Is addiction a brain disease?

[5HT2c]

I have been studying this topic for a while and I'd like to hear (read) your opinions. Do you think addiction is a disease? Do you think it is a disease of the brain? Do you think we should focus in the brain to treat addiction and think about human-drug interactions?

If you need to warm up I leave you some of the main articles on the topic:

1.- Alan Leshner (NIDA director at the time) first proclamation of the addiction as a brain disease model (ABDM)
Leshner, A. I. (1997). Addition is a Brain Disease, and it Matters. Science, 278(5335), 45–47. http://doi.org/10.1126/science.278.5335.45

2.- Nora Volkow (now NIDA director) defense of ABDM:
Volkow, N. D., Koob, G. F., & McLellan, A. T. (2016). Neurobiologic Advances from the Brain Disease Model of Addiction. The New England Journal of Medicine, 374(4), 363–71. http://doi.org/10.1056/NEJMra1511480

3.- Addiction is not a diesase:
Satel, S., & Lilienfeld, S. O. (2014). Addiction and the brain-disease fallacy. Frontiers in Psychiatry, 4(MAR), 1–11. http://doi.org/10.3389/fpsyt.2013.00141

4.- Addiction is a 'social' disease:
Levy, N. (2013). Addiction is not a brain disease (and it matters). Frontiers in Psychiatry, 4(APR), 1–7. http://doi.org/10.3389/fpsyt.2013.00024

5.- There is not enough evidence to suport the ABDM and it promotes social injustice:
Hart, C. (2017). Viewing addiction as a brain disease promotes social injustice. Nature Human Behaviour, 1(February), 55. http://doi.org/10.1038/s41562-017-0055

 

[FLA]

I'm too tired to read all that stuff. But it's a very good question. When my brother first started manifesting schizophrenia I would tell him to snap out of it. Pure denial. I could live without recreational drugs but it seems boring. Man has been altering his consciousness forever. Naturally I don't like withdrawals. From my point of view I seem to do it because I want to but I acknowledge something else could be going on. Something to do with escape. I like what Jung said about addiction. It's like a misguided attempt to reach the divine. Let me know if I misquoted him.

 

[5HT2c]

Let me mark a clear difference between drug use and addiction. As I understand addiction would be the persistence of severe problems related to drug use during a prolonged period of time. In the DSM-5 (one of the most widely accepted diagnostic manual) is defined (maybe to widely) as meeting at least two of the following during one year:

1. This substance is often taken in larger amounts or over a longer period than was intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control the consumption of this substance.
3. A great deal of time is spent in activities necessary to obtain this substance, use alcohol, or recover from its effects.
4. Craving, or a strong desire or urge to use this substance.
5. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home.
6. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of this substance.
7. Important social, occupational, or recreational activities are given up or reduced because of this substance consumption.
8. Recurrent substance consumption in situations in which it is physically hazardous.
9. Substance consumption is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by this substance.
10. Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of this substance to achieve intoxication or desired effect.
b. A markedly diminished effect with continued use of the same amount of substance
11. Withdrawal, as manifested by either of the following:
a. a. The characteristic withdrawal syndrome for this substance
b. This substance or a similar one are taken to relieve or avoid withdrawal symptoms

 

[WSH]

It could be that there is some predisposition, but I don't think that it would actually manifest in taking the drugs when the drug isn't at first initiated and that is a concious decision.

 

[Cotcha Yankinov]

^I suppose poor impulse control or enhanced novelty seeking could be seen as the biological precursors to the full blown addiction.

I personally think the state of addiction itself is very biologically mediated, there is only so much you can do if your e.g. orbitofrontal cortex is hypofunctioning and your self control goes out the window.

Enhanced cravings in response to conditioned cues seems very biological as well.

