The great debate?

Hi again. It’s me this time. No guests. I want to tell you about the debate I just had with a high priest of the Disease Church. Not the bishop, Nora Volkow. But her second in command, George Koob.

Those of us who oppose the disease label have been trying to organize a real debate for a long time. Nora Volkow has consistently ignored these requests or else replied No through her staff. But Koob made an marclewisgeorgekoobexcellent second choice. Judging by his picture and digital presence, I expected a slightly stodgy, soft-spoken academic/scientist type who saw addiction as a disease.

In fact Dr. Koob is the second author of the paper first-authored by Volkow in the January issue of the New England Journal of Medicine, the paper that made a lot of us anti-disease people more irate than usual. Here’s the title: Neurobiologic Advances from the Brain Disease Model of Addiction. And here’s a passage from the first paragraph:

In the past two decades, research has increasingly supported the view that addiction is a disease of the brain. Although the brain disease model of addiction has yielded effective preventive measures, treatment interventions, and public health policies to address substance-use disorders, the underlying concept of substance abuse as a brain disease continues to be questioned…

I used this quote to launch a counterattack that was published last week in the Guardian. I was pleased to see my little fusillade appear on page 1 of the US edition last Tuesday. And it’s snagged over 600 comments and 2,700 shares in the first week. So a lot of people seemed to agree with my criticisms of the disease model (specifically the claim that the disease label led to an “effective” response to addiction and reduced stigma). But, if you happen to browse the comments, you’ll see that many others thought I was out to lunch.

I actually wondered whether Koob had already read my article. Because he seemed hopping mad from the first words of the debate.

Here’s how it went.

I was sitting in a flashy looking studio in Arnhem. Yes, even in my town we have studios with lots of computers and screens and expensive looking microphones. So I was sitting there in a sound-proof room in front of a state-of-the-art mic, and George Koob was in Washington. The debate was set up by CBC (Canadian Broadcasting Corp — Canada’s national radio) and will be broadcast a few weeks from now. I’ll let you know.

I was nervous. More nervous than I’ve been in any kind of talk or interview for a long time. My voice came out raspy at first. Yet I’d done my homework. I’d reread lots of stuff on changes to the dopamine system, Berridge’s review of his incentive sensitization model, findings on the desensitization of the striatum and the resultant loss of connectivity with the prefrontal cortex. I’d also scanned articles showing that these brain changes are common to drug addiction, porn addiction, obesity, “internet addiction,” and even compulsive shopping — so I had a few arguments ready.

I’d also read a few Koob papers (which I forgot I’d already read thoroughly until I found my yellow highlighting throughout) and felt completely caught up on his theory of the “dark side” of addiction, viz withdrawal, viz the rebound invoked by the “antireward” system. I was ready to talk brain science, because I had no doubt (and I still have no doubt) that George Koob is a top neuroscientist, highly respected and rightfully so. Not to mention the director of the National Institute on Alcohol Abuse and Alcoholism.

But within minutes of the word Go, I realized that I’d done all that cramming for nothing. This debate wasn’t going to be about the neuroscience of addiction. It wasn’t going to be smart, sophisticated, strategic, or fun. It was going to be a slug fest.

The moderator/host (a seasoned radio/TV person in Toronto) started things off by asking Koob: Why do you say addiction is a disease?

He replied something like: What else could it be? And when she asked for a bit more substance: Because it changes the brain. It’s as simple as that. That’s what he said, almost verbatim. And I thought: that’s the most vacuous argument he could possibly make. Everybody knows that the brain is always changing, it changes whenever we learn something, it changes massively throughout development, and there’s this thing called neuroplasticity which is basically the brain’s job description. But that’s what he said: addiction is a disease because it changes the brain. So I had to retort with…well, some version of what I just said.

It didn’t get any better. He sounded angry throughout. He was belligerent at times. He talked about how four people he was very close to had died from alcoholism, because they could not stop drinking. Absolutely could not stop. And he specifically accused me (and us anti-disease folk) of trivializing addiction by not recognizing that it’s a disease. I told him I’d lost a friend to addiction too, but I wasn’t pleased with myself for stooping to such arguments. He even said that I wanted addicts to be stigmatized and that’s why I opposed the disease label. Which was exactly the opposite of what I’d just said: that I felt the disease label merely entrenched the stigma of addiction, and there were much better ways to overcome stigma, like connection, compassion…all the things Johann Hari writes about….and understanding what it really is without giving it a simplistic label.

