SEEING DRUGS AS A CHOICE OR AS A BRAIN
Dr. Alan I.
Leshner, the director of the National Institute on Drug Abuse,
a division of the National Institutes of Health, is known for
his slide shows. Two or three times a week he
The slides are of brain
scans, and they usually come in pairs. The
"before" slides show the
Lacing his presentation with
jokes and Yiddish expressions -- as a youth, Dr. Leshner
What the science shows, he
says, is that the brain of an addict is fundamentally
different from that of a non-addict. Initially, when a person
uses hard drugs like heroin or cocaine, the chemistry of the
brain is not much affected, and the decision to take the drugs
remains voluntary. But at a certain point, he says, a
"metaphorical switch in the brain" gets thrown, and
the individual moves into a state of addiction characterized
by compulsive drug use. These brain changes, Dr.
Leshner says, persist long after addicts stop using drugs,
which is why, he
In promoting this concept,
Dr. Leshner has stepped forthrightly into a debate that
Others are not convinced.
"I reject the notion that addicts fall under the spell of
The idea that addiction is a disease is not new. In the 1960's Alcoholics Anonymous began speaking of alcoholism as a disease. But, initially at least, A.A. used the term figuratively to suggest the tenacious hold drinking has on alcoholics. Over the last decade or so, however, advances in brain-imaging technology have allowed researchers to measure the impact of psychoactive substances on the brain with increasing precision. Investigators have found that drugs like cocaine, heroin and alcohol increase the brain's production of dopamine, the neurotransmitter that regulates pleasure, among other things. This helps account for the euphoric high drug users feel. But these drugs deplete the dopamine pathway, disrupting the individual's ability to function.
At the Brookhaven National Laboratory on Long Island, for instance, Dr. Nora D. Volkow has found that even 100 days after a cocaine addict's last dose, there is significant disruption in the brain's frontal cortical area, which governs such attributes as impulse, motivation and drive.
Dr. Volkow says that
"the disruption of the dopamine pathways leads to a
decrease in the
Dr. Herbert D.
Kleber, the medical director of the National Center on
But does causing changes in
the brain qualify addiction as a brain disease? Not according
to Dr. Gene M. Heyman, a lecturer at the Harvard
Medical School and a research psychologist at McLean Hospital
in Boston. "Since we can visualize the brain of
someone who's craving, people say, 'Ah hah, addiction is a
brain disease,' " he remarks. "But when
someone sees a McDonald's hamburger, things are going on in
the brain, too, but that doesn't tell you whether their
behavior is involuntary or not." While acknowledging that
addiction does induce compulsive behavior, Dr. Heyman
says that addicts still retain a degree of volition, as
"Smoking meets the
criteria for addiction, but 50 percent of smokers have
quit," he says.
Sally Satel first became skeptical about the brain-disease model in 1997, when she attended a conference of the drug-abuse institute on the medical treatment of heroin addiction. "So pervasive was the idea that a dysfunctional brain is the root of addiction that I was able to sit through the entire two-and-a-half-day meeting without once hearing such words as 'responsibility,' 'choice,' 'character' -- the vocabulary of personhood," Dr. Satel wrote in a paper called "Is Drug Addiction a Brain Disease?" Written with Dr. Frederick K. Goodwin and published as a booklet by the Ethics and Public Policy Center, the paper offers a blistering attack on the drug-abuse institute and its brain-disease terminology. "Dramatic visuals are seductive and lend scientific credibility to NIDA's position," the paper states, but politicians "should resist this medicalized portrait for at least two reasons.
First, it appears to reduce
a complex human activity to a slice of damaged brain tissue.
Second, and most important, it vastly underplays the reality
that much of addictive behavior is
Of the 1,300 people who were
found to have been dependent on or abusing drugs, 59 percent
said they had not been users for at least a year before the
interview; the average time of remission was 2.7 years.
"The fact that many, perhaps most addicts are in control
At the mention of Dr.
Satel, Dr. Leshner bristles. "Simplistic and
polarizing," he says of her writing. More generally, Dr.
Leshner maintains that his views have been distorted and
But where does choice end and compulsion begin? The slide showing that has not yet appeared.
Michael Walker specializes in treating addiction and chemical dependency.