 

[swilow]

Let me mark a clear difference between drug use and addiction. As I understand addiction would be the persistence of severe problems related to drug use during a prolonged period of time. In the DSM-5 (one of the most widely accepted diagnostic manual) is defined (maybe to widely) as meeting at least two of the following during one year:

1. This substance is often taken in larger amounts or over a longer period than was intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control the consumption of this substance.
3. A great deal of time is spent in activities necessary to obtain this substance, use alcohol, or recover from its effects.
4. Craving, or a strong desire or urge to use this substance.
5. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home.
6. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of this substance.
7. Important social, occupational, or recreational activities are given up or reduced because of this substance consumption.
8. Recurrent substance consumption in situations in which it is physically hazardous.
9. Substance consumption is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by this substance.
10. Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of this substance to achieve intoxication or desired effect.
b. A markedly diminished effect with continued use of the same amount of substance
11. Withdrawal, as manifested by either of the following:
a. a. The characteristic withdrawal syndrome for this substance
b. This substance or a similar one are taken to relieve or avoid withdrawal symptoms

I gotta say, atm I tick every single box there. Fuck, that is depressing, I'm gonna have to get high now.

 

[5HT2c]

I'll critically answer each of you, despite I don't think I have a clear idea of where I stand I think discussion will help ;-) Anyway, I advance to you that broadly I'd argue that now, addiction is better explained and understood in psychological and social terms.

WSH: I think everyone would agree in these two things: There is a genetic predisposition and starting taking a drug is a voluntary decision. Genetic predisposition: After spending several millions of dollars (maybe more?) in research several genes and alleles have been identified. After doing a complete genome study of a person the prediction power is still lower than asking the person if they parents had issues with drugs. I find it quite impressive. The voluntary decision and the 'brain switch': this is a theory proposed in the nineties without any empirical data as a support. It states that despite taking the drug the first time is a voluntary decision, after some point your brain switches and then you take the drug because your brain propels you to it.

Cotcha:Very interesting what you say... what if I changed 'prefrontal brain hypo-functioning' for 'persistent self disappointment'? could be the same thing at two different levels and maybe one is more empowering for drug users and drug addicts than the other...

Swilow: Almost for all drugs, 70-80% of the users don't get to meet these criteria, and the ones who meet these criteria most recover without help at a constant rate (with a higher rate at the late twenties and early thirties)

Did you know that in Vietnam a lot of US soldiers got really addicted to heroin and when they came back with their families almost all of them recovered without relapse the first time? I say this to remark the social context of the 'drug problems' over the biological context. If they had been affected by Parkinson's disease or neurosyphilis...

 

[swilow]

Interesting. I think a defining distinction between addiction and disease lies in the fact one has to actively maintain addiction through ongoing choices and actions. There are few, if any, diseases one can "quit".

We pathologise everything these days. Its the scientific urge to quantify human behavior. I'm not sure its possible to do so.

Active addiction feels involuntary, but I know deep down that I could just walk away from this if I decided to.

 

[Cotcha Yankinov]

Active addiction feels involuntary, but I know deep down that I could just walk away from this if I decided to.

I suppose the larger question here is if you did indeed decide to walk away from drugs, would it be of your own free will or would that same choice have been made every single time assuming the same state of the universe and random variation?

There have been some threads on free will before if anybody is curious.

 

[5HT2c]

I have to say that my point was about addiction being a BRAIN disease, I assumed addiction was a disease (or a disorder at least). I don't believe quitting is much about free will. No one can resist temptation forever (so it's a matter of how much time every person can resist) and anyone can quit given the adequate circumstances (knowledge, opportunities, commitment...)

 

[Cotcha Yankinov]

In that case I'd have to say wholeheartedly that addiction is a brain disease. Habits are built-in to the brain without too much conscious control over them, and there seem to be circuits that mediate activation of learned action sequences after a conditioned cue. Depending on the biology, there is going to be more or less response to the cue and more or less activation of said action sequences that often lead to the classic relapse - "I had no idea what I was doing - all of a sudden I was drinking again"

The other thing to consider is that its often co-morbid neuropsychiatric diseases that drive the original use of drugs as well as the continued use and subsequent development of addiction. I'd like to think that our society agrees that clinical depression is a disease and bootstrap talk isn't helpful (no more helpful than "pull yourself up by your boostraps" talk for a type 1 diabetic).

