Nora Volkow, the disease model, and moi

Hi people. It’s been awhile. I left off with some brief descriptions of the Dialogue and summaries/links for two great talks. Now I want to tell you something about Nora Volkow’s presentation and, more interestingly, the chat we had afterward.

I have been running to keep up with myself for at least a month, and now I’m finally able to slow down, relax, and post something. I’m in Toronto for a week. I came to give a couple of talks, see family and friends, and just hang out. Isabel IMG_1589and I have literally been playing tag team to accommodate travel and children. I’m away, she’s at home with the kids, she’s away, I’m at home with the kids. We’ve spent only 4 days in the same place for over a month! She was returning from the US last Thursday, the day I left for Toronto. We were in the Arnhem train station at the same time but texting, trying to meet up, when we must have walked right past each other. By the time we connected, I was in the train and she was getting in a taxi. Funny and a bit sad.

Ok, Nora Volkow, head of NIDA (National Institute on Drug Abuse).  She’s often been a voice in my head when I’ve argued against the disease model of addiction in my writing and blogging. Why? Because she is one of the most eloquent and knowledgeable proponents of the disease approach, she is a powerful force in the worlds of research funding and policy-making, and because she’s a highly respected researcher. Who better to argue with, at least in my head?

Nora and HHShe gave her presentation on day 3 of the dialogue. Here’s the link to the talk itself and here’s Shaun’s summary. She focused mostly on the blunting of dopamine reactivity in the brains of addicts, resulting both in the reduced “rewardingness” of drugs and a reduced capacity for cognitive control. A lot of people liked her talk. She’s a great speaker: passionate but clear, with well-defined logical connections between data and interpretation. His Holiness looked like he enjoyed her presence, and Richie Davidson seemed enraptured. I liked her talk too. However…

I was listening for a rethink or even a mild qualification of her well-know contention that addiction is a chronic brain disease. But it wasn’t there. She continues to see addiction as resulting from the “damage” caused by repeated drug use. And she uses that word “damage” insistently, even though the measures available for assessing brain changes generally show them to be reversible (e.g., grey matter density changes). Two things have bothered me about this position for quite some time: (1) it makes drug addiction a completely separate animal from all other addictions (e.g., gambling, sex, food), despite evidence of overlapping or identical brain changes; (2) it places the cause of addiction squarely in the molecular action of the substance itself, something Nora emphasized repeatedly, ignoring the crucial lessons of Rat Park and subsequent research on environmental determinants.

Ok, so she’s Nora Volkow, she’s a pillar of the medical establishment (NIH), and she finds it valid and convenient to classify dysfunction as disease. So what’s my problem? Maybe it was in reaction to a comment she made later that day that my blood boiled over (gently of course). During a discussion period she proposed to debate whether addiction is “a disease of the brain or a disease of the mind.” She was so sure of herself. I looked around the circle of fellow presenters and organizers. Doesn’t anyone else question whether it’s even a disease?

IMG_1587So during the final hour of the final session (Day 5, morning, following Sarah Bowen’s talk) I picked up the microphone and waved it around for a good 20 minutes before I got my chance. The clock was ticking toward the end of the session. Only a few minutes left. I waved the microphone a bit more frantically, and Richie Davidson, the moderator of that session, gave me the last few minutes before lunch. I was nervous. I’d been aware of my heart pounding most unprofessionally. I didn’t want to defy the great Nora or piss off my newfound colleagues. The proceedings so far had been quite lovey dovey, almost devoid of serious academic debate. I didn’t want to breach that policy. Yet it seemed cowardly to sit back. I thought of you guys and some of the heated comments you’ve made about the disease model — how the logic never quite spoke to you, or how it left you feeling boxed and helpless.

So I said my bit. (Most of you have heard it before.) Maybe addiction isn’t a disease at all…given that recovery seems to derive from self-reflection, concentration, and effortful revision of one’s perceptions and goals, given that brain change is essential to all learning processes, and given that radical synaptic restructuring is the rule at developmental transitions (e.g., adolescence). And if addiction isn’t a disease, then perhaps it is best treated, not by the medical profession, but by programs of the type that Sarah Bowen had just described so beautifully — based on mindfulness and other methods of revamping our responses to our own cravings.

Nora did not look particularly pleased with my comment. But Sarah did. Richie I couldn’t read. Then, as people got up and milled around, preparing for lunch, I sampled the vibes as much as I could. And concluded that some were glad to have an opposing perspective on the table, a few were not, and most didn’t much care.

Since Nora was among the last to leave the room, I walked over to her and asked her what she thought of my comment. Surely she’s been confronted with opposition to the disease model. And sure enough she had a string of arguments already loaded and ready to fire. Here they are:

  • Not all diseases show up as major bodily disruptions. Some are far more subtle.
  • Calling something a disease doesn’t mean that it can’t be helped by psychosocial interventions. Even cancer recovery can be aided by mindfulness (to improve the mood and the self-care practices of patients).
  • Drugs damage brain tissue. For example, cocaine has been shown to directly damage the brains of rats, and by extension, probably humans, as does alcohol.
  • But beyond the damage issue, when something doesn’t work the way it should, we call it a disease. That’s how the word is used — that’s how language works.
  • Calling addiction a disease mitigates massive volumes of stigma and guilt, and it deflects blame from those who’ve fallen prey to addiction.
  • Arguing definitions is futile. Call it anything you want. The point is to get help for people who need it. And if we don’t treat addiction as a disease, it won’t be treated at all.

I could argue with most of these points, I thought. For one thing, I just don’t believe that most drugs cause brain damage, except in cases of extreme quantities and other critical factors, such as the impact of vitamin deficiency in Korsakoff’s syndrome, impure or toxic concoctions, overdose, etc, etc. And if you don’t believe me, look at the articulate prose of someone like David Carr (the New York Times journalist who smoked a ton of crack and drank a ton of booze over many years, then wrote The Night of the Gun). And sex addiction, gambling, and the other behavioral addictions aren’t likely to cause brain damage either. And in a country where the government is not in the business of helping people in dire need of help (including the poor, the sick, the old, the young, single parents, victims of accidents, abused women and children…the list goes on), perhaps the disease definition is the best avenue for getting help for low-functioning addicts. But that’s politics, not science, and it’s politics that fits one country, not the world at large.

As (my now friend) Kent Berridge tried to convince me later, we shouldn’t have to accept one definition or the other — both might be accurate for different individuals, stages, or circumstances. Yet the working (sub)title of my current book is “…why addiction is not a disease.” So I’ve got quite a stake in the argument. I don’t want to get bogged down in a useless war of words, and I certainly don’t want to spend my efforts trying to dismiss a “straw man” — a contrived version of my intellectual opponent that’s easy to refute because it’s exaggerated or fraudulent. And Nora wasn’t interested in further debate just now. That was clear — and lunch was calling.

But I’ll end by saying that, if my scientific beefs about the disease model turn out to be valid, something fundamental has to change in the way we label, understand, and treat addiction. Because it’s not just a war of words. After reading thousands of comments and emails from ex- or recovering addicts, I’m convinced that calling addiction a disease is not only inaccurate; it’s harmful. It’s harmful because it replaces one stigma with another. People don’t often boast about their incurable diseases — they are nothing to be proud of. And a sense of responsibility probably doesn’t do much to combat most diseases, but it’s a crucial part of the arsenal for combating addiction. To put it differently, those who have fought addiction and won — really won — hardly see themselves as lacking responsibility. Nor are they keen to walk on egg-shells for the rest of their lives, lest the latent virus erupt once more. For them, for us, there are more satisfying ways to define ourselves than “My name is Joe and I’m an alcoholic.” Most of the recovered addicts I’ve talked to would rather see themselves, not as in remission, but as free. Maybe better than ever.




