A reader who disagrees with my views recently posted a link and told me it was “required reading”. The link goes to a page titled “Drugs and the Brain” from the NIDA pamphlet (National Institute on Drug Abuse & Addiction) titled “Drugs, Brains, and Behavior – The Science of Addiction”. What follows is my critique of the entire pamphlet. You can see the pamphlet here : sciofaddiction.pdf [2.2MB] Beware this post is long and in depth, and only for those who really want to test what they’ve been told by the NIDA.
The NIDA has been the leader of the “brain disease” theory of addiction. Their current director, Nora Volkow, can be seen in countless television interviews and magazine articles spreading this theory. She hails from the Brookhaven National Laboratory, the facility responsible for all the beautiful brain scans we’re now presented with when we’re told that addiction is a brain disease. If you’ve heard about the theory, it’s probably come from Volkow, so it’s fitting that the pamphlet opens with a picture of a brain scan and a quote from her:
“Drug addiction is a brain disease that can be treated”
Then she writes a preface in which she states:
Throughout much of the last century, scientists studying drug abuse labored in the shadows of powerful myths and misconceptions about the nature of addiction. When science began to study addictive behavior in the 1930s, people addicted to drugs were thought to be morally flawed and lacking in willpower. Those views shaped society’s responses to drug abuse, treating it as a moral failing rather than a health problem…. Today, thanks to science, our views and our responses to drug abuse have changed dramatically. Groundbreaking discoveries about the brain have revolutionized our understanding of drug addiction, enabling us to respond effectively to the problem.
There are way too many problems with this for me to tackle, but let’s just get this one point out of the way: they have not responded “effectively to the problem”. Treatment has been a net failure, and it hasn’t much improved. For my evidence I point to 2 studies both by Deborah Dawson, both sponsored by the NIAAA. She showed that in 1992, 33.2% of alcoholics who had ever received treatment, were still abusing alcohol – and that 25.8% of alcoholics who had NEVER received treatment were still abusing alcohol. So based on that, we can conclude that treatment probably isn’t very effective, since a higher percentage of those alcoholics who attend treatment continue to abuse alcohol. But then we have a follow up, a study she did in 2002 (10 years later) which showed that 28.4% of alcoholics who attended treatment continued to be alcohol dependent, and only 23.8% of alcoholics who had NEVER been to treatment continued to be alcohol dependent. So I guess we could say that treatment has improved slightly, but it still hasn’t surpassed natural recovery rates to the degree which it should in order to be seen as having any value.
Here are the links to the research mentioned above:
Some may take issue with the fact that I’m criticizing the NIDA with statistics on alcohol abuse, so I should mention that I’m using studies on alcoholics because to my knowledge there are no similarly thorough studies on specifically drug users, but that alcohol and drug addictions are essentially the same, the only difference being that one of the substances is legal. Alcohol works on the brain in many similar and nearly identical ways to every illegal drug, and substance abusers of both categories are usually treated in the exact same facilities in the exact same ways – leaving no suggestion that treatment should be any more or less successful for drug abusers than it is for alcohol abusers. Effectively, alcohol is just a liquid drug. Long story short – I believe Ms Volkow is incorrect in the very first claim she has made: we have not responded effectively to addiction.
She goes on to tout a bunch of nonsense about what a great job science is doing to address addiction and she states:
Despite these advances, many people today do not understand why individuals become addicted to drugs or how drugs change the brain to foster compulsive drug abuse. This booklet aims to fill that knowledge gap by providing scientific information about the disease of drug addiction…
So I’m promised that this booklet will fill my gap in knowledge about the disease of addiction with scientific proof. Also, she tells us that addiction causes “compulsive” drug abuse (compulsive means involuntary). I’m excited, let’s see if she can prove how this “disease” creates compulsive abuse!
On page 5, the disease is defined:
Addiction is defined as a chronic relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences. It is considered a brain disease because drugs change the brain – they change it’s structure and how it works. These brain changes can be long lasting, and can lead to the harmful behaviors seen in people who abuse drugs.
Did you catch that? This definition sounds like a tautology or circular argument of sorts. What it says is that drug abuse is both a symptom and a cause of the disease. Upon first examination it seems like total nonsense. Now, what they’re trying to say, and they explain it later (page 7), is that at first, the drug abuse is voluntary, and that over time it slowly shifts to a compulsive behavior as the drugs change the brain – and they hold up evidence of changes in the brain as proof that addiction is indeed a brain disease. This is a central talking point in the brain disease theory so it must be examined carefully.
