|Year : 2018 | Volume
| Issue : 1 | Page : 1-3
Can social psychiatry bridge the sociopolitical divide between brain disease and free will models of addictions?
Abhishek Ghosh, Debasish Basu
Department of Psychiatry, Drug De-Addiction and Treatment Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Web Publication||29-Mar-2018|
Dr. Debasish Basu
Department of Psychiatry, Drug De-Addiction and Treatment Centre, Postgraduate Institute of Medical Education and Research, Chandigarh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Ghosh A, Basu D. Can social psychiatry bridge the sociopolitical divide between brain disease and free will models of addictions?. Indian J Soc Psychiatry 2018;34:1-3
|How to cite this URL:|
Ghosh A, Basu D. Can social psychiatry bridge the sociopolitical divide between brain disease and free will models of addictions?. Indian J Soc Psychiatry [serial online] 2018 [cited 2018 Oct 17];34:1-3. Available from: http://www.indjsp.org/text.asp?2018/34/1/1/228788
“Addiction is a brain disease, and it matters:” This proclamation of Leshner, the then Director of the National Institute on Drug Abuse (NIDA), USA, in 1997, was a watershed in the history of addiction science. However, its acceptance in the scientific circles as well as among the lay public has been mixed at the best. There are serious critics of the “brain disease model of addiction” (BDMA), who have expressed their oppositional viewpoints, criticizing BDMA for assisting people to shrug off personal responsibility for their deliberate action of using psychoactive substances. Some of these critics are not even in agreement with the disease model of addiction. There is another group of dissenters who see the brain changes in addiction as a normative learning experience, rather than being a causal pathology. And, of course, there is the other group of addiction neuroscientists who strongly endorse the BDMA, with its large and commendable evidence base from neuroimaging, genetics, and developmental research. These highly polarized views need to be reconciled.
| Brain Disease Model of Addiction: Its Achievements|| |
BDMA posits that the “addicted brain” differs significantly from its nonaddicted counterpart. Specific brain areas are involved because of chronic drug use, which is responsible for the metaphorical “switch” from voluntary to compulsive drug seeking and “hijacking” of the normal brain reward system.
BDMA has brought about the much-needed paradigm shift in the scientific understanding as well as public opinion regarding addiction. Prior to that, people with addiction were often thought to be immoral by nature and culpable for their personal choice or free will. They were looked down upon by the rest of the society, resultantly alienating this already marginalized population.
BDMA has also contributed to the development of various behavioral and pharmacologic treatment strategies for substance use disorders. Varenicline, naloxone, acamprosate, and buprenorphine all could be considered as the corollary of the substantial research which is driven by the BDMA.
There are significant policy-level impacts of this brain model. Volkow et al., the current Director of NIDA, asserted that the Parity Law (the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act) is the outcome of continuous advocacy of the BDMA., This law ensured that medical insurance in the USA covers the cost of addiction treatment. The results of this act are apparent. Evidence from three states in the USA showed an increase in the treatment enrolment for substance use disorders and reduction in the emergency care visits. Moreover, a few states in the USA have started to take legal actions against the managed care providers for being allegedly discriminatory toward patients with substance use disorders, as compared to those with other chronic medical diseases. Another important policy impact of BDMA, as claimed by Volkow et al., was fixing the minimum age of drinking, which is a neurobiologically informed decision because the prefrontal and other cortical networks mature during the late adolescent period.
| Brain Disease Model of Addiction: Its Critique|| |
The dissemination of BDMA has not been a cakewalk so far. There is substantial presence of dissenting voices that see BDMA as propaganda, rather than a scientifically validated concept. In fact, its mastermind, Dr. Leshner, at the end of his tenure in NIDA, himself acknowledged that the origin of BDMA was driven by its potential for changing the prevailing public attitude toward addiction, without much regard to the existing evidence at that point in time. However, it has resulted into a considerable budgetary allocation for research and treatment in addiction medicine, which was another unspoken impetus behind the proposition and dissemination of BDMA.
One of the vocal critics of the BDMA is Lewis who interprets the neuroscientific evidence of addiction as an “extreme outcome of a normal functioning brain.” In his reformulation, the specific brain changes seen in addiction are results of learning the habit of pursuing a highly attractive goal, i.e., drug use or other addictive behavior. He sees addiction in light of coping behavior, developed in a definite social matrix.
