Addiction.com invited Nora Volkow to pit her “disease” argument against my (and others’) “learning” model of addiction. She declined, or at least didn’t agree, but I’m happy to announce that we have finally sort of crossed swords in the Huffington Post Blog network.
Here’s her initial post and here’s my response. And I’m really pleased that my response appears on the front page…that column of posts on the left side of the page…next to all that nasty news of the world.
I’d love it if we had a chance to engage in this dialogue directly. But…I don’t fault her. She’s an amazingly prolific neuroscientist, as well as an NIH administrator, and she probably gets publicity requests of one kind or another 20 times per day.
I’m just glad that we anti-disease campaigners got our foot in that particular door…and I do mean we.
Informed by unparalleled neuroscientific insight and written with his usual flare, Marc Lewis’s The Biology of Desire effectively refutes the medical view of addiction as a brain disease. A bracing and informative corrective to the muddle that now characterizes public and professional discourse on this topic.” —Gabor Maté, M.D., author of In The Realm of Hungry Ghosts: Close Encounters With Addiction
Great work Marc! I am really encouraged to see the build-up to your book. I think the timing is perfect and that we will see it becoming a major factor in the slow about-turn in the field of addiction.
She is an extremely smart (and swamped) woman. Maybe she doesn’t want to debate because some part of her is starting to agree. (oops…there’s the disease kicking in again trying to mind read)
Not the most flattering picture of her…that’d scare me, too…But that thing about people in authority…and not knowing if I was doing the right thing… wanting more control (over what? I didn’t know) instigated a lot of my use. I knew how to change my anxious internal state, and I knew how to do it in a heart beat…
Dr. Lonny Shavelson found that 70% of female heroin addicts were sexually abused in childhood.
http://powerandcontrol.blogspot.com/2004/09/heroin.html
Addiction is a symptom of PTSD. Look it up.
The NIDA says Addiction Is A Genetic Disease
http://powerandcontrol.blogspot.com/2007/01/addiction-is-genetic-disease.html
No surprise. PTSD is in part genetic and requires trauma to trigger it.
I read with amusement in your book about your having lunch with her in Dharmsala and envisioned if she tried to have you as appetizer or entree
YOu used the word fiery ( accurate) but the best part was the stoppage of the action in that group of eminent scientists when you mentioned Rat Park
Anyway this is of landmark importance– DEBATE ..and I at least will get a good seat and watch with interest
Appetizer, to be precise. She had forgotten about me by the time she got to the main course.
All famous people scare me, I admit, but she more than others. She’s a brilliant scientist who has contributed vastly to the field that I study, she’s hugely powerful politically and economically, she’s absolutely sure-footed in her approach to topics which are usually graded and contentious, and…she’s nice. And people like her. And I like her. And she looks a bit like my mother. Oy gevalt.
When did I mention Rat Park? Happen to know the timing of that comment?
It was during your talk with the DL– fairly early on i think.
YOu were going along and mentioned Rat park and the DL needed clarification. Junpa ( ??) the translator was claifiying but the looks in the room indicated little knowledge — which is what caught my attention
Surprised I guess that such powerful science folks werent familiar with it..
YOu went on to briefly explain the Alexander work
And this observation might well be mis interpretation of course as i was not there
The trouble with Rat Park is that it has never been replicated successfully. The other cornerstone of the non-disease (for lack of a better phrase) argument, the returning heroin-addicted Vietnam vets’ spontaneous recovery, is alternatively and adequately explained by state dependent learning or environmental tolerance.
Where did you hear that Rat Park wasn’t replicated? The following is from Bruce Alexander’s website:
The basic finding was later replicated and extended by other researchers in other laboratories (The first of the replications was by Schenk, S., Lacelle, G., Gorman, K., and Amit, Z. (1987) Neuroscience Letters, 81, 227–231. The most recent that I have found was by Solinas, M., Thiriet, N., El Rawas, R., Lardeux, V., and Jaber, M. (2009). Neuropsychopharmacology, 34, 1102–1111.)
I haven’t looked at these, but they are certainly in respectable journals.
