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In practical terms, that result means that if these brain images were shuffled into a single set, experts would not be able to distinguish between the brains of controls and those of abstinent users.

Drugs and the Future

Furthermore, if one subscribes to the brain-disease theory, one would anticipate that individuals with the largest methamphetamine addiction histories would have the lowest dopamine transporter binding potentials. This was not the case. Clinical relevance of the observed statistical difference in monoamine binding potential values between methamphetamine users and a control group might be limited.

If these brain images were shuffled into a single set, experts would not be able to distinguish between the brains of controls and those of abstinent users. Graph adapted from Johanson, et al. Psychopharmacology Springer-Verlag Some proponents of the brain-disease theory have implied that as more sensitive methodologies are developed, clear brain differences will be revealed.

It seems, much to our chagrin, that some addiction-as-a-brain-disease scientists are encouraging faith-based thinking rather than applying evidence-based methods to inform drug addiction theories. Our assertion can go no further than the revelations of contemporary methods. Regarding the cognitive findings in the study by Johanson and colleagues, the performance of methamphetamine users and control group participants did not significantly differ on most tasks.

Methamphetamine users, however, performed more poorly than controls on measurements of sustained attention and immediate and long-term memory.

In other words, the methamphetamine users were cognitively intact. Even though some drugs produce neurotoxicity when administered at high doses during long periods of time, it is not possible to generalize such effects to all drugs. To determine clinical relevance, cognitive scores should be compared against a normative database.

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Normative data, which are obtained from a large, randomly selected representative sample, incorporate important variables such as age and education, and establish a baseline distribution for a measurement. Unfortunately, this basic requirement is often ignored; as a result, the addiction literature is replete with a tendency to interpret any difference as deficits representing substantial loss of function.

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This point is highlighted in the conclusions drawn from multiple studies that compare the cognitive or brain functioning of people with drug addiction with that of nonaddicted control participants. For example, Sara L. Simon and others at the University of California, Los Angeles, warned the following in a article in the Journal of Addictive Diseases :.

The Craving Brain: A Conversation about Vulnerability to Drug Addiction with Dr. Marinelli - Part 1

Such warnings were based on measures that revealed statistically significant differences between methamphetamine users and controls, which alone are insufficient to determine true cognitive dysfunctions. Despite such inappropriately dire conclusions, findings from the bulk of the brain-imaging and cognitive literature assessing individuals who meet criteria for drug addiction indicate that they are virtually indistinguishable from their age- and education-matched non-drug-using counterparts.

As methamphetamine neurotoxicity in animals has been the most widely demonstrated, the failure to replicate these results in humans leads us to conclude that it is a tremendous stretch to argue that the scientific data show that drug use causes brain disease. Despite this empirical reality, the diseased-brain perspective has outsized influence on research funding and direction, as well as on how drug use and addiction are viewed in society.

For example, the U. Researchers will follow more than 10, people between the ages of 9 and 10 for a decade, collecting their genetic information and assessing their drug use and academic achievement. This research endeavor will give less consideration to important social factors, such as parental income, neighborhood, or family structure. This oversight is to be expected, in part, because most of the lead investigators are neuroimaging researchers. Notably, there has never been such an ambitious funding effort focused on psychosocial determinants or consequences for example, employment status, racial discrimination, neighborhood characteristics, or policing of drug use or addiction.

To be clear, our goal here is not to set up a dichotomy between biological and social factors involved in drug addiction, as if they are mutually exclusive. They are not. In addition, we recognize that many proponents of the diseased-brain theory of addiction habitually provide cursory and pro forma statements attesting to the importance of understanding the role of psychosocial and environmental factors in mediating drug addiction.

These statements are often unconvincing because they are not accompanied with actions consistent with the claims. Thus, our point is that there should be greater parity in the funding of drug addiction research and in how drug addiction is viewed. The weight of the evidence should drive research direction and funding. Through research published in that used the National Comorbidity Survey—Adolescent Supplement to study the substance use and mental disorders of more than 10, teenagers and also through our research, we now know that among the relatively small percentage of individuals who do become addicted, co-occurring psychiatric disorders and environmental and social factors account for a substantial proportion of these addictions.

This point indicates that far more research resources and efforts should be allocated to carefully studying these factors. It also suggests avenues for effective substance-use disorder interventions such as available mental healthcare and attractive alternatives such as career opportunities or sports facilities. The argument for a more pluralistic view of drug addiction does not exclude a role for neuroscience, as long as data justify that role. At present, the utility of explaining drug addiction from an exclusive—or almost exclusive—diseased-brain perspective seems limited.

