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Is This Your Brain on Drugs?

Going beyond the disease model of addiction

The Urge: Our History of Addiction by Carl Erik Fisher. Penguin Press, 400 pages.

The first time I heard the Lord’s prayer—and I mean really heard it—I was twenty-two-years-old and being treated for heroin addiction at a behavioral health hospital in Chicago. I had the familiar feeling that I was somehow in the wrong place. The medicine that calmed down my brain’s opioid receptors worked, so why were we holding hands and praying?

Taking effective medicine wasn’t enough, the doctors and counselors explained. After “detoxing,” I would need to go to an expensive “rehab” to reform my character. But even that, they warned, might not be enough because addiction was a brain disease—chronic, progressive, and fatal, which sounded scary and incurable, like Alzheimer’s. At least the fatal part felt real. A lot of people I knew had died of drug overdoses. Their post-mortem toxicology results almost always revealed the presence of several different substances in their system. I told myself I had survived all these years because I rarely mixed drugs. I was still in control; I could still make calculated decisions. So at what point did my opioid use cross the invisible line and become an addiction? Did chemicals “hijack” my brain, scrambling my innate survival operations? Is addiction really a disease of free will? Is it a fixed, static trait, cemented somewhere in our physiology? And do we even have the power to change it?

Understanding addiction requires a science of unreason, a logic for the illogical.

“The point is not that these questions have easy answers, but that these are not purely scientific or medical questions,” writes Carl Erik Fisher in The Urge: Our History of Addiction, a book I devoured, seeking answers to questions about how my own addiction was treated. For over five years, Fisher had to pee in a cup in front of a “urine monitor” in order to keep his license to practice psychiatry. Slogging through years of strict urinary oversight, Fisher began to think about why America treats addiction in such humiliating and punitive ways. “I knew that the addiction treatment system was broken, having experienced it firsthand, but the why was mystifying,” Fisher writes. “Why was there a totally separate system for addiction treatment? Why do we treat addiction differently from any other mental disorder?”

Drawing on his experience with addiction, as well as his training in medicine and bioethics, Fisher has produced a meticulous history of addictions—exploring why, across time and place, we pursue our compulsions and obsessions unto grave consequences. For centuries, there’s been little by way of science and reason to be found in the way that addiction gets treated, the way drugs are regulated, and the way laws are written. “It was clear that addiction was not just an issue of medical science,” Fisher writes, “but also one of identity, power, commerce, and fear—as well as one of devotion.” Understanding addiction, what Fisher describes as “a terrifying breakdown of reason,” requires a science of unreason, a logic for the illogical.

The notion of addiction as a disease dates back over two hundred years, to the scholarship of Benjamin Rush. A Pennsylvania doctor and surgeon general to the Continental Army, his 1785 medical broadside against alcohol, An Inquiry into the Effects of Ardent Spirits upon the Human Body and Mind, became the first influential text to characterize addiction as an “odious disease” that expressed itself in a “numerous train of diseases and vices of the body and mind.”

Traveling across postwar Pennsylvania in 1784, Rush was horrified by the social and physical effects heavy drinking had on soldiers. “The quantity of rye destroyed and of whisky drunk in these places is immense and its effects upon their industry, health, and morals are terrible,” he wrote. (Would Rush say the same thing about the effect of opioids on rural Pennsylvanians today?) He wasn’t exactly wrong: Americans everywhere post-Revolution were getting toasted. But Fisher argues that Rush’s fixation on alcohol was more ideological than scientific. Rush subscribed to the Enlightenment belief that social problems could be remedied by the positive forces of reason and progress. His brand of medicine was also deeply invested in the exercise of man’s God given freewill. “For elite white men like Rush, who had access to that idealized freedom and autonomy, drunkenness was a threat to all they held dear in their young republic,” Fisher writes.

Numerous other chemical intoxicants would go on to be viewed as malignant tumors on the body politic—a clear and present danger to hierarchy and social order that needed to be excised by whatever means necessary. “We have long wielded the concept of addiction as a weapon, using it to wage war—not just ‘on drugs’ but also on people who use drugs,” Fisher writes, citing Chinese laborers and opium, Mexican migrants and marijuana, Southern black men and cocaine, hippies and LSD, and on and on. But more than anything, drugs have long served as an expedient pretext for achieving a diverse set of political goals, from enhancing border security to reducing immigration quotas and justifying severe prison sentences. As for the corrupting hooch that so troubled Rush, the U.S. government, prompted by religious and women’s organizations, imposed a strict prohibition in 1920, only to reverse its self-imposed sobriety thirteen years later—despite alcohol being physiologically more harmful than nearly all outlawed substances.