My reading of the two you mention has to do with risk and protective factors. It’s easy to see how an enriched environment might make the drug less reinforcing because of competing rewards. And conversely how the drug might be more reinforcing in an impoverished one. I don’t see the relevance to whether addiction is a disease.
Really?! So your tuberculosis or cancer is going to be a lot more troublesome when you’re alone than when you’re with other people? Maybe it’ll disappear if you just hang out with your pals? I don’t think so….
I am not sure what this is ” state dependent learning or environmental tolerance.”
Marc and I are not in agreement on some things ,and I at least dont know what this ” thing” we call addiction is.. But we do strongly agree what it is NOT .. A disease
This is a 180 U turn for me. Im a retired MD and I for a long time said ” of course its a disease – take a look at the brain”
With Marc’s help I have taken a better look at the brain . and you will too when you read the book– and come to the conclusions that the disease model is not only wrong but dangerous.
Now the biggie !!!?? if it isnt,, what is it ??
Maybe Marc will elucidate me in another book 🙂
No, in this book: p. 169. At least that’s a stab at it. Admittedly it’s a tough question.
Right– and it is a very good answer
Actually I re read the whole darn thing cause there is so much good stuff in it.
But Im also now convinced even more that not only is he disease model is wrong, it is dangerous because of possible harm it can create ..ie Counter- productive to ” Recovery”
another word we both do not like
Got it, thanks Bill. I do remember now.
Marc, I hope the two of you do begin to have increasingly public dialogue. If so, I hope you both will bear in mind a teaching I try to carry with me from Rodney Smith (Lessons from the Dying): “The truth, unkindly told, is a lie.” At the very least, unkind truths do little to win over the other side – a side you BOTH probably think would be good to win over. Best, Mark
P.S. Do you think Nora knows that there are over 300,000 peer-reviewed neuroscience studies published EVERY YEAR?!
About a third of them are probably hers…
But you’re very right about telling the truth unkindly. I don’t expect we’ll ever debate face to face, but we are often preaching to the same congregation. Thanks for that astute reminder.
Maybe not but maybe so
If those of us here feel so moved, a chorus of commentary might add to the debate
The only thing that is going to inform debate is volume from the number of voices advocating for the truth needed to formulate policy adequate to afftect the problem
And of the neuroscience studies related to addiction about 80% are NIH/NIDA funded – WORLD WIDE. I am currently doing an analysis of all peer-reviewed addiction studies conducted in South Africa over the last 7 years to see who is funding what and what fields are being most researched and what kind of research is being done – I am very interested to see what the outcome will be.
We all will!
Shaun, that is an amazing statistic!!!! I’m sure I’ll be using it a lot from here on it. If you have a summary report, please send it along.
Wonders if there is possibly selection bias in the funding process favoring those who might support the disease model
Indeed a nasty thought – shame on me
Here is an article on the FIX that I have a lot of issues with, but the data is really interesting: http://www.thefix.com/content/fix-special-report-maddening-state-addiction-research-funding?page=all
The disease of free will?? Didn’t Hitler have that?
Oy vey iz mir
i just read what she had to say and its not too bad. Came away with the thought that the disagreements would lose alot of steam if she just made a simple word exchange in her rhetoric
From Addiction IS a disease of the brain …
To Addiction CAUSES a disease of the brain
Rhetoric? That’s kind of the problem!… to frame it that way sounds like it’s becoming a civil rights issue. I find that a little inflammatory, but that’s just me. Granted it affects executive control, but mankind has been dealing with the idea of free will since the beginning of time. That’s about attitude, not addiction.
Not sure what you mean here Matt. If youve ever heard her speak, you’d know rhetoric as at least I use the word here
and in just the few days ive been thinking about all this , and Marc might be helfpful here, that even the statement that Addiction causes a disease of the brain . What Im saying here is that the known ” changes” in the brain may not be characteristic or different enough , to warrant the term disease.
And that is very laden question.
It is a very laden question. That was my point about rhetoric. She is a brilliant woman (I have seen her speak) with enormous responsibilities she has to deal ; with various political agendas, funding etc, as has been mentioned. So I was shocked when I saw the title, that’s all I’m saying. I found it disturbingly tangential…especially for her.
