A bill introduced by Sen. Joe Biden (D-DE) that would define addiction as a brain disease is moving in the Senate. Treatment professionals, mainstream scientists, and recovery advocates see it as a good thing. There are some skeptics, though.
NIDA book cover, with brain scan image
The bill, the Recognizing Addiction as a Disease Act of 2007
(S. 1011), would also change the name of the National Institute on Drug Abuse (NIDA) to the National Institute on Diseases of Addiction, and change the name of the National Institute on Alcohol Abuse and Alcoholism to the National Institute on Alcohol Disorders and Health.
"Addiction is a neurobiological disease -- not a lifestyle choice -- and it's about time we start treating it as such," said Sen. Biden in a statement when he introduced this bill this spring. "We must lead by example and change the names of our federal research institutes to accurately reflect this reality. By changing the way we talk about addiction, we change the way people think about addiction, both of which are critical steps in getting past the social stigma too often associated with the disease. This bill is a small but important step towards stripping away the social stigma surrounding the treatment of diseases of addiction," said Sen. Biden.
The measure is garnering bipartisan support. It passed out of the Senate Health, Education, Labor and Pensions (HELP) committee in June with the backing of Sen. Mike Enzi (R-WY), the ranking minority committee member. "Science shows us the addiction to alcohol or any other drug is a disease," Enzi said in a statement marking the vote. "While the initial decision to use drugs is a choice, there comes a time when continued use turns on the addiction switch in the brain. That time can vary depending on factors ranging from genetics to environment to type of drug and frequency of use. Because of that and the continued stereotypes and challenges that are often barriers to people with addiction issues seeking treatment I am proud to support this legislation. Although the names of the Institutes will change, their mission -- preventing and treating drug and alcohol addiction -- will remain the same."
The politicians are taking their cue from neurological researchers led by NIDA scientists who have been working for years to find the magic link between the brain and compulsive drug use. Dr. Nora Volkow, current head of NIDA, has been leading the charge, and Biden and Enzi could have been reading from her briefing book.
"Drug addiction is a brain disease," said Volkow in a typical NIDA news release. "Although initial drug use might be voluntary, once addiction develops this control is markedly disrupted. Imaging studies have shown specific abnormalities in the brains of some, but not all, addicted individuals. While scientific advancements in the understanding of addiction have occurred at unprecedented speed in recent years, unanswered questions remain that highlight the need for further research to better define the neurobiological processes involved in addiction."
Not surprisingly, the treatment and recovery communities, anxious to see the social climate shift to one of more support and less punishment for the addicted, support the legislation. "Recognizing addiction is the next step forward," said Daniel Guarnera, government relations liaison for the NAADAC -- The Association for Addiction Professionals. "NIDA and its scientists have demonstrated overwhelmingly that addiction is not a behavioral trait, but rather is caused by physiological changes to the body that make people want to use addictive substances. This bill allows the terminology to catch up with the science."
Although the bill does little more than make a congressional pronouncement and rename a couple of institutes, it is still an important step, said Guarnera. "Yes, it's symbolic, but that symbolism is hugely important, because language should reflect medical knowledge, and medical knowledge has demonstrated that drug abuse is a physical phenomenon."
"We utterly endorse this bill," said Pat Taylor, executive director of Faces and Voices of Recovery, a treatment and recovery advocacy umbrella organization. "I think it's a great idea to rename the agencies. People with drug and alcohol problems can and do recover from addiction. Calling them 'abusers' just stigmatizes them."
Taylor and her organization are actively supporting the bill, she said. "We've sent letters of endorsement for the bill," she said. "People blame people for their drug and alcohol problems, so this is an important issue for the recovery community. We need to rethink how we talk about this."
Is addiction in fact a brain disease? Some researchers think that's too simple. Scott Lilienfeld, a professor of psychology at Emory University told ABC News last week: "What I find troubling with the brain disease rhetoric is that it's grossly oversimplified, it boils down an incredibly complex problem to not necessarily the most important explanation. You can view a psychological problem on many levels. Low level explanation refers to molecules in the brain. There are other levels including people's personality traits and moods, people's parents, environment. Higher level than this is community."
"Every level tells you something useful," Lilienfeld continued. "Brain disease is only one level among many and not even the most helpful. Implying it's the only level of explanation, that's counterproductive."
