The
United States is stuck in its drug abuse metaphors and in polarized
arguments about them. Everyone has an opinion. One side insists that we
must control supply, the other that we must reduce demand. People see
addiction as either a disease or as a failure of will. None of this
bumpersticker analysis moves us forward. The truth is that we will make
progress in dealing with drug issues only when our national discourse
and our strategies are as complex and comprehensive as the problem
itself.
A core concept that has been evolving
with scientific advances over the past decade is that drug addiction is
a brain disease that develops over time as a result of the initially
voluntary behavior of using drugs. The consequence is virtually
uncontrollable compulsive drug craving, seeking, and use that interferes
with, if not destroys, an individual's functioning in the family and in
society. This medical condition demands formal treatment.
We now know in great detail the brain
mechanisms through which drugs acutely modify mood, memory, perception,
and emotional states. Using drugs repeatedly over time changes brain
structure and function in fundamental and long-lasting ways that can
persist long after the individual stops using them. Addiction comes
about through an array of neuroadaptive changes and the laying down and
strengthening of new memory connections in various circuits in the
brain. We do not yet know all the relevant mechanisms, but the evidence
suggests that those long-lasting brain changes are responsible for the
distortions of cognitive and emotional functioning that characterize
addicts, particularly including the compulsion to use drugs that is the
essence of addiction. It is as if drugs have highjacked the brain's
natural motivational control circuits, resulting in drug use becoming
the sole, or at least the top, motivational priority for the individual.
Thus, the majority of the biomedical community now considers addiction,
in its essence, to be a brain disease: a condition caused by persistent
changes in brain structure and function.
This brain-based view of addiction has
generated substantial controversy, particularly among people who seem
able to think only in polarized ways. Many people erroneously still
believe that biological and behavioral explanations are alternative or
competing ways to understand phenomena, when in fact they are
complementary and integratable. Modern science has taught that it is
much too simplistic to set biology in opposition to behavior or to pit
willpower against brain chemistry. Addiction involves inseparable
biological and behavioral components. It is the quintessential
biobehavioral disorder.
Many people also erroneously still
believe that drug addiction is simply a failure of will or of strength
of character. Research contradicts that position. However, the
recognition that addiction is a brain disease does not mean that the
addict is simply a hapless victim. Addiction begins with the voluntary
behavior of using drugs, and addicts must participate in and take some
significant responsibility for their recovery. Thus, having this brain
disease does not absolve the addict of responsibility for his or her
behavior, but it does explain why an addict cannot simply stop using
drugs by sheer force of will alone. It also dictates a much more
sophisticated approach to dealing with the array of problems surrounding
drug abuse and addiction in our society.
The essence of addiction
The entire concept of addiction has
suffered greatly from imprecision and misconception. In fact, if it were
possible, it would be best to start all over with some new, more neutral
term. The confusion comes about in part because of a now archaic
distinction between whether specific drugs are "physically" or
"psychologically" addicting. The distinction historically
revolved around whether or not dramatic physical withdrawal symptoms
occur when an individual stops taking a drug; what we in the field now
call "physical dependence."
However, 20 years of scientific research
has taught that focusing on this physical versus psychological
distinction is off the mark and a distraction from the real issues. From
both clinical and policy perspectives, it actually does not matter very
much what physical withdrawal symptoms occur. Physical dependence is not
that important, because even the dramatic withdrawal symptoms of heroin
and alcohol addiction can now be easily managed with appropriate
medications. Even more important, many of the most dangerous and
addicting drugs, including methamphetamine and crack cocaine, do not
produce very severe physical dependence symptoms upon withdrawal.
What really matters most is whether or
not a drug causes what we now know to be the essence of addiction:
uncontrollable, compulsive drug craving, seeking, and use, even in the
face of negative health and social consequences. This is the crux of how
the Institute of Medicine, the American Psychiatric Association, and the
American Medical Association define addiction and how we all should use
the term. It is really only this compulsive quality of addiction that
matters in the long run to the addict and to his or her family and that
should matter to society as a whole. Compulsive craving that overwhelms
all other motivations is the root cause of the massive health and social
problems associated with drug addiction. In updating our national
discourse on drug abuse, we should keep in mind this simple definition:
Addiction is a brain disease expressed in the form of compulsive
behavior. Both developing and recovering from it depend on biology,
behavior, and social context.