I’d better stop. I don’t remember everything, and maybe my memories are blurred by the adrenalin I was surfing through most of the debate….which lasted about 45 minutes.

But here’s the point I want to make. I’m pretty sure I “won” the debate because I said smarter things and backed them up better than my opponent. And I’m pretty sure I came off smelling sweeter because my tone wasn’t as antagonistic as his.


The problem is that we weren’t talking. We were just fighting. We weren’t listening to each other. We weren’t getting to know each other’s views any better. We certainly weren’t arriving at some kind of middle ground that might benefit from both our perspectives.

And that is so sad!

47 thoughts on “The great debate?

  1. Shaun Shelly June 13, 2016 at 4:48 am #

    That’s the nature of people who’s entire careers are built on quick-sand. It must be very frightening and attack is the only form of defence. He can ONLY support a single point of view. The paper in the NEJM is an absolute disgrace – it says nothing, and the defence of the rebuttal is even worse!

    Sorry it wasn’t a more intelligent debate Marc.

    • Marc June 13, 2016 at 8:17 am #

      I felt the same way about that article, Shaun. It was the self-righteous tone, and the pedantic confidence underlying the points made, that were the most offensive to me. Still, I wish I’D been more intelligent in my responses. As is often the case, I thought of a lot of things I SHOULD have said on the drive home.

  2. David Hardgraves June 13, 2016 at 6:06 am #

    What seems very sad Marc is the futility of misguided intelligence, perhaps even driven by hidden agendas (one can only speculate) and the counter-productivity of its connection to power and influence. Why must the ability to concede to a better supported theory – that also highlights the limitations or faults of other, often competing beliefs – be so rare? Change Of Heart Disease? Anti-Realisation Syndrome? Common Sense Cancer? Acknowledgement Deficit Disorder? Or maybe it’s because it’s not a disease either. Rather, it comes back to the complexity of us beautiful but flawed creatures and our trials and tribulations in our ever changing environments.

    • Marc June 13, 2016 at 8:15 am #

      Beautifully put, David. But of course I suffer from that “ailment” as well. How much more effective might I have been if hadn’t become defensive in response to his jabs. I might have said “I see your point, but…” at least a few times. But I don’t think I did even once.

      My greatest hero in the neuroscience of emotion (Don Tucker, U of Oregon) once summed up everything he thought and felt about emotion, and though it’s rather simplistic, it’s stuck with me for years: emotion makes you stupid.

  3. Mark June 13, 2016 at 6:34 am #

    I’ve been studying and teaching listening skills to aspiring professional listeners (clinical psychology graduate students) for 25 years. I’ve researched and written a half dozen books on the subject. I’ve come to believe, for many reasons, that Skillful Listening is one of the most challenging spiritual practices that one can take up.

    One reason: the better you get at it, the more you care and connected you become, the more likely you are to hear things your brain (and heart) simply aren’t ready to hear, along with all the neurobiological stress responses that usually generates.

    Marc, the most useful response after I find I’ve been listening unskillfully (and I consider myself a C+ listener much of the time) is kindness and self-compassion and … a resolve to return to this incredibly difficult practice.

    • Marc June 13, 2016 at 8:20 am #

      That is so true. And the other fringe benefit is that you actually earn the chance to modify another person’s perspective….which is a rare event, let’s face it.

      • Mark June 13, 2016 at 8:56 am #

        I also suspect, although I haven’t researched it, that much more reward circuitry comes into play from talking than it does from listening. But that doesn’t necessarily mean learning and rewiring can’t happen. We have a name for people for whom that listening sensory reward circuitry rewiring may have happened – we call them saints. Saint Dopamine. 😉

        • Marc June 15, 2016 at 3:28 am #

          Hah! But yes, talking is action, listening is motionless. Actions of all sorts initiate dopamine uptake, part of which increases arousal, excitement, anticipation, and an assertive forward-thrust. Listening is a completely different trip. It sounds cheesy, but listening is a lot like love.