Habits are learned. They are learned through reinforcement. The more they are repeated the stronger and more automatic and autonomous they become until they can be evoked without consciousness. There are good habits and there are bad habits. Good habits are self-reinforcing: when I practice playing the guitar my guitar playing gets better which motivates me to practice which makes my playing better. . . . I get dopamine at both ends, the motivational and the resultant. Bad habits deplete dopamine or its activity (through down regulation) after an initial surge, motivating the same behavior but in a law of diminishing returns fashion: more gets less. So while motivation may get ramped up (sensitized), result does not. That is why bad habits are pathological. They are a distortion of the same mechanisms responsible for formation of good ones.
“They[bad habits] are a distortion of the same mechanisms responsible for formation of good ones.”
Nice concise description of addiction.
Thanks. How about a pathological distortion?
This is interesting and I like it alot. Perhaps could you develop it a bit more because I think you are onto something important
Thanks. Pretty standard disease model stuff I’m afraid. I wish we could stop squabbling and arrive at some consensus that helped more people afflicted with whatever it is get better sooner. In that regard I think that we get further with seeing and treating the addicted as patients rather than as learning disabled.
Patients are people who are sick with diseases and need treatment with drugs to cure them or manage their illness by the dictates of the authoritarian doctor!!!
Yes yes a little strong but you get the idea 🙂
It is definitely an interesting take on the problem, Nick. But bad habits (like drug taking) do give you a serious dopamine charge..during the anticipation phase. Admittedly, the result causes a net decrement in dopamine signalling.
Still, do we really want to define good vs. bad habits based on whether the outcome is reinforcing? Going to the dentist, maybe even brushing my teeth, would be among the first to go…
Do you mean to say that having a sparkling smile and fresh breath aren’t reinforcing? What you call the anticipation phase I called motivational.
Aren’t they pretty much the same thing?
Yes
okay…
Don’t mind me, I often just put my wading boots on and stroll into the middle of a deep conversation…
THIS IS PERFECT: “The disease model of addiction has made its contribution, but it’s time to move on. We don’t have to ignore the biology of addiction to appreciate its psychology and to approach those who suffer humanistically rather than moralistically.”
Amazon just notified me my preordered copy of the new book is in the mail – more later
Guy
I agree with Guy that your last line is spot on: “we don’t have to ignore the biology to appreciate its psychology”. I think there is a fear that if we begin to characterize addiction as anything other than a disease, we threaten the financial security of an already tenuous funding situation for NIDA. She has to advocate for government funding, and the disease model has been effective thus far. Altering her stance may not be good politically. Maybe your book will help with a grassroots movement to garner support of a more developmental approach to addiction that STILL NEEDS good neuroscience research in order to make progress. She may change her stance in public media when she realizes a new approach to addiction, away from the pure disease model, will still be politically favorable.
I completely agree, Liz. It’s true that people worry, and Volkow worries: how will we get treatment for these people if we don’t stick with the disease definition.
First, you can’t solve a scientific problem by trying to untangle an economic problem, actually an economic debacle in a country called the United States….not the paragon of health care in any case.
Second, it’s just wrong thinking. How much federal money has been spent on anti-racism, anti-bullying, and other campaigns to control the nasty extremes of human behaviour?
Third, there are models of care that are bottom-up or horizontal rather than top-down and expert driven. Some of us think that these models will work far better for addicts, partly because they require self-motivation and empowerment and partly because they build on community support. Both are critical.
It’s true. I think the top-down (and “hurry up and wait”)model may have helped nudge some of my relapses over the edge. Some states fund “recovery centers”— clearing houses that addicts can walk into when they’re ready, receive council from other addicts, and various other services to support recovery. The person with the problem gets a chance to choose from a range of options, when THEY are ready. Consumer driven (I thought that an appropriate US term) and informed by self-motivation, not coercion…
This is so right on — polititics and funding
I think even there was a senate resolution offered ? passed? by Joe Biden stating that addiction is a disease
If the congress says so., doesnt that make it absolutely true??
Nora Volkow? Formidable, whether you agree with her or not. If you could get her to engage that would really be something. She’s probably very very busy.
Looking forward to the Kindle release of your book.
