within the sphere of treatment and public health, that boils down to a blame game: it’s either your own damn fault or else you are a victim of some nasty circumstances — and that can determine who ought to pay. Well said!

    But from a scientific point of view, I think we can say that addiction is neither a disease nor a “free” choice. There are many reasons for this, and it’s not just about taking a middle road. Yes, there is some choice involved, to be sure. But we know so little about how the brain actually makes a choice, and what we do know suggests that it’s anything but free. So “choice” doesn’t mean we shouldn’t look at neurobiological factors, in other words draw from basically the same data base as the disease camp draws from.

    Given that the brain is involved any way you slice it, and given that all brain events are products of the brain’s structure and functional characteristics at the present moment, and given that these variables have a lot to do with the brain’s structure and functional characteristics the moment before that (and on and on), it seems to me that addictive behaviors involve some agency, some intention, and a lot of sensitivity to one’s personal history and learning experiences. Not to mention the synaptic changes that keep on happening every time we do something (like shoot heroin or drink a bottle of whiskey) that has a lot of personal meaning and emotional punch to it.

    Let’s just say: like you, I’d rather find a solution than an excuse, and I think finding a solution will be a lot more challenging that flinging around easy category labels like “choice” and “disease”.

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  36. nicolas ruf says:

    Let’s start with the old ‘stick and carrot’ model of learning: behaviors which provide pleasure or relief are reinforced; behaviors which cause pain or distress are extinguished. Something goes wrong in ‘addiction’ with this model as a punishing behavior is continued. (let’s leave out for the moment the distinction between abuse and dependence – althought it’s critical). We use ‘loss of control’ as a description and criterion for diagnosis of this aberrance since, unless the individual is a sadist, presumably the individual did not intend the consequences of the behavior. So if one chooses the behavior but not the consequences, the behavior must be determined by motivational factors and not by payoff or results. ‘Choice’ can be governed by emotion, impulse, compulsion, reason, and probably a bunch of other factors that I can’t think of right now, but let’s admit that impulse and compulsion are seen as deficits in or absense of choice.
    Let’s use alcohol consumption as our example of ‘loss of control’. There are two aspects (with relevance to abuse v. dependence): loss of control over how much is drunk and loss of control over initiation of drinking. The first is a result of impulsivity and loss of inhibition, the second a result of compulsivity driven by cues or by stress.
    My brain’s tired and I haven’t even gotten to homeostasis and state-dependent learning yet.

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    • Marc Lewis says:

      Hi Nick. You’ve rediscovered the steps (no, not THOSE steps!) leading to the demise of behaviorism. As you conclude, choice is governed by many motivational factors — that used to hide in the “black box” in the heyday of behaviorism. Which in a long string of linked reinforcers are we aiming for, anyway? A problem compounded by the fact that each step is probabilistic.

      So if choice is governed by “motivational” rather than “logical” factors, it’s going to be a bit tricky to determine something so nebulous as “absence of choice.”

      But I really like your straightforward example of impulse giving way to compulsion: first comes initiation of drinking and then comes the difficulty in stopping. Good, clean example.

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  37. Pingback: Substance Dependence | The Addiction Hotline

  38. travis says:

    I am an alcoholic, and stay sober wit AA. I always question why addictive behavior is only profiled in drug and alcohol cases. I like to think, disease or not, it is a behavior that affects many people. Whether it be coffee or cocaine the symptoms are essentially the same. What do you recommend as a suitable solution? I don’t think “extreme form of normality” is an actual thing for me, because my thoughts on alcohol are anything but normal. I need to think it’s a disease, that I am getting better, addicts need some progress.

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    • Marc Lewis says:

      The disease idea is great as a way of talking ourselves into getting sober/straight and staying that way. It’s a wonderful metaphor for many people. I just don’t think it holds up as a scientific model. We coach ourselves with all kinds of cool phrases that are not literally true. E.g., “Nothing can stop me!” They don’t have to be literally true in order to organize our behavior effectively.

      And by the way, addiction is often discussed with respect to things other than drugs and alcohol. Behavioral addictions (e.g., gambling, sex, porn, gaming) are being studied all over the Western world. Yes, many people are addicted to SOMETHING.

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  39. Wayne Lynch says:

    I am a nurse working in a community drug & alcohol facility in a rural country town in New South Wales, Australia. We offer, amongst other things, counselling for people who wish to reduce or cease their substance use.