          • Mark Brady June 15, 2016 at 6:29 pm #

            Paul Tillich thought the first duty of love was to listen, and Dave Isay built his whole StoryCorps enterprise on the notion. 😉

    • matt June 16, 2016 at 9:34 am #

      This is so true, and the most relevant emotional impediment is fear, my favorite acronym from AA: False Evidence Appearing Real. I always catch myself fearing logical inevitabilities characteristic to all humans. We fear change, we fear difference, and we really fear being wrong because it exposes our vulnerabilities, that our perspective may be flawed and we may be putting ourselves and others in danger. As you say Mark, the best antidote to this is kindness and compassion, to others and to ourselves.

  4. Tim Greenwood June 13, 2016 at 7:08 am #

    Really looking forward to listening to the CBC broadcast. I get where Koob is coming from. Like so many others I know those whose addictions have taken them to their grave or are going to take them there. Many of those have tried countless interventions unsuccessfully. Don’t think the “disease’ model answers this conundrum any better than the learning model. Because if it were a disease why were these individuals not ‘cured’ by the interventions? I think Thomas Kuhn’s observations on Scientific Revolutions and how change in paradigms tends to come with the death and passing of the most dedicated adherents is apparent in this current situation. Don’t know if it will take “death” but something close to it.
    Think this whole issue is so difficult because it related to the most profound and perplexing questions about free will and fate. Today I had this thought – one can be addicted to anything and everything except for Spiritual Growth. Spiritual Growth one has to choose each and every day. Here is the other side of that – at least in my experience and the experience of many others – Spiritual Growth and commitment to a Higher Reality is the Path out of Addiction.

    • Marc June 13, 2016 at 8:32 am #

      Tim, these are wise words indeed. Your extract from Kuhn’s thinking reminds me of how that famous bible passage was explained to me as a kid: the Hebrews had to wander in the desert for 40 years, not because the Holy Land was so far away but because all those who were raised in slavery had to die off before real freedom was possible. (Too bad that didn’t quite work out.)

      As for the disease-cure issue, one of my challenges to Koob during the debate was to name one drug that cured addiction…taunt, taunt…though I did give lip service to OST for helping opiate addicts in withdrawal or maintenance. It was a cheap shot on my part. There’s no medication that can cure Alzheimer’s or pancreatic cancer either…but those are certainly diseases. I was just fed up, because Koob, like other disease model people, insisted that doctors are the ones who should be at the front line, and, except for OST and some adjunct services (like SSRIs for depression and benzos for seizures), that seems so completely irrational to me. Doctors don’t have a clue what to do for most addictions!

      • Terry June 13, 2016 at 6:31 pm #

        Exactly Marc. Current approaches by the establishment to medicalise the issue further by providing the smokescreen of medical cannabis which distracts from the real discussion needing to be had about legalisation and the attitude towards drug users only enhances the nonsense of having legal drug pushers funded by big pharmacology taking over. Doctors are handmaidens of big pharma and do little else of any use (except for surgery) than write scripts. Being under the control of a doctor who has little or no life experience of the real world is scary. It is only slightly better than having a judge in charge, or a politician. Any moves to have those with vested interests change opinion is going to be tough, real tough, and many as you have found out will simply not engage in any debate. A bit like trying to bring about world peace by removing armies through challenging and changing the rationale that bigger guns and more nuclear bombs prevent wars.

        • Marc June 15, 2016 at 3:37 am #

          Man, those are strong words. I also despise the influence of Big Pharma. My brother is a GP, and he is hounded and manipulated by that entity at every turn. Still I wouldn’t say that George Koob is rigid in his stance because of his vested interests. I think he really believes that addiction is a disease because of the modifications to brain circuits that he has studied.

          It’s not a stupid position, and it’s not intrinsically wrong-headed. I just see it as inadequate, a limited step toward a more precise and more powerful explanation. The problem occurs when players in the rehab industry take hold of this (inadequate) model and make it into the holy grail and then profit from it. The fact that this system is so big and so powerful helps explain how it can back up (think reflux) to affect the thinking of the scientists at the wellspring of the neuro data.