My main question is, do changes in the brain qualify something as a disease? What happens when you learn something, such as multiplication tables? Do you think your brain stays the same, or do you think it changes? When you first learn multiplication, you often have to go through a few steps. To solve the problem 4 x 5 =, you may have to actually add the number 5 together 4 times, so that your work, if represented on paper would read: 5 + 5 + 5 + 5 = 20. But as you encounter this problem more frequently, it becomes easier and ingrained, and automatic. How so? Well, as you practice math more, it causes changes in the brain – it creates physical connections. So instead of relying on the connections we built while learning addition, we now rely on the connections we built while practicing our multiplication tables, then we see the problem of 4 x 5 and immediately answer 20. Our brain is changed.
When we use drugs for a high the first time, it’s new, we don’t know what it’s gonna feel like. If it feels good, then we build connections as we do it more and more to expect a good feeling from it. It becomes automatic to associate feeling good with being on drugs, the equation becomes Drugs + Me = Feeling Good – and the next time the opportunity arises to use drugs, we don’t go through the steps of wondering whether it will feel good, whether it is something we should do, we just do it. Our brain has changed, we have learned something.
Is learning therefore a disease? Why is it a disease when we learn to use drugs, but not a disease when we learn multiplication? Some would reply that drug abuse is bad, and math is good, and that’s what makes the difference. But what if we were to teach someone that 2 + 2 = 5? Now they go through life doing all sorts of math problems wrong. It leads to them going into debt, and being kicked out of their home, and other horrible consequences. Would we then call that person diseased? Would we seek medical treatments to help them? Or would we simply try to re-teach them the correct way to do math? Would you classify a process of teaching as treatment, or as education?
Let’s not forget the claim they made in their definition of the disease:
It is considered a brain disease because drugs change the brain – they change it’s structure and how it works.
You’ll see again and again throughout this pamphlet that addiction is treated like learning, so it’s not so crazy to think about learning and whether or not it is a disease, and whether or not we should try to correct the learning of something which is incorrect with medical treatment .
Page 8 of the pamphlet brings up the factors which determine whether or not someone will become addicted. They mention both genetic and environmental factors, but they offer nothing truly definitive or worthy of our examination. Pages 9-14 discuss adoloescents and prevention, but also offer nothing that truly speaks to the science of their brain disease theory. But when we get to page 15 it gets a little more interesting.
Now we’re at the section titled “Drugs And The Brain”, the part I’ve been told was “required reading” for me. All this section does is review some very basic information about the different regions of the brain. It’s the type of stuff you might learn in week 1 of a basic neuropsychology class – but this is where the snow job truly begins. When you start speaking about neuroscience to the average person, they shut down a bit and accept whatever conclusions you reach. The reason why is that we’re laymen, we hear the scientific jargon, assume the speaker is an expert and knows what they’re talking about, and we suspend judgment. All this section does though is describe the basic functions of the brain, and then explain how drugs physically work within it to create a high. This is interesting stuff, but it does nothing to actually prove the brain disease theory. They go on to claim that:
When some drugs of abuse are taken, they can release 2 to 10 times the amount of dopamine that natural rewards do. In some cases, this occurs almost immediately (as when drugs are smoked or injected), and the effects can last much longer than those produced by natural rewards. The resulting effects on the brain’s pleasure circuit dwarfs those produced by naturally rewarding behaviors such as eating and sex.
This number may or may not be correct for humans, and I note this because the research they refer to when stating this fact is all done on rats. Furthermore they state:
The effect of such a powerful reward strongly motivates people to take drugs again and again. This is why scientists sometimes say that drug abuse is something we learn to do very, very well.
Learning is brought up yet again, and by the way – the facts they’re making this conclusion on, are all based on RATS. Rats are not rational. Do we know how much dopamine is released when a rat graduates from college? Do we know how much dopamine is released when a rat sings a song he wrote himself? Do we know how much dopamine is released when a rat completes any long-term complex goal? NO. Rats can’t do these things. Furthermore, you can’t simply compare drugs to sex and eating – there is more to life than that for humans. The implication here is that drugs are more rewarding than anything, and personally I don’t buy it. I don’t believe that all there is to life is drugs, sex, and food.