 

[5HT2c]

In this case Cotcha, I'm after you. You think something is a brain disease just because there is a brain correlate of what is happening? When we are in love we also have brain differences and we don't say 'love is a brain process'. People with Parkinson disease or severe depression, as you say, don't get better if offered jobs or monetary incentives, as most of the people who suffer from addiction do.
Anyway, with depression talk is not enough but I think it makes a difference, especially relieving the suffering from self-blame and self-guilt.

 

[Cotcha Yankinov]

IYou think something is a brain disease just because there is a brain correlate of what is happening?

Not just a correlate but rather a causal correlate - for example block the dopamine release that occurs when a cue is observed by an addicted animal and this will decrease their addiction related behavior. Or alter the induction of certain genes like DeltaFosB and we can then observe those effects on addiction related behavior


I see now what you wrote about offering an addict a job and they can (occasionally) get better, whereas very little environmental stimuli will affect Parkinson's disease symptoms.

The ability of the environment to modulate various diseases effectively or not could be viewed as a spectrum. To clarify my argument, I would tend to think that most addicts tend to lean further towards the "environment has a weaker effect on the disease" spectrum.

Maintaining sobriety isn't necessarily curing addiction. You can have cases where addicts manage to stay sober for many years but they still have intense cravings when subjected to conditioned drug cues like paraphernalia. In that sense I would think about the addict's diseased brain is untreated even if they are sober, because they are still having cravings/withdrawals et cetera and are liable to relapse (especially when exposed to stress, which is an environmental component I suppose)

In my opinion, modulation of the environment to treat the sensitized response to cues would probably be weak. You may be able to alter the environment to increase the likelihood of sobriety, and that's certainly what we should do, and I'm sure that creating a low-stress/neurotrophic environment will help decrease sensitization (see stress mediated enhancement of cue responses and the relationship between stress and relapse) but the magnitude of effect of something like ibogaine that decreases cravings may be unique to biological therapies.


If a sober meth addict is shown a picture of a meth pipe and their brain lights up on fMRI and they get cravings - I would say their disease hasn't necessarily been treated as much as their undesirable behavior has been corrected.

And I certainly agree that CBT and psychotherapy are important in treating clinical depression.

 

[Cotcha Yankinov]

^The concept you refer to is basically hebbian learning "neurons that fire together wire together"

But anyways, it seems to be that the same systems mediate natural reward/reinforcement and drug related reward/reinforcement but there is a lot of debate as to whether or not we should classify "behavioral addictions" as addictions. It's in human nature to have sex/eating compulsions but not to crave drugs - the latter is much more learned and tends to be overwhelmingly pathological

If we treated all cravings (e.g hunger) as a pathological disease then we would practically have to force ourselves to eat - whereas treating drug cravings seems to have categorically different consequences.

Most people don't want to stop having hunger or stop feeling horny, but there are definitely people who want to stop having drug cravings. In that sense, drug cravings are much more pathological (even if all types of cravings operate on the same circuits).

So I wouldn't treat hunger as a disease unless somebody is having satiety issues and can't stop over eating (eating disorder) - then even a relatively normal genre of compulsion could be classified as a disease if it's causing harm and is unwanted by the person suffering from the compulsion.

 

[Vastness]

I think this is largely a discussion of semantics and honestly I don't think it really matters if addiction is a "brain disease" or not. I have read the thread so far but I am also still a little unclear on what exactly the definition of a "brain disease" is.

 

[5HT2c]

I think this is largely a discussion of semantics and honestly I don't think it really matters if addiction is a "brain disease" or not. I have read the thread so far but I am also still a little unclear on what exactly the definition of a "brain disease" is.