72 thoughts on “Nora Volkow, the disease model, and moi

  1. Carolyn Kay November 29, 2013 at 5:44 am #

    Years of overindulging in the typical Western diet cause molecular changes that result in obesity, diabetes, heart problems, and cancer. Are those not diseases?

    There have to be physical changes somewhere, somehow, in addiction, since it involves needing more and more of the substance or the excitement. The disruption of brain chemicals can only be reversed by abstention, in most cases. Just as eating a healthier diet can mitigate, if not reverse, metabolic disease, and maybe even cancer.

    The advantage of the disease designation is that people tend to take that label more seriously, and may be more inclined to do something about the problem.

    • Marc November 29, 2013 at 8:52 am #

      Traffic congestion is an incredibly serious problem in some places, child prostitution in others. Abuse — spousal or child — very serious. Bullying, pedophilia, suicidality — the list goes on. The advantage of designating and understanding these problems as problems is that people are more inclined to do something about them. (I’m paraphrasing you.) But do we have to call something a disease in order to try to fix it?

      If you call obesity a disease, you’re one of the few. We are always going through molecular changes, in pregnancy, adolescence, learning, falling in love… That’s just not enough for the designation of disease.

  2. Janet II November 29, 2013 at 8:18 am #

    Bravo for standing up and speaking your Truth. It takes courage – coeur (heart) and rage – to risk your sense of harmony and belonging with a group, to risk being the “asshole”, to risk seeming contentious before the Dalai Lama. Heart, we know you have – pounding with excitement before you got to speak. Rage – this is often just a sign you want to be treated better – and a powerful transformative force at the same time – and I believe you were a single point of voice for all the addicts who ever felt helpless, stuck, disempowered and riddled with incurable disease that found their way out of that maze. You can appreciate Nora Volkow’s passion, dedication and trail blazing in the field while still wondering about her conclusions. Question orthodoxy. Peer behind the pillars that hold up our institutions to see if they are hollow or rotten. Say what you know and feel – and share it with your friends. Thanks for this post.

    • Marc November 29, 2013 at 8:55 am #

      Aaaagh, big breath of fresh air and with it relief. I actually just got home an hour ago. I posted this from the airport last night. It’s good to be home…and I mean home with you guys too.

  3. Nicolas+ November 29, 2013 at 8:23 am #

    There’s organic brain damage as we can see in autopsies of late stage alcoholic or methamphetamine addicts’ brains. More to the point there’s programmatic damage in those who have lost control over how much of the substance or behavior, and in those who have lost control over whether to use (initiation of the behavior). I don’t think that one can read the accounts of Bill Wilson or Bob Smith or other early AA’s and not agree that they were ‘sick’.

    • Marc November 29, 2013 at 8:59 am #

      I know that’s your view, Nick, and I really do see it both ways. But once, again, if loss of control is the criterion, then falling in love, whether with a person or with money, counts as disease as well. People lose control of their impulses all the time, and yes, that’s key to addiction. And addiction can be terribly serious. However…

  4. Jenny Hong November 29, 2013 at 8:32 am #

    Hi Marc, I think your book would be more accurate to (sub)title it as “Why addiction is not a brain disease, nor a free choice.”

    Also I think drug addiction is different from other addictions. For one, other addictions do not kill people when overdose.

    • Marc November 29, 2013 at 9:04 am #

      I don’t mind your title, Jenny. Just a bit wordy. But food addiction can kill too. And the proportion of people who actually die as a result of drug addiction is rather small. Probably less than five percent. And I’m not sure where to put smokers. The death rate is higher, but the disease label has a harder time sticking.

      • Kevin Cody December 5, 2013 at 10:56 pm #

        Thanks Marc for saying what your heart and mind tells you, whether right or wrong, only time and good science will tell.

        Anyone else in the meantime, me included which tries to say different is only coin tossing.

        We always forget about thrill-seeking junkies-mountain climbers, parachutists etc are all selfish-aholics.

        I also take exception with the idea of “losing control”, in the above example of the snake oil salesmen Bill and Bob-I think the best term is “finding it hard to control” or “finding a way to stop.” I think those AA’s sold us on the idea we had no power to control or stop…when in fact we are the only ones who do have the power and control to stop and/or get better.

        I think as humans, and not zealot religiousness-robots-or perfect in all ways we have a natural tendency to err especially in the realm of feeling good via brain chemicals…my examples where we intend to not break the speed limit to work and do or maybe drive too slow if you work where I do (out in the bloody cold), haha.

        Finding equilibrium might be the most sane thing we do…and for that help I thank you Dr Marc.


        • Marc December 6, 2013 at 7:04 am #

          Excellent points, Kevin. Indeed, we find it hard to control, but not impossible, and those are incredibly far apart on the spectrum. Yes, we err in the direction of feeling good. But another way to say it is that we err in the direction of protecting ourselves from feeling bad. We want to be SURE to avoid the suffering that seems just beyond the next curve. So our motivation (for using, for example) is not only “attraction” but also (after a while maybe only) repulsion — avoiding the bad. And that’s driven by anxiety (ie. fear) more than anything else.

  5. Nicolas Ruf November 29, 2013 at 8:47 am #

    Sorry. I’m not done yet; hit the post button by mistake. Here’s my point: if we think of kindling behaviorally as in cult members, depression sufferers, and OCD where the circuit closes, a closed system results, and one is caught in a trap that he/she can’t spring. Studies show that rats never decondition if their PFC is removed post conditioning. Other studies show that cue recognition and extinction involve new learning and are context specific. In the old environment the old learning is reinstated pretty quickly. This is what happens in relapse. Addictive disorders, whether substance or behavioral, can become kindled. There may or may not be neurodegeneration, they may or may not fit everybody’s definition of disease, some individuals may be able to gain or regain control (if kindling hasn’t occurred), and while we don’t want to over diagnose or misdiagnose, people aren’t going to die from abstaining; they well might from not. We need to stop fighting about what to call it and get better at helping those with it.

    • Marc November 29, 2013 at 9:10 am #

      I think I agreed with everything until the first clause of the final sentence. If addiction can be fully explained as a learned phenomenon, then where does the disease definition actually gain entrance? I can’t even imagine how the two would be reconciled. As I said in the post, I don’t want to indulge in a useless war of words. I really just want to know how it works.

      By the way, as you know, I think context dependence and the “kindling” metaphor are hugely important windows on the causal heart of the matter.

    • Kevin+Cody December 5, 2013 at 11:01 pm #

      people aren’t going to die from abstaining; they well might from not.

      I do not think this is a completely accurate understanding, they may well commit suicide or homicide if the addict is self-medicating with street drugs which appears to be a lot people, btw.

      • Kevin+Cody December 5, 2013 at 11:02 pm #

        BTW, I do agree with everything else above though.

  6. Elizabeth November 29, 2013 at 9:12 am #

    Holy, wow! What bravery it took to contest Nora Volkow. I’ve seen her speak a few times, but usually in giant venues (re: SfN). She’s quite a presence! Very strong. I’d be incredibly intimidated, but I’m glad there are those of you out there willing to challenge the status quo. If we don’t challenge the interpretation of the evidence presented by disease model (and fail to acknowledge dissenting evidence), we hold ourselves back in terms of scientific progress. I hope you feel proud for contributing to good science, and I hope you felt well-received in your expression.

    • Marc December 2, 2013 at 7:18 am #

      Thanks so much. Truthfully, I’m a wimp when it comes to this kind of thing. I often get nervous before speaking, especially if I’m about to challenge someone or something. And yes, she has a very strong presence, which must have helped her attain a position of great influence. But she’s also very likeable.

      Well, it’s all over now…until my book comes out. Maybe this was sort of a dry run.