          Also, neurobiologists have an unfortunate tendency to ignore the potency of social and psychological forces in people’s lives, not to mention societal and financial realities. So the disease model makes their thinking simpler and, obviously, a lot less constructive than it might be.

          • Terry June 15, 2016 at 6:08 pm #

            My passion overtakes at times. Only because I see so much failure to help those with addictions because so many continue to abide by the illusion that the disease theory is an answer and a solution when in fact we in the industry because of that have very little to offer our clients in the way of solutions. Yes there is merit in that theory to a degree, ask any alcoholic who seemingly cannot stop the obsessive self destruction. And yes doctors are victims also not only of big Pharma but also of those many who believe they have all the answers when in fact they have very little to offer other than pills and potions. Perhaps we all need to stop and admit we don’t know much of what is going on despite the grand theories and thus should try a different approach. Give science a problem and they will find a scientific answer but as you say it doesn’t factor in the other aspects of humanity. Addiction is more biopsychosociocultural and spiritual than simply bio.

      • John Fox June 17, 2016 at 8:26 am #

        I think your correct I have worked in the area of OST for over 13 years in the UK and worked with many GPs in my time. Who are lost around what to do at times. The best outcomes I have seen is when someone re-learns how to cope with situations in their life. This has been through work and self empowerment and the want to change. The disease model can just become an excuse and justification for some addicts too. I am recovered addict who does not believe in the disease model. Like I said further down the page I have re learned how to live my life by educating myself around my problems causes and solutions to maintain change. I have a life I do not have a disease this stigmatises me more than what my addiction did.

    • matt June 14, 2016 at 3:57 pm #

      Hi Tim

      Addiction did almost take me to my grave, as it did many of those very close to me. It didn’t because I didn’t give up, but more importantly, I had a cadre of caregivers and loved ones who didn’t give up on me. Not everyone has that luxury. Calling it a disease doesn’t help them. Calling it a maladaptive behavior that needs to be replaced by an adaptive one might, as long as there is access and options. But that’s a social problem, not a medical one.

      Maybe the old guard needs to die off, but there are a lot of people just fed up and following the old adage, ” It’s easier to beg forgiveness than to ask permission”, and changing things for the better by force of will. (yes, taking back our will can be a good thing.)

      I agree with you that there is necessarily a large spiritual component. When someone understands and overcomes a negative addiction, they become a better person just by virtue of doing the right thing for themselves— and consequently for everyone else. I don’t think it requires connection or commitment to a Higher Reality. Good old garden variety reality works just fine.

      • Marc June 15, 2016 at 3:40 am #


  5. Annette June 13, 2016 at 8:45 am #

    Marc, it’s great that the debate happened but sad that views were entrenched. Some people would rather die (literally) than change – we see it around us all the time. Great comment from Mark, btw. Skillful listening is darn, darn hard!

    My family all died too young from their addictions, which made me feel very angry and helpless. But I also know that we CAN find a way out, and it’s through some kind of surrender where the resistance and stuckness to the substance (and poor me syndrome!) just starts to melt away. Spiritual discipline certainly helps, along with mindfulness and getting in touch with that prefrontal cortex and compassion. The ‘disease’ tag is just too simplistic, imho. Does it make the medical profession and pharma feel they’re doing a grand job? 🙁

    Society also prefers people to stay stuck. Judgement about addiction + projection: they’d rather point fingers than sort themselves out first), it seems to me. Recovery is possible – I managed it after 40 years of heavy drinking, without rehab, or medication.

    • Marc June 15, 2016 at 3:49 am #

      I hear you loud and clear, Annette. One of the things that bothered me most about Koob’s argument is that he said it was “you people who deny that addiction is a disease” who are hampering the system of care. He said this, I think, after I pointed out the inadequacy of medical and rehab resources despite the huge glut of money they take in. He literally said we need more of those resources: addiction is gravely undertreated. And that’s your fault! That made me mad, and I remember saying something like: It’s you guys who have all the influence wrt policy makers, government, research funding bodies, the courts, and treatment settings themselves. You can’t blame us because it’s not working!

      Then it turns into a finger-pointing extravaganza, and nobody comes out the wiser.

