Views of Addiction Neuroscientists and Clinicians on the Clinical Impact of a ‘Brain Disease Model of Addiction’

A survey of international addiction researchers' views on implications of brain-based explanations of addiction and the responsibility of affected persons

Aim: To complement existing stakeholder surveys by exploring addiction researchers' views on the implications of brain-based explanations of addiction and the responsibilities of addicted persons. Methods: A total of 190 researchers from 29 countries (13.2%) participated in a LimeSurvey. Their perspectives on implications of brain-based explanations of addiction were explored qualitatively using open-ended questions. In addition, respondents could indicate their views on the responsibility of addicted individuals for their condition and actions using a Likert scale and a free-text field ("mixed methods light"). Qualitative analyses inductively identified the most frequent themes and deductively assessed the overall impact (positive, negative or both/ambivalent). Quantitative analyses included frequencies and proportions. Results: The major themes mentioned were medicalisation and the neglect of other factors, better treatment options and access, (reduced) stigma and (impaired) agency of affected persons. The overall evaluation yielded 46% positive, 33% negative and 16% ambivalent views. Approximately 60% of the participants considered addicted persons to be responsible for their condition and 80% for their actions. Conclusions: According to researchers, a brain-based approach to addictions has positive and negative implications. In particular, the neglect of factors other than biomedical seems to be of concern. Thus, a re-consideration of research priorities as well as affected individuals' agency and role in treatment and care seems warranted.

The Influence of Using Novel Predictive Technologies on Judgments of Stigma, Empathy, and Compassion among Healthcare Professionals

BACKGROUND

Our objective was to evaluate whether the description of a machine learning (ML) app or brain imaging technology to predict the onset of schizophrenia or alcohol use disorder (AUD) influences healthcare professionals' judgments of stigma, empathy, and compassion.

METHODS

We randomized healthcare professionals (N = 310) to one vignette about a person whose clinician seeks to predict schizophrenia or an AUD, using a ML app, brain imaging, or a psychosocial assessment. Participants used scales to measure their judgments of stigma, empathy, and compassion.

RESULTS

Participants randomized to the ML vignette endorsed less anger and more fear relative to the psychosocial vignette, and the brain imaging vignette elicited higher pity ratings. The brain imaging and ML vignettes evoked lower personal responsibility judgments compared to the psychosocial vignette. Physicians and nurses reported less empathy than clinical psychologists.

CONCLUSIONS

The use of predictive technologies may reinforce essentialist views about mental health and substance use that may increase specific aspects of stigma and reduce others.

Is a brain-based understanding of addiction predominant? An assessment of addiction researchers' conceptions of addiction and their evaluation of brain-based explanations

INTRODUCTION

Brain-based explanations of addiction have become a prominent explanatory model in recent decades. Although opposing views have been published, there is no large-scale study of researchers' opinions, unlike for treatment staff, the public and affected individuals. Therefore, this study aimed to examine international addiction researchers' perspectives on: (i) brain-based explanations of addiction; (ii) the perceived dominance of the concept in science, society, treatment and among those affected; and (iii) researchers' general conception of addiction in terms of ontologies and causes.

METHODS

A sample of 1440 international addiction researchers was compiled. Views were assessed online via LimeSurvey using a 'mixed methods light' approach (Likert-type scales, free-text fields). Qualitative content analyses of free-text comments complemented descriptive statistics.

RESULTS

One hundred and ninety researchers participated (13.19% response). The classification of substance use disorders as brain diseases/disorders was shared by about 60% of the respondents. Approximately 80% considered it the dominant view in science, but fewer in treatment, society and affected persons. Approximately 75% found it an oversimplification, but regarded it as helpful for understanding substance use disorders. Altogether, various biological, psychological and social factors were considered causal. Comments indicated that an over-simplistic nature of brain-based explanations of addiction was viewed as particularly problematic.

DISCUSSION AND CONCLUSIONS

A rejection of a simplistic view of addiction in favour of a multi-causal concept in which the brain plays a role seems to be the majority view of participating researchers. Therefore, the orientation of future research, treatment and support for addicted persons need to be reconsidered accordingly.

