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What Does It Mean When We Call Addiction a Brain Disorder?

March 23, 2018

The term acknowledges that addiction is a chronic but treatable medical condition involving changes to circuits involved in reward, stress, and self-control.

MRI scan of a brainPhoto by jkt_de

As a young scientist in the 1980s, I used then-new imaging technologies to look at the brains of people with drug addictions and, for comparison, people without drug problems. As we began to track and document these unique pictures of the brain, my colleagues and I realized that these images provided the first evidence in humans that there were changes in the brains of addicted individuals that could explain the compulsive nature of their drug taking. The changes were so stark that in some cases it was even possible to identify which people suffered from addiction just from looking at their brain images.

Alan Leshner, who was the Director of the National Institute on Drug Abuse at the time, immediately understood the implications of those findings, and it helped solidify the concept of addiction as a brain disease. Over the past three decades, a scientific consensus has emerged that addiction is a chronic but treatable medical condition involving changes to circuits involved in reward, stress, and self-control; this has helped researchers identify neurobiological abnormalities that can be targeted with therapeutic intervention. It is also leading to the creation of improved ways of delivering addiction treatments in the healthcare system, and it has reduced stigma.

Informed Americans no longer view addiction as a moral failing, and more and more policymakers are recognizing that punishment is an ineffective and inappropriate tool for addressing a person’s drug problems. Treatment is what is needed.

Fortunately, effective medications are available to help in the treatment of opioid use disorders. Medications cannot take the place of an individual’s willpower, but they aid addicted individuals in resisting the constant challenges to their resolve; they have been shown in study after study to reduce illicit drug use and its consequences. They save lives.

Yet the medical model of addiction as a brain disorder or disease has its vocal critics. Some claim that viewing addiction this way minimizes its important social and environmental causes, as though saying addiction is a disorder of brain circuits means that social stresses like loneliness, poverty, violence, and other psychological and environmental factors do not play an important role. In fact, the dominant theoretical framework in addiction science today is the biopsychosocial framework, which recognizes the complex interactions between biology, behavior, and environment.

There are neurobiological substrates for everything we think, feel, and do; and the structure and function of the brain are shaped by environments and behaviors, as well as by genetics, hormones, age, and other biological factors. It is the complex interactions among these factors that underlie disorders like addiction as well as the ability to recover from them. Understanding the ways social and economic deprivation raise the risks for drug use and its consequences is central to prevention science and is a crucial part of the biopsychosocial framework; so is learning how to foster resilience through prevention interventions that foster more healthy family, school, and community environments.

Critics of the brain disorder model also sometimes argue that it places too much emphasis on reward and self-control circuits in the brain, overlooking the crucial role played by learning. They suggest that addiction is not fundamentally different from other experiences that redirect our basic motivational systems and consequently “change the brain.” The example of falling in love is sometimes cited. Love does have some similarities with addiction. As discussed by Maia Szalavitz in Unbroken Brain, it is in the grip of love—whether romantic love or love for a child—that people may forego other healthy aims, endure hardships, break the law, or otherwise go to the ends of the earth to be with and protect the object of their affection.

Within the brain-disorder model, the neuroplasticity that underlies learning is fundamental. Our reward and self-control circuits evolved precisely to enable us to discover new, important, healthy rewards, remember them, and pursue them single-mindedly; drugs are sometimes said to “hijack” those circuits.

Metaphors illuminate complexities at the cost of concealing subtleties, but the metaphor of hijacking remains pretty apt: The highly potent drugs currently claiming so many lives, such as heroin and fentanyl, did not exist for most of our evolutionary history. They exert their effects on sensitive brain circuitry that has been fine-tuned over millions of years to reinforce behaviors that are essential for the individual’s survival and the survival of the species. Because they facilitate the same learning processes as natural rewards, drugs easily trick that circuitry into thinking they are more important than natural rewards like food, sex, or parenting.

