Alva Noe, a University of California philosopher, discusses the recent Surgeon General’s report on addiction in the link below, a NPR op-ed piece. In taking issue with the characterization of addiction as a "… brain disease," he emphasizes - I believe correctly - that multiple other factors determine the development of addiction beyond those which are biologically-centered. He goes on to say, “This doesn't make the slogan that 'addiction is a disease of the brain' false, exactly. But it does show it to be a bit misleading.” Unfortunately what follows seems to be an unnecessary dichotomization, using the example of diabetes.
…”Bad diet and low levels of exercise trigger type 2 diabetes in those prone to the disease. In a similar way, drug abuse causes addiction. But diabetes comes down, finally, to a difficulty managing glucose levels in the blood. You can't say that addiction boils down to something straightforwardly physiological in the same sort of way.”
This is unfortunately a false syllogism. Because it is not true that diabetes is simply a disruption in glucose metabolism or a failure on the part of the pancreas to perform its assigned duties. For those who have dealt with people with diabetes, there are clear changes in personality and in behavior, the most familiar of which is difficulty with adherence to treatment regimens. These accompany the more measurable elements of that illness. The similarities between diabetes and addiction are much greater than Dr. Noe might appreciate, greater interestingly than their differences.
Dr. Noe questions whether emphasizing the brain as a site of the disease of addiction risks “…suggesting that they [those with addiction-WFH] are solely bystanders unjustly afflicted by mechanisms in their brains.” Ultimately addiction is a brain disease, but is also much more, and for those of us tasked with bringing medical students to the frontiers of understanding, the analogy is an important one to preserve. The part that may be missing for those reading Dr. Volkow for the first time is the enormous distance that medicine had to come, in accepting the notion that addiction is at least a brain disease. Just as, again, diabetes is at least a disorder of glucose metabolism. NIDA Directors from before Alan Leshner in 1998 and up to the present, Nora Volkow, have been tireless in raising understanding of addiction as more than a moral failing.
A part of me wants to appreciate and to thank Dr. Noe for showing sensitivity to the complexity of addiction as an illness. I am hoping that my remarks won't seem churlish, so much as they are an effort to remind us that the chronic, progressive, relapsing disorders, whether tuberculosis or diabetes or multiple sclerosis or schizophrenia or addiction, have these common qualities: a biological component; and consequences that are physical, behavioral, social…and spiritual.
(Please accept our wishes from ASAMW for a joyous and prosperous and healthy new year.)
Editor-in-Chief: William Haning, MD, DFASAM, DFAPA