I agree. Definitions are important. I opened the thread because the topic interest me and because I think we abuse too much of neurotalk or braintalk. As we know any terms like, firing neurons, dopamine, whatever we go there and we talk as if this stuff matters, when the only things that matter are the ones you can feel and see. I suppose the belief is that neurons matter because we believe they correlate with life, but I would not be that sure about that at least with the fMRI and PET/SCAN technology.

Main point: When we talk about addiction we like to talk about brain circuitery, cravins and drug-cues, and I believe this is misleading and we as society are investing bilions in neuro-research when there is simple interventions for addiction like CBT, contingent managment and motivational interviewing that have proven to be the equal or better (CM) than any other treatment (and most of addicts are not offered those evidence-based therapies).

Goto: Totally agree, brain differences seen in addiction could be just a temporary and reversible correlate of learning. My brain before Game of Thrones yesterday could light and fire quite beautifully, probably.

 

[5HT2c]

Before making such claims I'd recommend reviewing this suggested literature: ;-)

3.- Addiction is not a diesase:
Satel, S., & Lilienfeld, S. O. (2014). Addiction and the brain-disease fallacy. Frontiers in Psychiatry, 4(MAR), 1–11. http://doi.org/10.3389/fpsyt.2013.00141

4.- Addiction is a 'social' disease:
Levy, N. (2013). Addiction is not a brain disease (and it matters). Frontiers in Psychiatry, 4(APR), 1–7. http://doi.org/10.3389/fpsyt.2013.00024

5.- There is not enough evidence to suport the ABDM and it promotes social injustice:
Hart, C. (2017). Viewing addiction as a brain disease promotes social injustice. Nature Human Behaviour, 1(February), 55. http://doi.org/10.1038/s41562-017-0055

 

[Cotcha Yankinov]

Main point: When we talk about addiction we like to talk about brain circuitery, cravins and drug-cues, and I believe this is misleading and we as society are investing bilions in neuro-research when there is simple interventions for addiction like CBT, contingent managment and motivational interviewing that have proven to be the equal or better (CM) than any other treatment (and most of addicts are not offered those evidence-based therapies).

I'd just like to clarify what I suspect might be a point of confusion, especially in regards to your reference #5 -

1. Addiction can still be a brain disease even if it primarily has societal/environmental etiological roots with very little genetic component.

2. A neuropsychiatric "brain disease" can still be treated with counseling type therapies. This is true with few exceptions, for example schizophrenia which is known to not do very well with the counseling type therapies.

However, CBT and other counseling therapies are offered at many rehab clinics, yet many patients are in and out many, many times over and are constantly relapsing. Even if some are maintaining sobriety, many of those who are sober are still struggling with residual cravings that can take many years to fade.

By all means, make CBT and mindfulness et cetera available to addicts, but don't expect it to end the opioid epidemic.


Just some food for thought, the inverse disease to addiction is probably PTSD - which arguably has environmental etiology with once again some environment X gene interaction. The brain can learn aversion to a memory(s) so strongly that it should at some point be classified as a disease. The opposite is true with addiction - the brain can receive such strong reinforcement with impairment of self-inhibition circuitry that addicts have an extremely hard time breaking the cycle.

One advantage to treating addiction as a brain disease is that its a big improvement from viewing addiction as a moral failure, which is the old thinking that we're still trying to dispel.

brain differences seen in addiction could be just a temporary and reversible correlate of learning. My brain before Game of Thrones yesterday could light and fire quite beautifully, probably.

I think you're trivializing the difference between a chronic hard drug addict's brain and someone who gets excited for a TV show, and of course trivializing the difference between e.g. opioids and TV.

Would you be willing to trade your health, your family, all of your money and financial security so you could keep watching the TV show? Would you ever find yourself in a situation where it all seemed to slip away regardless of whether you were willing or not?

