The brain disease model of addiction: is it supported by the evidence and has it delivered on its promises?
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We need a similar critique of the American Society of Addiction Medicine (ASAM) and its affiliates on this side of the Atlantic as “addiction medicine” is slated to be approved by the American Board of Medical Specialties in 2016 even though the discipline falls far short of the educational and professional standards for quality practice developed and implemented by all other ABMS member boards. According to the ABMS these 24 boards are:“committed to the principle of examining doctors based on six general competencies designed to encompass quality care: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice.”
These areas have been collectively identified by the ABMS, the American College of Graduate Medical Education (ACGME) and the Institute of Medicine (IOM) in order to standardize graduate medical education.
Any critique of the ASAM would find a number of issues antithetical to the six general competencies which stress “learning and improvement.” In contrast the ASAM rests on the conviction that their views are absolutely certain and patently rejects open-minded inquiry. An academic analysis of addiction medicine from the vantage point of the ASAM would reveal false assumptions, bias, dogmatism, and data-dredging. It would also reveal that those claiming expertise are in fact illegitimate and irrational authority who believe in an ends-justifies-the-means approach to push forth the chronic relapsing brain disease with lifelong abstinence an d imposed 12-step recovery. These are false experts who rationalize unethical, unprofessional and even criminal behavior as zeal for the faith if it aligns with the brain disease model of addiction (BDMA) Their viewpoints are fixed and final.
They have not been held to truly objective judging, analysis, evaluation or outside critique. The purpose of critique is the same as the purpose of critical thinking: to appreciate strengths as well as weaknesses, virtues as well as failings. Critical thinkers critique in order to redesign, remodel, and make better. This direly needs to be done. The evidence-base for both the BDMA and the drug and alcohol testing, assessment and treatment is poor. They are claiming physician health programs are the crown jewel of addiction treatment– a replicable model to be replicated in other populations. It is all hyperbole and propaganda. In reality they are using medical assessment and treatment as tools to repress and punish doctors. Those running the state physician health programs are typically morally disengaged bullies with Machiavellian egocentricity. And all the congratulatory backslapping is based on a singe poorly designed opinion piece.
Science and medicine need to be predicated on competence, thoughtfulness, good faith, civility, honesty, and integrity. This is universally applicable. What they are doing betrays the trust of society and breaches the most basic ethical obligations of not only doctors but human beings.
But no one seems to be challenging them. Why is no one questioning this self-appointed authority. If people do not start talking, writing, discussing and debating the current paradigm then what Robert Dupont describes in the ASAM White Paper on Drug Testing will be ushered in. As with doctors you won’t know it until it hits you. If the ASAM becomes an ABMS medical specialty then it will be too late. They will impose their authority on you as a patient and their won’t be a damn thing you will be able to do about it.
Once illegitimate and irrational authority are sanctified by the American Board of Medical Specialties there will be nothing left to do except watch the profession of medicine go up in flames.
Right now it’s just doctors and pilots. What you need to see is that you are next. I base that prediction on past public-policy, regulatory, administrative and medical practice tinkering as well as the documented paper trail of “research” and opinion. And even though all of this can be explained using documentary evidence, fact and critical analysis no one seems alarmed.
If you map it out you will see the trajectory is aimed at the transportation industry, students with federal loans, high school athletes, schools, gun owners, and eventually schools.
If you have something to lose that is affiliated with a state or federal agency they will hold it hostage if you get a positive hair, nail, sweat blood, or urine test at your doctors visit. The positive test is the golden ticket for them and a ticket to an assessment facility in Kansas, Arkansas, Mississippi and some other places for you on your dime. And these are one-way tickets. No return to normality available. One way ticket. No return flight.
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Proponents of the brain disease model of addiction (BDMA) have been very influential in setting the funding priorities of NIDA, and by extension the bulk of publicly supported research on addiction. In 1998, Leshner testified that NIDA supports more than 85% of the world’s research on drug abuse and addiction.3 The American Society of Addiction Medicine has defined addiction as a “primary, chronic disease of brain reward, motivation, memory, and related circuitry”.4 In July, 2014, newly appointed Acting Director of US National Drug Control Policy, Michael Botticelli, launched a reformist strategy nationally, claiming decades of research have demonstrated that addiction is a brain disorder—one that can be prevented and treated.5 The BDMA has also been widely discussed in leading scientific research journals3, 6 and most recently in a positive editorial in Nature.7
In the USA, proponents of the BDMA have argued that it will help to deliver more effective medical treatments for addiction with the cost covered by health insurance, making treatment more accessible for people with addictions.1, 2, 6 An increased acceptance of the BDMA is also predicted to reduce the stigma associated with drug addiction by replacing the commonly held notion that people with drug addiction are weak or bad with a more scientific viewpoint that depicts them as having a brain disease that needs medical treatment.
In this Personal View, we critically assess the scientific evidence for the BDMA reported in leading general scientific journals and the extent of the social benefits that advocates of the BDMA claim it has produced, or is likely to produce, with its widespread acceptance among clinicians, policy makers, and the public. The BDMA is not co-extensive with neuroscience-based explanations of addiction. This review is not intended as a critique of all neuroscience research on addiction. We focus instead on the popular simplification of work in this specialty that has had a major influence on popular discourse on addiction in scientific journals and mainstream media.
Considerable scientific value exists in the research into the neurobiology and genetics of addiction, but this research does not justify the simplified BDMA that dominates discourse about addiction in the USA and, increasingly, elsewhere. Editors of Nature were mistaken in their assumption that the BDMA represents the consensus view in the addictions specialty,7 as shown by a letter signed by 94 addiction researchers and clinicians (including one of the authors of this Personal View).74Understanding of addiction, and the policies adopted to treat and prevent problem drug use, should give biology its due, but no more than it is due. Chronic drug use can affect brain systems in ways that might make cessation more difficult for some people. Economic, epidemiological, and social scientific evidence shows that the neurobiology of addiction should not be the over-riding factor when formulating policies toward drug use and addiction.
The BDMA has not helped to deliver the effective treatments for addiction that were originally promised by Leshner and its effect on public health policies toward drug addiction has been modest. Arguably, the advocacy of the BDMA led to overinvestment by US research agencies in biological interventions to cure addiction that will have little effect on drug addiction as a public health issue. Increased access to more effective treatment for addiction is a worthy aim that we support but this aim should not be pursued at the expense of simple, cost effective, and efficient population-based policies to discourage the whole population from smoking tobacco and drinking heavily. Nor should the pursuit of high technology cures distract from the task of increasing access to available psychosocial and drug treatments for addiction, which most people with addictive disorder are still unable to access.
Our rejection of the BDMA is not intended as a defence of the moral model of addiction.65 We share many of the aspirations of those who advocate the BDMA, especially the delivery of more effective treatment and less punitive responses to people with addiction issues. Addiction is a complex biological, psychological, and social disorder that needs to be addressed by various clinical and public health approaches.65 Research into the neuroscience of addiction has provided insights into the neurobiology of decision-making, motivation, and behavioural control in addiction. Chronic use of addictive drugs can impair cognitive and motivational processes and might partly explain why some people are more susceptible than others to developing an addiction. The challenge for all addiction researchers—including neurobiologists—is to integrate emerging insights from neuroscience research with those from economics, epidemiology, sociology, psychology, and political science to decrease the harms caused by drug misuse and all forms of addiction.46
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