To the Editors:
In “Is Drug Addiction a Brain Disease?” (May–June), Marc Grifell and Carl L. Hart lament that a narrow focus on the neurobiological aspects of addiction draws needed attention away from behavioral therapy and research into societal contributing factors. How much more does this warning apply to the vast and tragic realm of emotional and mental disorders?
An ever-growing list of diagnoses is treated pharmacologically, with little or no evidence of specific neurochemical mechanisms.
Drs. Grifell and Hart respond:
The debate about treating mental disorders through a pharmacological lens is highly polarized, and it is difficult to critique the pervasiveness of neurobiology without being associated with antipsychiatry, antipharmacology, and exclusively humanistic approaches to mental health.
The development of psychopathology, psychopharmacology, and evidence-based medicine have been of incalculable value to mental-health professionals.
That being said, the mental-health field also may be affected by an overly narrow focus on neurobiology and a disregard for psychosocial paradigms. This opinion is based on the limited applicability of the medical model to the mental-health field. Despite developing this argument, we want to clarify that we have not assessed the neurobiological data accounting for the medical approach in mental health, as it is not our field.
For the psychiatrist, the medical model (restoring a dysfunctional organ or tissue to a previously defined state of health) can represent a disturbing challenge: The primary function of the mind is not easy to determine. Our current paradigm considers the mind to be functional when an individual can be a functioning part of society without significant suffering. A mental disorder, then, is the inability to function in society without significant suffering. The functionality of an individual in a society, however, may depend on both the individual and the society. For this reason, some authors reject this definition of a functional mind.
The main implications of this critique are that mental disorders can’t be explained only through neurobiological discourse and that mental-health professionals should be cautious to avoid imposing their views on what the mind’s function is to their patients. For this reason, we think that conversations about mental health that regard only neurobiology are skewed.
It would be inconsistent to argue that neurobiology has a disproportionate influence on mental health but then demand the study of specific neurochemical mechanisms to approve treatments. Treatments should be approved based on their efficacy.
In conclusion, neurobiology and pharmacotherapy may be overrepresented in the mental-health field. The solution to this overrepresentation may be to ask better questions when designing research, focusing on what improves mental health instead of on neurobiology.
To the Editors:
Drs. Grifell and Hart’s article “Is Drug Addiction a Brain Disease?” looks at an area of medicine very differently than I have. As a retired, board-certified pain management anesthesiologist with a degree in biochemistry, drugs are something that I have dealt with for many years.
The first thing I noticed when reading the article is a difference in definitions. Opiates can cause the following effects: tolerance, dependence, withdrawal, and addiction (now more politely called substance-use disorder). The problem is that tolerance, dependence, and withdrawal are not unique to opiates. A diabetic is dependent on insulin. Beta blockers can cause a dangerous rebound if suddenly withdrawn. Some drugs (including caffeine) require dose increases as the patient becomes more tolerant. The defining feature of addiction is its use for no medical purpose, even to the detriment of the individual or others.
An observation in the 1980s forced us to reconsider earlier thinking. Patients taking high doses of opiates for what were considered terminal diseases were being cured. Surprisingly, they self-tapered their opiate intakes and stopped their use. I saw this in my practice, too.
Certainly addiction is a different brain disease than Parkinson’s disease. I think comparing contingency management plus behavioral counseling to the 12-step program results after only 8 weeks is not too useful. When talking to patients in Alcoholics Anonymous, they will tell you that they are still an alcoholic but are not drinking now.
Substances are not the only thing that can be addicting. Compulsive gambling is recognized as a “nonsubstance” or behavioral addiction in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). There are other compulsive activities that we recognize that fit the defining definition of addiction above. Because all these addictions involve behavioral changes, it seems that the brain is involved and is a significant aspect of the disease process. The fact that we see addiction in all strata of society suggests that it is not a psychosocial disease, if that term is understood to be environmental.
M. Craig Pinsker
Glen Allen, VA
Drs. Grifell and Hart respond:
We agree that withdrawal, dependence, and tolerance are not unique to psychoactive substances. As stated in our article, however, the defining feature of addiction is not that a substance is used for no medical purpose, because the vast majority of users of illicit drugs do not have an addiction problem. The defining feature of addiction, according to the DSM-5, is the significant distress to the user or the disruption of psychosocial functions (such as meeting obligations).
The observation that patients with pain spontaneously stopped their opiate use supports our thesis that addiction is not a brain disease caused by the specific actions of psychoactive substances in the brain.
Dr. Pinsker acknowledges that addiction is not a brain disease like Parkinson’s disease, but still states that addiction is a brain disease without any supporting evidence. We find the anecdote of the alcoholic unfortunate. Simply because an alcoholic—or anyone—tells one something does not make it true.
Finally, Dr. Pinsker’s statement that “we see addiction in all strata of society” as a reason that it is not a psychosocial disease is not logical. We know that psychiatric illness is strongly associated with the development of addiction, and psychiatric illness is present in all strata of society, so addiction must also be present. We insist on avoiding dichotomous thinking. We understand the importance of neurobiology; we simply say we should take other factors as seriously as we take neurobiology.