It is also important to correct the
common misimpression that drug use, abuse, and addiction are points on a
single continuum along which one slides back and forth over time, moving
from user to addict, then back to occasional user, then back to addict.
Clinical observation and more formal research studies support the view
that, once addicted, the individual has moved into a different state of
being. It is as if a threshold has been crossed. Very few people appear
able to successfully return to occasional use after having been truly
addicted. Unfortunately, we do not yet have a clear biological or
behavioral marker of that transition from voluntary drug use to
addiction. However, a body of scientific evidence is rapidly developing
that points to an array of cellular and molecular changes in specific
brain circuits. Moreover, many of these brain changes are common to all
chemical addictions, and some also are typical of other compulsive
behaviors such as pathological overeating.
Addiction should be understood as a
chronic recurring illness. Although some addicts do gain full control
over their drug use after a single treatment episode, many have
relapses. Repeated treatments become necessary to increase the intervals
between and diminish the intensity of relapses, until the individual
achieves abstinence.
The complexity of this brain disease is
not atypical, because virtually no brain diseases are simply biological
in nature and expression. All, including stroke, Alzheimer's disease,
schizophrenia, and clinical depression, include some behavioral and
social aspects. What may make addiction seem unique among brain
diseases, however, is that it does begin with a clearly voluntary
behavior--the initial decision to use drugs. Moreover, not everyone who
ever uses drugs goes on to become addicted. Individuals differ
substantially in how easily and quickly they become addicted and in
their preferences for particular substances. Consistent with the
biobehavioral nature of addiction, these individual differences result
from a combination of environmental and biological, particularly
genetic, factors. In fact, estimates are that between 50 and 70 percent
of the variability in susceptibility to becoming addicted can be
accounted for by genetic factors.
Over time the addict loses substantial
control over his or her initially voluntary behavior, and it becomes
compulsive. For many people these behaviors are truly uncontrollable,
just like the behavioral expression of any other brain disease.
Schizophrenics cannot control their hallucinations and delusions.
Parkinson's patients cannot control their trembling. Clinically
depressed patients cannot voluntarily control their moods. Thus, once
one is addicted, the characteristics of the illness--and the treatment
approaches--are not that different from most other brain diseases. No
matter how one develops an illness, once one has it, one is in the
diseased state and needs treatment.
Moreover, voluntary behavior patterns
are, of course, involved in the etiology and progression of many other
illnesses, albeit not all brain diseases. Examples abound, including
hypertension, arteriosclerosis and other cardiovascular diseases,
diabetes, and forms of cancer in which the onset is heavily influenced
by the individual's eating, exercise, smoking, and other behaviors.
Addictive behaviors do have special
characteristics related to the social contexts in which they originate.
All of the environmental cues surrounding initial drug use and
development of the addiction actually become "conditioned" to
that drug use and are thus critical to the development and expression of
addiction. Environmental cues are paired in time with an individual's
initial drug use experiences and, through classical conditioning, take
on conditioned stimulus properties. When those cues are present at a
later time, they elicit anticipation of a drug experience and thus
generate tremendous drug craving. Cue-induced craving is one of the most
frequent causes of drug use relapses, even after long periods of
abstinence, independently of whether drugs are available.
The salience of environmental or
contextual cues helps explain why reentry to one's community can be so
difficult for addicts leaving the controlled environments of treatment
or correctional settings and why aftercare is so essential to successful
recovery. The person who became addicted in the home environment is
constantly exposed to the cues conditioned to his or her initial drug
use, such as the neighborhood where he or she hung out, drug-using
buddies, or the lamppost where he or she bought drugs. Simple exposure
to those cues automatically triggers craving and can lead rapidly to
relapses. This is one reason why someone who apparently overcame drug
cravings while in prison or residential treatment could quickly revert
to drug use upon returning home. In fact, one of the major goals of drug
addiction treatment is to teach addicts how to deal with the cravings
caused by inevitable exposure to these conditioned cues.
Implications
Understanding addiction as a brain
disease has broad and significant implications for the public perception
of addicts and their families, for addiction treatment practice, and for
some aspects of public policy. On the other hand, this biomedical view
of addiction does not speak directly to and is unlikely to bear
significantly on many other issues, including specific strategies for
controlling the supply of drugs and whether initial drug use should be
legal or not. Moreover, the brain disease model of addiction does not
address the question of whether specific drugs of abuse can also be
potential medicines. Examples abound of drugs that can be both highly
addicting and extremely effective medicines. The best-known example is
the appropriate use of morphine as a treatment for pain. Nevertheless, a
number of practical lessons can be drawn from the scientific
understanding of addiction.
