The message written on a walkway window at the airport in Burlington, Vt., is a striking departure from the usual tourist posters and welcome banners:
“Addiction is not a choice. This is a disease that can happen to anyone.”
The statement is part of a public service campaign in other communities affected by drug use aimed at reducing stigma and encouraging treatment.
For decades, medical science has classified addiction as a chronic disease of the brain, but the concept has always been a sell for skeptics. That’s because, unlike diseases like Alzheimer’s or bone cancer or Covid, personal choice plays a role in both starting and ending drug use. The idea that those who use drugs themselves are to blame has been gaining fresh traction recently, driving crackdown efforts. Criminal penalties for drug possession and for Cut funding For syringe-exchange programs.
But now, even in some treatment And the scientific community is rethinking the label of chronic brain disease.
In July, behavioral researchers published a critique of the classification, which they said could be counterproductive for patients and families.
“I don’t think it helps to tell people that they are chronically ill and therefore incapable of change. Then what hope do we have?” said Kirsten E. Smithassistant professor of psychiatry and behavioral sciences at the Johns Hopkins School of Medicine and co-author of the paper published in the journal Psychopharmacology. “The brain, like our environment, is highly dynamic.”
Recent scientific critiques are driven by an ominous urgency: Despite addiction’s long-standing classification as a disease, the deadly public health disaster has worsened.
Almost no one is calling for a complete scrapping of the disease model. There is little controversy that the continued use of stimulants such as methamphetamine and opioids such as fentanyl has a detrimental effect on the brain.
But some scientists argue that brain-centered disease traits of addiction do not sufficiently incorporate factors such as social environment and genetics. In recent criticism, researchers have argued that, rather than emphasizing brain breakdown in perpetuity, the definition of addiction should include the motivation or context in which a person chooses to use drugs.
That choice, they said, is often an escape from messy situations like stuffy homes, undiagnosed mental health and learning disorders, bullying or isolation. Generations of family addictions run the gamut toward substance use.
And in many environments, they added, drugs are more readily available than healthier, rewarding options, including education and jobs.
Choosing drugs can be understood not as a moral failure but as a form of decision-making with its own implicit logic.
In combination with medications that subdue opioid cravings, clinicians can help patients identify the reasons they use drugs and then encourage them to make choices that result in meaningful, sustainable rewards.
In A 2021 In a paper in the Journal of Neuropsychopharmacology, Dr. Holy MarkThe former director of research at the National Institute on Alcohol Abuse and Alcoholism defended the brain-disease diagnosis, saying the evidence was well documented. But, their paper acknowledges, “brain-centered accounts of addiction have long failed to pay sufficient attention to the inputs that social factors provide to the neural processing behind drug seeking and taking.”
In clinical practice, the term “addiction” is becoming increasingly nuanced. John F. CallieProfessor of Addiction Psychiatry and Psychologist at Harvard Medical School, defines addiction as “a severe substance use disorder that is at the point where there are many changes in the prefrontal cortex as well as in the deep brain regions” that regulate emotions and behavior.
But only a small minority meet that criteria, he said. “Even within that severe category, there are many different degrees that can occur,” Dr. Kelly added. Genetics can increase the severity of the response.
He likened it to boarding a speeding train. “It starts out as a fun ride, but at some point it gets out of control and derails. It’s a matter of when you can pull the emergency cord and get off,” he said, adding that some drug users There is never an opportunity to do this before it is too late.
That moment is different for everyone: “People will change only when there are negative consequences, but also when there is hope and optimism that change is possible, possible and sustainable.”
In disputing the characterization of addiction as a disease marked by compulsive or repetitive use, some experts have argued that some drug and alcohol abusers may leave without treatment—and even occasionally return to safe use.
Dr. Smith began using drugs as a teenager and became addicted to heroin. During her darkest spell, when she was 23, she was injecting herself four times a day. She was involved in two bank robberies and then served nearly four years in federal prison, where she attended a modest treatment program. Upon release, she completed college and completed graduate and postdoctoral studies.