Now on page 19 we get to the 4th image of a brain scan presented in the pamphlet. Why is this significant? Remember when I said how we often shut down our judgment and become very accepting of a given speaker’s conclusions when we hear neuroscientific jargon? It’s not just a random claim I’m making, it’s backed up with hard evidence. In 2008, Deena Skolnick Weisberg showed this very fact in her paper “The Seductive Allure of Neuroscience Explanations”. In the study, she showed people both good and bad explanations for psychological phenomena, and she showed each with neuroscience explanations and without neuroscience. Specifically, she would add the phrase “Brain scans indicate” to an incorrect explanation – and both layman and actual neuroscience students found the faulty explanation far more satisfying when paired with the phrase. In short, we’re excited about the great technological advances of our age and ready to believe anything someone tells us as long as they mention a neuroscientific study, and when they show us pretty brain scans, then we’re really sold.
Skolnick Study available here: http://www.mitpressjournals.org/doi/abs/10.1162/jocn.2008.20040?journalCode=jocn
In this review of the brain disease theory we won’t be so ready to accept their conclusions. We’re going to honestly and rationally examine what their neuroscientific evidence actually proves. So this brain scan on page 19 is simply used to demonstrate that after some time of abusing drugs, your dopamine transporters get worn out and don’t work quite as well. This doesn’t prove a disease is present in and of itself – it only proves that the brain can be damaged. It also doesn’t prove that this damaged state causes compulsive (involuntary) drug use. As you’ll see later, with further brain scans they present, this dopamine function begins to return to normal as the user remains abstinent for a decent period of time. My main question is, if the damage to the dopamine function is responsible for involuntary use – then how does this addict stay sober long enough for the subsequent brain scans which show that the brain has repaired itself?
We’ll get to that, but first we have to skip over pages 21 through 24 though, which focus on co-occurring illnesses such as HIV, cancer, lung disease, and hepatitis. What I will say about this section though, is that yes these diseases can be caused by drug abuse, but they’re really irrelevant to the matter at hand. They don’t prove that the act of drug abuse itself is caused by a disease, but this information is included to keep you thinking in medical terms and to lend credibility to their theories by associating drug abuse with real diseases.
Now on page 25 we get back to PET scans of meth abusers’ brains. And they ask the question “Can addiction be treated successfully?”, then they respond in giant block letters “YES”. They go on to say that:
Like other chronic diseases, addiction can be managed successfully. Treatment enables people to counteract addiction’s powerful disruptive effects on brain and behavior and regain control of their lives.
Then they present a brain scan of a meth user who has regained function in the damaged part of their brain. So the implication is that this meth user was abusing drugs involuntarily, they were treated, the treatment was the cause of their abstinence and subsequent regaining of control over their life, and repaired brain function. Does this brain scan actually prove that though?
This info is based on 2 separate studies. The first study gathered 15 sober meth abusers from rehab programs. 12 of them were newly sober (within a 2 week – 6 month range). This study scanned their brains each once. The goal was simply to see the decreased effects of dopamine transporters, and related symptoms. We also know that “No subject was taking medications at the time of the study”. And indeed, that isn’t too surprising, since there is no methadone or bupe equivalent of a pharmaceutical treatment for meth abusers. They were in treatment, but not on prescriptions for their addictions, and there is also no mention of some sort of surgical procedure which cured them. So ostensibly, they were going to group therapy sessions and 12-step meetings as their form of “treatment”. So did treatment really help them? I don’t know how we can make that claim, especially since there was no control group of untreated subjects (there was however a control group of non-addicts whose brains were scanned, but this is essentially meaningless). So right there – this “evidence” of the ability to counteract addiction’s effects with treatment is completely irrelevant. It does not prove what they claim it proves. It gets worse though.
Of those original 12, only 5 made it to the second study, which was designed to measure whether this dopamine transporter function could be regained with extended periods of abstinence. These 5 “were able to remain drug free for at least 9 months”. So what happened to the success of treatment? Only 5 out of 12 could stay sober long enough for the study? That doesn’t fare well for their treatment programs – it would only be a 42% success rate – but to be fair, they don’t tell us why all 12 didn’t make it into the second study. They do however tell us that these 5 were “enrolled in a California drug-court monitoring rehabilitation program and were evaluated weekly or biweekly with drug screens to ensure lack of drug use during the abstinence period.” Which means that these people, who weren’t on medication, and who weren’t cured with a surgical procedure, were however under the direct threat of jail time if they didn’t stay clean. So perhaps, this brain scan shouldn’t be presented as evidence of the effectiveness of treatment, but instead should be presented as evidence of the effectiveness of threats. These people stayed sober because they didn’t want to go to jail, bottom line. But how would talk therapy, group meetings, and threats of jail time be able to help a “compulsive” drug abuser who is fundamentally unable to make the decision to stop abusing drugs because of the damage done to their brain? HOW? There is no answer for this question. Decision making is about weighing pros and cons, consulting your values, exercising rationality, and we are told over and over again that these substance abusers are unable to do those things. None of it makes sense. They stayed sober, without medication and without surgery, something which should be an impossibility if you believe the picture of the brain disease which has been taught to us thus far.