It is no wonder addicts cannot
simply quit on their own.
They have an illness that requires biomedical treatment. People often
assume that because addiction begins with a voluntary behavior and is
expressed in the form of excess behavior, people should just be able to
quit by force of will alone. However, it is essential to understand when
dealing with addicts that we are dealing with individuals whose brains
have been altered by drug use. They need drug addiction treatment. We
know that, contrary to common belief, very few addicts actually do just
stop on their own. Observing that there are very few heroin addicts in
their 50 or 60s, people frequently ask what happened to those who were
heroin addicts 30 years ago, assuming that they must have quit on their
own. However, longitudinal studies find that only a very small fraction
actually quit on their own. The rest have either been successfully
treated, are currently in maintenance treatment, or (for about half) are
dead. Consider the example of smoking cigarettes: Various studies have
found that between 3 and 7 percent of people who try to quit on their
own each year actually succeed. Science has at last convinced the public
that depression is not just a lot of sadness; that depressed individuals
are in a different brain state and thus require treatment to get their
symptoms under control. The same is true for schizophrenic patients. It
is time to recognize that this is also the case for addicts.
The role of personal
responsibility is undiminished but clarified.
Does having a brain disease mean that people who are addicted no longer
have any responsibility for their behavior or that they are simply
victims of their own genetics and brain chemistry? Of course not.
Addiction begins with the voluntary behavior of drug use, and although
genetic characteristics may predispose individuals to be more or less
susceptible to becoming addicted, genes do not doom one to become an
addict. This is one major reason why efforts to prevent drug use are so
vital to any comprehensive strategy to deal with the nation's drug
problems. Initial drug use is a voluntary, and therefore preventable,
behavior.
Moreover, as with any illness, behavior
becomes a critical part of recovery. At a minimum, one must comply with
the treatment regimen, which is harder than it sounds. Treatment
compliance is the biggest cause of relapses for all chronic illnesses,
including asthma, diabetes, hypertension, and addiction. Moreover,
treatment compliance rates are no worse for addiction than for these
other illnesses, ranging from 30 to 50 percent. Thus, for drug addiction
as well as for other chronic diseases, the individual's motivation and
behavior are clearly important parts of success in treatment and
recovery.
Implications for treatment
approaches and treatment expectations.
Maintaining this comprehensive biobehavioral understanding of addiction
also speaks to what needs to be provided in drug treatment programs.
Again, we must be careful not to pit biology against behavior. The
National Institute on Drug Abuse's recently published Principles of
Effective Drug Addiction Treatment provides a detailed discussion of how
we must treat all aspects of the individual, not just the biological
component or the behavioral component. As with other brain diseases such
as schizophrenia and depression, the data show that the best drug
addiction treatment approaches attend to the entire individual,
combining the use of medications, behavioral therapies, and attention to
necessary social services and rehabilitation. These might include such
services as family therapy to enable the patient to return to successful
family life, mental health services, education and vocational training,
and housing services.
That does not mean, of course, that all
individuals need all components of treatment and all rehabilitation
services. Another principle of effective addiction treatment is that the
array of services included in an individual's treatment plan must be
matched to his or her particular set of needs. Moreover, since those
needs will surely change over the course of recovery, the array of
services provided will need to be continually reassessed and adjusted.
What to do with addicted criminal
offenders. One obvious
conclusion is that we need to stop simplistically viewing criminal
justice and health approaches as incompatible opposites. The practical
reality is that crime and drug addiction often occur in tandem: Between
50 and 70 percent of arrestees are addicted to illegal drugs. Few
citizens would be willing to relinquish criminal justice system control
over individuals, whether they are addicted or not, who have committed
crimes against others. Moreover, extensive real-life experience shows
that if we simply incarcerate addicted offenders without treating them,
their return to both drug use and criminality is virtually guaranteed.
A growing body of scientific evidence
points to a much more rational and effective blended public
health/public safety approach to dealing with the addicted offender.
Simply summarized, the data show that if addicted offenders are provided
with well-structured drug treatment while under criminal justice
control, their recidivism rates can be reduced by 50 to 60 percent for
subsequent drug use and by more than 40 percent for further criminal
behavior. Moreover, entry into drug treatment need not be completely
voluntary in order for it to work. In fact, studies suggest that
increased pressure to stay in treatment--whether from the legal system
or from family members or employers--actually increases the amount of
time patients remain in treatment and improves their treatment outcomes.
