Addiction is not a brain disease

People cannot decide to give up pneumonia or decide not to be diabetic. They can and do, however, decide to give up their addictions to drinking, smoking and taking drugs, in large numbers.This I believe is a strong and common sense argument for saying that addiction to drinking, smoking or taking drugs does not fit any sensible notion of what a ‘disease’ is. Not everyone agrees.

In 1997, Professor Al Leshner (Leshner 1997), head of the National Institute on Drug Addiction (Maryland USA) at the time, wrote a paper entitled ‘Addiction is a Brain Disease, and it Matters’. This remains one of the most powerful, most cited, yet conceptually most puzzling papers on addiction. It explicitly brings together biological determinism and personal responsibility in a single model, without any inkling that there might be a problem here. The paper has nonetheless been republished in many places and formats and remains highly influential. This current paper seeks to shed light on why Professor Leshner’s paper, and other papers with a similar message, continue to shape addiction discourse despite a considerable number of important dissenting voices (see for example Kalant 2009) which are largely ignored, to the detriment of both science and service provision.

In the Leshner paper it is argued that ‘Scientific advances over the past 20 years have now firmly established that addiction is a chronic relapsing (brain) disease’ (p45). Similar strong claims have been made elsewhere, giving primacy to reductionist/materialist descriptions of the action of drugs on the human brain. In themselves, such descriptions provide useful knowledge and in no way constitute a problem; except that in some circles they seem also to promote the philosophically contentious idea that the reasons why people take drugs have also been explained. In other words, the assumption is that the neurology of drug action is the same as (isomorphic with) the neurology of motivated action.¹ If such were true, then the direct effects of having a cup of coffee on my brain would also explain when, why, where and with whom, I decide to have another one; or decide not to have another one after all; or decide to give up coffee altogether. The theory, of course, cannot come close to explaining these things. It must be clear, therefore, that the desire to do something, however caused, is independent of some entity that makes decisions about whether, when, how and why, to indulge the desire. It does not matter whether this independent entity is conceptualised as ‘mind’, ‘soul’ or as a different-level neurology (Ryle 1949; Koestler 1967). One of these entities must exist, and it has to be both independent of, and superordinate to, the pharmacolgy of drug action. By contrast, the Leshner argument posits a mechanism that is both cause and effect simultaneously. Hence under the primitive philosophy of ‘brain disease’ the finding of, say, an action of coffee on dopamine levels would warrant the classification of coffee drinking as a ‘brain disease’. Needless to say, the ability to take pictures of the insides of people heads and colour them in (Hickman 2014) sheds no light on these issues whatsoever, regardless of whether the pictures devolve from cocaine, caffeine, or watching the Super Bowl; or indeed doing brain disease research.²

The argument that direct drug action on specific brain function explains why people take drugs can only be rescued by asserting that ‘reasons’, if they exist, are epiphemonenological, that people ’really’ take drugs for no real reason, that voluntary action only ‘feels’ voluntary, that drug taking is not ‘reasoned’ but only ‘caused’, and consequently there are no reasons that need to be explained. Such a point of view, naturally, implies a much broader characterisation of the human condition, and threatens to describe the whole of human action (including the behaviour of the researchers themselves) as based on motivational delusion. It has to be said (at risk of stating the obvious) that it makes no sense, except as an act of insoucient egocentrism, to adopt a position that implies that the behaviour of drug users is based on motivational delusion, whereas my reasons as a researcher are real.