  7. William+Abbott November 29, 2013 at 9:50 am #

    Well Marc Huzzah for you!!!. I was watching that segment live and I was out of my chair cheering for you when you took on Volkow. Shes so strident in this view and its way to unidimensional and simplistic. Sure it has some features of a biologic disease , but is that the whole story ? Hell no. !! And who cares if its a disease or not, we need prevention and treatment strategies that work .

    That being said , as a scientist myself, I still ask just what the hell is this thing that so gripped me. . And Im still fond of the idea of medicalizing it to get it out of the criminal justice system where it clearly does not belong with the well known disastrous failure of the war on drugs.

    Im not enough of a neuroscientist to know for sure but I sure am concerned about the specificity of neuro-imaging to be so certain about the changes seen as to cause and effect .And for sure they are at least partially reversible no matter what she says .
    This was an outstanding conference , and having HH behind this is a marvelous thing. So envious of your being there which however was hugely important as evident by the reactions to you . The world, even those emineneces there really dont understand this problem as we do- those with first hand experience. The scintific community still often has that prevalent opinion ” You have a alcohol problem? why dont you just quit ? ”
    Finally do you really want to write yet another book about Is it a disease ? What will it accomplish?? Id rather read what you really think it is, how we know this, and what we yet need to know – about its complexity and as yet unexplored sociologic ( in science effects) and yes spiritual aspects. . Mind altering substances alter the mind ( yes the brain too but thats not all ) Since we yet know too little as to how the mind works in even physical terms , much less even the brain itself, how can we take such a stance yet??


    PS – the DL really seemed to like Rat Park too.

    • Marc December 2, 2013 at 7:33 am #

      Hi Bill. Thanks…lots to chew on and I appreciate the good review. Three things to say:

      1. You say we might as well “medicalize” addiction to get it out of the criminal justice system. Yes, it has to get out of the justice system…in large part, but no, we don’t have to medicalize it. Think of, say, autism by analogy. It’s some kind of developmental shaping of a style of thinking and feeling. But it’s no disease. And it has many gradations, from Bill Gates on down to the Rain Man. Should we medicalize autism in order to make it better? Or should we adjust the way we conceive of cognitive/interpersonal differences so that autistic people fit more comfortably and productively with others?

      2. You’re right: the eminences really don’t understand it. That is the MAIN reason why I flog the importance of combining subjectivity with science. It’s not just a sales pitch. The scientists’ choice of what to examine is often a shot in the dark. they need input from addicts as much as addicts need input from scientists.

      3. I didn’t mention the part of the title that comes before the subtitle. It’s “The biology of desire”. I’m taking the stand that the machinery at work in addiction is a big part of just being a human animal. Long story. But I think it’s a good story, and the “disease” argument is partly a hook and partly a useful political/scientific stance. That’s how I see it. The book has to sell, after all.

      • William Abbott December 2, 2013 at 10:08 am #

        Dont get me wrong– medicalize is pure and simple political and pragmatic. Addiction , no matter what we call it has an identified cause , a morphology, and a ” treatment” that has some efficacy . Autism like Downs is a development problem for which there is little yet that can be done ” medically”

        And how else are you going to get addiction out of the criminal system where there is also tons of money already?? The medical profession and primary care in particular is well positioned to intervene early in the problem and its already known that so-called brief interventions are THE most effective ” treatment” yet known.

        The lack of understanding is a huge problem – and lergely responsible for the lingering stigma . To call addicts sick seems far preferable to generate empathy and compassion than degenerates and crooks.

        And the more of us willing to tell the truth about it is surely one way to ameliorate that.

        At the conference all the stuff about desire ( craving) pleasure, want and need was facinating and I suspect thats what you imply in the title?

        Anyway Ill buy it no matter what you call it 🙂

        • Marc December 2, 2013 at 10:53 am #

          Yes! Political and pragmatic…. ok, but… When you say “And how else are you going to get addiction out of the criminal system where there is also tons of money already?? The medical profession and primary care in particular is well positioned to intervene early in the problem” … are really only talking about one country. I know it’s hard for you folks to conceptualize, but there are others….. : < ) Political solutions are specific to particular societies. Science just doesn't work like that…well, mostly, anyway. We hope.

          You could send me the $30 now and I'll save you a copy when it's done…

  8. Dirk+Hanson November 29, 2013 at 10:31 am #

    Well, if you really plan to subtitle your new book “Why addiction is not a disease,” then I see why Volkow’s view is problematic for you, since the obvious alternative is that addiction is a lifestyle choice. I know you don’t really believe that, but the above subtitle certainly suggests it. The combative challenge of that subtitle doesn’t sound very conducive toward defining a Third Way.

    • Marc December 2, 2013 at 7:38 am #

      I should have mentioned the full title. My bad.

      “The biology of desire: Why addiction is not a disease” (working title)

      Because you’re right, I sure don’t see it as a choice (in the conventional sense). I see it as the result of a biological machine shared by all mammals that flips into a mode that makes it hard to turn off. I am indeed looking for a Third Way — a definition and model that does better than the two obvious contenders you mentioned. That’s the hope.

      • Dirk+Hanson December 2, 2013 at 10:14 am #

        “The Biology of Desire” is a great title!

        • Marc December 4, 2013 at 3:34 pm #

          Thanks. I like it too. Or should it be “The biology of need”? Since desire per se may not be the best description once you reach the compulsive stage. And/or should the subtitle be “How (not why) addiction is not a disease” ? Kent Berridge favored that one, and he has a very sophisticated and balanced perspective.

          Maybe write the thing first and worry about the title later….

        • Marc December 10, 2013 at 6:17 am #

          Dirk, I just came across an interview with you on a new addiction site, All Treatment (now listed on my list of relevant sites). Informative and thoughtful, as usual, but I was struck by the thought that my “anti-disease” stance these days is directly at odds with your “addiction is a disease” position. I know we’ve talked about this before, like last year in Amsterdam. What troubles me now is that we see eye-to-eye on so many things, it feels wrong to peg you as my arch-rival. Well, okay, I’ve lately delegated that spot to Nora Volkow — at least you’re in good company.

          Well, as you mentioned, above, it’s the choice-vs-disease debate that’s the root of the problem, and you know that “choice” is not my, um, choice argument. Anyway, this is just to say that I want to keep our dialogue going, or I should say re-start it, so that I can stay on track and not rehash or reinvent meaningless rivalries.

          What I think I want to emphasize in the upcoming book is an evolutionary trajectory. We went from the moralistic-punitive era, to the disease era, which gave rise to the disease-vs-choice die-off (a relatively minor ice age which left most species intact)….and now it’s time to move on to…..well, I still have to get that part crystal clear, no doubt, but it has to do with re-thinking the neural evidence in the context of development rather than disease.

          Anyway, it’s good to have you back on my radar, where I can keep track of you!

      • Julia December 12, 2013 at 11:51 am #

        Marc & friends, I finally got the time to read the post and got halfway through the comments (which are always great and as interesting as the post!) before I felt I had to add my two cents.

        I think the debate around “is addiction a disease or not,” is a dead-ended back and forth. Maybe it’s neither and both and the question itself inherently leaves out other questions that are far more important.

        I think we’re at the point in addiction (has anyone defined that to everyone’s satisfaction yet? I think not!) research that we were years ago with cancer (not trying to add weight to addiction as disease, just using a clear and simple example). Medical science now knows that all the conditions that were once classified as cancer are anything but one single thing. The word is almost becoming obsolete in the sense that the variety of cancers is vast and the differences between them so significant that they can barely be called the same disease. Some cancers are fairly easily treated and even cured while others are still almost completely mysterious and completely fatal.

        But I’m getting away from my main point. I understand my own experience with food addiction (now very long behind me) as simply a major detour/pothole along my journey of development and maturation as a person. In meeting life’s challenges (both particular to my life and those which are pretty universal) I fell into using some pretty damaging and unproductive behaviors and thought patterns. But my sense is that it could just as well have been any number of other sorts of detours, drugs, sex, cults, power, fame, etc., etc. except for the accidents of what came or didn’t come across my path when I was vulnerable. (And possibly also some individual proclivities, both inborn and learned which steered me in that direction.)

