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The most important question there is about addiction

A response by Dr. Kevin McCauley, M.D. to the article posted on Slate.com, "Medical Misnomer: Addiction isn't a brain disease, Congress"

The question of whether or not addiction is really a disease is the most important question there is about addiction, and the reputation of addiction medicine rests upon its ability to provide a coherent answer. One of the major projects at our institute is to investigate the possibility of such an answer.

Her odd association with an ultra-conservative think thank (The American Enterprise Institute) notwithstanding, Dr. Satel’s monograph “Is Drug Addiction a Brain Disease?” is the best-articulated argument against the conceptualization of addiction as a disease (it can be found at http://www.eppc.org/publicatio​­ns/bookID.19/book_detail.asp). Likewise, Dr. Lillianfeld’s effort to expose semantic mistakes in psychology is commendable. However their views on addiction reveal fundamental mistakes regarding the nature of addiction and the experience of the addicted patient.

On the question of language, the authors claim that characterizing addiction as a brain disease appropriates language used to describe conditions such as multiple sclerosis and schizophrenia. Yes, and rightly so. Our modern concept of disease – the “Disease Model” – emerged from Germ Theory over a century ago, and evolved such that today it can be defined as a physical, cellular defect or lesion in a bodily organ or organ system that leads to the expression of signs and symptoms in the patient. This is a very rigorous standard for disease (it is also the standard demanded by Dr. Thomas Szasz, another opponent of the conceptualization of addiction as a disease).

For most of the last century, it has not been possible to fit addiction to this standard. That has changed. The organ involved in addiction is the limbic brain (specifically the ventral tegmentum and nucleus accumbens/extended amygdala). The defect is a stress-induced/genetically predisposed dysfunction of the limbic dopamine system (specifically a hedonic dysfunction – a broken “pleasure sense”). And the symptoms of greatest importance are 1) loss of control, 2) craving, and 3) persistent drug use despite negative consequences. Addiction meets the standard definition of disease better than multiple sclerosis and schizophrenia, two diseases whose pathophysiologies are far less elucidated. This is why medicine can claim, with confidence, that addiction is a disease.

On the question of personal agency and choice, the authors complain that calling addiction a “disease” undermines personal agency and our concept of free will. This is not, however, a problem with addiction. The standard definition of disease as it is used in medical practice today strips patients of their power of choice and hands that power to the doctor. In exchange, the patient gets to enter the sick role – a helpless, compliant role, and one relieved of responsibility. So the problem of addicts claiming that they have a disease and must be absolved of responsibility for their behavior is not a problem with addiction. It’s a problem with our standard definition of disease. Most of the authors’ trouble in calling addiction a disease stems not from whether or not addiction fits our standard definition of disease (it does), it stems from the problems inherent in the Disease Model itself.

As for choice, in addition to being a broken hedonic system in the brain, addiction is also a disorder of volition. Craving states cause a selective hypofunctionality of the prefrontal cortex. This is visible on neuroimaging scans such as functional MRI. The area of the brain of particular interest is the ventro-medial prefrontal cortex, an area of the brain that assesses future consequences. It is hard to underestimate the importance of these findings. They imply that choice is a variable quantity during some brain disease states. The exciting opportunity here is to figure out how choice really works. How is it realized in the brain? What are the conditions under which it best operates? And how do we set those conditions so that addicted patients can exercise free will according to their true values?

The authors may be correct in their assertion that these neurological scans may not mean all that their proponents say they do. But they do mean something. At the very least, the activity visible on these scans correlates with conscious experiences such as craving. This evidence, while preliminary, cannot be ignored. Entire fields of scientific research are based on less.

On the question of stigma, the authors support the idea of considering addiction a moral failing. They believe the stigma against addicts is good, and that shame motivates people to stop using drugs. The correct answer here is “sort-of.” Stigma motivates drug and alcohol ABUSERS to get sober. When faced with the negative consequences of their drug use, the abuser can bring these negative consequences to bear on their decision-making. But stigma, or shame, or the threat of prison or death, will not work to change the behavior of addicts because the limbic brain equates drugs with survival at a very deep and unconscious level of brain processing. In light of this and the failure of the “consequence appreciating” areas of the cortex, the utility of stigma and punishment in the motivation of addicts is dubious. When craving kicks in, the drug comes first. The addict literally believes that the best way to stay out of jail is to get high (secure survival) now, and deal with the consequences later. This is the most fascinating and frustrating feature of addiction: negative consequences have no effect on the pattern of drug use. If you really are dealing with an addict, punishment doesn’t work.

As it stands in addiction medicine today, there is no way to tell the difference, not with definitive certainty, between the really bad drug abuser and the not so bad drug addict. The conflation of these two populations – abusers and addicts – creates much confusion. The promise of these neuroimaging scans is that they may someday be able to detect the minute differences in brain activity that differentiate the abuser from the actual addict.

In the meantime, we would do well to remember the long and painful history in medicine of labeling the behavior of people we didn’t like as “badness,” only later to learn something new about the way the brain or body works and realize that these behaviors were, in fact, symptoms – of a disease process. How do we know we are not making the same mistake again with addicts? The risk of being terribly wrong suggests caution. It is a strange specialty of medicine that uses shame as a therapeutic modality or stigmatizes patients to promote health. In fact, medicine’s contribution to the concept of justice lies in its ability to reveal the difference between those behaviors that are, in fact, symptoms, and those that are truly bad. Doctors cultivate an intuition – a “sixth sense” – that tells us: but for the disease process, the patient would not act this way. I get that feeling when I look at addicts.

Lastly, on the question of spiritual change the authors cite the experience of Jamie Lee Curtis as an example of how many addicts enter recovery. In Ms. Curtis’ case, she never went to treatment to get sober; rather she had a spiritual experience and relied solely on her attendance at A.A. meetings. But what got her sober? Was it the shame of some stigma or punishment hanging over her head (a stick)? Was it the reward of a promising career in film (a carrot)? Or was it the fact that she found something that was deeply, personally, emotionally meaningful - in her case, a relationship with God?

These deeply personally meaningful things – which will be individual to each person (“God as he/she understands Him”) – have the power to break the hold of craving. They are spiritual. They restore the function of the prefrontal cortex, and with it the addict’s power to choose meaningful things over drugs. The task of addiction treatment is to teach the addict stress coping tools to decrease their craving, while at the same time helping them find the one thing that is a little more meaningful (a little “higher in its power”) than drugs or alcohol. Or food, or sex, or gambling. A.A. does this nicely, but none of this comes to the patient overnight. Treatment that understands addiction as a disease can be indispensable as well.

So is addiction a disease? Yes. Do addicts need to take responsibility for managing their addiction? Certainly. But so do all patients. So do patients with multiple sclerosis and schizophrenia. The problem I have is in holding one group of patients more responsible than other groups of patients. Most people will take responsibility to the exact extent that they know how, or are supported. That is what good medicine is all about.

Kevin T. McCauley, M.D.
The Institute for Addiction Study
Park City, Utah



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