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Addiction Is Not a Brain Disease

The idea that drugs and biology are to blame for addiction has done more harm than good.

The idea that addiction is a brain disease is an appealing narrative: drugs hijack the brain’s natural pleasure-seeking system, leading to changes in the nervous system that present as tolerance, physical dependence, and cravings. It’s also a theory that has been buoyed by doctors, politicians, and media pundits alike, all of whom have claimed addiction is not a moral failing but a product of biology. But there’s one problem: It’s not true, a new paper in Nature Human Behavior argues.

“Some people think that [the addiction-as-disease narrative]is more compassionate,” says Carl Hart, chair of the psychology department at Columbia University, who has spent decades studying how drugs affect the brain and behavior. Unfortunately, Hart writes, there’s not much to support the theory that addiction is a disease of the brain, and it has done more harm than good.

The problem, as Hart explains, is that, if addiction arises from the effects of drugs on the brain, there are two paths to a solution: eliminate the drug from society (via restrictive policies and law enforcement) or look for a fix within the brain. But there are several problems with these approaches:

  1. Relying on law enforcement to remove drugs from communities has led to rampant discrimination.Viewing drug use as a chronic medical condition has not prevented drug use from being a criminal justice problem. Roughly 20 percent of the people in our nation’s prisons and jails were locked up for non-violent drug offenses. And black Americans are significantly more likely than whites to be incarcerated for drug offenses, despite equivalent or sometimes lower rates of drug use.
  2. The drugs themselves are probably not to blame.Indeed, drugs have the same neurochemical effects on the brain of every user, but only a small subset of people actually become addicted. And despite decades of research with increasingly powerful brain imaging technologies, there is still no scan that can discriminate between addicted and casual drug users, or make predictions about who will go on to abuse drugs. “To date,” Hart writes, “there has been no identified biological substrate to differentiate non-addicted persons from addicted individuals.”

Rather than a disease, addiction is more likely a learned behavior. As Maia Szalavitz previously wrote in Pacific Standard:

[A]ddiction isn’t simply a response to a drug or an experience — it is a learned pattern of behavior that involves the use of soothing or pleasant activities for a purpose like coping with stress. This is why simple exposure to a drug cannot cause addiction: The exposure must occur in a context where the person finds the experience pleasant and/or useful and must be deliberately repeated until the brain shifts its processing of the experience from deliberate and intentional to automatic and habitual.

The theory of addiction as a brain disease ignores that context—the psychosocial factors that contribute to drug abuse: namely, a lack of opportunities for employment and education, poverty, and co-occurring psychiatric illnesses like depression, anxiety, or schizophrenia. There are plenty of reasons people abuse drugs, and thus prevention techniques need to be tailored. “Prevention may look different if you are targeting someone from rural Appalachia versus someone who is fairly well off and they are urban,” Hart says. Yet researchers continue to look for a one-size-fits-all cause or cure for addiction—perhaps because federal agencies and funding organizations are more likely to fund brain-related research than society-based solutions.

“We need to make sure people have jobs, we need to make sure people have opportunities, we need to make sure that they don’t have other psychiatric illnesses,” Hart says. “It requires a commitment and that commitment is not as sexy as telling you that there’s something deep in your ventral forebrain that’s causing you to overindulge in drug use.”