        Using the term addiction, for me, just reinforces my attention on what I’m trying to get AWAY from. The only way I got back on a better track to maturing and developing was to focus on that which would help me more productively address the challenges I was avoiding by obsessing about food. Equally important was finding ways and places to process emotions that had built up and were limiting my ability to access those more productive avenues.

        I really like the approach presented by Dr. Carl Hart (who think I mentioned in a comment to a previous post), author of High Price: A Neuroscientist’s Journey of Self-Discovery That Challenges Everything You Know About Drugs and Society. I don’t know if he says this in the book but in the Q&A after his talk he addressed the question of drug addiction being a problem in itself. He responded by saying that he tries to educate his own children about all the potential pitfalls and dangers they may be tempted to fall into as they go out into the world: alcohol, sex, driving recklessly, seduction by untrustworthy adults, as well as drugs.

        He tells them that there are any number of ways they can jeopardize their futures or even risk their lives and that using drugs in excess is simply one of them. He doesn’t worry that casually trying some of them (as long as the setting is not unsafe in itself), even the harder ones, will somehow instantly turn them into raving maniacs driven to use above all else. He cites the statistics which show that most drug users are functioning in their lives and that there is a continuum from total abstinence to self-destructive obsession. He emphasizes that the social context (availability of social support, job opportunity, respect from the larger society, etc.) is as important if not more so than the substance itself.

        All this to say that all this debate about terminology is completely absent what I think are the more important operative factors: looking a person’s whole life context, where and when they are born and grow up, who their parents are, what race, class, etc. they are born into… etc., etc., etc. Certainly understanding the biological mechanisms of learning, of substance use, of destructive behaviors, etc. is useful. But how to live well and how to negotiate the complexities of life successfully are beyond what any of that can tell us. That’s what I love about your work, Marc. It embraces the whole of a person, using a foundation of solid science but including the social and philosophical context. Don’t let your wonderful insights get hijacked by the addiction/not addiction debate!.

        I was lucky to have a lot of factors in my favor and believe that was essential in being able to pull myself back out of my “addiction” and find my way to being a more healthily developing person. Life is hard no matter which way you come at it. There are so many ways to get it wrong but what it looks like when you’re getting it right are pretty well agreed upon: treating oneself and those around you with respect and care, being engaged with others in mutually supportive ways, contributing to the greater good, continuing to learn and grow, taking pride in ones accomplishments and being acknowledging mistakes and faults.

        Thanks for the space to speak my piece… keep up the great work and looking forward to your new book! Julia

  9. Denise November 29, 2013 at 10:52 am #

    I side with you Marc, though I believe addiction has some aspects of a disease. Ultimately I would say it’s not important to debate over a label so much, however, as you (and NV) point out, what it’s called has serious implications for both treatment and for the psychology of the addicts ourselves. That being the case, I would rather define addiction as more of an existential issue. As an addict who comes from a family of addicts (parents and sibling), I am very aware of both nature and nurture aspects here. Again, though, I relate way more to the nurture part. Given who my parents were: how they lived their lives and their psychologies, my brother and I were doomed, however, not in the way someone who inherits the gene for breast cancer is doomed. While we may have inherited genetic components for the “disease” of addiction, we learned from day one of our respective lives, how to live and think like addicts because look who we imprinted on. We were guaranteed a fight out of those imprints in our futures. To me, this has little to do with “disease.” What also confuses me, and it could be that I don’t understand enough about it, but if NV would call drug addiction a disease because the brain gets damaged by chemicals, then where does the implication of knowing someone will be an addict (as in the case of my brother and me) before ever using any substances? Thanks again for all you’re doing!

    • Marc December 4, 2013 at 3:48 pm #

      Hi Denise. I too see early childhood experiences as highly formative. Well of course they are! Few people doubt that. So….if we see addiction as an extension of personality development (which I do) then a new model starts to emerge. Taking or doing stuff repeatedly is soothing (watch babies rock some time), it provides structure, hope, a sense of closure and companionship….many of the things we miss growing up with parents who aren’t completely there for us (maybe despite their best intentions).,

      So we might be “doomed” to addiction in the way that some people are doomed to passivity, or temper outbursts, or depression — rather than the way they are doomed to breast cancer due to genetic factors. These are really different “dooms” — one being psychological and the other medical. I guess the good news is that neither “doom” is definite…just probabilistic….and both can be overcome in a variety of ways.

      Our job is to figure out which ways are most likely to succeed, which will depend on how we classify the type of “doom” we’re dealing with.

  10. China Krys Darrington November 29, 2013 at 11:17 am #

    Marc, As someone who has done some government contracting on substance abuse curricula in the past two years, particularly some which is funded by SAMHSA, NIDA and IHS, I’ve learned that funding streams are fattened up with compassion and sympathy when you have a “disease” and revoked when there is *any* indication that a person might have 1% capacity to convince their cortex to make good decisions. “Yes I smoked an ounce of crack last night, but gosh darn it I AM A FORCE OF WILL and I demand that I stop smoking right *now* and take a shower so I can go to work!” Yeah, disease or not….I never was able to make that decision on a regular basis.

    The Federal agencies (and their mouthpieces) sometimes compromise their scientific demand for fact and measures, but the need to keep that budget fat. And if that means that I use the word “disease” and pull on some heartstrings to keep that money flowing….then so be it.

    I know I was at an Opiate conference last year with some of the leading Suboxone/Subutex prescribing doctors in our area and when I posited about the opiate receptors in my brain not really caring if I got it from the street, my grandmothers Oxycontin script or my MAT treatment professional’s prescription for me. As long at the “fuel” binds to my receptors then my engine will purr like a kitten.

    Couple that with the fact that several of those doctors are buying vacation homes from the extra money they are getting by being “X” prescribers while their clients have to decide between paying their mortgage or staying with their MAT prescriptions. Add a side order of judges, magistrates and PO’s saying “as long as your are on parole/probation you need to continue MAT.” (I think it’s so they know where they will be at 5AM each morning…in the MAT/Methadone line at the clinic! Easier to keep track of those pesky addicts.)

    So yeah. For those of us *with* addiction I personally don’t care if it’s a disease or not! Just what I’m going to do with this crazy obsession for more, more, more! But I’m all for someone saying the words that will get this industry as much money as possibly for research, treatment, housing, social supports, training and all the other good stuff we need as we emerge from that active addiction and all the strange and all the other crazy rules which that world operates.

    • Marc December 4, 2013 at 4:10 pm #

      Hi China. Your portrayal is much like that of Bill Abbott (above). But with a lot of the blanks filled in. And it’s an argument that fits very well in the introduction to the book I’m trying to write: The biology of desire: Why (or How?) addiction is not a disease. Does that sound paradoxical? It should. We’re calling addiction a disease because that’s what works best with the social ecosystem in which we live. From government money to golf games. So it’s not “really” a disease, or a “choice” for that matter, and the rationale for picking one label above the other has nothing to do with psychology OR medical science. It’s guided by social anthropology — the nature of the cogs of the societal machine we live in.

      I’d love to dispense with all that by the time I get to chapter 1. People like Bruce Alexander and maybe Stanton Peele have said what needs to be said pretty comprehensively already. I want to know what addiction is — scientifically — not which label serves our societal cuckoo clock the best.

      While reading your comment, it struck me that the medicalizing of drug addiction is very much like the move to make gambling cool and acceptable. I’ve learned that casinos actually send out Christmas invitations to compulsive gamblers, to keep the cogs turning, to grease the wheels. So your bad habits, whichever they are, fit in a social structure that is all built up already, and which has adopted various mechanisms to keep you from going over the edge, so that the structure will keep on keeping on. Methadone or buprenorphine for one, complementary return tickets and monetary “limits” for the other. Sounds a bit cynical doesn’t it.