  6. Peter June 13, 2016 at 8:48 am #

    Well, it seems to me that the argument is really about the scientific process. If Koob’s immediate response to intellectual challenge isn’t based in science (you’re spoiling the progress we’ve made so far…..), it seems to reveal that there may be a biased interpretation of the current data to “fit” a predetermined theory. Not great science, even though the intention is very noble.

    We are talking about a word, a label that has an agreed upon definition. I find that I often think I know the meaning of words I use everyday, but often my understanding is just a bit off. So, looked it up in the Cambridge dictionary.

    Before I read your article Marc, I was thinking that addiction is much more like ADHD, than cancer…..go figure. But there seems to be many “diseases” where the symptoms are caused either by physical predisposition (coronary artery disease), or lifestyle choices (bad diet, etc.). Addiction is sort of like that. Isn’t addiction sort of like that?

    I think Koob is trying to fit the data to reinforce his noble cause (bad for science, and irritating to scientists), and I think we need more research in the area of brain development/brain pathology. I think better knowledge in this (these) areas will be more likely to direct new treatments than pursuing the “disease” model further.

    • Marc June 15, 2016 at 3:55 am #

      Yes, Peter, addiction is “sort of like that” — emphasis on “sort of”. Regarding the use of words, I sometimes think and sometimes argue: What if I asked you what sex is? Or what politics is? Would you tell me it’s a this or a that? There are things that don’t fit larger categories….they are things in themselves, and they can’t be reduced (to simple components) or joined with other “things” in categories defined by other words. What is life? What is ambition? Just try fitting the big meanings into smaller categories. It doesn’t work.

      I hear you about the benefits of simplification for people’s thinking, scientists included. See above. Also you’re in the company of Maia Szalavitz, a very smart and thorough commentator on addiction, to say that it’s like ADHD. A learning disorder is just what she calls it. That’s close enough for me.

  7. Jennifer June 13, 2016 at 9:08 am #

    Hi Marc,
    This is so interesting. I have a situation in our family of addicts – addiction with an underlying yet to be diagnosed chemical imbalance/ personality disorder. Is it possible
    or probable one can have a disease as well as addiction (non disease). It does not
    surprise me that Koob takes the position that he does. I have spent the past month
    watching Drs. trying to treat a disease, they are dogged, it is what they are trained to do.
    I guess we should be thankful for that. Thank you for fighting to have your work heard.
    My personal experience seems to have fallen into your model. I do have family members that haven’t.
    I look forward to your future work.

    • Marc June 22, 2016 at 4:36 pm #

      Hi Jennifer,
      The water gets pretty muddy when we delve into all the definitional issues. Is depression a disease? Well, not normal depression, but maybe bipolar disorder? Major depressive disorder? There are colliding zones or overlap zones, to be sure.

      So you’re right: we can respect doctors for what they do best, and we shouldn’t try to shout down those who talk about addiction and disease in the same sentence. Rather, I think, we should enrich the conversation by showing that all mental problems, from autism to schizophrenia to depression, develop. And if we think seriously about development then we can talk about how some pathways get stuck and others keep evolving. I think that’s the crux of it with addiction.

      • Jennifer June 22, 2016 at 6:50 pm #

        I like the way you put that! Development and stuck pathways. I think of ruts in the road. How do we get the dangerous pathways to atrophy and the healthy to grow? I admire your work and your effort to move the conversation forward. Thank you!

  8. Erin June 13, 2016 at 11:58 am #

    Please keep trying. I’m at the premier drug addiction conference in the U.S. right now and am so disenchanted with it all….didn’t hear Koob speak yesterday but did hear Volkow. They really and truly believe the disease model will reduce stigma. I know faculty mentors who have also gotten very angry at suggestions that addiction is not a disease.

    What that unquestioning view leads to is uninspired research. The topics here are digging deeper and deeper into the brain, leaving little room for a sense of humanity. There is of course a place for dry papers, but they dominate here. Of all the conferences that could be interesting, this should be it! You really have to try hard to make drug addiction uninteresting. I think that’s their goal – that so-called objective distance will get us the answer we’ve struggled to find for centuries.

    All of the scientists winning awards here are from neuroscience or biology and most of the sessions are along those same lines. What I wouldn’t give to attend a conference driven by research based on these different perspectives from you, Hart, and others, with people at the center of the work – people who are addicted, the people in their families, the people they turn to for help. I recognize there might be better conferences for that kind of work, but most likely not in the U.S.

