In 2005, Nature Neuroscience published a special issue on the neuroscience of addiction that summarized the advancements in unraveling the biological mechanisms that contribute to the etiology and progression of addiction to a wide spectrum of psychoactive drugs. The technical papers included in the 2005 special issue stood as a progress report on the biological model of addiction that has been aggressively promulgated by National Institute on Drug Abuse Director Nora Volkow, MD, and National Institute on Alcohol Abuse and Alcoholism Director George Koob, PhD. The state of addiction science was updated in 2011 in Nature, and Nature has just published a special supplement of articles on addiction that provides a further update.
In reviewing this series of collected papers, it is difficult not to be swept up in the advancements in our understanding of the neurobiology of addiction. These papers mark an evolution from a deeper understanding of the underlying mechanisms of addiction, to new treatment options that will grow exponentially in the coming years, and, in this latest review, to increased interest in the neurobiology of long-term addiction recovery. The addiction IS / IS NOT a brain disease debates that have accompanied these scientific breakthroughs do not diminish the potential clinical import of this work and what it could mean to future generations of people seeking help for alcohol- and other drug-related problems.
While the neurobiological research and the public/political promulgation of biological models of addiction are extolled for their great promise, history suggests that social context plays a major role in whether such models help or harm affected individuals, families, and communities. We should not forget the untoward effects of earlier biological models of addiction. Such a view rose within the early twentieth century eugenics movement on the heels of the American temperance movement’s proclamation “Drunkards beget drunkards.” The eugenics movement promoted the prolonged sequestration (e.g., inebriate colonies, psychiatric state hospitals) of people addicted to alcohol and other drugs (AOD) and their inclusion in mandatory sterilization laws—laws that, in the name of purifying the racial stock, also included people who were mentally ill, developmental disabled, or members of sexual minorities. African Americans were inordinately targeted for such interventions within all of these groups.
Biological views of addiction’s intractability justified other horrific interventions into AOD problems, including electro- and chemo-convulsive “therapies,“ psychosurgical interventions (prefrontal lobotomies), and toxic and lethal drug therapies—each wrapped for a time in the mantle of science and medicine. The “harm in the name of help” spawned by biological models within the history of addiction treatment bodes caution in exploring how such models may generate unforeseen and unintended consequences when embraced within larger social and political agendas. How to best prevent such eventualities must be part of the conversation as neurobiological research on addiction proceeds.
In 1998, Dr. Barry Brown also voiced concern that characterizing addiction as a “chronic relapsing disorder” rendered addiction a “no-fault condition” in which continued drug use was neither the responsibility of the drug user nor the addiction treatment professional. His concern was that such an understanding could potentially lead to social, therapeutic, and personal pessimism related to the prospects of addiction recovery in spite of clinical and community studies revealing substantial rates of long-term addiction recovery. Debates about the role of choice in addiction and addiction recovery are thus important—clinically, professionally, and socially.
A recent study by Wiens and Walker revealed a decrease in personal agency (“This is something I can change.”) related to biological conceptions of addiction, but this may well be determined by which populations such conceptions are applied and how the neurobiology of addiction is communicated. (The Wiens and Walker study evaluated the effects of a quite dated biological model of alcoholism on a small community sample of persons with mild to moderate alcohol problems who had not sought addiction treatment.) Views of the etiology, course, and treatment of AOD problems are best nuanced across the dimensions of problem, severity, and chronicity. Suggesting that addiction constitutes a chronic health condition and that loss of control over drinking and drug use is related to underlying brain mechanisms DO NOT reduce personal responsibility for self-management of that condition. Such concepts are used in the treatment of diabetes, hypertensive disease, cancer, and other chronic health conditions while emphasizing patient responsibility to assertively self-manage such illnesses over the life course.
There is also no guarantee that biological models of addiction (which emphasize personal vulnerability over person culpability via the image of the hijacked brain) will lessen social stigma attached to addiction. I have argued in an earlier paper that: 1) communicating the neuroscience of addiction without simultaneously communicating the neuroscience of recovery and the prevalence of long-term recovery will increase the stigma facing individuals and families experiencing severe alcohol and other drug problems, and that 2) the longer addiction science is communicated to the public without conveying the corresponding recovery science, the greater the burden of that stigma will be. For, example, studies noting that addiction-induced brain changes may extend for years into recovery (see Zou et al. 2015, for example) can further marginalize people in recovery (via reinforcement of the “once an addict, always an addict” stereotype) without tandem communications that such effects are not universal and may be compensated for by the brain itself or by adaptational learning.
Recognizing the potential risks inherent in the conceptualization of addiction as a chronic disorder, Tom McLellan and I argued in a 2008 paper that all such communications should also be accompanied by the following scientific findings:
1. All AOD problems are NOT chronic; most do NOT have a prolonged and progressive course. Some do, and research is needed to identify early signs predictive of chronic progression. (It is critical that we distinguish between mild/moderate and often transient AOD problems in community populations and the alcohol and other drug addictions most often seen in clinical populations. Click here for elaboration.)
2. All persons with AOD problems do NOT need specialized, professional, long-term monitoring and support. Many recover, particularly those with lower problem severity and high recovery capital, with only family or peer support.
3. Among those who do need treatment, recurring episodes of post-treatment AOD use are NOT inevitable, and all persons suffering from substance dependence do NOT require multiple treatments before they achieve stable, long-term recovery.
4. Not everyone at risk for a chronic disorder contracts the disorder or experiences the same course of the disorder. Chronic disorders exhibit a high degree of variability in pattern of onset, course and intensity (self-accelerating, constant, alternating cycles of remission and relapse, or decelerating).
5. Both full and partial recoveries are possible. Millions of individuals and families throughout the world live full lives in long-term recovery. Partial recovery is common and can constitute a prelude to resumed substance dependence, a permanent state, or a stage of ambivalence and instability that precedes the achievement of full recovery.
6. Recovery processes vary. There are multiple pathways, patterns, and personal styles of long-term recovery. Greater time and resources are usually required as substance use disorders become more severe and complex and as a personal, family, and community recovery capital diminishes.
7. Intervening early makes a difference. There are brief windows of opportunity within the course of AOD problems and addictions that can be capitalized upon to help initiate and solidify long-term recovery. Family, peer, and professional supports are available that can shorten addiction careers.
8. Recovery from the most severe and complex addictions is a marathon that can bring unexpected gifts. Some individuals and families will be stronger, healthier, and live more personally meaningful and fulfilled lives as a result of their recovery experience.
Breakthroughs in understanding the neurobiology of addiction have profound personal, professional, social, and political implications, and the effects of such breakthroughs could prove immensely helpful to individuals, families, and communities. That said, unforeseen and harmful consequences of these breakthroughs must be anticipated and assertively managed.