      But logical, and sensible. Thanks for that perspective.

  11. Peter November 29, 2013 at 12:31 pm #


    I really like this blog post and I’ve watched a lot of the Mind and Life conference online, and it’s been fascinating. I think you raise some very good points here, especially by keeping behavioural and process addictions on the radar- but I question why you lean the way of basically saying because there are such things as behavioural addiction this provides further evidence or doubt as to addiction being a disease. Why can’t it be the other way, basically saying just as drug and alcohol addiction causes changes in brain chemistry and damages the brain, thereby giving weight to the disease model, perhaps behavioural addictions like food, sex and gambling damage the brain as well.
    I am very inspired that you are keeping behavioural addictions in the picture but now being in grad school for addiction studies I am seeing a tendency to hold drug and alcohol addiction on pedestals, but as you say the science seems to suggest there is little different in the processes between drug, alcohol and behavioural addictions. Why can’t all that further supporter the disease model rather than refute it?
    Thanks for your time.

    • Marc December 3, 2013 at 5:21 am #

      Peter, This is an excellent point. Why indeed? I guess because it gets harder and harder to draw a line. If over- (or under-) eating is a disease, if internet addiction is a disease…then what about compulsive shopping? What about compulsive arguing (which so many couples get into)? What about sexual fetishes? What about falling in love? That often comes to mind for me. Falling in love, especially the head-over-heels variety we often experience in high school or soon after, has so many of the same features as addiction proper, and I have no doubt that striatal activation patterns match up as well. So…….how could it possibly help our analysis, and where on earth would we place the parameters, if all these kinds of behaviours were classified as “disease”. That’s why I lean the other way.

      • Peter December 6, 2013 at 11:31 pm #


        Thank you for your response, I can see the dilemma, it becomes difficult to know where to draw the line. That being said the recovery field, and 12 step in particular has classified for a long time all sorts of behaviors that fall within addiction parameters and therefore disease paramters- as you’ve said before, look how many 12 step groups there are out there- some for overeating, sex addiction, love addiction, internet addiction, gambling addiction, emotions anonymous, Al-anon, codependency- heck you name it and it’s out there. What does this suggest about the level of health within society, I don’t know- but it is an unpleasant or sobering thought that most of us can find at least one or more groups to belong to. Does this make us all diseased? If you look at therapeutic theories, like family systems, it would suggest perhaps the entire organism is diseased, and therefore it has manifested itself in symptoms within every individual within the organism/system.

  12. cheryl November 29, 2013 at 12:36 pm #

    It really is important to have a book that asked Why addiction is not a disease. The stigma of disease is as bad as addict that has infiltrated law enforcement, government and now that you are in that system it infiltrates jobs, housing, child custody and more. I would like to know why we live in a society that is so unaccepting of disorders, all disorders. I would like to know why we live in a society that need a harsh label in order to treat it. Disorders occur in life that need to be addressed and some are more intense and pressing than others but as individual people and a society we better know and have faith that alone or together we can find a resolution to them. The system now does nothing but enter you into a system since it now is labeled under the government and health care which now affects every part of your life as long as you live. Every day you get to be reminded that you do not fit into this society, you are different, you must be punished. ITS A DISORDER that has now turned into a life sentence! Marc you say at the end of your post ” Most of the recovered addicts I’ve talked to would rather see themselves as, not in remission, but free. Maybe better than ever.” I think most would rather see themselves as the whole human being they are who just happened to get out of line with things for a while and happy that it passed. I don’t say Hi my name is Cheryl I’m a pregnant woman because first it would be obvious and second it happened 30 years ago that I was pregnant. Labels define from the outside in to the outside out. They matter in our society and our society is not nearly careful enough about the labels they pin on people. I am no scientist but would bet brain waves change depending on the label you have been pinned with. Words do matter and pretending they don’t is ignorant. The disease label is more for saving face with families and to gain government funding but the person who had a disorder for a while will pay both back the rest of their lives. Not sure the lable disease holds any advantage in the end.

    • Marc December 6, 2013 at 7:17 am #

      Cheryl, You make so many points that resonate with me, and I love the analogy with “my name is Cheryl and I’m pregnant” — Yes, experiences and habits come and go, but labels have a way of sticking. Actually, psychologists know a lot about the harm done by labels. There are many experiments that show that teachers will give lower grades to “students” (contrived by the researcher) who label themselves as “black” or “female” or whatever seems to be the out-group in that particular context.

      As for your larger message, disorders not diseases, I’m on board with that too. There are many who say there’s too thin a line between these categories, so it doesn’t matter which we use, but I think it’s a really important line. The sense of being overtaken or invaded or controlled by an outside agency is implicit in the word “disease” — and it perfectly captures what the NIH or ASAM want to say about drugs. Too perfectly. Because, as I think you’re saying, it’s just a way of sweeping up a mess, not a way of helping.

  13. Dirk+Hanson November 29, 2013 at 12:40 pm #

    One strong and true strain in these comments is: what does it matter what we call it, as long as we get better at loosening its grip. In January I’ll be attending a conference in Germany on neuroplasticity and addiction, with Carl Hart as one of the featured speakers. It will be interesting to see what kind of definitional issues arise.

    • Shaun Shelly November 30, 2013 at 3:43 am #

      Dirk, I would love to hear feedback from this conference. Actually I’d love to be there, but those of us who are unfunded working with the homeless and unemployed get little opportunity to travel!

      • Dirk+Hanson November 30, 2013 at 10:27 am #

        I plan to blog about the conference upon my return, and maybe a freelance piece or two.

        As you mentioned above, the disease concept was one attempt to throttle back law enforcement’s tendency to round up and jail addicts as social deviants rather than untreated medical cases. It hasn’t worked so well in that respect, except for controversial drug courts.

        • William+Abbott December 2, 2013 at 12:04 pm #

          Drug courts are still a step in the right direction

          • Kevin+Cody December 5, 2013 at 11:28 pm #

            will all respect, drug court vs jail time always take the jail time even if you want to quit….just my former life speaking up.

            The injustice system will be in all our lives why would one voluntarily subject oneself to more invasive injustice.

            Stupid idea, stupid implementation.

            Why not just CC the NSA/FBI/DEA to start off life?

      • Marc December 6, 2013 at 7:20 am #

        I’d love to be there too. In fact, I’m going to try my best, even if I have to drag my kids with me. Turn them into video-game addicts while Papa learns more about the brain’s plasticity. Thanks for turning us onto this, Dirk. Should we start up a fund to help Shaun get there too?

  14. Shaun Shelly November 30, 2013 at 4:20 am #

    As I have said Marc, I was very disappointed that your question came in so late and they went immediately to lunch. But I suppose that it would have caused some indigestion if the conversation had continued!

    After watching Volkow’s talk, and listening to her over the sessions, I realised that really there is a lot at stake regarding the disease concept and her adamancy comes from a desire to de-criminalise and treat substance users . It seems that in terms of the criminal justice aspect it is important that the disease concept is accepted. Unfortunately this has had implications on the treatment side, and the reductionist view is not helpful to finding effective treatments in the long-run.

    As previously stated, my personal view is that addiction occurs through the confluence of varied and confounding factors. These can accumulate in different proportions until the scale “tips” and the metaphorical switch is switched. These factors include areas as diverse as brain structure, religious beliefs, social context, attachment, direct drug chemistry and the like.

    Indeed I see most addictions as an extreme form of “normal” behaviours – it finds itself at the end of the bell-curve. However, for some people addiction does look remarkably like a disease, and I do believe that in a percentage of patients there is a disease component.

