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Addiction

Understanding the Brain Disease Model of Addiction

New research explores beliefs about addiction and whether they affect attitudes.

Is addiction a disease? From a medical perspective, are substance use disorders (SUDs) on par with, say, heart disease—if not, how do they differ?

Jesse Orrico/Unsplash
Source: Jesse Orrico/Unsplash

These questions are hotly debated within medicine and health care and also in the wider public sphere. The debate is centered on what’s often called the “brain disease model of addiction” and whether it or related concepts are the correct way of thinking about SUDs.

The brain disease model of addiction holds that SUDs are chronic, relapsing brain diseases and that relapses are symptoms, and part of the expected course, of the disease (Morse, 2017). As with other diseases, SUDs are caused by multiple forces, including behavioral, environmental, and biological ones. The general disease conception of addiction, which includes the brain disease model, is supported by all major psychiatric authorities, including the National Institute on Drug Abuse (NIDA) (Volkow & Koob, 2015), the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013), and the American Academy of Addiction Psychiatry (Freed, 2010).

It is not a recent trend in thinking. As early as 1784 in the United States, Benjamin Rush discussed addiction in terms that anticipated the disease model (Mann, Hermann, & Heinz, 2000). In 1956, the American Medical Association (AMA) affirmed that alcoholism qualified as an illness, and by 1987, the AMA officially affirmed the brain disease model of addiction (Lesher, 1997).

You might be wondering at some common counterpoints. Extreme acts of will, for example, can certainly prevent future substance use, or so the argument goes, but no act of will, no matter how great, will cure Alzheimer’s disease. Here’s Judge Morris Hoffman writing in the Federal Sentencing Reporter: “[I]f addiction were really a brain disease, how could any of you live with yourselves for sending drug possessors to prison? We don’t send Alzheimer’s patients or the clinically depressed to prison.” He continues, “[W]e all recognize, down deep and despite the industry orthodoxy otherwise, that like all behaviors, addictions are a complex mix of many ingredients, including that old-fashioned one now held in such disrepute: will.”

Yet, even if one agrees that there is some element of will, does that mean that the disease label is mistaken. For example, what if we compare addiction to epilepsy? When it comes to responsibility for one’s behavior, epileptics face diachronous responsibility: the responsibility at moments of quiescence for taking whatever actions necessary to prevent likely future harm. For instance, a person with epilepsy should not be responsible for their physical actions during an epileptic episode, but they also should not drive a vehicle if there is the potential of an epileptic episode occurring. Likewise, some suggest that there may be a duty for individuals with SUDs to seek treatment and care during non-craving moments so as to prevent future use and behavior. Similarly, Professor Gideon Yaffe has argued for some form of intermediate treatment—between insanity and full culpability—for addicted criminal defendants.

Matthew T Rader/Unsplash
Source: Matthew T Rader/Unsplash

In his review of the literature, Professor Stephen Morse identified different intellectual camps when it comes to addiction (Morse, 2017). There are those who “believe that addiction is a chronic and relapsing brain disease or neurologic disorder … and that addicts have little choice about whether to seek and use.” Others believe that, while seeking and using by individuals with SUDs are constrained choices, they are not as constrained as suggested in the previous definition. Still others “believe that addiction reflects a weakness of willpower and moral shortcoming, and that addicts simply need to, and can, pull themselves up by their bootstraps.”

Some who would fall into this last group partly affirm what is called the “moral model of addiction," wherein addiction is thought of as a failure of personal and moral responsibility (Peele, 1987). This model may be related to addiction stigma (Richter, Vuolo, & Salmassi, 2019), which is defined as negative attitudes towards individuals with SUDs that arise on account of the substance use disorder itself and are likely to impact physical, psychological, social, or professional well-being (Avery & Avery, 2019). Addiction stigma yields a range of negative consequences, including decreasing the chance that an individual with SUDs will seek or receive proper treatment (Pachankis et al., 2017; Avery et al., 2013; Rao et al., 2009). Such stigma may be largely driven by the perceived blameworthiness of the individual: the thought that he or she is personally irresponsible (lacking in self-control) or morally weak (Duncan et al., 2014).

Gustavo Fring/Pexels
Source: Gustavo Fring/Pexels

Research on Beliefs Regarding the Disease Model

For an overview of research on physician beliefs and attitudes regarding the model, there is an excellent and recent review (Barnett et al., 2018). A 1987 survey found that a majority of respondents (lay individuals) accepted a characterization of alcoholism as “an illness" (Caetano, 1987). Russell and colleagues (2011) found that U.S. addiction treatment providers (N=219) tended to embrace the disease model of addiction at higher rates than U.K. treaters (N=372). In a small study (Bell et al., 2014) of addiction neuroscientists and clinicians, it was found that 15 non-clinician neuroscientists believed that substance users have no control over use, while the other 10 non-clinicians and all 16 clinicians believed that substance users have impaired or diminished control. A U.S. survey (Lawrence et al., 2013) that included 1,427 primary care physicians and 487 psychiatrists found that 82% attributed addiction to disease, and 14% attributed it to moral failings. Tentative evidence has suggested the importance of embracing a disease model for creating nonjudgmental treating environments (Lawrence et al., 2013; Fraser, 2015; Karasaki et al., 2013).

Implications of Beliefs Pertaining to the Disease Model

While this is not an appropriate forum for full vetting of the merits of the disease model of addiction, we must acknowledge our recent research, which suggests that one’s beliefs about the disease model of addiction are related to one’s attitudes towards individuals with SUDs (Avery, Avery, Mouallem, Demner, & Cooper, 2020). We surveyed physicians and attorneys who work with patients and clients with SUDs. For both groups of participants, there was a strong correlation between support for the disease model of addiction and attitudes towards individuals with SUDs: the weaker the support, the more negative the attitudes. These results point the way towards addressing negative attitudes towards individuals with SUDs. Education regarding the disease model of addiction—or education regarding this finding of an association between conceptions of addiction and attitudes—could be important for decreasing stigma and encouraging proper referral and treatment engagement.

Portions of this post were adapted from Avery, J. J., Avery, J. D., Mouallem, J., Demner, A. R., & Cooper, J. (2020). Physicians’ and attorneys’ beliefs and attitudes related to the brain disease model of addiction. The American Journal on Addictions. doi: 10.1111/ajad.13023

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Avery, J. J., Avery, J. D., Mouallem, J., Demner, A. R., & Cooper, J. (2020). Physicians’ and attorneys’ beliefs and attitudes related to the brain disease model of addiction. The American Journal on Addictions. doi: 10.1111/ajad.13023

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