Okay, I’m either going to do a toke or write this. I dunno which, I find crack more enjoyable than communicating my thoughts. But what Nora Volkow said got my attention, and there’s something here I can’t resist. Not the neuroscience stuff; I’ve been publicly proclaiming that Marc has nailed that coffin shut since, well, probably since before he even started writing this great new book. Bad brain science is just annoying. Like a drunk grabbing onto a lamp post, it’s all about support not illumination. And I see Volkow reaching similarly for support when she says that addictions are about a lack of “free will.” She’s stretching towards philosophy and there’s no truth for her there either. Philosophers can’t agree on free will, but mostly they seem to be saying that it doesn’t exist. (I encourage you to read a very entertaining short book on the topic by Sam Harris–the only short and entertaining book I know of by a contemporary philosopher.)
If you think you have free will, then prove it by planning out the next series of thoughts you’re going to have, and then think them without deviating from your plan. If you can’t choose your thoughts, how can you say you choose what you do? You really can’t, but that’s not the whole story. For example, you might get lucky, like me. I get to practice a little ‘free won’t’ and distract myself here and there. And without free will, I’m actually better off. It’s not about what’s in my brain, it’s about what I put my brain in. My choices still really really matter, even more so, and some habits, like altruism, make beautiful sense to me. Don’t they for you?
But wait a second, I forgot what I was doing. Oh yeah, it’s time for my yoga class, which I always do around now. I think. I’m gonna grab a mat and head up onto the roof, see if anybody else shows up.
…maybe she’s going toward a neurophilosophical approach?…
Aagh! Too many layers! I think I sprained a neuron…
We havent heard from psycho-surgery yet !!
Give it to the surgeons,, fix it up fast !!
full disclosure- Im a surgeon
Damn straight, John. All this fuss about free will when it probably doesn’t exist. I didn’t mean to write that…it just came out. Hey, so did that. Hey…
I read a longish book by Harris which I loved. What’s the short one called? Or maybe I read the short one, but slowly. It was called Waking Up…which I’m about to do as soon as I get some coffee, maybe a piece of toast, none of which I thought of until this moment.
I love your message about free won’t and self-distraction. Another word for self-distraction is self-programming. Since what you do later isn’t going to be freely chosen, you might as well stack the deck in favour of something useful.
The short and entertaining work of contemporary philosophy–yes, it’s possible–to which I refer, is called Free Will, and it’s by Sam Harris. To be distinguished, Marc, from that longer book by Harris, and the much longer, more dense but ultimately very rewarding books by another philosopher, a friend of yours, the neurophenomenologist Evan Thompson. Apparently you contributed to both of his huge books, and I paraphrase, gratefully, from them where in the above comment I say: “It’s not about what’s in my brain, it’s about what I put my brain in.”
And Happy Fourth of July to you, too, William ,even if I’m not an American, and now I can’t stop thinking about Katy Perry singing “like the 4th of July/ ‘Cause baby you’re a firework/Come on let your colors burst…”
Where’s the choice in this matter, I can’t help but ask?
(Colours, not colors.)
P.S. Now I can’t stop thinking about that piece of toast.
Crikey!!! Free will?? Whats next consciousness ?? Arghhhhh..the abysss
any way Happy Independence day even if you aren’t American .. I celebrate my freedom and independence from alcohol today !
Great pieces and comments!
Happy Interdependence Day everyone!
It’s most interesting to read this dialogue. I have stumbled across Dr. Volkow’s contributions to Neuroscience repeatedly in recent years. She is evidently a rigorous intellectual and diligent scientist/practitioner. However she -as is the case with most of us, to a lesser or greater degree- is not without her ideologies.
I find myself quoting and paraphrasing Dr. Gabor Maté a lot. In one of his talks on addiction he speaks of the dominant medical perspective on addiction by saying that yes, the addicted brain can appear diseased but “how did those circuits get there? … don’t you know that the brain develops in interaction with the environment?”
Thank-you for engaging in this ‘semblance of a debate’. It is much needed within the sphere of the study of addiction. Also, it sheds light on the nature of human development more broadly –relevant amid today’s plethora of myopic popular science literature.
Levi