    This may seem even more so in the case of drugs that have a strong dependency component, such as with heroin addiction. If we do not treat the physical dependency we have little chance of treating the addiction. I personally believe that we need to treat this dependency issue separately from the “addiction” issue.

    When we look at OST studies with Buprenorphine, we see that a lot of heroin addicts, if they have good social support, only need the buprenorphine in the right dose, in a primary health context to find recovery. I believe that this is NOT proof FOR the disease concept, but rather against it. Change the set and setting and the addiction disappears, as long as we are dealing with the dependency issue effectively.

    So for me, I suppose, “dependency” is a pure medical issue, while “addiction” is far more complex and involves different approaches depending on the aetiology of that particular individual’s component parts that have helped tip the scale towards addiction.

    • Marc December 6, 2013 at 8:47 am #

      Shaun, I agree that the recovery of heroin addicts, given buprenorphine, in the right social context is indeed an argument AGAINST the disease concept. So is Rat Park, and so is the now legendary account of heroin-addicted Vietnam vets who got clean once they returned to the USA.

      For me, the only place where your account gets blurry is when you talk about physical dependency. I think you are saying that the physical dependency is the precise translation of “disease”….and nothing else goes in that box.

      Well, maybe, but so many addictive substances, including cocaine and, well, food and sex, and marijuana, do not promote physical dependency. Yet we know very well that addictions to these things can be extreme and intense. A disease model person would, I think, include these — or at least coke and pot — under the disease nomenclature. But you apparently would not.

      Can you clarify where you stand on this?

      By the way, your emphasis on multicausality is really important — and it serves as a constant reminder to me.

      • Shaun Shelly December 6, 2013 at 11:01 am #

        Hi Marc, what I am saying is that through the terminology used in the previous DSM, we think of dependency and addiction as the same thing. In other words that physical dependency, (like in stop taking this and you will die, or feel like dying, you have physical withdrawal symptoms), is the same as addiction, or perhaps a component of addiction. What I am saying is that I see this type of dependence as a separate entity to the addiction. So, some alcoholics become dependent – they stop drinking they may die. This is a result of pure chemistry. Same with heroin addiction – not that they will die, but the physical withdrawal is based on pure chemistry. Often the dependency requires a medical intervention. But just to cure the dependency does little to cure the addiction.

        People get dependent on pain meds and antidepressants and heart meds, but they are not addicted. In the same way that someone may be dependent on their buprenorphine, but they are not addicted.

        I hope that makes it clearer – many of these ideas are very fluid at this stage. I am grappling with the questions and trying to develop a model that is predictive and can inform treatment, which may take 2 lifetimes!

        • Marc December 6, 2013 at 4:50 pm #

          I understand your point, Shaun. I’ve always differentiated physical from psychological addiction — which is the same distinction you’re making.

          My question was simply whether physical “dependence” is equivalent to “disease” in your model — meaning that psychological addiction (what you call “addiction”) is a different animal.

          And there’s the other point, that addiction can easily arise without dependence, as exemplified by cocaine.

          • Shaun+Shelly December 7, 2013 at 1:48 am #

            Is physical dependence disease in my model? That is a difficult question to answer Marc. Would a doctor who prescribes an SSRi, which we now know causes dependence, say they are causing a disease state? I doubt it. So, no I would not say dependence is equivalent to disease.

            I am, quite frankly, still trying to understand what a disease is. I have read many definitions hundreds of times, and at times it seems that everything is a disease, and at others like nothing is!

  15. Bill Boswell November 30, 2013 at 9:54 am #

    I am a recovering cocaine addict/alcoholic. I have been in recovery for three years and practiced Soto Zen Buddhism those three years and attended NA and AA regularly. My practice of Zen Buddhism included a seven day Sesshin so I am not just giving Zen lip service.

    Buddhism/mindfulness alone would not stop my addictive behavior. I tried multiple times and relapsed. I have been clean and sober 4 months now. For me it took an ineffable God, perhaps thusness in Buddhist terms. Brad Warner does a good job of discussing an ineffable God in his book There is no God and He is Always with You.

    Just my own experience. I think drug addiction, alcohol is a drug, for addicts is qualitatively different than “addictions” of non addicts. As my Zen teacher shared, she has her addictions but she was not willing to self destruct in the ways you and I have.

    • Shaun+Shelly December 1, 2013 at 8:05 am #

      Bill, I think similar points came out for the whole Mind & Life dialogue regarding mindfulness as treatment. I’m not sure of your circumstances or experience, but certainly there was the feeling that mindfulness techniques could very helpful in preventative phase. Mindful awareness practice has also been useful as an adjunct to treatment. The experience I have had with patients in the contemplative stage has shown mindfulness-type practices help those afflicted with addiction make conscious decisions around their drug use. For many of our patients the goal is not abstinence, but conscious decision making around drug use, which we are finding often leads to abstinence!

      As your teacher says, almost all of us have our “addictions”, but only a few of us develop this pathological relationship with the object of our addiction.

      • Bill Boswell December 2, 2013 at 7:22 am #

        Mindfulness/Buddhism have most definitely helped me to face reality and live without drugs and alcohol. It also helped me to understand when I would make a conscious decision, as opposed to autopilot, to use again. I started to have a perspective on the emotions/inner dialogue I was escaping from. In order to totally abstain, I needed a twelve step program and an ineffable God. Again, just my experience. I know of others who recovered without mindfulness or a twelve step program.

        What prompted me to visit this site and comment was Dr Lewis’s article

        Overall I found it very informative. It did seem to infer that years down the road I could drink again. If he intended to say that, it seems like a very dangerous message, but perhaps I misunderstood. Maybe alcoholics/addicts can drink again with the right therapies.

        • jim maguire December 2, 2013 at 9:50 am #

          Subject: the disease concept and AA
          Marc,just read your Nora Volkkow’s dialogue . I wanted to add my .02
          about The AA community and the disease” world view ” in AA .
          Its almost a “red badge of courage” in AA. ” I have a permanent
          disease” ,” I’m an alcoholic ” , “I have road rage because I have this
          disease” ,I have trouble with relationships because Im an alcoholic”,
          I procrastinate because Im an alcoholic” and so on ad nausium . I
          could list hundreds of quotes . Sometimes I want to shake people and
          say your human for Christ’s sake ! We all have these issues or
          personality traits its not just addicts. Its humans ! I have about
          fifty employees and I speak with many and they have the same damn
          issues and most are not substance abusers .
          I think ,at least in the 12 step recovery community the disease model
          creates an “aristocracy ” among its adherents . Me and you we have
          this disease and as a result were different ,not necessarily in a bad
          way but in a bonding way like people who have a sport or hobby in
          common with each other. Along with that come the ” vernacular ” of
          that specific activity .” One day at a time” , ” let it go” etc. Golf
          it would be ” dog leg right, nice ly ,short game ( i hate fuckin golf
          never play ) . cops have their own, ex Marines,etc.I drag race and we
          have our own cause were cool, ” short time,”spray”, “hook up”,bump
          stick ” “good air” .Im tired of writing hope you get my point.
          The disease model bonds and binds us together and gives people a
          feeling of comradery ,fellowship and ameliorates that negative feeling
          of uniqueness and replaces it with a positive feeling of similarity
          within ” our group” ( like the Mafia ) .
          So I say, disease concept – maybe, Genetic pre-disposition – maybe,
          environmental aka family environment – maybe, luck of the draw – maybe
          . All of the above – probably ,theres that nasty ” overdetermined ” I
          hate because its so hard to qualify and quantify. In the end for me ”
          who cares” .
          Im not defined nor limited by what I did in the past . I think I’m
          enriched by it and I have accumulated knowledge other people don’t
          have and I wouldn’t change it for the world.
          Be well,Jim Maguire

          • Denise December 4, 2013 at 9:09 am #

            Right on, Jim!