It should be obvious by now that many of those currently involved in the hot debate about these issues fail to realise that what they are in fact trying to do is solve a specific instance of the mind³-body problem. It is possible to say or write the words, ‘Neural mechansim is the cause of addiction, but people are still responsible,’ (paraphrased from Leshner, op cit) but they are literally meaningless. Recently Dennet (Thornhill 2017), in a piece entitled ‘Don’t kid yourself that robots are colleagues’, pointed to the ‘latent contradiction’ in the idea of ‘Casper the friendly ghost’. Casper can walk through walls and also catch a baseball, thus being both immaterial and material simultaneously. The same ‘dualist delusion’ lies at the heart of Leshner’s contention that people are both the subject of mechanism, but also responsible beings at the same time. That being the case, esoteric to-and-fro academic discussions about the precise role of neural mechanisms, or the precise role of clinical/social mechanisms of addiction, and their putative interactions, merely conpound the error. They are doomed to get nowhere on this particlaur issue since the underlying problem of body/mind dualism remains unaddressed, and according to Dennet, ‘Nobody’s ever solved that problem remotely satisfactorily’ (p4). Since in academic terms the brain disease theory is internally contradictory, and impervious to serious debate (it covers all the bases at once within a dualist theoretical framework which is both volitional and non-volitional simultaneously), it appears that we must search for the unfortunate pervasiveness of the ‘brain disease’ model elsewhere than within the logic of serious academic debate.

The reasons why the ‘brain disease’ model of addiction is so powerful are entirely social, and nothing to do with its scientific merit. Firstly, people like scientistic explanations that absolve them of responsibility for their disapproved-of behaviours, which recast them as ‘suffering from’ bogus diseases like air-rage, road-rage, or the ‘disease’ of addiction. (Davies 1992, 1997). Secondly, and more important, is the misunderstanding of ‘science’ amongst the general and not-so-general public. Science can be done with a pencil on the back of an envelope; conversely big machines that hum and have flashing lights can be used for totally unscientific purposes; science is not synonymous with technology (Davies 2013). However, the brain-disease community has all the heavy weaponry, scanners, radio isotopes and million-dollar equipment grants; whilst the non-disease fraternity has only some questionnaires, some interview transcripts, and some crucial but unspectacular clinical data on quit rates, to show for their efforts. In equipment terms, it’s asymmetric warfare.

How the issue will be resolved, or if it will be resolved, is not contingent on the academic rigour of the arguments. It’s a power struggle, a war about grants, conference expenses, influence, world travel, and the trumpeting (or Trumpeting) of bold assertions (‘Addiction is a brain disease and it matters’) which have no place in serious academic discourse. But on the other hand the message is simple, easy to understand, backed up by big machinery and long words, and colourful images of brains make for good television; plus the key movers are skilled in media real politik. In sharp contrast, the opposing arguments are complex, multi-faceted, far from clear cut, highly qualified, not backed up by big machines, and sheets of data aren’t likely to attract big viewing figures; meanwhile the key proponents are classical academics who write disgruntled opinion pieces and talk to each other. The fact that the latter might reveal something closer to operational truth is irrelevant in these days of post-truth, because the key reference is not Volkow et al but Foucault. It’s a power struggle, and yet we continue to fight our battle with self-selected inadequate weapons. Meanwhile, the medium is indeed the message (McLuhan 1964).

Hell! If its big, costs a fortune, goes hum, you don’t quite know how it works, it’s been on TV, and some of the words are difficult to spell, then it’s obviously science so it must be true.^4,5 What? You got some contradictory stuff on a piece of paper? You gotta be kidding.

Notes

1 And by necessary implication, once we are motivated, that is sufficient to ensure we’ll do it. The idea of being highly motivated to do something, but not doing it, struggles in the context of this single-level argument.

2 If we took pictures of the parts of Professor Leshners’s brain that are involved when he does his research, and surely we could, the same simplistic logic enables the whole enterprise to be disqualified as the symptoms of a brain-disease-research disease. The pictures would explain what happens when he does it, and also why he does it.

3 however conceptualised

4 You saw it on TV. It must be true,” says Dustin Hoffman in the hilarious comedy Wag the Dog (1997) where he plays the role of the movie director who faked the moon landings.

5 “Your talk,” I said, “is surely the handiwork of wisdom because not one word of it do I understand.” Quote from unnamed narrator, in the strange and disconcerting novel The Third Policeman (Flann O'Brien, 1940)