    • Marc June 22, 2016 at 4:44 pm #

      What you say is fascinating, Erin. Okay, I will keep trying, and thank you so much for pushing me in that direction. (sometimes I do feel like giving up)

      Yes, they really and truly believe that calling addiction a disease is helpful, in reducing stigma, objectifying the problem, and sewing it up in the impersonal language of neurobiology. They are sincere people, their heart is in the right place, and they are very determined. And it’s not that they’re “wrong”…it’s just that they miss big pieces.

      Those of us who’ve lived with addiction in our lives see it in a way that “objective” career scientists often miss. And I love science, don’t get me wrong. But like you, I want to expand the view of what it is we think we’re studying.

  9. John Fox June 13, 2016 at 1:33 pm #

    Marc being a recovered addict and following yours and other people’s work around the anti disease movement If that’s what we can call it. And of course my own work as a substance misuse practitioner. I hated been told I had a disease. I am not diseased I don’t have a disease. I had past traumas,environmental factors and learned behaviours. I now have a life and not a diseased one. I feel I have learned new things new skills opened up new pathways that were underdeveloped due to my addiction and the age I started using substances. I do not have a disease I have a LIFE today

    • Marc June 22, 2016 at 4:47 pm #

      It’s good to hear you say it so simply and clearly, John. Many of us in this blog community see it the same way. I can’t tell you how many times I’ve heard former addicts not only reject but also recoil at the notion that addiction is a disease.

  10. John Becker June 13, 2016 at 4:28 pm #

    Denial is characteristic of addictions, it’s probably safe to say, just like open-minded curiosity is a key value in the practice of science. When confronted with this person denying any alternative to the disease model, with this guy suggesting that even stating a contrary view dishonours the suffering of people with addictions, I sense that I’m facing a person in the addiction frame, not in the science mode.

    By calling addiction a disease and calling addicts sick, he is denying that addictions are part of human nature. And however terrible our addictions are, to say that they are abnormal denies that the problem of addictions is one we all share. Because in fact, addictions are about us, all of us human beings, and understanding addictions is about understanding ourselves, and hopefully, it’s about learning to act responsibly.

    Even as he accuses those of us who oppose the disease label as trivializing addictions, he is doing just that. We have all lost people to addictions. As tragic as this is, we must also realize that the psychology of addictions is at the heart of our growing global crisis, in the destruction of our planet’s environment, and in economic and social injustice. The behaviour of consumerism, the hyper-capitalism that feeds it, our cradle to grave distractedness, these are our new addictions in action, and what is truly being denied is not respect for those we’ve lost, but our responsibility to take what addictions uncover about us, and use it to save the world for future generations.

    • John Fox June 14, 2016 at 2:47 pm #

      Here here well said

  11. Psych Nairo June 14, 2016 at 1:01 am #

    Indeed it is sad but all is not lost- at least the debate has begun and hopefully will boil down to a discussion that will lead to help for the addicts and the people immediately affected. you are doing an amazing job helping us understand addiction.

  12. Yeferson June 14, 2016 at 4:28 am #

    Hola Marc, saludos desde Colombia.

    En mi paìs y regiòn todo el mundo y hasta mi universidad argumentan que es una enfermedad, pero yo opino que no es asì. He leìdo algunos escrito suyos, que me brindan bases para argumentar algo que ya venia pensando: “La Adicciòn no es una enfemedad, es otra cosa, pero no es una enfermedad”.

    Le pido respetuosamente me regale minutos de su tiempo para compartir ideas y experiencia. Soy un estudiante universitario, pero inquieto eso sì.

    Nuevamente, saludos y mi reconocimiento por su labor. Es grato conocer alguien que opina cientìficamente algo distinto a la ciencia mèdica occidental.

