Dissolving the brain disease model of addiction

vivianimbriotis | Nov. 22, 2022, 2:20 p.m.

I originally wrote the below for the 2022 Allan J Foster Memorial Prize, from the University of Tasmania, which I received.

 

“What are you up to, doctor?”

That’s Socrates. He has walked in from the streets. His toga is pressed. His hair is combed. He stinks of alcohol.

“I’m reading this article arguing against the brain model of addiction.” That’s Hippocrates. He’s wearing an anachronistic stethoscope and tapping away at a slightly-more-anachronistic laptop.

“Gosh Hippocrates, that sounds pretty erudite.”

“I try. I was going to write an essay about it, but I think I might write one of those Socratic dialogues.” Hippocrates spins on his ergonomic chair and faces Socrates, the blue-tinged sunlight of Athens (classical era, c. 430 BCE) trickling lazily into his office.

“You’re making me blush,” says Socrates, pulling up a (non-ergonomic) chair. “What is the brain disease model of addiction?”

“It goes something like this –” and then, in stage whisper, “for which I refer you to Leshner (1997):

[A]ll drugs of abuse have common effects, either directly or indirectly, on a single pathway deep within the brain…That addiction is tied to changes in brain structure and function is what makes it, fundamentally, a brain disease. A metaphorical switch in the brain seems to be thrown…Understanding that addiction is, at its core, a consequence of fundamental changes in brain function means that a major goal of treatment must be either to reverse or to compensate for those brain changes. These goals can be accomplished through either medications or behavioural treatments.

Meanwhile the main opposition to this argument runs that the neurological deficit seen is necessary but not sufficient to produce addiction, so there must also exist a social component (Levy 2013).”

“Wow. Amazing how you pronounced the parentheses and brackets.” Socrates pauses for a long moment, then asks, “Are you a materialist, Hippocrates?”

“I’m sorry?”

Socrates nods and tries again. “Do you believe that thought and mind arise from the substrate of the brain? That they are instantiated by and equivalent to the activity of the brain?”

Hippocrates opens his mouth and words begin to tumble out. “Well I’m not sure I believe Keith Frankish (2016) when he talks about Illusionism, the idea that there is no inner consciousness at all; no qualia or subject, just the illusion of them generated by physical materials. But I suspect at least some of Eliminative Materialism is true – the idea, most recently captured by Paul Churchland (1981), that some folk psychology ideas are probably not real--”

Socrates sniffs, glancing back down from the ceiling. “Sorry, I didn’t catch all of that.”

“Yes, fine, I think the mind comes from the brain.”

“You think the mind is like a candle-flame, an emergent process generated by the physical properties of interacting materials.”

“Something like that.”

“Okay, and different brain-states correspond to different mind-states?”

“Yes.”

Socrates nods. “What about long term brain-states? Brain-structure? If I examined the structure of the brains of married men, might they look different from the brain of bachelors?”

“On average they must must, I suppose, have they on average different minds. In fact, there is evidence of an association between marital status and brain structure, identified by Zhu and colleagues (2018),” Hippocrates says, again pronouncing the parentheses.

“It seems then, that to say that addiction is a disease of the brain, and to say that it is a disease of the mind, is tautology. Is marriage caused by a brain lesion?”

Hippocrates huffs and puffs out his chest. “Well Socrates, hang on a moment. Let’s listen to Volkow and Koob (2015), who tell us:

[P]reclinical and clinical studies have consistently delineated specific molecular and functional neuroplastic changes at the synaptic and circuitry level that are triggered by repeated drug exposure…”

Socrates shrugs. “So there’s a neurobiological pathway involved. Is there not a similar pathway involved in any thought process you care to name? In attention (Carrasco 2011)? In love (Carter and Porges 2013)?”

Hippocrates looks unhappy as Socrates continues, “So…what is the actual distinction between a pattern of behaviour so undesirable and damaging that it constitutes a social or mental disease, which you admit must induce a change in brain state, and a neurobiological brain disease, which alters behaviour?”

Hippocrates has had enough. “Well, the causal structure is different! In one the brain change causes the behaviour, and in the other the behaviour – potentially a socially driven behaviour – causes the brain to change.”

“But don’t you tell me that the brain and the mind are in essence one and the same?”

Hippocrates harrumphs. “Even hypothetically if I agreed with that, one is a person’s fault, and one isn’t. We have control over our behaviours. We do not have control over our neurobiology. They are ethically different. We treat people with more dignity when we describe addition via biology.”

