The term acknowledges that addiction is a chronic but treatable medical condition involving changes to circuits involved in reward, stress, and self-control.
Photo by jkt_deAs a young scientist in the 1980s, I used then-new imaging technologies to look at the brains of people with drug addictions and, for comparison, people without drug problems. As we began to track and document these unique pictures of the brain, my colleagues and I realized that these images provided the first evidence in humans that there were changes in the brains of addicted individuals that could explain the compulsive nature of their drug taking. The changes were so stark that in some cases it was even possible to identify which people suffered from addiction just from looking at their brain images.
Alan Leshner, who was the Director of the National Institute on Drug Abuse at the time, immediately understood the implications of those findings, and it helped solidify the concept of addiction as a brain disease. Over the past three decades, a scientific consensus has emerged that addiction is a chronic but treatable medical condition involving changes to circuits involved in reward, stress, and self-control; this has helped researchers identify neurobiological abnormalities that can be targeted with therapeutic intervention. It is also leading to the creation of improved ways of delivering addiction treatments in the healthcare system, and it has reduced stigma.
Informed Americans no longer view addiction as a moral failing, and more and more policymakers are recognizing that punishment is an ineffective and inappropriate tool for addressing a person’s drug problems. Treatment is what is needed.
Fortunately, effective medications are available to help in the treatment of opioid use disorders. Medications cannot take the place of an individual’s willpower, but they aid addicted individuals in resisting the constant challenges to their resolve; they have been shown in study after study to reduce illicit drug use and its consequences. They save lives.
Yet the medical model of addiction as a brain disorder or disease has its vocal critics. Some claim that viewing addiction this way minimizes its important social and environmental causes, as though saying addiction is a disorder of brain circuits means that social stresses like loneliness, poverty, violence, and other psychological and environmental factors do not play an important role. In fact, the dominant theoretical framework in addiction science today is the biopsychosocial framework, which recognizes the complex interactions between biology, behavior, and environment.
There are neurobiological substrates for everything we think, feel, and do; and the structure and function of the brain are shaped by environments and behaviors, as well as by genetics, hormones, age, and other biological factors. It is the complex interactions among these factors that underlie disorders like addiction as well as the ability to recover from them. Understanding the ways social and economic deprivation raise the risks for drug use and its consequences is central to prevention science and is a crucial part of the biopsychosocial framework; so is learning how to foster resilience through prevention interventions that foster more healthy family, school, and community environments.
Critics of the brain disorder model also sometimes argue that it places too much emphasis on reward and self-control circuits in the brain, overlooking the crucial role played by learning. They suggest that addiction is not fundamentally different from other experiences that redirect our basic motivational systems and consequently “change the brain.” The example of falling in love is sometimes cited. Love does have some similarities with addiction. As discussed by Maia Szalavitz in Unbroken Brain, it is in the grip of love—whether romantic love or love for a child—that people may forego other healthy aims, endure hardships, break the law, or otherwise go to the ends of the earth to be with and protect the object of their affection.
Within the brain-disorder model, the neuroplasticity that underlies learning is fundamental. Our reward and self-control circuits evolved precisely to enable us to discover new, important, healthy rewards, remember them, and pursue them single-mindedly; drugs are sometimes said to “hijack” those circuits.
Metaphors illuminate complexities at the cost of concealing subtleties, but the metaphor of hijacking remains pretty apt: The highly potent drugs currently claiming so many lives, such as heroin and fentanyl, did not exist for most of our evolutionary history. They exert their effects on sensitive brain circuitry that has been fine-tuned over millions of years to reinforce behaviors that are essential for the individual’s survival and the survival of the species. Because they facilitate the same learning processes as natural rewards, drugs easily trick that circuitry into thinking they are more important than natural rewards like food, sex, or parenting.
What the brain disorder model, within the larger biopsychosocial framework, captures better than other models—such as those that focus on addiction as a learned behavior—is the crucial dimension of interindividual biological variability that makes some people more susceptible than others to this hijacking. Many people try drugs but most do not start to use compulsively or develop an addiction. Studies are identifying gene variants that confer resilience or risk for addiction, as well as environmental factors in early life that affect that risk. This knowledge will enable development of precisely targeted prevention and treatment strategies, just as it is making possible the larger domain of personalized medicine.
Some critics also point out, correctly, that a significant percentage of people who do develop addictions eventually recover without medical treatment. It may take years or decades, may arise from simply “aging out” of a disorder that began during youth, or may result from any number of life changes that help a person replace drug use with other priorities. We still do not understand all the factors that make some people better able to recover than others or the neurobiological mechanisms that support recovery—these are important areas for research.