    “Ice” (methamphetamine) use is very prevalent in our community, and one of the hardest drug use with which to work.

    Just wondering have you seen anything or know anything on what happens to neurotransmitters after cessation of amphetamine use?

    Someone was saying to me that use of “Ice” results in various neurotransmitters ‘shutting off’ and it takes quite some time – up to 6 months – for the NT to return to normal and hence people who stop “Ice” use are usually depressed/dysthymic for a long period of time.
    Thank you

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    • Marc Lewis says:

      I haven’t looked at the data recently, but there are many studies of this phenomenon. Neurotransmitters including dopamine, norepinephrine and serotonin may be greatly reduced, when the release and reuptake mechanisms rebound after meth use. Also, sensitivity to these molecules may be greatly reduced in the receptor sites, after the bombardment has stopped. So, yes, it takes time for the system to normalize.

      For greater detail, I’d just start googling!

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  40. Wayne Lynch says:

    Apropos my previous question (“I am a nurse…for a long period of time”), I neglected to tick the box below.
    Thanks again

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  41. Sherry Fizer says:

    Cocaine Addicit-Used for 4+years

    Are they of sound mind in active addiction vs being clean for a month or more? How long do they have to be clean to make sound decisions?

    How does cocaine affect the decision making?

    Please, only professionals respond to this question.

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  42. Amy says:

    All I see here is a well educated man, making unjust statements that you understandably have no education on.

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  43. John Calluzo says:

    This is an excellent article, it brings out a different perspective on addiction other then your traditional 12 step model of aa or na, however the condition of alcoholism is deadly as well as the condition of addiction is deadly, when a person is addicted to opiates his or her state of mind is in an obsessive compulsive state.
    There is nothing a person can do at that point, so the term disease is a little too dis-concerning, I prefer condition because a person conditions themselves in to active drug addiction unless of course they are born addicted.

    http://www.kleantreatmentcenter.com non 12 step program It saved my life

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    • Marc Lewis says:

      Thanks for your comments. I know that addiction can be deadly, and that is certainly the case for some (not all) who are addicted to alcohol, opiates, and stimulants. Reckless driving is dangerous too, but we don’t call it a disease. We might call it a bad habit.

      I’m fine with your definition of addiction as a “condition”. I think that’s perfectly sensible.

      Thanks also for referring people to a non-12-step program. These are increasing in number and quality, and I have a lot of respect for them.

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  44. Ray Aldred says:

    Hi Marc,

    This was a really interesting and informative read. I’m not sure I follow your reasoning for why the neurobiology of addiction implies that a “disease model” can’t apply to addiction. In other words, I don’t think I follow what the problem was with a disease model, from a brain’s eye point of view. I wonder what your thoughts are about depression or other personality disorders. The physiology of depression, as you may know, involves brain systems that are regularly involved with a stress response. Regularly, a stress response allows us to respond to threats or danger, but depression appears to be a disorder resulting from a maladaptive stress response. More specifically, prolonged exposure of stressors can trigger prolonged secretion of stress hormones that can trigger a cascade of pathological events (like depression). Indeed, I suspect that many mental disorders (mental diseases?) involve systems that are adaptive, but they become maladaptive through a peculiar interaction of the brain, body and environment. So we might say that many mental disorders might be understood as “extreme normalcy”, in some sense. Couldn’t depression be an extreme response to stress? Similarly, couldn’t BPD involve normal brain systems that become maladaptive and pathological? Or are depression and BPD, under your view, also not a disease? Or maybe depression is a stress disease, but then I wonder why addiction can’t be a learning, memory and pleasure disease. In other words,addiction involves maladaptive, pathological brain systems that are normally involved in learning, memory and pleasure.

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    • Marc Lewis says:

      Hi Ray. Thanks for the compliment. The question you raise does keep cropping up, and I don’t pretend that I have a fool-proof way to distinguish disease from non-disease in the development of neural outcomes. For me, schizophrenia would typify a mental “disease” …and yet it’s also a developmental phenomenon. So I know I can’t easily get away by saying that addiction develops and therefore is not a disease.