Nothing about this brain scan proves the claim that addiction is a brain disease or that it can be treated successfully. It proves only one thing, that if a substance abuser chooses to stay sober for an extended period of time, then much of the damage to their brain will be reversed naturally. I use the term “choose” because their is nothing to indicate that anything other than a personal choice was responsible for these subjects’ sobriety.
Links to the 2 meth abuser studies:
http://www.jneurosci.org/cgi/content/full/21/23/9414
http://ajp.psychiatryonline.org/cgi/reprint/158/3/377
Moving on to page 26, they ask the question: “Does relapse to drug abuse mean treatment has failed?” To which they answer
NO. The chronic nature of the disease means that relapsing to drug abuse is not only possible, but likely. Relapse rates (i.e., how often symptoms occur) for drug addiction are similar to those for other well-characterized chronic medical illnesses such as diabetes, hypertension, and asthma, which also have both physiological and behavioral components.
So they’re equating addiction with real medical conditions here, then they present a pretty chart comparing relapse rates for the different conditions. This is first of all, an excuse for their failure at “treatment”, furthermore, it is a meaningless comparison. It doesn’t do anything to prove that addiction is disease which causes compulsive drug use, it just draws a specious similarity between the behavior of missing doses of insulin and missing a day of abstaining from drugs. Many people get out of bed late in the morning too, and then they fix it for a while by using a clock, and then they relapse into getting up late again because they stop setting their alarm. It doesn’t mean there’s a disease called gettinguplateism or forgettingtosetmyalarmism.
And then they get into talking about their specific treatments, starting with pharmaceuticals. I concede that medications can be of help, such as methadone. But the way in which these medications work is suspect, and doesn’t actually prove that addiction is a disease, or that it requires treatment. I wrote a nice piece on these meds before, read it for my opinion. In short, I could take a poison everyday which makes me nauseous so that I don’t want to eat – but it wouldn’t be a true cure for my obesity.
Then they discuss other treatment methods (very vaguely) which may or may not have value individually and in the proper setting- but when accompanied by the disease theory I believe any positive effects of these are a wash. As we’ve seen in the Dawson studies I presented at the beginning of the piece, on a whole, treatment is actually less successful than no treatment.
Finally the pamphlet ends with web addresses to other information resources on the NIDA’s effort to use scientific approaches, spread their brain disease rhetoric, and various research they’ve compiled. End result, they haven’t proven that addiction is a disease which causes the compulsive drug use which they’re always talking about. They’ve only given out random information and made it look like they’ve presented a scientific case for the brain disease model of addiction.
I will say, it can be tough to quit abusing substances. The brain changes shown by the NIDA are probably involved, but I think it’s a giant leap to then say that addiction is a disease which requires medical treatment. If we say that, and believe it to be fully true based on the ideas presented in this pamphlet, then we must categorize and treat many other normal problems and non-problems alike as diseases, and I don’t think that will help anything a bit, especially people with substance abuse problems.
As someone who saw the HBO special featuring Dr. Volkov, Dr. Childress, Dr. Willebring et al in a rehab I feel abused. They had me convinced I had a disease and I was relieved to tell my angry relatives “see it’s not my fault. I need help” Well, I improved for about a year but things got tough and I relapsed because they told me relapse was a feature of the disease. I had no idea how to handle stressful situations and returned to the solution I had learned over a lifetime (lot’s of beer). I returned to rehab (because it is a disease after all) but I continued to drink, got in lots of trouble with DMV etc. etc. I had no defense. We seem to confuse the triggers with the cause. I have a disease and if something stressful happens I’m going to drink because I have no defense. AA drives me to drink. I’m empiricle not spiritual. When I read that, at it’s core, addiction is an engrained habit learned the normal way I was able to find a way out. I don’t think these neuroscientists are craven but driven to discover some truth that may help solve the problem. I think they justify their actions as the only way to keep funding and they believe their work is vital. I believe great strides will be made in pharmacotherapy in our life time. That said, they have to know better. It took me about a year of research done part time to become convinced the habit (learned behavior) model is the best model. It has been around since BF Skinner taught his pidgeons how to bowl and has been backed up by solid human research dating from the 1960’s, 70’s and 80’s.
Please excuse my spelling. That should be empirical and pigeons. I’m lost without spellcheck.