What the brain disorder model, within the larger biopsychosocial framework, captures better than other models—such as those that focus on addiction as a learned behavior—is the crucial dimension of interindividual biological variability that makes some people more susceptible than others to this hijacking. Many people try drugs but most do not start to use compulsively or develop an addiction. Studies are identifying gene variants that confer resilience or risk for addiction, as well as environmental factors in early life that affect that risk. This knowledge will enable development of precisely targeted prevention and treatment strategies, just as it is making possible the larger domain of personalized medicine.

Some critics also point out, correctly, that a significant percentage of people who do develop addictions eventually recover without medical treatment. It may take years or decades, may arise from simply “aging out” of a disorder that began during youth, or may result from any number of life changes that help a person replace drug use with other priorities. We still do not understand all the factors that make some people better able to recover than others or the neurobiological mechanisms that support recovery—these are important areas for research.

But when people recover from addiction on their own, it is often because effective treatment has not been readily available or affordable, or the individual has not sought it out; and far too many people do not recover without help, or never get the chance to recover. More than 174 people die every day from drug overdoses. To say that because some people recover from addiction unaided we should not think of it as a disease or disorder would be medically irresponsible. Wider access to medical treatment—especially medications for opioid use disorders—as well as encouraging people with substance use disorders to seek treatment are absolutely essential to prevent these still-escalating numbers of deaths, not to mention reduce the larger devastation of lives, careers, and families caused by addiction.

Addiction is indeed many things—a maladaptive response to environmental stressors, a developmental disorder, a disorder caused by dysregulation of brain circuits, and yes, a learned behavior. We will never be able to address addiction without being able to talk about and address the myriad factors that contribute to it—biological, psychological, behavioral, societal, economic, etc. But viewing it as a treatable medical problem from which people can and do recover is crucial for enabling a public-health–focused response that ensures access to effective treatments and lessens the stigma surrounding a condition that afflicts nearly 10 percent of Americans at some point in their lives.

This page was last updated March 2018

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Communicating that addiction is brain disorder

This is a very useful blog post. This is a much-needed conversation to help reduce the stigma of addiction which is discouraging our addicts and their families from seeking help, and preventing others from being part of the solution. I feel that understanding that addiction is brain disorder is so important to bringing people in to help combat this epidemic, and in the recovery process for both the addict and their families. I have struggled as a member of a towns addiction task force as to how to best communicate addiction as a disease to a general audience, your thoughtful blog pulls many pieces together. Thank you again

Addiction

This is one of the best description of the problem of addiction that I have encountered. Congratulations to NIH. My experience with addiction started in 1965 as a State Parole Officer. My office was in Newark, NJ and I got to witness the problem face-to-face with the thousands of addicts who went through a treatment program in Newark, NJ that I founded in 1968. Thanks for this excellent piece!

Complexities of addiction

I appreciate the discription of the biological, psychological, social, behavioral, economic, societal, etc. complexities of the disease of addiction. As a clinical addictiion professional and a person with nearly 30 years of long-term recovery I absolutely agree this disease is treatable. I however caution the use of the term “recover”. This is a chronic disease. With treatment and a commitment to recovery this disease can be in remission and long term recovery possible.

Disease versus choice

All well said and agreed, but by the same token, ignoring the learned aspect of addiction prevents people from taking responsibility for their actions which can also delay recovery. Treating addiction as a learned dysfunctional behavior shifts the focus of recovery from a person’s biology to a person’s actions. The actions need not be seen in a moral context (“bad” or “good”) but rather as not helpful to one’s goals. An emphasis on the learning model moves the control of addiction from the physician to the patient, and moves the control of recovery from the patient’s biology to his or her relationships.
Neither model is 100% accurate, and both models are helpful in understanding this bewilderingly complex part of human life.