It has been more than six years since she used opioids and more than 15 she was addicted to them. Dr. Smith credits the benefits of his middle-class background and family support.
She rejects the idea that she will always be tied to a chronic state of mind.
“I’m not in recovery,” she said. “I have recovered.”
Theories of addiction have been debated for centuries. In the 1780s, a signer of the Declaration of Independence, Dr. Benjamin Rush started calling out alcoholism “That loathsome disease.” (“The various preparations of opium are a thousand times safer and more harmless than spirituous liquors,” he wrote.)
Adding to the modern confusion about the nature of addiction, psychiatry continues to refine the criteria for what it labels “substance use disorder.” In its current edition Diagnostic ManualAccording to DSM-V, a person has a mild disorder if they experience at least two of the 11 symptoms. More the symptoms, more the severity of the disorder.
Research on drug use began in the 1970s. By 1997 Alan I. LeshnerThen head of the National Institute on Drug Abuse, published the Foundational position paper, “Addiction is a disease of the brain, and that’s important.”
For the public, policymakers and health care workers, he wrote, “addiction as a chronic, relapsing disease of the brain is a brand new concept.”
But he did not ignore the contributing factors. “Not only must the underlying brain disease be treated, but the behavioral and social cue components must also be addressed,” he wrote.
His much-publicized research summary, which appeared a year after Purdue Pharma launched the highly addictive prescription opioid OxyContin, had a powerful, positive impact. The brain-disease designation would stimulate funding for research, expand insurance coverage for treatment, and be used to prompt changes in public policy and criminal law, where newly minted drug courts—now increasingly known as “recovery courts”—treat defendants. requests. The brain-disease framework would eventually be adopted by mainstream medicine, including the Surgeon General.
And it offers patients and families the building blocks toward compassion as well as ways to combat pervasive hatred.
The model maintains value, said Dr. Nora Volkow, who now heads the organization. She refers to addiction as a “chronic, treatable medical condition.”
In a statement, she added, “Acknowledging that addiction involves changes in the brain does not discount the many genetic, social, environmental and other factors that play an important role.”
Whether the brain will ever recover adequately after prolonged abstinence, however, requires further study, the argument goes 2022 review research, although the authors suggested that the evidence is promising.
But as scholars wrestle with how to frame addiction, patients and loved ones struggle painfully with a lack of certainty.
Nadia, whose father fatally overdosed on fentanyl in 2023, said defining addiction as a disease absolves users of responsibility.
“It’s hard to hear people call addiction a disease like cancer or a progressive illness,” wrote Nadia, who lives in Minneapolis but asked that her last name be withheld to protect her family’s privacy. “My father often chose drugs. He missed all three of my graduations, my wedding and the birth of my child, as well as all my sister’s milestones. It’s hard to say he can’t control it. That we weren’t important enough to him to push it away.
Nadia was one of hundreds of readers who answered questions from The New York Times about their families’ struggles with substance use. Many said they were distressed: they were angry at the person who had used drugs or alcohol. Yet many also felt guilty for expressing strong resentment toward a parent, sibling, child, or spouse who, they admitted, was suffering from a disease.
“People want to unburden themselves of the mixed feelings they have about their loved one, but that’s an inherent burden in this situation,” said Keith HumphreyStanford University psychologist and addiction specialist. That’s why, he said, it’s easy for people to view addiction in absolute terms — as a choice or a disease.
Overwhelmingly, family members described their burnout. “When a loved one is addicted to drugs, it’s like being bitten by a vampire,” wrote Robin Pratt, whose sister has used opioids for a dozen years. “They never stop plotting what they can take from you to support their habit. The same person who, before drugs, you trusted with your life, becomes the same person you trust with your wallet. Don’t believe it.
About 30 years ago, when Dr. While Leshner argued for the brain-disease designation, he did so to break down what he called “the impurity and misunderstanding” that had long simmered around addiction.
Then he added: “Indeed, if it were possible, it would be best to start with some new, more neutral word.”
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