Some mavericks go even further. "No, addiction is not a brain disease," said Dr. Jeffrey Schaler, a psychologist and professor in the Department of Justice, Law and Society at American University in Washington, DC, and author of "The Myth of Addiction." "Diseases are physical wounds, cellular abnormalities. Addiction is a behavior, something that a person does. Diseases are things a person has," he argued.
"You can't will away a real disease," Schaler continued. "But people will away behaviors they don't like all the time."
Others feel that the concept of addiction itself is too imprecise. "There is no clear conception of what people mean by the word 'addiction,' and there are numerous papers on this unsatisfactory concept," said Professor John Davies, head of the Center for Applied Social Psychology at the University of Strathclyde in Scotland, another prominent critic of the "addiction is a brain disease" model. Using drugs and 'addiction' are not synonymous," Davies continued, noting that many "fun drug users" become "addicts" as soon as they end up in court.
"Of course, people can and do get into an awful mess when they fail to manage their habit effectively," Davies concedes. "But look at the data. Harmful damaging drug use is heavily social-class related whereas drug use per se is less so. People give up the so-called 'disease' when their lives change, they get a new partner, a new job, a move of house."
"Sen. Biden's crusade is part of a decades-long, political struggle to isolate drug habits in users and to obscure the social and historical factors that ultimately underline so-called drug problems," said Richard De Grandpre, author of "The Cult of Pharmacology: How America Became The World's Most Troubled Drug Culture" (see review here next week), citing the case of the Vietnam war veterans who picked up opiate habits, but who, for the most part, rapidly shed them upon returning home.
"These vets used chronically and were said to be addicted. What happened to their addictions?" De Grandpre asked. "The feared epidemic did not materialize because the social factors that sustained heroin use in Vietnam had all but disappeared upon returning."
Davies sees the addiction label as having pernicious consequences for problem users as well. "It makes things far worse," he said. It makes people believe that the roots of their behavior are beyond their capacity to control, which is the last thing you need when you're trying to get someone to change their behavior."
How should drug policy reformers (e.g., those concerned first and foremost with loosening prohibitionist drug policies) respond to the Biden bill? Rhetorically, both the "disease" and "choice" models have been used repeatedly to justify draconian policies -- the former at drug sellers, who mostly are not kingpins or monsters seeking to addict children to their goods, but get charged as such in the court of public opinion -- the latter at problem users, or even users in general, because they should just stop, because it's a choice.
"I tend to think that language changes that reduce the fuel in the drug discussion will help rather than hurt our cause," said David Borden, executive director of Stop the Drug War (DRCNet, publisher of this newsletter). "Terms like 'Diseases of Addiction' pack less verbal or rhetorical punch than shorter ones like 'Drug Abuse,' and are less useful for purposes of political propaganda. If the names of the agencies shift, the language coming out of the agencies will also have to shift, at least somewhat, and that will help -- it will be harder for politicians to focus their rhetoric on nonsense statements like 'all use is abuse,' if 'abuse' is no longer the government-endorsed term of choice in the discussion."
"Those are political concerns, however," Borden pointed out. "If 'disease' is a scientifically imprecise term for describing the set of conditions that are commonly known as 'addiction' -- and it seems to me that it probably is -- then Congress and NIDA probably shouldn't be using the term for that purpose. I'd be more comfortable with the bill if it used slightly different language." Still, he thinks it's probably a net positive. "I think the obvious message of the terminology shift would be to say that people with drug problems are not really criminals, and that's a good thing."
"Plus if addiction isn't a disease, there's still obviously some condition that some people have, physical for at least some of them, that makes it harder for them to make favorable choices," Borden added. "Otherwise I don't think there would be thousands of people risking arrest or overdose to inject themselves daily with heroin, or millions knowingly doing what they're doing to themselves with cigarette smoking. So I'm not sure that the imprecision in the term chosen for the discussion is such a big problem."
Schaler disagrees. "Drug policy reformers play into the hands of the therapeutic state when they support the idea that drug addiction is a treatable disease," he said. "It means doctors have more power over people instead of just drug agents."
In principle, neither Congressional fiat, nor therapists' concerns over what the right message is to send to patients, nor advocates' concerns over what will ultimately lead to better policies, should take a second seat in this debate -- the question is fundamentally a scientific one, and a philosophical one. With Congress holding the purse strings for the bulk of addictions research in this country, however, Congress' choices now may indeed affect the language being used in the future for some time to come. And language can indeed have an impact in ways going beyond its initial purposes.