“You told me that you believe the mind is produced by the brain! If that is so, how can we possibly have ‘control’ over our behaviours? If our minds are the consequence of physical material that follows physical laws of cause and effect, by what mechanism could we control these ‘decisions’ that it feels like we are making? By your account, our behaviours are our neurobiology!”

Hippocrates lowers his forehead to his desk, and muffled, plaintively, says “My head hurts, Socrates. Don’t you have some hemlock to go and drink?”

Socrates beams at him. “Not until next week my dear.”

Hippocrates continues, face still hidden, “Anyway, those two accountings are only equivalent if you hold this particular set of philosophical beliefs that you have laid out.”

“But regardless of your other philosophical beliefs, if you believe that the mind comes from the brain, what predictive power, what falsifiable distinction, could exist between a ‘brain change causing behaviour’ and a ‘behaviour resulting in brain changes’?”

“Does there need to be a falsifiable distinction?”

“It does if you want them to be scientifically distinct, and you believe Popper (1985).” Socrates is a fast learner and has figured out how to pronounce the parentheses.

And while Hippocrates is still pondering that, Socrates begins again: “And why should we be more respectful, and endow with more dignity, those who by an accident of moral luck (Nagel 1993) are struck down by a brain lesion, and those who by an accident of fate were born with a predilection for a certain kind of behaviour? They did not choose to be the type of person that they are, or their circumstances, or their lives and interactions and facilities. They may have chosen their choices, but they did not choose to become the sort of person who would make those choices. They simply are.”

Hippocrates sniffs, raising his head up from the desk. “Sorry, I didn’t quite catch that.”

“I told you earlier I didn’t understand why it make an ontological difference, and now I’m asking why it makes a moral difference.”

Hippocrates shrugs, sighs, and tries again. “Perhaps the distinction is about the socialness of the disease – that it cannot fully described, fully captured or realized, with a single mind or brain.”

“But you say that a particular person has the disease of addiction, yes? Is a ‘social disease’, dispersed amongst a group, even a disease? What is a disease?”

“It seems pretty clear actually, Socrates, that we don’t have any good consensus on what a ‘disease’ actually is in the general case (Powell and Scarffe, 2019).”

“Seems pretty rich to try and help people with a brain disease when you don’t even understand the semantic meaning of the word ‘disease’, doesn’t it?” says Socrates, pulling a flask from his toga.

Hippocrates knocks it away, a wild grin flashing across his face, and cries, “Ah, to try to help despite uncertainty – Socrates my friend, you have discovered medicine!”

 

 

Carrasco, M 2011, “Visual attention: the past 25 years,” Vision Research, vol. 51, no. 13, pp. 1484–1525.

Carter, CS & Porges, SW 2013, “The biochemistry of love: an oxytocin hypothesis,” EMBO Reports, vol. 14, no. 1, pp. 12–16.

Churchland, PM 1981, “Eliminative Materialism and the Propositional Attitudes,” The Journal of Philosophy, vol. 78, no. 2, pp. 67–90.

Frankish, K 2016, “Illusionism as a Theory of Consciousness,” Journal of Consciousness Studies, vol. 23, no. 11–12, pp. 11–39.

Hall, W, Carter, A, & Forlini, C 2015, “The brain disease model of addiction: is it supported by the evidence and has it delivered on its promises?,” The Lancet Psychiatry, vol. 2, no. 1, pp. 105–110.

Leshner, AI 1997, “Addiction Is a Brain Disease, and It Matters,” Science, vol. 278, no. 5335, pp. 45–47.

Levy, N 2013, “Addiction is Not a Brain Disease (and it Matters),” Frontiers in Psychiatry, vol. 4, viewed 19 September 2022, <https://www.frontiersin.org/articles/10.3389/fpsyt.2013.00024>.

Nagel, T 1993,“Moral Luck,” in D Statman (ed.), Moral Luck, State University of New York Press, pp.141–166.

Popper, K 1985,“The Rationality Principle,” in D Miller (ed.), Popper Selections, Princeton, pp.357–365.

Popper, K, Bartley, WW, & III 1985, Realism and the Aim of Science: From the Postscript to The Logic of Scientific Discovery, Routledge, London.

Powell, R & Scarffe, E 2019, “‘Rethinking “Disease”: a fresh diagnosis and a new philosophical treatment,’” Journal of Medical Ethics, vol. 45, no. 9, pp. 579–588.

Volkow, ND & Koob, G 2015, “Brain disease model of addiction: why is it so controversial?,” The Lancet Psychiatry, vol. 2, no. 8, pp. 677–679.

Zhu, X et al. 2018, “Together Means More Happiness: Relationship Status Moderates the Association between Brain Structure and Life Satisfaction,” Neuroscience, vol. 384, pp. 406–416.