The U.S. Surgeon General's new report, "Facing Addiction in America," is the first time the office has explicitly addressed addiction to illicit drugs. With the epidemic of addiction to drugs from Vicodin to heroin raging across the country, the report is timely.
But although the report provides a solid summary of established findings, the Surgeon General perpetuates key misconceptions that have come to dominate the field of addiction. These views, frequently repeated but infrequently scrutinized, bear critical implications for how we treat addiction.
The first dubious claim is that addiction is a “brain disease.” The National Institute on Drug Abuse has championed this rhetoric for many years. To be fair, the point of medicalizing addiction is well-intentioned: obtaining more funding for addiction research and treatment, combatting the “shame and stigma” associated with the problem, and softening criminal and other punitive approaches.
Aside from being vague, however, the brain disease concept is deeply troubled. It’s not that the brain is irrelevant to addiction – it would be absurd to claim as much. But maintaining that drugs “hijack” the neural circuits involved in motivation, pleasure, and impulsivity to produce out-of-control behavior, as the report does, paints far too fatalistic a picture.
There’s no question that the brain undergoes changes during addiction, but what do those changes mean? Is drug abuse beyond a person’s control in the same way that the symptoms of Alzheimer’s disease or most other neurological conditions are? No.
Imagine bribing an Alzheimer’s patient to keep her dementia from worsening, or threatening to impose a penalty on her if it did. That would be pointless, not to mention cruel, because the kinds of brain changes intrinsic to dementia leave the afflicted individual resistant to rewards or penalties. By contrast, people who are addicted can indeed respond to many foreseeable consequences.
The classic demonstration of the power of incentives was the military’s Operation Golden Flow. In Vietnam, between ten and twenty-five percent of GI’s were addicted to high-grade heroin. In 1971, President Nixon commanded the military to begin drug testing. No soldier could board a plane home until he had passed a urine test. As word of the new directive spread, most GIs stopped using narcotics, and almost all soldiers who were detained passed the test on their second try.
Once they were home, heroin apparently lost its appeal. Opiates may have helped them endure the war’s alternating bouts of boredom and terror, but stateside, civilian life took precedence. Only five percent of the men who became addicted in Vietnam relapsed within ten months after return, and just twelve relapsed briefly within three years.
Contingency management is the technical term for the practice of imposing consequences, both positive and negative, and it is supported by a great deal of research evidence.
Further, over-medicalizing addiction shortchanges the crucial role of motivation in recovery. At the same time, it hypes the promise of medication. Consider a person with a conventional brain disease, say herpes encephalitis, an inflammation of the brain caused by a virus. She can remain in a coma while the acyclovir works its wonders.
Recovery from addiction demands motivation and much more. A person must be hyper-vigilant: alert to environmental cues (the proverbial “people, places, and things”) and internal cues (such as thoughts and emotional states) that trigger craving. She needs to be creative in developing techniques to manage craving when it breaks through despite those efforts.
Finally, the brain disease model discourages the idea that peoples’ decisions to use drugs are driven by psychological reasons. No one would ever dream of asking someone with a brain tumor what function the cancer is serving in her life. But drug use does serve a psychological purpose. The protagonist of any addiction memoir will tell you that drugs helped medicate persistent self-loathing, anxiety, alienation, boredom, or loneliness.
Moving now to another logical lapse in the report, the Surgeon General presents a choice: “It’s time to change how we view addiction,” he writes. “Not as a moral failing but as a chronic illness that must be treated with skill, urgency and compassion.”
This may sound benign, and we of course support treating addiction with skill, urgency, and compassion. At the same time, the Surgeon General’s proposed choice is a false one.
True, addiction per se is not a character flaw, but neither is it an involuntary process, which is precisely what “hijacked” neurobiology and “brain disease” imply. A society should be able to create a vibrant middle ground in which we can do both: recognize the choice-making capacities in addiction and leverage them to therapeutic ends while advancing public investment in humane care.
Finally, the Surgeon General subscribes to what we call the “shame narrative,” the idea that people with drug problems are too ashamed to ask for help. As he writes, “This unfortunate stigma [attached to addiction] has created an added burden of shame that has made people with substance use disorders less likely to come forward and seek help."
Again, this sounds reassuring, but does it mean that society should not disapprove of parents who overdose in their cars with their kids in the backseat? We hope not. Why insulate individuals from the adverse consequences of their behavior when those very consequences often motivate them to seek help?
Stigmatization is a normal dimension of human interaction; it can exert a civilizing effect on communities, and it is often the basis of the anti-drug messages we give to children. Condemning the reckless and harmful behaviors that a minority of addicts commit is socially adaptive.
Citizens, lawmakers, and politicians should be able judge behavior and still call for quality treatment over incarceration: contrary to the widespread implication of the brain disease narrative, these two courses of action are not mutually exclusive.
As for clinicians, they are not in the business of casting judgments. Their role is to boost addicts’ confidence that they can improve their lives, provide them with strategies for recovery, and encourage insightful thinking about why they continue to use drugs despite their self-destructive potential.
And what about the Surgeon General’s claim that addicts stay away from care because they are ashamed? This may be true in certain cases, but we doubt that it affords anywhere near a comprehensive explanation for avoiding treatment. One of us (S.S.) works in a methadone clinic and has never encountered a patient who’s said she was too ashamed to get help – rather, ambivalence about quitting or the availability of a clinic were the primary obstacles. If anything, it is because of their shame that people seek help. They may have hurt many people: their kids may be disappointed in them, the boss may be about to fire them, or their spouse may be ready to leave them.
The Surgeon General’s report adopts mainstream philosophy and, to be honest, we understand its appeal. After all, positioning addiction as a “brain disease” to give it medical gravitas — and in doing so, banishing the notion of accountability – means that politicians and society will take the problem seriously.
But it is critical that we see addiction realistically: as a complex set of behaviors that operate on several dimensions, ranging from brain physiology to psychology, psychosocial environment, and social and cultural relations.
Doing so will ultimately lead to the most effective treatments and policies. In the end, visible progress in addiction treatment will come from embracing the complexity of addiction, not from feel-good and oversimplified slogans that neglect scientific evidence.