A large proportion of people who previously were addicted managed to abstain without professional help, according to a couple of studies by Catalina Lopez-Quintero, Carlos Blanco, and their coauthors.


For other people struggling with addiction, as noted above, the most effective treatments are behaviorally based. Despite the effectiveness of evidenced-based behavioral therapies, they are not widely used, according to a review by Danielle Davis of University of Vermont and colleagues and a review by Kathleen M.

Carroll of Yale University School of Medicine. Even when medication-assisted treatments are used, such treatments are far less effective without adjunctive behavioral therapies, as is argued in a paper in Drug Safety by James Bell and Deborah Zador of the Langton Centre in Australia. Viewing addiction as a disease of the brain has demonstrated, thus far, limited utility for the development of effective strategies to deal with drug addiction.

Notably, the most relevant biological treatments, such as methadone, disulfiram, and others, were developed prior to the establishment of the brain-disease model of addiction. Many studies show that offering alternative reinforcers—nondrug alternatives that decrease problematic drug-taking—is effective in treating substance-use disorders. This study followed 37 patients who regularly used cocaine and were enrolled in a methadone counseling program. One group received a voucher redeemable for retail items when they abstained from cocaine; the control group received vouchers that were not contingent on their cocaine avoidance.

This and subsequent studies indicate that people with drug addictions can and do make rational decisions, providing an argument against the notion that they have diseased brains. Higgins, S. The influence of alternate reinforcers on cocaine use and abuse: a brief review. Pharmacology Biochemistry and Behavior — Elsevier Science Inc.

Disproportionately viewing drug addiction through the brain-disease lens contributes to unrealistic, costly, and harmful drug policies. In both cases, there is neither genuine need for nor interest in understanding the role of socioeconomic factors in maintaining drug use or mediating drug addiction. The entire removal of recreational psychoactive substances from society is both impractical and impossible.

There has never in history been a drug-free society, and it is unlikely that there ever will be one. In spite of this fact, law enforcement is charged with the unenviable task of carrying out repressive recreational drug-use policies that emphasize abstinence. Despite the claim that viewing addiction as a brain disease would lessen stigma and reduce drug-related arrests, millions of people are arrested annually for drug possession.

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In the United States, for example, data from the U. Federal Bureau of Investigation indicate there were 1. Even worse, the abhorrent practice of racism continues to flourish in drug law enforcement. In the United States, blacks are four times more likely than whites to be arrested for cannabis possession, even though both groups use cannabis at similar rates. And more than 80 percent of those convicted of heroin trafficking are black or Latino.

There are considerably more white heroin users than black or Latino users, and most drug users buy their drugs from dealers within their own racial group. An insidious assumption of the diseased-brain theory is that any use of certain drugs for example, crack cocaine, heroin, or methamphetamine is considered pathological, even the nonproblematic, recreational use that characterizes the experiences of the overwhelming majority who partake of these drugs.

For example, in the s crack cocaine addiction was said to occur after only one hit. Drug experts with neuroscience leanings weighed in. In , the U. Congress passed legislation setting penalties that were times harsher for crack than for powder cocaine violations. Even today, some politicians enact misguided drug policy based on these neuroexaggerations.

The recent actions of Philippine President Rodrigo Duterte represent but one example. A year into his presidency, more than 4, people accused of using or selling illegal drugs have been killed. Duterte justifies his actions by stating that methamphetamine shrinks the brains of users, and as a result, these individuals are no longer capable of rehabilitation. Despite the claim that viewing addiction as a brain disease would lessen stigma and reduce drug-related arrests, in in the United States there were 1.

There has never been an ambitious funding effort focused on psychosocial determinants or consequences of drug use—for example, employment status, racial discrimination, neighborhood characteristics, or policing. Many addiction researchers begin with the assumption that this condition is a brain disease.

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The present evidence indicates that this assumption should be reevaluated to formulate a more accurate view of drug addiction. An evidence-informed view would be more inclusive, would emphasize a prominent role for psychosocial and environmental factors, and would focus on offering alternative reinforcers—nondrug alternatives that decrease problematic drug-taking. From a practical or clinical perspective, this approach means it is unacceptable to tell substance-use disorder patients that they suffer from a diseased brain.

Instead, a comprehensive psychosocial assessment should be employed, and the resulting findings should dictate intervention strategies. Research has now shown repeatedly that alternative reinforcers can be used effectively to treat substance-use disorders.

This kind of treatment is called contingency management. The idea comes from basic behaviorism: Our actions are governed to a large extent by what we are rewarded for in our environment. These cause-and-effect relationships, where a reward is dependent contingent upon the person either doing or in the case of drugs not doing a particular behavior, can be used to help change all types of habits.