Fisher’s exegesis of the brain disease model traces how, for better or worse, it shaped the way addiction came to be treated. In Rush’s time, the field of medicine began to turn its gaze toward the physical and material roots of illness, even mental illness—which called for aggressive remedies. “Rush himself was an enthusiast for extreme physical treatments like cold-water plunges and his particular favorite, copious bloodletting,” according to Fisher. But Rush also believed in the power of religion, prayer, and shame to help treat drunkenness, which he thought to be its own type of insanity. In his wake, quack cures proliferated. During the 1890s, the golden era of snake oil, an entrepreneur named Leslie Keeley announced the discovery of his “tested and infallible” “Gold Cure for Drunkenness.” The ingredients of this “permanent” cure were, of course, proprietary and kept secret. Simplicity was key to Keeley’s marketing success: “Drunkenness is a disease and I can cure it,” he alleged. “This pattern of using an exclusively scientific explanation to sell treatment has repeated itself incessantly,” Fisher writes.  

Until recently, one of the fanciest rehabs on the “Rehab Riviera,” in Malibu, California, notoriously promised an “Alcoholism and Addiction Cure,” advertising cure rates as high as 60 percent after their thirty-day program, available for $112,000.   

There is no peer-reviewed research to back up such a bold claim. But what about the science supporting the idea that addiction is, in fact, a disease? What does calling addiction a disease really mean? “That a therapeutic approach is the single best way to address the problem, that the causes are best located in reductionist biology, or that the problem is a discrete category neatly divided from the ‘normal’ population,” Fisher argues. “None of those claims are true for addiction.”

Though the idea of addiction as a disease is an old one, it found new footing in 1997 after Alan Leshner, then director of the National Institute on Drug Abuse (NIDA), published an editorial in Science: “Addiction Is a Brain Disease, and It Matters.” According to Leshner, “Scientific advances over the past twenty years have shown that drug addiction is a chronic, relapsing disease that results from the prolonged effects of drugs on the brain.” The argument is quite simple: people take drugs, and over time, those drugs fundamentally rewire—they “hijack”—the brain, though Leshner stopped short of calling the result “brain damage.” Leshner’s editorial, which would go on to be cited thousands of times, along with the “hijacked” brain metaphor, offered “the how to the what of disease: a detailed description of what actually happened to those warped brain circuits,” Fisher writes. These functional changes indicate pathology—something abnormal, possibly irreversible.

Setting the brain research aside, calling addiction a brain disease also had clear, even noble, societal objectives. First, it meant the medical and research communities ought to respectively treat and study addiction as a genuine illness. Relatedly, the disease model might theoretically reduce the burden of stigma and scorn heaped upon those who are suffering from it. If addiction is a disease, then it couldn’t be the result of an individual’s moral failing, and no one should be punished when symptoms (i.e., drug use) manifest. In the disease formulation, people aren’t bad; the drugs sure are.

Though the media, scientists, and professional medical groups all played roles in boosting addiction as a brain disease, Fisher attributes outsized influence to Leshner’s editorial in pushing Congress to fund much needed addiction research and insurance companies to begin covering addiction treatment. Today the idea of addiction as a brain disease is ubiquitous, taught everywhere from medical schools to treatment facilities. Politicians from both major political parties tout the disease model of addiction to argue for expanded treatment and diversion programs like drug courts. Some, however, have no problem criminalizing what they see as a brain disease. Gil Kerlikowske, Seattle’s former chief of police and President Obama’s first drug czar, advocated for “using the criminal justice system to spur people in need of treatment to get it.”

Applying biology and medicine to ideas like agency, free will, and choice yields narrow, incomplete answers.

Over the years, some addiction researchers––like neuroscientist Dr. Carl Hart––have gotten fed up with the federal government’s singular focus on the brain. Fisher argues that locating addiction solely in the brain warped the national research agenda “toward reductionist biological research and away from social, epidemiological, clinical, and policy investigations.” Has spending billions of dollars imaging every nook and cranny of the brain’s reward system helped prevent hundreds of thousands of Americans dying from drug overdoses in the last decade? No. And what about stigma? Decades of campaigns to destigmatize addiction are considered abject failures. While the disease framework theoretically reduced the burden of stigma on the afflicted, “research suggests that the brain disease narrative erodes hope,” Fisher writes. “The largest and most rigorous studies of this kind show that biological explanations increase aversion and pessimism toward people with psychological problems.” Calling addiction a disease can produce a sense of fatalism: What can a person do to fix their own brain? 