      But I think depression is a good example of how I see addiction. You’re right that brain systems that deal with stress become activated more and more often, eventually settling into a self-perpetuating cycle. Yet I know a lot of people who are depressed sometimes. In fact I’m depressed sometimes. When I’m depressed, I think that my amygdala, ventral PFC, and a few choice systems have certainly fallen into an “attractor” state — that is, a quasi-stable pattern that maintains itself. But it may also dissipate in an hour or two. So I wouldn’t know where to draw the line with depression either — the line between “normal” depression and depressive illness. And the DSM classification of major depressive disorder does not seem to help.

      I wouldn’t call BPD a disease either. It’s a type of personality. Maybe addiction is a type of personality engaged in a really bad habit. Personality differences also correspond with differences in brain activation patterns — of course they do. Even with genetic differences, as in the long v.s. short 5HTT alleles and their role in anxiety/depression.

      So I keep coming back to the logic that differences, divergences, developmental trajectories, of brain development, even when they lead to stable and unpleasant psychological habits, still seem like….well, like brain development, not brain disease.

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  45. Marc -

    I hope you are well. Following up on our early discussion, I wanted to bring your attention to an article I co-wrote with Dr. Andrew Tatarsky. It is called “Addiction is a Mental Illness” and we published it in The Fix. You can find it here: http://www.thefix.com/content/addiction-mental-health-problem-integrative-addiction-psychotherapy8955

    I am grateful to say that it seems to be getting some attention and stimulating an interesting conversation in the comment section.

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    • Marc Lewis says:

      Hi Scott.
      Thanks for sending me the link. On a quick read, I agree with just about everything you say — except the title! And you say something like “this” kind of disease model as opposed to older AA models. I didn’t quite get that point, except as emphasizing complexity rather than simplicity in treatment. Complexity — you bet! Mental illness? I’m not so sure. I’ll read it again when I’m more relaxed and see if I can come up with anything more interesting to say.

      Oh, one more point. Although many with addictions have other psychiatric conditions, as you say, many do not. So I think your definition has to stand apart from the issue of comorbidities.

      Cheers,
      Marc

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    • Marc Lewis says:

      P.S. I really like that you advise people to be not only knowledgable about but also respectful of the reasons people have addictions. Very important.

      As you once said, we’re not really very far apart on most issues.

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      • Hi! Nice to hear from you.

        Addiction, in the form of Substance Dependence, is in the DSM-IV-TR and it will be in the DSM-V. This means that it is already a Psychiatric Disorder/Mental Illness. We were not making a call for a new model – we were affirming what is already the case. In addition, NIDA has also said that addiction is a mental disorder.

        In our longer discussion of this issue, which can be found here: http://www.tandfonline.com/doi/full/10.1080/07347324.2012.635544

        we wrote the following: ” Given that the disorder (1) has a strong behavioral component, (2) utilizes the brain as its primary organ of action, (3) benefits from the development of new medications that target or involve the brain, (4) occurs in the context of many other psychiatric disorders, and (5) requires the same treatment skills that are needed in other forms of psychotherapy, it clearly seems the most appropriate paradigm to use. Last, studies have shown that 60% to 80% of patients with an addiction have another mental health disorder, and 40% to 60% of those with a mental illness also have a substance abuse disorder (Sciacca, 2009). Above and beyond this, the rest of those who use substances do so for reasons that may also need specific attention. Centering addiction treatment in psychiatry and mental health also has certain treatment advantages. First, it provides a strong foundation for the judicious use of addiction-related medications (i.e., methadone, naltrexone, suboxone, topiramate, acamprosate, and disulfiram) and psychiatric medications, while also providing the medical base necessary for the use of such harm reduction and public health interventions as naloxone distribution. Second, it supports the purposeful and creative use of the cognitive, behavioral, psychodynamic, and experiential therapies not only in the treatment of the addiction but also in work with the underlying causes and the co-occurring disorders. ” This certainly provides strong utilitarian support for more deeply anchoring addiction within this paradigm.

        The 12 Step Fellowship movement used the concept of “disease” but they never really meant it. It was actually more of a metaphor and it really fit a moral model better than a medical model. This was manifested in the widespread opposition to methadone and to psychotropic medications. The NIDA Brain Disease model is a “true” medical model.