          • Marc December 15, 2013 at 10:09 am #

            Hi Jim. I love your comment. This is a completely different perspective. Readers of this blog and I too have criticized the disease model for this and that. But I can see that it creates a club people can join and then identify with. All you have to do is sign off on your willpower, self-direction, responsibility, and you’re in.

            I shouldn’t be so cynical. There is an optimism and warmth that goes with belonging, and of course those feelings help us get by. You put it really well here. It reminds me of the value cancer patients and victims of abuse get from joining groups specifically built around whatever terrible things have happened to them. The problem comes, as you say, when you put the word “because” into the equation. I can’t do this because I’m an x. I have trouble with that because I’m a y. Causation just doesn’t work that way. These labels are descriptive, at best, and they don’t actually represent any cause-effect relation.

            That’s the whole problem with the disease model, in my humble opinion, in a nutshell. It completely bypasses the issue of causation.

        • Marc December 6, 2013 at 5:13 pm #

          Hi Bill. Many who are dependent on alcohol and on various drugs (probably NOT heroin, and maybe not coke) can indeed use again in a conscious, deliberate way….without becoming “readdicted” according to most standards. The stats bear that out. It’s not really disputable. (though it generates tons of debate, often under the rubric of harm reduction — probably not the right place for it.)

          So yes, I’m saying that some alcoholics CAN become social drinkers. See Richard’s comment just below. But the reason I think and hope my message is not dangerous is that I would never advise this for anyone. There’s a great deal of individual diversity here, and people probably don’t really know whether they can drink again, socially, unless they try it. On the other hand, if they try it and fail, it’s probably not the end of the world. They’ve learned something about themselves that’s important to know.

      • William+Abbott December 2, 2013 at 12:09 pm #

        Mindful Awareness Practice is not THE solution but sure seems helpful as part of the package.

  16. Richard Henry December 2, 2013 at 1:42 pm #

    YES! I won… I beat the torment of the daily use of substance abuse. Today I live a life of moderation, although I prefer not to drink, I can on a occasion go out for a beer with my son. It’s like I have had a second chance, a chance to start all over, the experimental stage of use, and yes I do enjoy on occasion a treat with other past addictions. It is no longer a means to avoid sadness but only a means of enjoyment with an end. For me learning the repercussions and the negative affects of what I went through, keeps me from crossing that line again. Thanks for sharing Nora Volkow video I found it very educational..
    Regards Richard Henry

  17. Persephone December 4, 2013 at 10:26 am #

    Marc, thank you. I completely agree, the stigma is just as bad either way, and while I’ve met many who WILL boast of their incurable diseases (that is endemic to any chronic pain support circles, and it sickens me in that arena as well) I find that most people would rather just not be sick in the first place. Regardless of the illness. Which, of course, leads to the thought that much of it is an inability to move on and stop dwelling on it.

  18. NN December 4, 2013 at 11:22 am #

    Hi Marc,

    I’m so glad you challenged Ms. Volkow, and I think your arguments, as evidenced above are getting sharper.

    I think you have focused on a key one: Just because one can give an account of semi-unusual brain events/states in addicts–i.e. describe a physical basis–does not mean we have ‘disease.’ It is quite possible that there are unusual brain states for compulsive shoppers, hair-pullers, overly zealous joggers and crazed novelists like Balzac who stay up all hours (eat poorly, etc.) trying to get a book written.

    But I think the issues of ‘what’s at stake?’ has to be clarified, particularly as regards scientific issues. You want to say–I think–that barring the extreme and degenerative cases, looking for *brain disease* (as opposed to brain process), is sort of like, in the old days, looking at the phsiognomy or skull shapes of criminals–it’s pseudo scientific, wrong, and just doesn’t lead anywhere, in part because lots of it is backwards reasoning (looking firstly at criminals’ faces or heads).

    Unfortunately there doesn’t seem to be a useful and common term; ‘bad habit’ seems mild; ‘stuck’ or maladaptive behavior pattern isn’t quite enough. Corruption of learning is pretty good: I think for example of those pidgeons that got fed randomly, and developed all kinds of weird ‘superstitious’ behaviors; were they diseased? Further, I’m sure you’re aware of the debunking of the ‘rats who do anything for cocaine’ experiments, which in their set-up left no healthy alternatives.

    Rats, like returning Vietnam vets, have natural ways out the addictive pattern. This element, self- or spontaneous cure is crucial, as I’m sure you’ve said. You will note that the phenomenon is mentioned neither in AA literature, nor the most recent formulations of the American Society of Addiction Medicine, which echo AA, and say,

    [i]Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.[/i]

    Keep up the fight, my friend,


    • Marc December 5, 2013 at 8:06 am #

      Hi NN. I follow you completely. I love the analogy with — what’s it called? — phrenology, the bumps on the head. And yes, the trick is to find another category for it. Ideally a category with a compelling and provocative name. But what if it’s a category of one? That’s not much of a category. That would be like saying, a fence is a….fence. Yet there are things like that. Colour? What type of thing is a colour? No type at all…it’s a category of one.

      I think “habit” comes close, but, as you say, it’s a bit too mild. And yet “habit” is an immensely important concept. So much of what we do and who we are depends entirely on habit. That’s what “learning” tries to establish…and what mindfulness attempts to break down. And what Kahneman calls “system 1” thinking — quick, automatic, and not very smart.

      So far, consistent, right?

      In writing the book, this is exactly what I’m searching for. And I’m thinking that the term “habit” viewed as a stable outcome of personality development is the direction I want to go in.

      Thank you, my friend, for your ongoing support and very good ideas.

  19. NN December 4, 2013 at 11:36 am #

    Here are some references to back up some of the statements of my last post:

    Interview with Dr. Carl Hart, regarding his autobiography, _High Price,
    A Neuroscientist’s Journey of Self Discovery that Challenges
    Everything You Know about Drugs and Society_.

    C.L. Hart, M. Haney, R.W. Foltin and M.W. Fischman
    Alternative reinforcers differentially modify cocaine
    self-administration by humans
    Behavioural Pharmacology 2000, Vol 11 N

    Carroll ME, Lac ST, Nygaard SL 1989 . A concurrently available
    nondrug reinforcer prevents the acquisition or decreases the
    maintenance of cocaine-reinforced behavior.
    Psychopharmacology 97:23- 29.

  20. NN December 4, 2013 at 11:57 am #

    Comments on Bill Boswell’s points,

    Bill Boswell November 30, 2013 at 9:54 am #

    I am a recovering cocaine addict/alcoholic. I have been in recovery for three years and practiced Soto Zen Buddhism those three years and attended NA and AA regularly. My practice of Zen Buddhism included a seven day Sesshin so I am not just giving Zen lip service.

    Buddhism/mindfulness alone would not stop my addictive behavior. I tried multiple times and relapsed. I have been clean and sober 4 months now. For me it took an ineffable God, perhaps thusness in Buddhist terms. Brad Warner does a good job of discussing an ineffable God in his book There is no God and He is Always with You.

    Bill Boswell, Dec 2, 2013.

    Mindfulness/Buddhism have most definitely helped me to face reality and live without drugs and alcohol. It also helped me to understand when I would make a conscious decision, as opposed to autopilot, to use again. I started to have a perspective on the emotions/inner dialogue I was escaping from. In order to totally abstain, I needed a twelve step program and an ineffable God. Again, just my experience. I know of others who recovered without mindfulness or a twelve step program.

    I want to underscore the issue you mention in your last sentence. Yours is a single case. So your comments, echoed by William Abbott, that mindfulness programs may be insufficient on their own; that the stern stuff of AA may be a required addition, have to be placed in perspective. Their general applicability is open to question. It could well be, of course, that such issues as making a commitment, having a group witness it; proceeding step by step ('one day at a time') are vital components. But that is something short of the AA overall package.