Fisher says the term “brain disease” is so overused and ideologically freighted that it has become misleading, if not entirely meaningless. But the federal government’s premier addiction research agency refuses to let it go. Dr. Nora Volkow, who now leads NIDA, puts the effect of drugs on the brain in stark terms, sounding almost like Dr. Benjamin Rush himself, who was terrified that intoxicants would destroy man’s God-given will. “The “brain [of an addicted person],” Volkow has said, “is no longer able to produce something needed for our functioning and that healthy people take for granted, free will.” In 2015, Volkow argued that addiction is “A Disease of Free Will.” Volkow’s contemporary formulation, rooted in neurobiology, completes the synthesis with post-Revolutionary American Christianity.  

This framework attempts to draw a clear line: you’re either addicted or you’re not. But as Fisher often points out, applying biology and medicine to ideas like agency, free will, and choice yields narrow, incomplete answers. “Lived experience flies in the face of such a stark binary,” Fisher writes. “Many people with addiction feel themselves occupying a confusing middle ground between free choice and total loss of control.” When people are deemed unable to make decisions for themselves, institutions are all too eager to step in and strip people of choice altogether. 

In the popular imagination, drugs are evil foreign agents, usurping our brain’s pleasure center, turning users into hostages, even slaves. Fisher doesn’t think addiction is a disease, and he doesn’t think mere exposure to drugs causes addiction. “We cannot pin down one unchanging and essential addiction,” he writes. If addiction is neither a disease nor a choice, and taking drugs isn’t enough to cause addiction, then what is it?

In one sense, Fisher thinks most of those who’ve opined on the subject are hubristic and wrong. But many of them, in their own way, stumble onto certain truths. “Addiction is a brain disease, a spiritual malady, the romantic mark of artistic sensibility, a badge of revolution against a sick society, and all of these things at once,” Fisher writes. Maybe it sounds like an unsatisfying copout, but I agree with Fisher, in that addiction is highly personal and contingent upon the time and place in which it occurs. A strange disease indeed, one that tends to be self-diagnosed.

Fisher, departing from the mainstream of his own profession, rejects the reductionist frameworks and biological determinism that dominate today’s addiction discourse, which often feed right into the fear and propaganda machine that governments and law enforcement agencies use to villainize drugs. America’s disastrous drug war strikes at the heart of what addiction is, and what we think drugs, including alcohol, do to us. Fisher spells out facts that our own government has either ignored or tried to suppress: “Addiction does not proceed inevitably from use,” Fisher writes. “Most people who use drugs––including crack, methamphetamine, and heroin––do not develop significant problems. No more than 10 to 30 percent of people who use drugs develop significant substance use disorders.” Perhaps most importantly, Fisher concludes, “Drugs are not ‘addictive’ in themselves; they don’t cause addictions in isolation.” There are cultural, social, economic, and numerous other external, environmental factors beyond the brain’s chemistry that work to accelerate and intensify addiction. In other words, there’s a reason why a state like West Virginia has the highest overdose death rate in the nation. Poverty, pain, trauma, racism, and alienation all steer one toward compulsive drug use.  

An encounter with addiction does not spell doom.

Fisher ultimately lands on a deeply humanistic note. He writes, “I’m still not convinced that I have a specific disease, and I’m not even convinced that I am fundamentally different from the rest of the population.” Channeling authors like Maia Szalavitz and Marc Lewis—who have both written excellent books about addiction, the brain, and human desire—Fisher finds that addiction is not a pathological deviation, a disease that can be clearly demarcated from the rest of society. “Addiction is just the place where our universal human vulnerabilities are most clearly on display,” he writes. “Everyone, at some time, will experience a loss of control, a loss of power.”

That’s what addiction is––at least for me. I don’t believe addiction annihilates free will and choice completely; rather, addiction can put constraints on and skew the horizon of choice. I was not mindlessly sticking myself with a needle. I could still calculate and discern risk, choosing when, where, and how to dose. Still, addiction can feel dizzying and confusing. How did this happen, again? How did I wind up here, again? But it’s also momentary, specific, and most importantly, treatable. Drug use simply does not have to be so damn deadly, as it has become in recent years. Over 20 million people currently alive in America report having recovered from a substance use disorder at some point in their life. Unlike Alzheimer’s, Parkinson’s, certain forms of cancer, and truly degenerative brain diseases that are incurable, people who struggle to control their drug use, gambling, sex drive, or those who for the life of themselves cannot log off—whatever it is—can and do get better. An encounter with addiction does not spell doom.

“By accepting that addiction has been and will continue to be a part of human life, we can abandon dreams of eradicating it and free ourselves to look instead at the full variety of interventions available to help,” Fisher writes. “The primary goals should not be victory or cure, but alleviating harm and helping people to live with and beyond their suffering––in other words, recovery.” Being treated for addiction in my early twenties, counselors dished out slogans like once an addict, always an addict. A behavior, in their eyes, determined not just a diagnosis, but the core of who I was. All these years later, I’ve learned that addiction can be progressive, addiction can be fatal—but it more often isn’t, and it doesn’t have to be.