I’m a doctor fighting the opioid crisis. Here’s why I think reducing addiction to a brain disease is dangerous.

Dr. Celine Gounder
Mar 14, 2018 · 6 min read

My uncle Jean-Pierre was an alcoholic and addicted to prescription sedatives. He never moved out of my grandparents’ house. He rarely left his room after taking an early retirement in his 50s, emerging mostly to eat. In addition to abusing the benzos he was prescribed, he regularly stole prescription pills from my grandmother. His brother André, who lived nearby, became accustomed to calls from emergency room staff, alerting him that Jean-Pierre was intoxicated and in their care. One day, André came to check on my grandmother and found Jean-Pierre motionless in bed, having overdosed for the last time.

Jean-Pierre died because no one delved into the underlying drivers of his alcohol and drug use. He went to numerous detox programs to dry out, but no one provided the comprehensive care he desperately needed.

Let’s go back a bit. It wasn’t until 1987 that the American Medical Association began defining addiction as a disease, the result of efforts to both better understand the pathophysiology of addiction and to destigmatize addiction. While this is an idea many of us take for granted today, it was a huge accomplishment for the medical community, achieved nearly three decades after organizations like Alcoholics Anonymous pressured medical organizations to stop framing addiction as a moral failing.

As a doctor, I’m grateful for any attempt to destigmatize disease because it makes it more likely people will seek help — and that they will receive more compassionate care when they do. However, reducing the cause of addiction — which is brought on by a multitude of factors — to neurobiology alone can severely limit our thinking about treatment strategies. Additionally, research shows that calling addiction a brain disease hasn’t actually reduced the desire to punish people struggling with addiction, and doesn’t reduce feelings of shame in drug users. In fact, it may weaken their sense of agency, convincing them their addiction is irreversible and causing them to give up entirely.

We must start by being honest with ourselves — addiction is also a disease of the environment and bad options in life. Jean-Pierre didn’t just wake up addicted. He was depressed for most of his life, and it’s likely he suffered from other undiagnosed mental illnesses. When I asked my grandmother about her life during World War II, she would say there were certain secrets she would take with her to the grave. I can only guess at what traumas she might have suffered while my grandfather was away at war and how those shaped her as a parent. While I saw her as stoic, my mother, aunt and uncles thought her a hard, distant woman. My mother and I also suspect that Jean-Pierre was an unhappily closeted gay man — a circumstance that was not talked about in our family and was likely extremely isolating for Jean-Pierre, forcing him to struggle with his identity alone. All of these heavy, personal burdens were important pieces to the puzzle that was Jean-Pierre’s addiction, and none of them can be ignored.

Your environment also has a very powerful pull on your probability of being addicted to drugs. Studies done throughout the late 60s found of the 35 percent of soldiers who tried heroin while serving in Vietnam, 19 percent became addicted. However, once they detoxed and returned to the US, only 1 percent became re-addicted. The availability and price of heroin and alternative drugs had something to do with it, as well as not being under the stress of active combat. But the moral of the story is that it clearly wasn’t just neurobiology. A simple change in their living situations allowed many soldiers to turn away from heroin forever.

And it’s not just soldiers at war who are at risk for addiction due to their environment. More recently, the tearing down of public housing projects in Atlanta and Baltimore shed light on the link between neighborhood deprivation and the risk for substance abuse. Researchers found that people who moved from poor to less poor neighborhoods were more likely to quit using drugs — but those who moved down the socioeconomic ladder were less likely to quit. Many features of a neighborhood predict the risk for using drugs, including psychological stress, hopelessness, social norms, access to social capital, local investment in housing, new businesses, and jobs, and more.

Intuitively, we know that a person’s environment has a huge impact on the life they’ll lead. That’s why parents want their kids to grow up in safe neighborhoods with good schools, reliable infrastructure, and positive, public role models. Those advantages count — especially when it comes to the risk for drug addiction. We must take these protective parental instincts and apply them to society as a whole by looking for the complex cultural and socioeconomic factors that are driving opioid use and working to combat them through creative, people-based approaches.

But it can’t stop at environment. We know that family history is a major predictor of addiction, through a combination of our genetics and our childhood experiences throughout our upbringing — nature and nurture. If you’re born to parents who struggle with addiction, you’re at higher risk of becoming addicted yourself — though it’s unlikely that genetic testing for addiction risk would provide much more information than just taking a family history. Over the last two decades, we’ve also learned that adverse childhood experiences — ranging from physical or emotional abuse to a having an absent parent as a result of circumstances like divorce or incarceration — increase the risk someone will smoke, drink or use drugs. I suspect that some combination of genetics, his childhood experiences and not feeling understood were at the root of Jean-Pierre’s addiction.

So, addiction is complicated. What’s our solution? It can start with compassion. I believe if someone had asked Jean-Pierre about his past trauma — something that isn’t currently a routine part of medical care — and had acted on that information, his life might have turned out very differently.

Overall, we cannot limit ourselves to a single track approach. Just look at how America is combating smoking. If we had pinned all our hopes on a neurobiological solution, we might have waited until 2006 — when the FDA approved varenicline (Chantix) for treatment of tobacco addiction — and prescribed it to every American smoker then. Varenicline has been shown to double the chances someone will successfully quit smoking — that’s big! But not as big as it sounds when you consider that only about 6 percent of smokers quit each year on their own. Instead, after the Surgeon General’s 1964 report, we raised taxes on cigarettes, banned tobacco ads, and restricted where people could smoke. None of these actions were biomedical interventions to treat a brain disease — but, over the past 50 years, policies like these have brought smoking rates down from over 40 percent to under 20 percent among adults in the United States. Thanks to our multi-pronged approach to smoking, we’ve saved countless lives from lung cancer, heart disease, stroke and other smoking-related diseases. There’s no reason the opioid crisis should be treated any differently.

Plus, even when the brain disease model of addiction has yielded new treatments — like buprenorphine — many people with opioid addiction can’t access them. And most drug treatment programs still don’t provide care based on the latest science; their practices haven’t changed much since the 1950s.

There’s much to be gained from ongoing research on the neurobiology of addiction. But in this country, we’re overly biased towards high-tech solutions, which are often more expensive and less effective compared to public health and social programs. Is it because Big Pharma and private prisons can make loads of money on the backs of people with drug addiction? Or because we live in an individualistic society that doesn’t acknowledge hard work and smarts don’t always predict success in life? Or because we don’t want to help “undeserving addicts”? So long as we prioritize neurobiology so single-mindedly, many will continue to die. It’s up to all of us to work to shift the narrative in order to save lives.

Dr. Celine Gounder

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Doctor, epidemiologist, storyteller, and one of People Magazine’s 25 Women Changing the World. Check out my podcast: https://insicknessandinhealthpodcast.com