But when people recover from addiction on their own, it is often because effective treatment has not been readily available or affordable, or the individual has not sought it out; and far too many people do not recover without help, or never get the chance to recover. More than 174 people die every day from drug overdoses. To say that because some people recover from addiction unaided we should not think of it as a disease or disorder would be medically irresponsible. Wider access to medical treatment—especially medications for opioid use disorders—as well as encouraging people with substance use disorders to seek treatment are absolutely essential to prevent these still-escalating numbers of deaths, not to mention reduce the larger devastation of lives, careers, and families caused by addiction.
Addiction is indeed many things—a maladaptive response to environmental stressors, a developmental disorder, a disorder caused by dysregulation of brain circuits, and yes, a learned behavior. We will never be able to address addiction without being able to talk about and address the myriad factors that contribute to it—biological, psychological, behavioral, societal, economic, etc. But viewing it as a treatable medical problem from which people can and do recover is crucial for enabling a public-health–focused response that ensures access to effective treatments and lessens the stigma surrounding a condition that afflicts nearly 10 percent of Americans at some point in their lives.
Dr. Nora Volkow, Director
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Comments
Communicating that addiction is brain disorder
This is a very useful blog post. This is a much-needed conversation to help reduce the stigma of addiction which is discouraging our addicts and their families from seeking help, and preventing others from being part of the solution. I feel that understanding that addiction is brain disorder is so important to bringing people in to help combat this epidemic, and in the recovery process for both the addict and their families. I have struggled as a member of a towns addiction task force as to how to best communicate addiction as a disease to a general audience, your thoughtful blog pulls many pieces together. Thank you again
Addiction
This is one of the best description of the problem of addiction that I have encountered. Congratulations to NIH. My experience with addiction started in 1965 as a State Parole Officer. My office was in Newark, NJ and I got to witness the problem face-to-face with the thousands of addicts who went through a treatment program in Newark, NJ that I founded in 1968. Thanks for this excellent piece!
Complexities of addiction
I appreciate the discription of the biological, psychological, social, behavioral, economic, societal, etc. complexities of the disease of addiction. As a clinical addictiion professional and a person with nearly 30 years of long-term recovery I absolutely agree this disease is treatable. I however caution the use of the term “recover”. This is a chronic disease. With treatment and a commitment to recovery this disease can be in remission and long term recovery possible.
Disease versus choice
All well said and agreed, but by the same token, ignoring the learned aspect of addiction prevents people from taking responsibility for their actions which can also delay recovery. Treating addiction as a learned dysfunctional behavior shifts the focus of recovery from a person’s biology to a person’s actions. The actions need not be seen in a moral context (“bad” or “good”) but rather as not helpful to one’s goals. An emphasis on the learning model moves the control of addiction from the physician to the patient, and moves the control of recovery from the patient’s biology to his or her relationships.
Neither model is 100% accurate, and both models are helpful in understanding this bewilderingly complex part of human life.
Brain Disease / Addiction
Bravo Dr. Volkow ! Once again you have clearly and succinctly expressed the true nature of the Brain Disorder we call Addiction.
The biopsychosocial model is indispensable. Genetic, developmental, and environmental factors all interact with the person over time to create vulnerability. Absent adequate protective factors, persons with vulnerability exposed to psychoactive chemicals will likely develop brain addiction for the reasons you describe. Policy and programming must continue to evolve in an inclusive manner. Simplifying brain addiction by excluding any contributing factor weakens the potential of treatment. Thank you and your colleagues for your compassionate perseverance in this most important public health crisis.
Addiction is a brain disease.
You mention Dr. Leshner in your article. Leshner made a video entitled "The Great Disconnect" and the last thing he says is that it is the responsibility of treatment to change the brain back to where it was before the addiction occurred. Use of medication appears to go against this end, i.e. by continuing to use addictive medications to keep someone in control of their addiction, we also do not "change the brain back" but may even reinforce the physical and psychological addiction. Was Leshner wrong?
Treatment cannot return the
Spiritual component of addiction
While there is a great amount of research of the brain with regards to addiction (pleasure center of the brain), it is necessary to keep in mind the huge role spirituality also plays within addiction. I fully agree there are biological, psychological, and social factors, which is where the term of "biopsychosocial" was coined to refer to as an assessment. This term is however incomplete without the word, "spiritual" attached to it. It is very interesting this term is omitted, whether it was intentional or an oversight, given the entire chapter from A.A. Big Book, "There Is A Solution", being devoted to this component.
