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
gives a speech — to treatment counselors and prevention specialists, physicians and
policymakers — and almost all feature slides culled from the work of the 1,200 researchers
supported by his institute.
The slides are of brain scans, and they usually come in pairs. The “before” slides show the
activity of a normal brain; the “after” ones depict a brain that has had prolonged exposure to
Lacing his presentation with jokes and Yiddish expressions — as a youth, Dr. Leshner
summered at a Catskills hotel owned by his grandparents, and he has a bit of Alan King in
him — he tries to translate the science into plain English.
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
continues, relapse is so common. Addiction, Dr. Leshner declares, should be approached
more like other chronic illnesses, like diabetes and hypertension. Going further, he says that
drugs so alter the brain that addiction can be compared to mental disorders like Alzheimer’s
disease and schizophrenia. It is, he says, a “brain disease.”
In promoting this concept, Dr. Leshner has stepped forthrightly into a debate that has
smoldered for decades: are drug addicts responsible for their behavior? Should they be treated as sick people in need of help, or as bad people in need of punishment? Dr. Leshner has come down squarely on the side of illness. And he is winning many people over. Today the brain-disease model is widely accepted in the addiction field, and Barry R. McCaffrey, the White House drug adviser, routinely invokes it.
Others are not convinced. “I reject the notion that addicts fall under the spell of drugs and
become a zombie and so are not responsible for anything they do,” says Dr. Sally L. Satel, a
senior associate at the Ethics and Public Policy Center in Washington and a practicing
psychiatrist at a methadone clinic. To her and other critics, the brain-disease model is a new orthodoxy based less on science than on a desire to soften the stigma attached to addiction.
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
reinforcing value of normal things, and this pushes the individual to take drugs to
compensate.” Other researchers have found a physiological basis for the craving so many
addicts experience, but it is not yet clear how long such physiological changes remain.
Dr. Herbert D. Kleber, the medical director of the National Center on Addiction and
Substance Abuse in New York, says that the brain-disease concept fits with his experience
with thousands of addicts over the years. “No one wants to be an addict,” he says. “All
anyone wants to be able to do is knock back a few drinks with the guys on Friday or have a
cigarette with coffee or take a toke on a crack pipe. But very few addicts can do this. When
someone goes from being able to control their habit to mugging their grandmother to get
money for their next fix, that convinces me that something has changed in their brain.”
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
evidenced by the many who stop using drugs.
“Smoking meets the criteria for addiction, but 50 percent of smokers have quit,” he says.
This change, he goes on, is “demonstrably related” to the data about the hazards of smoking
that have emerged since the surgeon general’s report on the subject in 1964. By contrast, Dr.
Heyman says, “information about schizophrenia hasn’t reduced the frequency of that illness.”
Dr. Heyman also cites a well-known study of Vietnam veterans who were dependent on
heroin while overseas.Within three years of their return to the United States, the study found, nearly 90 percent were no longer using it — strong evidence, Dr. Heyman says, that the addictive state is not permanent.
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
voluntary.” To support that claim, Dr. Satel cited the results of the Epidemiologic Catchment Area study, paid for by the National Institute of Mental Health, which asked 20,300 adults about their psychological history.
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 of their
actions and appetites for circumscribed periods of time shows that they are not perpetually
helpless victims of a chronic disease,” Dr. Satel said.
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
misinterpreted. Still, he says, he has lately modified his message, giving more recognition to
the role of volition in addiction. “Today’s version,” he says, is that addiction is “a brain
disease expressed as compulsive behavior; both its development and the recovery from it
depend on the individual’s behavior.”
But where does choice end and compulsion begin? The slide showing that has not yet appeared.
Dr. Gnap is a family practice physician and behavioral medicine specialist in suburban Chicago. Dr. Gnap developed the Inner Control™ Program in 1970 and has worked with thousands of people to improve and correct medical, emotional, behavioral and learning problems including performance. He started the Inner Control program because so many patients asked, “what more can be done along with traditional treatment methods?”