  13. Richard Henry June 14, 2016 at 6:51 am #

    Way to go Marc…
    You the man!
    keep up the fight.
    You guys should have went on the Dr, Phil show, he could of helped you guys debate? hahaha…
    Although he had the U.S Minister of Health on there one day claiming drugs and alcohol “Highjack the brain” I was very disappointed in the show and in that they have a lot of people who trust Dr. Phil and then to have the Minister of Health say a person’s Brain gets Hijacked was ridiculous in my view. I wrote a couple of articles to debate that theory in response to the show.
    Cheers Marc

  14. Donnie June 14, 2016 at 1:41 pm #

    I’ll just leave this here again :

    When AA co-founder Bill Wilson was asked in 1960 about AA’s position on
    the disease concept, he offered the following response:
    “We have never called alcoholism a disease because, technically speaking,
    it is not a disease entity. For example, there is no such thing as heart disease.
    Instead, there are many separate heart ailments, or combinations of
    them. It is something like that with alcoholism. Therefore, we did not
    wish to get in wrong with the medical profession by pronouncing
    alcoholism a disease entity. Therefore, we always called it an illness,
    or a malady – a far safer term for us to use.”

  15. Cheryl Riley June 14, 2016 at 4:44 pm #

    Thank you for your perspective.

  16. Percy Menzies June 14, 2016 at 5:48 pm #

    Yesterday Dr. Williams, a research psychiatrist from Columbia University in New York City spent several hours at my clinics talking to the staff on how we treat patients with addictive disorders. We treat patients ranging from CEOs to street addicts and suffice to say he was impressed.

    This morning Dr. Williams did a three-hour workshop on the use of MAT in the treatment of alcoholism, nicotine and heroin addiction. It was a very balanced, objective presentation devoid of any personal biases or comments that so often sully our discussions. Just to remind our group that the US has around 28 million addicted to drugs and alcohol (does not include smoking) and less than 10% receive any medical intervention. Imagine if neurologists got into an argument whether Parkinsonism is a disease or a disorder or cardiologist debated if cardiovascular problems was a disease or disorder. The treatment regimen is the same. We have over 29,000 people die from legal and illegal opioids and over 100,000 die from the complications of alcoholism per year and we are debating if addiction is a disease or disorder!

    And how many medications do we have to treat addictive disorder? Exactly eight and we expend more energy attacking these medications rather than see how they can help patients.

    The stigma is going to persist no matter what we call the problem. Show better outcomes and the stigma will fade away. These patients are desperate for help and debates and talk shows, do little to help these patients and remove the stigma.

    • David June 14, 2016 at 8:03 pm #

      I believe that determining whether it is a disease or a disorder would be step one in figuring out the best way to treat it. I spent (wasted) 35 years in a program based around the disease therory. I finally figured out that my lifelong struggle with addiction was actually bad behavior. Doing any kind of activity too much eventuall becomes problematic. Drinking or using is a behavior not a disease. I had always seen my addiction as partially beyond my control because I believed I had a disease I had no control of except to treat it with meetings and a Higher Power and keep professing that I was an addict every time I spoke. I could stay sober if I did that stuff but I hated it and I hated my like. I realized THAT was the thing behind my feelings that were behind my bad behavior. I have a theory that there would not have been a desire to feel diffrent if I had loved how I felt my and loves their life. If that had been the case I would not have hurt myself all those years trying to escape the way I felt if I had a wonderful life and I was happy. If I liked how I felt I would not have tried to change that with drugs I eventually became addicted to. I believe addicts need to figure out what causes their bad behavior and correct it. Relapse is what happens when the root cause gets brought to the surface and the addict goes back to the only skill they have to change their feelings. Recovery for me meant finding the source of my pain and unhappiness and addressing those issues. I have no desire to use drugs to change my feelings anymore because I have skills that work better than the drugs ever did plus I do not want to get messed up and miss one minute of this life that I love so much or the people who are in it. The disease theory only helps the doctors and pharma stay in business. It is hurting addicts because you are right about how many a dying from addiction. That is exactly the point of this debate. I do not want to die anymore and my interest is only helping others to see what their problem is so they can figure out a path to achieve success in their recovery. I believe this is the most important debate of our lifetime. The industry professionals should be ashamed of a 5 to 8 % success rate for addiction recovery. A pill will not show anyone what their problem is. There is no pill that can cure bad behavior because all my bad behavior was based around looking for a pill like that. I was never powerless. I was sold a lie. That lie nearly killed me. An expert or a program could have never cured me. They made me believe that certainly I could not cure myself when the truth was I AM THE ONLY ONE WHO CAN.