The whole point of classifying some compulsive related disorders as diseases is that there can be severe consequences to the compulsive behaviors which do not correct the behavior. This is biologically mediated. There are parts of your brain that would allow you to say "Hey this isn't worth trading my family/health/finances for, I'm going to stop this behavior". Addictive drugs seem to do a great job of harming the orbitofrontal cortex that mediates much of this self-inhibition.

https://academic.oup.com/cercor/article-lookup/doi/10.1093/cercor/10.3.318

From wiki - "Stimulating the OFC in laboratory animals results in drug self-administration.^[27] In animal studies the OFC is hypothesized to not only be associated with the response to reward, but also to respond and adjust animal behavior when the rewarding properties of the reinforcement change^[37] - as well as learning the association between stimulus and reward.

The damage to the OFC results in deficits in reversal of stimulus reinforcement in which an animal perseverates on a behavior and fails to extinguish a behavior.^[38]

This perseveration and inability to extinguish a behavior can be related to drug administration in substance abuse and substance dependence where individuals compulsively self-administer a drug even with drastic decrease of reinforcing effects of that drug and tolerance to the pleasurable effects and in the presence of adverse consequences of drug use.

Rats who are reintroduced to an environment in which they used cocaine experience activation of the OFC.^[39] In addition, in rats, repeated alcohol use causes degeneration of the OFC.<sup>[40]"

There are now many studies linking orbitofrontal cortex and related circuit's dysfunction to addiction, and this isn't something that is easily reversible (as if it were "psychological", whatever that word means anymore)</sup>

 

[5HT2c]

First, I want to aplologize, I got caught in the theoretical discussion and I didn´t want to trivialize. Addiction is a very serious disease that generates huge amounts of suffering.

I find this discussion interesting, so I'll go on. I insist I have my doubts but I am playing the role to counter the main and strongest position here, in this case Cotcha.

1.- Why can't you reverse your point? addiction is a psychosocial disease despite has brain correlates? When I say it is not a brain disease I mean that with the current state of science we don't have enough knkowledge to think addiction in brain terms in a useful way for the people who are suffering. Imagine you are dealing with an addict. Will you talk about orbitofrontal cortex or about families, friends and hope?

Would you be willing to trade your health, your family, all of your money and financial security so you could keep watching the TV show? Would you ever find yourself in a situation where it all seemed to slip away regardless of whether you were willing or not?

See here, when you 'destory' me you go to the psychosocial view of addiction, being willing to lose health family and money. Thats the discourse I believe explains better addiction and not the changes in orbitofrontal cortex seen in skewed models of addicted rats. And I am not saying we should not give methadone or buprenorfine, they are truly important. I'm just after this predominant view of addiction as a brain disease that started in the nineties. I just say we have to give the brain the proportionate importance in the problem, and now, for the evidence we have it's low. Your citations refer to studies with rats and monkeys, except the one of Nora Volkow, wich is in PET. Nora recognized in a supplement of an article published in the BJM last year (the second reference I give in the first post) that most of the addicted brains are like the normal brains and despite there are significant differences with healthy controls there are not out of the range of normality. She says this is due to the limited technology we have now, and I believe so. I hope in the future we will have the possibility to understand everything from a brain pespective as we can do now from a psychological one.

I also have to acknowledge that viewing addiction as a brain disease has been used to reduce stigma, to increase funding for treatment providers and to include addiction in insurances programs. However, it has created another stigma and has mislead bilions of dolars in brain research when most of addicts don't have access to simple, cheap and proven treatments. Anyway, we cannot chose to believe what fits better for politics, rather than the most evidence-supported theory.

I think it is clear that addiction is not like parkinson. But we can also research the brain and give biological and useful treatments, especially for opioids, alcohol and nicotine.

We could open another thread about the opioid crisis...

 

[5HT2c]

I'd also want to add that the main risk factor for having problems with drugs is poor education, low income, and not being white (I could not give evidence of the last one). Of course the way your brain is wired matters, some of that you are born with and some of that is built on education and family. Anyway, I'd not want to offend white well-educated people who have problems with drugs, there is a lot of other factors, but when we refer to a crisis and massive problems I think the main maintaining causes are poverty, poor education and lack of attractive alternatives to drug use.