    More importantly, however, that mindfulness alone fails (or has failed you) has to be taken along with the fact that AA (and similar) fails a majority of the time.

    I'm not making any special plea for 'mindfulness,' though I think it's intriguing and promising. I'm simply saying that one needs to look at evidence, not anecdote, to arrive at a general conclusion. And if I had to guess what the real evidence shows, it could be that a number of combinations have worked for different people; while commitment may be vital, no one program is essential to recovery.

  21. Persephone December 5, 2013 at 11:29 am #

    Latest thoughts on the disease model and Marc’s thoughts on learning. Pardon me for thinking out loud a bit here:

    Having now experienced another withdrawal syndrome that was devoid of any addictive thinking, using, abuse or craving, I have noticed too many similarities. The looping thoughts are the main component. Obsessive thinking, which isn’t focused on anything specific. (Completely anecdotal, and based largely on support groups for people in withdrawal without addiction as a component in the last year, specifically low dose benzodiazepine.) People during addiction learn their “normal” as Marc describes, the process of desire building into procuring and using a drug, then relief. That’s the normal. People not using addictively but prescribed just have whatever their normal is. Yet the withdrawal process in both cases seems to be predicated on looping obsessive thoughts. In addiction cases, these thoughts frequently are on using their drug of choice. However, in non addiction cases of bad withdrawal, the thoughts are on both normalcy (that’s what is craved) as well as the symptoms of withdrawal. Hypochondria is a major symptom listed for these withdrawal syndromes, even when the people have never had such a problem and even though it abates. It’s essentially an issue of uncontrollably obsessive thoughts driven by fear. Fear of the abnormal, which for the addict is function without the drug of choice. Same thing.

    Regardless, the thoughts circle and circle endlessly, and I believe it is essentially the same phenomenon, neurologically speaking (the common thread, as I perceive it, being the nervous system). They eventually do go away, thankfully, but those who never go back to normal (on the non-addicted side) tend to spiral into nervous system disorders, in other words, the brain getting stuck in the temporary process, so to speak.

    Sorry for the stream of consciousness thinking out loud, just had to get out my unplanned bizarre research project of the year. Desire is the root, and learning to just be seems the polar opposite, which is quite Buddhist. But what to do in the meantime when the “desire” isn’t real, but a product of a brain that got shot into a realm of operation well outside of its normal range?

    • Marc December 6, 2013 at 5:04 pm #

      Thanks for posting this. It sounds like you’re talking about an OCD-like phenomenon. In previous posts I’ve described OCD as a sort of grandfather of addiction. The common thread is very evident, but it;s not just the “nervous system” — it’s the striatum, in fact probably a subcomponent of that structure (the dorsal striatum). When using is no longer driven by reward-seeking, then thoughts about it are no longer driven by craving (desire). The aim becomes a packaged behavior that gets triggered and has no off-switch. That’s the same with OCD. The main emotion involved is anxiety, or fear, as you say. And it’s really rather shallow: what I fear is not being able to complete the act….that would be so awful. Clearly this is also a phenomenon that builds on itself. As they say, the thing we’re most afraid of is fear itself.

      • Persephone December 6, 2013 at 5:36 pm #

        Yes, it does seem rather OCD like in nature I suppose, and structurally could be exactly the same (you obviously know more than I do). The main difference to that and how you describe it in your comment is that it’s still just a withdrawal syndrome, and it does end. I experienced this when I was taken off of everything 3 years ago, and it resolved completely, and it does with many of the people I’ve been observing as well. It’s like a chemically triggered period of extreme OCD-ish-ness that eventually resolves?

        I’ll reread those posts, but I find this fascinating and would love to know more.

  22. Jenny Hong December 6, 2013 at 6:31 pm #

    Marc, there are many comments are not shown; they are blank. Is there a problem with this blog site?

    • Marc December 8, 2013 at 7:06 am #

      I don’t see this, Jenny. It could be a problem with your browser…?

  23. Lovinglife52 December 9, 2013 at 4:42 am #

    Well done for challenging the disease theory. I feel it holds so many back in their recovery. It gives a poor excuse for dreadful lifestyle choices. My recovery has been based on taking full responsibility for my actions and changing the way I live. I do see addiction as an illness. Like many, I have also used mindfulness and have recently started to write a few ideas myself, which I hope to develop in the future.
    Many mainstream recovery methods hvae not moved with the times, and many do not find the type of help they need.

    • Marc December 15, 2013 at 9:57 am #

      Hi. I’m a bit confused: you see addiction as an illness, but you don’t like the “disease theory”. Anyway, I’m glad to hear that you resonate with some of the points I raised above.

      • lovinglife52 December 15, 2013 at 4:38 pm #

        I see addiction as an illness caused by lifestyle factors, such as stress or the need to escape reality or responsibility. It is a learnt behaviour and after a while becomes a coping mechanism. This may lead to extra problems such as depression being magnified, which in turn means that further attempts, at self medication go out of control.

        I see a disease as something you catch from a virus etc. It can be down to bad luck although again, lifestyle can play a part. The thing I don’t like about the disease theory, is when people say they have no choice about becoming and addict, and I heard this a lot when I was in a 12 step group. I feel, too many are looking for an excuse for their past actions, and as a result, do not find a good solution for their problems. I believe the only way to beat and addiction, is to be determined, take it seriously and take responsibility for your life and actions.

        I feel once you have done this, and changed the way you think , you can move on and be free. This is much better than saying you have a disease, and that you are powerless over it. You still have the thought process of an addict, and in fact you can reinforce those feelings of being a victim. It is an unrealistic approach for me.

        If you change the way you feel about a substance, and something like mindfulness, can really help this, then you will react in a different way, to somebody who still views themselves as an addict, even after years of abstinence, in moments of pressure. By being a victim, you set yourself up for failure.

        I view addiction as a self inflicted illness, because I always had the option of stopping, yet chose not to do so for many years, until most parts of my health were seriously affected. I would have died by now if I had not stopped as my liver was failing.

  24. NR Sign Inc. December 16, 2013 at 1:20 pm #

    When you label something, you negate it. Such as calling it a disease. It is not helpful.

  25. Jaliya December 19, 2013 at 12:57 pm #

    “Drugs damage brain tissue.” ~ This one sentence stands out in my (first, rather quick) reading of this post and its comments.

    I think: Injury.

    Over time, and with immoderate use, any ingested substance (other than food and water, which we require to ingest for survival) can damage — injure — the material of us.

    Perhaps it’s time for us to consider the bodily damage — however it shows itself — as injury.

  26. Patti Lewis May 12, 2015 at 12:58 am #

    Though I seem to be a bit late to the party, I salute you for challenging Nora Volkow on her chronic brain disease premise of addiction. I was most interested in the list of arguments she ran through in your follow-up chat, especially the final one, “Arguing definitions is futile. Call it anything you want. The point is to get help for people who need it. And if we don’t treat addiction as a disease, it won’t be treated at all.” Might I use this quote, obviously citing you and your article as the source, in a piece I’m completing now addressing the critical implications of her chronic disease definition? My email is noted above, and I invite you to visit my site. I’d appreciate hearing your thoughts. Thank you very much.

  27. Peter. December 19, 2015 at 6:43 pm #

    Thanks for that, I like Nora Volkow as a person, she comes across as very compassionate and very intelligent, I’ve always wondered how she could disregard the environmental aspects of addiction and, still use caged rats as an evidence base for drug related findings. But reading her more candid remarks, maybe she is not so seemingly blind to other factors in addiction but chooses to pursue a path in order to get results that she believes to be for the greater good, rightly or wrongly. I believe some bits right but quite a lot wrong. I don’t question her motives though ,I think she genuinely believes that this is the best avenue to help people in relation to “chaotic” substance use but after reading that I think that privately she must reflect a bit more on this than she would appear.

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