In a recent article in the journal Neuroethics, the editors have compiled almost all the important opposing voices. Among them, we have the likes of Satel, Lilienfeld, Flanagan, and Wakefield who are even averse to the idea of labeling addiction as a “disease” or argue against the term “addiction” itself, whereas, there are others like Hall, Berridge, and Heather who do not have any qualms in calling addiction a disorder or disease but oppose the idea of the brain disease model. Satel and Lilienfeld see addiction as a continuum of normative complex behavior which is to be understood at multiple dimensions. Hall et al. criticize the oversimplification and generalization of BDMA. They also expressed disappointment that BDMA has failed to deliver more effective treatments and is only modestly effective in changing public health policy and perception. Nick Heather sees addiction as a disorder of choice. He describes, “Addiction is seen as a disorder of choice in the sense that it represents a kind of failure to make consistent choices over time.” Very recently, Hart, while expressing his personal views, mentioned, “The view of drug use and drug addiction as a brain disease serves to perpetuate unrealistic, costly, and discriminatory drug policies.” With all these opinions, the presence of a powerful dissenting voice can never be ignored.
| Brain Disease Model of Addiction and Its Antithesis: a Dialectic Solution|| |
The apparent antithetical opinions of the proponents and opponents of the BDMA might result in an undesirable impasse. On one hand, the disease of “free will” or “choice” understanding could potentially cause, or rather revive, the notorious “War on Drugs,” which has already been witnessed in the recent extrajudicial killings of drug users in the Philippines. On the other hand, the oversimplified and reductionist view of BDMA might propagate “pseudo-scientific” ideas depicted by hilarious roadside hoardings or newspaper advertisements and may not serve its original purpose.
The choice is in our hands, whether to search for the “One Single Ring to Rule Them All” as John Tolkien would have described and to end up finding none, or to look for a dialectic solution. This has been tried by authors like Heim in his correspondence, “Addiction is not just a brain malfunction.” He eloquently summarized and represented the voice of 94 other signatories, endorsing the aforementioned viewpoint: “Substance abuse cannot be divorced from its social, psychological, cultural, political, legal and environmental contexts: It is not simply a consequence of brain malfunction. Such a myopic perspective undermines the enormous impact people's circumstances and choices have on addictive behaviour.” In another correspondence in response to a Nature Editorial, Cunningham simplified Heim's and others' views with an excellent analogy: “…addiction is the car crash and the brain is the vehicle: The person driving it contributes a psychological component, the others on the road represent social factors, and road conditions correspond to the environment. To promote any one of these as the prime cause of addiction, as in the brain-disease model, overlooks the importance of the other components.”
| Concluding Remarks|| |
If the latter half of the 20th century would be remembered for its infamous “War on Drugs” with its perils of incarceration, stigmatization, violation of human rights, and loss of many lives, the early part of 21st century has witnessed a definite revolution with the advent of the BDMA. To our mind, it was the need of that hour and expectedly it had produced lots of positive results, in many aspects of treatment, research, and policy. Perhaps now the time has come to reconcile and accept some of the inevitable socio-political issues of addiction and propose an amalgamated model which would place the patients at the top of the hierarchy and medicine at the bottom, reversing the metaphorical pyramid which is in vogue presently, as suggested by Lewis.
Social psychiatry does not negate brain and its intricate mechanisms. Neither does it claim to take away the issue of personal responsibility or “free will” of the individual. It does, however, assert that all sorts of “social” factors (used in the broadest sense, incorporating macro factors such as culture, immigration, displacement, mass conflicts, major disasters including economic and social crises, and micro factors such as interpersonal conflict, stress, and stigma, among others) moderate the functioning of the brain as well as individual agency of willed action in both health and disease. Thus, we believe that social psychiatry has an important role to play in bridging the artificial sociopolitical division between the brain disease and free will models of addictive behaviors.
| References|| |
Leshner AI. Addiction is a brain disease, and it matters. Science 1997;278:45-7.
Snoek A, Matthews S. Introduction: Testing and refining Marc Lewis's critique of the brain disease model of addiction. Neuroethics 2017;10:1-6.
Volkow ND, Koob GF, McLellan AT. Neurobiologic advances from the brain disease model of addiction. N
Engl J Med 2016;374:363-71.
Busch SH, Epstein AJ, Harhay MO, Fiellin DA, Un H, Leader D Jr., et al.
The effects of federal parity on substance use disorder treatment. Am J Manag Care 2014;20:76-82.
McLellan AT, Woodworth AM. The affordable care act and treatment for “substance use disorders:” Implications of ending segregated behavioral healthcare. J Subst Abuse Treat 2014;46:541-5.
Lewis MD. The Biology of Desire: Why Addiction is Not a Disease. New York: Public Affairs; 2015.
Hall W, Carter A, Forlini C. The brain disease model of addiction: Is it supported by the evidence and has it delivered on its promises? Lancet Psychiatry 2015;2:105-10.
Hart CL. Viewing addiction as a brain disease promotes social injustice. Nat Hum Behav 2017;1:0055.
Chapman AR, Babor TF. Duterte's war on drugs and the silence of the addiction science community. J Stud Alcohol Drugs 2017;78:491-3.
Heim D. Addiction: Not just brain malfunction. Nature 2014;507:40.
Cunningham JA. Addiction: Many factors contribute. Nature 2014;507:40.