Brain Disease / Addiction

Bravo Dr. Volkow ! Once again you have clearly and succinctly expressed the true nature of the Brain Disorder we call Addiction.
The biopsychosocial model is indispensable. Genetic, developmental, and environmental factors all interact with the person over time to create vulnerability. Absent adequate protective factors, persons with vulnerability exposed to psychoactive chemicals will likely develop brain addiction for the reasons you describe. Policy and programming must continue to evolve in an inclusive manner. Simplifying brain addiction by excluding any contributing factor weakens the potential of treatment. Thank you and your colleagues for your compassionate perseverance in this most important public health crisis.

Addiction is a brain disease.

You mention Dr. Leshner in your article. Leshner made a video entitled "The Great Disconnect" and the last thing he says is that it is the responsibility of treatment to change the brain back to where it was before the addiction occurred. Use of medication appears to go against this end, i.e. by continuing to use addictive medications to keep someone in control of their addiction, we also do not "change the brain back" but may even reinforce the physical and psychological addiction. Was Leshner wrong?

Treatment cannot return the

Treatment cannot return the brain to “where it was before” the addiction started. Nor is this what recovery means. Because the brain is constantly changing, there is no going back to some original state, but only a restoration of balance between the circuits involved in reward, stress, and self-control. Medications do not replace one addictive substance for another or, by themselves, restore balance, but they can reduce the incentive for the individual to take an illicit drug—either by moderating the cravings and withdrawal symptoms (in the case of agonists, buprenorphine and methadone) or by blocking opioids from having an effect (in the case of the antagonist, naltrexone). In this way, by supporting abstinence from more potent and euphoria-inducing opioids, they make recovery much more likely than quitting cold turkey.

Spiritual component of addiction

While there is a great amount of research of the brain with regards to addiction (pleasure center of the brain), it is necessary to keep in mind the huge role spirituality also plays within addiction. I fully agree there are biological, psychological, and social factors, which is where the term of "biopsychosocial" was coined to refer to as an assessment. This term is however incomplete without the word, "spiritual" attached to it. It is very interesting this term is omitted, whether it was intentional or an oversight, given the entire chapter from A.A. Big Book, "There Is A Solution", being devoted to this component.

Neurobiology of Addiction

I really enjoyed reading this post. In reference to the "falling in love" metaphor, I am curious if you have seen the research that discusses the strong connection between attachment and opiates. For example, in 1998 researchers found opiates to decrease distress vocalizations from baby animals when separated from their caregivers. The "loaded feels like loved" research also shows drugs and alcohol to provide the same reward to the brain as close, social bonds. It may help explain why addicted individuals isolate when they use, and struggle with accepting support/asking for help even in recovery.

Find Help Near You

The following website can help you find substance abuse or other mental health services in your area: www.samhsa.gov/Treatment. If you are in an emergency situation, people at this toll-free, 24-hour hotline can help you get through this difficult time: 1-800-273-TALK. Or click on: www.suicidepreventionlifeline.orgExternal link, please review our disclaimer.. We also have step by step guides on what to do to help yourself, a friend or a family member on our Treatment page.

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    NIDA. (2018, March 23). What Does It Mean When We Call Addiction a Brain Disorder?. Retrieved from https://www.drugabuse.gov/about-nida/noras-blog/2018/03/what-does-it-mean-when-we-call-addiction-brain-disorder

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    Dr. Nora Volkow: Video Highlights

    NIDA Director, Dr. Nora D. Volkow Videos

    • National Committee for Quality Assurance (NCQA): Quality Talks, October 2016
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    • Kentucky Educational Television, May 2016
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    • TEDMED, January 2015
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    • The World Science Festival, April 2014
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    • Rockburn Presents, November 2012
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    • Brookhaven National Laboratory WBNL Video, October 2012
      Chemistry celebration: FDG: Contribution to Our Understanding of Addiction
    • CBS 60 Minutes, April 2012
      Hooked: Why Bad Habits Are Hard to Break 
    • Science Times, June 2011
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