        CASA, as you probably know, just issued a report that had three components. 1. Addiction treatment is not working; 2. We should use evidence-based practices; and 3. Internal Medicine physicians should lead teams to treat the addicted. While the first two components are correct, the third is a total misstep – for the reasons I have outlined above. Addiction Psychiatry and Addiction Psychology are the main forces that are developing innovative addiction treatments; Internal Medicine physicians know nothing about psychotherapy or the mechanisms of change so this is a model that is fundamentally flawed. Again, co-occurring disorders is the norm, not the exception.

        These are the main reasons why I believe this is clearly the best paradigm for treatment.

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        • Marc Lewis says:

          Hi Scott. Once again I find myself agreeing with most of what you say. But I wonder at your suggestion that addiction treatment should be rooted in a medical consultation. You say psychiatrists AND psychologists are best suited to treat, and I agree, but psychologists are not doctors. (and psychiatrists are not psychologists, I might add) However, if there are co-occurring issues that are clearly psychiatric in nature, then of course psychiatrists should be ground zero. Also appreciate your clarification that AA never took the disease model seriously — or took it as a metaphor. That clears up a lot of my confusion.

          Anyway, I no longer participate in this blog, so only occasionally still review comments. Please check out my personal blog, http://www.memoirsofanaddictedbrain.com if you’re curious about the issues I’m presently tackling. There’s also a lively and intelligent dialogue going on with addicts, ex, recovering, and not so recovering. You might appreciate hearing their views. Cheers, Marc

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  46. Kasia Kamieniarz says:

    Thank you for everything I could learn from the text. I am a sexaholic wife and a social psychologist. Now I am doing clinical psychology and therapy M. A. and after that me and my husband (also a psychologist) want to help people who struggle with this problem. We are Polish, and to be honest, it is extremely difficult to find good specialists or even scientific resources to learn. Could You be so kind, and give me some hints about where I should seek informations, especially those related with chemical brain changes or so?
    Best regards
    and thank You once again
    Kasia
    ps. not a mental disease but choice. only till the thin red line…if they cross it, there is no choice (no more).

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    • Marc Lewis says:

      Hi Kasia. You sound like you live an interesting and very confusing life! As far as the thin red line, yes, I know about that. Addictive behaviour becomes compulsive at a certain moment, and thus very hard to resist. But I don’t think that makes it a disease. Some people compulsively bite their nails or pick their nose — you get my point. Perhaps check out my home blog, at my website address, above. My last couple of posts have been about the stages of addiction and the shift to compulsivity.

      As far as resources for sex addiction. I really couldn’t tell you. But I am going to a “behavioral addiction” conference, starting this Monday. It’s in Hungary. Here’s the link: http://icba.mat.org.hu/. I’m sure these people know a lot and would be useful resources. I’m attending just as an audience member.

      All the best to you.

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      • Kasia Kamieniarz says:

        Thank you- I’ll have a look of course. I wish the conference is so soon- no chance to me to be there :(
        And yes- my life is full of…hmmm…everything :)

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  47. Carey Raxter says:

    I enjoy you because of your whole labor on this website. My mother enjoys setting aside time for investigation and it is obvious why. We know all of the powerful medium you give important tips on this web site and even invigorate contribution from visitors on the concern so our favorite girl is in fact studying a great deal. Take advantage of the remaining portion of the new year. Your conducting a tremendous job.

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  48. John McConnell says:

    This is a wonderful article. Me and two of my friends all went to drug addiction therapy around the same time period. I argued with my therapist for months about this topic, I didn’t buy any of it and just stopped going. My two friends on the other hand did, they would say things like, “The therapist said doing drugs is beyond my control” or “its a disease I can’t help it.” Saying that drug addiction is a disease takes all the responsibility away, especially for younger people (we were 18 when we did this). The only times I’ve ever quit was when I wanted to. If I wasn’t paying enough attention in school or something I’d stop until summer came. Simple as that. I made the CHOICE to quit just like I made the CHOICE to do drugs. One more thing, why can’t therapist’s and doctors accept that some people do drugs just because there fun? My therapist told me one time that 100% of people that do drugs have some type of underlying problem, to that I said “So you’ve personally gone out and interviewed every single drug addict in the world and they all told you that they do drugs because they have a deep/underlying problem of some sort?” No matter how many times I told him that I had no problem and that life was good(and I said that honestly), he would not accept it. Obviously some people do drugs because their trying to escape something and have emotional problems, but not 100%. Maybe he was just a bad therapist, who knows.