Neurobiology of Addiction
I really enjoyed reading this post. In reference to the "falling in love" metaphor, I am curious if you have seen the research that discusses the strong connection between attachment and opiates. For example, in 1998 researchers found opiates to decrease distress vocalizations from baby animals when separated from their caregivers. The "loaded feels like loved" research also shows drugs and alcohol to provide the same reward to the brain as close, social bonds. It may help explain why addicted individuals isolate when they use, and struggle with accepting support/asking for help even in recovery.
Good article: Now teach this vigorously in grade school
Excellent article!
Now teach this to grade schoolers with the same degree of vigor we are teaching sex education and venereal disease. Unpleasant, but you know what, America fell in love with recreational drugs over the last fifty years. The rock stars, the entertainment industry, even sports stars, our society acts as though using illegal drugs is normal. It's pandemic. And NOW unfortunately, we are paying a huge price. What a waste!
To cure this gigantic mistake, teach the kids about the risks of using drugs, and about the insidious horrors of drug addiction. Show pictures of aging addicts, describe how those with this brain disorder risk losing all the wonders life has to offer- all of them. It is enslavement indeed, and very often explains how women can be coerced into prostitution, how sex slavery works, and why so many of our inner cities are so dysfunctional because of the incessant violence from the drug traffickers.
And now our country seems committed to legalizing marijuana! What the heck. Marijuana is also addictive, or can set the physiological conditions toward greater addiction vulnerability. Even later in life, which might explain in part the current opioid crisis.
Youth are the key. Start them right, educate them about the hazards and horrors of drug abuse and addition, and maybe we can start to tackle this disaster in a few decades. As the older, hippiedom generation dies off, maybe a more cogent/wiser, younger generation will steer our country on the right course.
Stigma, shame, moral outrage, but compassion
I wholeheartedly agree that those who do become addicted should be provided care and compassion and not be reviled as though they are moral failings. However, I do think those among our liberally permissive, popular culture who do promote and encourage drug abuse SHOULD be reviled and shamed with the kind of moral outrage we used to have. Not idolized as is so often the case!
In essence, we need to re-direct the mindset of the country.
Addictive Parents?
I have wondered for a long time what the science is regarding how addictive parents may pass on bad traits to their offspring. That is, if say a mother has an addiction problem with drugs such as cocaine or heroin, or whatever, can some negative characteristics be inherited by the offspring?
And these might present themselves as behavioral, learning or adjustment problems for the children as they grow up, or maybe render them more vulnerable to addiction?
One real life example might be this most recent school shooting massacre in Florida. It has been said the alleged perpetrator had been adopted at a very young age from a biological mother who was addicted to drugs. The big question that I have is whether or not this kid's problems could have been a direct inherited consequence of his mother's addiction to drugs? Perhaps had his mother never been addicted to drugs, the child would never had been so violent, and this massacre would never have happened. Bunk or merit to this? And if true, this might be a big wake-up call for society.
Please inform me what the latest science on this topic is. Thank you in advance.
While genetic risk factors
How to Stop Drug Abuse
There is no way to stop it short of the death penalty for all drug dealers and Users.
Increased Awareness
I hope there continues to be increased awareness to remove the stigma. It is NOT a moral failing. Addicts continue to avoid treatment for medical conditions caused by their addiction due in part to the stigma but also due to the lack of medicinal treatment to help with withdrawals. Things need to move faster. Progress has been slow and deaths continue as a result. One lost is one too many.
Making sense of it all
There seems to be few articles which address the possibility of the brain disorder being present BEFORE a person starts using...that drugs &/or alcohol TREATS the problem and over time becomes it's own problem. This would explain why some people become addicted and others do not...the effect of the substance on each brain is not one and the same. If brains develop depending on so many different factors, which are out of a person's control, this is NOT a matter of choosing differently or punishing people who are seeking relief. What if your brain did not work the way it does...it could have been any one of us. For the record, it IS me and although it has been my RESPONSIBILITY to deal with, I know longer believe that it is my FAULT that I live with a severe substance abuse disorder. Everyone taking responsibility for things that can be changed is so important...that all people have access to treatment and help, that we start earlier...not with the person who is already addicted, but with the children who are born into unhealthy environments today...they will be the future addicts if our society does not change it's view and consequent treatment of ALL people. Educate people on healthy lifestyles and minds. Food programs, school programs, treat all people like they matter.
Testing