      • Marc June 15, 2016 at 3:21 am #

        David, I read this and it seems to incorporate many of the same realizations other people express who’ve been involved in 12-step/disease-model based treatment. That this goes on for decades, and people don’t start to love life and love themselves a bit more, is so very sad. I’m glad you realized that the possibility for control was within yourself. That’s really the whole story, right there.

      • John Fox June 17, 2016 at 8:28 am #

        I truly agree David well written and well said.

  17. The Addicts Mom June 14, 2016 at 7:25 pm #

    If you are looking for online support dealing with a family members addiction, please find The Addicts Mom group on Facebook.

  18. Karen Tutt June 19, 2016 at 5:41 pm #

    Addiction is a disease, because it changes the brain?? As Marc says, the brain is constantly changing. A lot of emotional problems, found to be associated with brain wiring and brain chemistry, were assumed to be genetic / inborn, but are now thought to arise during the baby’s first few months of life, and even before birth, as a result of interaction (or lack thereof) with caregivers. This is the subject of Sue Gerhardt’s book Why Love Matters: how affection shapes a baby’s brain.

  19. abraham hempel July 10, 2016 at 1:31 pm #

    This reminds of a hilarious absurdity in the movie School of Rock. Jack Black complains to his 3rd grade students that he is badly hungover and one of them sarcastically shouts, ” You have a disease dude!” This scene really captures the divide between what we semantically associate with “disease” in everyday parlance and the medical use of the “disease of addiction”. Ask the question “Is smoking cigarettes a disease, or does it cause diseases like lung cancer and OCD?” Maybe a disease can cause a disease? I don’t know.
    I am not one for victim blaming or a hard nose neoliberal attitude of personal responsibility. However, I think many people may need the empowerment of taking responsibility for their unconscious choices to become an addict. 12 step meetings con offer guidance and a we-can-attitude, and that is their beauty, but the group dynamic can be impersonal and isolating as well.
    I think the concern is with the disease model the subject gets wiped in the sands of time, and you are just left with a brain but no person. The same thing that has happened with psychiatric diagnose, where its all a chemical imbalance.

    • Marc July 10, 2016 at 5:53 pm #

      That is an eloquent synopsis of what many of us in the “anti-disease” camp feel. As for losing the subject, yes, for sure. I’m a neuroscience person but I’m not interested in a brain with nobody home.

  20. Ollie Morgan PhD July 15, 2016 at 9:38 pm #

    I’m so sorry you were treated this way. Seems to me we need more humility from the disease AND the choice crowd. Neuroscience can tell us a lot about WHERE the addiction problem is and WHAT the mechanisms are. But, it limits our focus on addicted individuals. Hari, Alexander, Szalavitz and yourself remind us that connections, attachment, relationships and social ecology are also powerfully involved. Seems to me these factors hold more promise for recovery.

    • Marc July 16, 2016 at 8:01 pm #

      I totally agree, Ollie. Even though my work has been focused on brain mechanisms, I know that there is only one way to change the brain (short of whacking someone on the head)…and that’s to change the activity (read: experience, sensorimotor feedback, engagement, etc) that this brain is involved in. Experience change is THE inroad to brain change, and because the brain is most tuned (from infancy onward) to socioemotional events, judgements, goals, etc., changing the addict’s interpersonal flowthrough is the ticket to changing his or her neural configurations. Even supporters of the disease model should recognize this (but they don’t, usually).

      And yes, humility is critical. We have to start listening to each other. No one is “right” yet.

  21. Margot August 3, 2016 at 11:56 pm #

    I know I’m behind … but I just caught up on this terrific post. The learning has to be how to think on your feet to disarm your opponent emotionally when you are under attack like that. Easier said than done! I’ve watched similar tirades against Sam Harris. The debate is not a debate when one party makes so many assumptions about the other … it is not a level playing field emotionally. Fascinating. So difficult to take emotion out of debate sometimes, but I don’t think we can effectively debate unless we are at least willing to keep emotions under control and have the courage to test whether our assumptions are correct or not. This is a great example. We should learn to be aware ourselves … if we are getting emotional … are we really listening?

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