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    • Marc Lewis says:

      Well I agree that choice is important, in fact fundamental. It’s great that you were able to choose to quit when you needed to, without much difficulty. But others do have a really hard time. To me the central issue is that we don’t really understand choice very well. Choice is not always “free choice”. Sometimes it has a stiff price tag, and people need to struggle to choose wisely.

      I agree also that many people take drugs because they’re fun, without deep underlying problems. That doesn’t get said aloud much, especially in this type of forum, but it is no doubt true.

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  49. Marc Lewis says:

    To others writing comments concerning this post, please check out my home blog, at http://www.memoirsofanaddictedbrain.com/. I no longer participate in the PLOS blog, and I only check for comments occasionally. My home blog is all about addiction and recovery, approached both from a personal and a scientific perspective. Hope to see you there!

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  50. anonymous says:

    I really enjoyed your opposing perspective. Let me preface my opinion by stating that I believe in order to formulate your own beliefs, you first must understand every side of the argument. This is reason why I enjoy reading about addiction regardless of what the authors opinion is. Lets get started-
    I am not opposed to hearing opinions that disagree or even don’t understand the disease concept. I enjoy having conversations with colleagues and other well educated people in the addiction community. Every person has their own opinion and I 100 percent respect it. However, your article has flaws in my eyes and so do various comments.
    1) You fail to state that many people who recover from “addiction” may not suffer from the disease. Many people can become physically dependent upon substances without actually suffering from the addiction disease. These people certainly suffer through horrible times, but if they truly did recover and are no longer addicts, I’d argue that they do not suffer from the disease, but instead were just physically dependent whether it came from prescriptions and recreational use.
    2) Through recent studies, we now know what the physical defect of addiction is and where it is in the brain-it is in the hedonic system, the system that perceives pleasure, which is deep in the part of the brain that handles basic survival. The addicted individual perceives drugs and alcohol as something needed to survive just like water, food, and drugs. Unless educated on this, addicts do not know this and it is a subconscious matter. The addict is not hindered on their ability to chose to use or drink, but they have no control over their cravings.
    To the other comments especially those who are recovering addicts:
    If you truly have a conflict with the disease concept and are truly active participants of AA or NA, go and talk to your sponsor and others. Practice your 2nd and 3rd steps and chose to let this go for the time being if it is impairing your recovery. Anyone who has worked the 12 steps knows this; they work! As a recovering addict myself, the only method to help my addiction was practicing the 12 steps. If you’re having a problem in dealing with the disease concept and as a result are becoming less active in your home-group or other meetings, you are most likely allowing your disease to take control of your thinking. START being honest. If you stop going to meetings and stop seeking support, the real reason is most likely you are losing ownership of your disease and looking for ways to convince yourself you can start using/drinking again. Self-delusion is a dangerous thing, especially for an addicted individual or a recovering individual. Re-visit your Step One.
    This is a purely my opinion and strictly that. To anyone who disagrees, I’ll agree to disagree and respect your opinion regardless.

    Thanks,

    A Recovering Alcoholic

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  51. J. Watt says:

    This is really interesting. I used MDMA recreationally for years. I reckon over around four years I went through around three, six to eight month periods of heavy usage. By heavy usage I mean up-to four times a week, but often it would slip into 48 hour binges. I couldn’t have a sip of alcohol without getting huge cravings for MDMA. I wouldn’t say I was ‘addicted’. Other than big cravings for the stuff I never suffered any other negative effects really, but after the last six month period I just stopped over night. Was like a switch went in my head and I’d simply had enough.

    The strange thing was I just simply didn’t want to take it anymore. The other times when I’d stopped I still wanted to take it and I tried to stop myself doing so, but it never worked in the long run – I’d often slip back into it whether it was weeks or months later. Logically I had wanted to stop, but emotionally I hadn’t. But now I wouldn’t touch the stuff with a bargepole. Interestingly I have many friends who I used to take MDMA with who constantly say they want to stop taking it, but can’t/don’t.

    It was like I outgrew it and once I truly realised it was temporary solution to feeling good – and that other things in life were much better and healthier and led to longer term happiness – the craving for it just died. It felt like logic over-rided my emotional attachment to it and my cravings just went.

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