Findings such as these are the
underpinning of a very important trend in drug control strategies now
being implemented in the United States and many foreign countries. For
example, some 40 percent of prisons and jails in this country now claim
to provide some form of drug treatment to their addicted inmates,
although we do not know the quality of the treatment provided. Diversion
to drug treatment programs as an alternative to incarceration is gaining
popularity across the United States. The widely applauded growth in drug
treatment courts over the past five years--to more than 400--is another
successful example of the blending of public health and public safety
approaches. These drug courts use a combination of criminal justice
sanctions and drug use monitoring and treatment tools to manage addicted
offenders.
Updating the discussion
Understanding drug abuse and addiction
in all their complexity demands that we rise above simplistic polarized
thinking about drug issues. Addiction is both a public health and a
public safety issue, not one or the other. We must deal with both the
supply and the demand issues with equal vigor. Drug abuse and addiction
are about both biology and behavior. One can have a disease and not be a
hapless victim of it.
We also need to abandon our attraction
to simplistic metaphors that only distract us from developing
appropriate strategies. I, for one, will be in some ways sorry to see
the War on Drugs metaphor go away, but go away it must. At some level,
the notion of waging war is as appropriate for the illness of addiction
as it is for our War on Cancer, which simply means bringing all forces
to bear on the problem in a focused and energized way. But, sadly, this
concept has been badly distorted and misused over time, and the War on
Drugs never became what it should have been: the War on Drug Abuse and
Addiction. Moreover, worrying about whether we are winning or losing
this war has deteriorated to using simplistic and inappropriate measures
such as counting drug addicts. In the end, it has only fueled discord.
The War on Drugs metaphor has done nothing to advance the real
conceptual challenges that need to be worked through.
I hope, though, that we will all resist
the temptation to replace it with another catchy phrase that inevitably
will devolve into a search for quick or easy-seeming solutions to our
drug problems. We do not rely on simple metaphors or strategies to deal
with our other major national problems such as education, health care,
or national security. We are, after all, trying to solve truly
monumental, multidimensional problems on a national or even
international scale. To devalue them to the level of slogans does our
public an injustice and dooms us to failure.
Understanding the health aspects of
addiction is in no way incompatible with the need to control the supply
of drugs. In fact, a public health approach to stemming an epidemic or
spread of a disease always focuses comprehensively on the agent, the
vector, and the host. In the case of drugs of abuse, the agent is the
drug, the host is the abuser or addict, and the vector for transmitting
the illness is clearly the drug suppliers and dealers that keep the
agent flowing so readily. Prevention and treatment are the strategies to
help protect the host. But just as we must deal with the flies and
mosquitoes that spread infectious diseases, we must directly address all
the vectors in the drug-supply system.
In order to be truly effective, the
blended public health/public safety approaches advocated here must be
implemented at all levels of society--local, state, and national. All
drug problems are ultimately local in character and impact, since they
differ so much across geographic settings and cultural contexts, and the
most effective solutions are implemented at the local level. Each
community must work through its own locally appropriate antidrug
implementation strategies, and those strategies must be just as
comprehensive and science-based as those instituted at the state or
national level.
The message from the now very broad and
deep array of scientific evidence is absolutely clear. If we as a
society ever hope to make any real progress in dealing with our drug
problems, we are going to have to rise above moral outrage that addicts
have "done it to themselves" and develop strategies that are
as sophisticated and as complex as the problem itself. Whether addicts
are "victims" or not, once addicted they must be seen as
"brain disease patients."
Moreover, although our national
traditions do argue for compassion for those who are sick, no matter how
they contracted their illnesses, I recognize that many addicts have
disrupted not only their own lives but those of their families and their
broader communities, and thus do not easily generate compassion.
However, no matter how one may feel about addicts and their behavioral
histories, an extensive body of scientific evidence shows that
approaching addiction as a treatable illness is extremely
cost-effective, both financially and in terms of broader societal
impacts such as family violence, crime, and other forms of social
upheaval. Thus, it is clearly in everyone's interest to get past the
hurt and indignation and slow the drain of drugs on society by enhancing
drug use prevention efforts and providing treatment to all who need it.