Understanding addiction: The shift from epistemology to ontology

This essay contrasts a late modernist epistemological paradigm with an ontology-oriented Anthropocene-conscious Approach (ACA) as frameworks for understanding the coming into being and the making of addiction. Operationalizable theories and concepts of addiction have been crucial in an era with a great demand for compartmentalizing and systemically defining psychological struggles and social problems. In the modernistic progress story, the addiction phenomenon materializes through the conceptual division between capacity and non-capacity, with those capable of mastering their urges on one side and those incapable of doing so on the other. The ACA strives actively to move beyond artificial divides between agency/structure, culture/nature, mind/matter and instead explore phenomena ecologically across these continuums. This entails a conscious re-focus away from authoritative human-made assumptions towards new types of knowledge and knowing. In the ACA assemblage-like ontology, different elements are brought together in their capacities to affect each other into entities. Due to its claims of practical uses, I predict that the ACA will become as influential as Foucauldian genealogy in the field of addiction studies.

Neural imaginaries at work: Exploring Australian addiction treatment providers' selective representations of the brain in clinical practice

Although addiction neuroscience hopes to uncover the neural basis of addiction and deliver a wide range of novel neuro-interventions to improve the treatment of addiction, the translation of addiction neuroscience to practice has been widely viewed as a ‘bench to bedside’ failure. Importantly, though, this linear ‘bench to bedside’ conceptualisation of knowledge translation has not been attentive to the role addiction treatment providers play in reproducing, translating, or resisting neuroscientific knowledge. This study explores how, to what extent, and for what purpose addiction treatment providers deploy neuroscientific representations and discuss the brain in practice. It draws upon interviews with 20 Australian treatment providers, ranging from addiction psychiatrists in clinics to case-workers in therapeutic communities. Our findings elucidate how different treatment providers: (1) invoke the authority and make use of neuroscience in practice (2) make reference to neuroscientific concepts (e.g., neuroplasticity); and sometimes represent the brain using vivid neurobiological language, metaphors, and stories; and, (3) question the therapeutic benefits of discussing neuroscience and the use of neuroimages with clients. We argue that neurological ontologies of addiction, whilst shown to be selectively and strategically invoked in certain circumstances, may also at times be positioned as lacking centrality and salience within clinical work. In doing so, we render problematic any straightforward assumption about the universal import of neuroscience to practice that underpins narratives of ‘bench to bedside’ translation.

Drug and alcohol treatment providers' views about the disease model of addiction and its impact on clinical practice: A systematic review

ISSUES

Addiction treatment providers' views about the disease model of addiction (DMA), and their contemporary views about the brain disease model of addiction (BDMA), remain an understudied area. We systematically reviewed treatment providers' attitudes about the DMA/BDMA, examined factors associated with positive or negative attitudes and assessed their views on the potential clinical impact of both models.

APPROACH

Pubmed, EMBASE, PsycINFO, CINAHL Plus and Sociological Abstracts were systematically searched. Original papers on treatment providers' views about the DMA/BDMA and its clinical impact were included. Studies focussing on tobacco, behavioural addictions or non-Western populations were excluded.

KEY FINDINGS

The 34 included studies were predominantly quantitative and conducted in the USA. Among mixed findings of treatment providers' support for the DMA, strong validity studies indicated treatment providers supported the disease concept and moral, free-will or social models simultaneously. Support for the DMA was positively associated with treatment providers' age, year of qualification, certification status, religious beliefs, being in recovery and Alcoholics Anonymous attendance. Greater education was negatively associated with DMA support. Treatment providers identified potential positive (e.g. reduced stigma) and negative (e.g. increased sense of helplessness) impacts of the DMA on client behaviour.

IMPLICATIONS/CONCLUSION

The review suggests treatment providers may endorse disease and other models while strategically deploying the DMA for presumed therapeutic benefits. Varying DMA support across workforces indicated service users may experience multiple and potentially contradictory explanations of addiction. Future policy development will benefit by considering how treatment providers adopt disease concepts in practice.

Prehending Addiction: Alcohol and Other Drug Professionals' Encounters With "New" Addictions

This article investigates the ways new forms of addiction are encountered by professionals working in the area of alcohol and other drugs. Combining interviews with policymakers, service providers, and peer advocates in three countries (Australia, Canada, and Sweden), and Mike Michael's utilization of the notion of prehension for science communication, we track the notions of addiction, drugs, and subjectivity that emerge when alcohol and other drug professionals encounter what Fraser, Moore and Keane call the addicting of nonsubstance-related practices. The analysis has three parts: constituting addiction unity, questioning addiction unity, and conflicting logics of addicting processes. We argue that specific articulations of drugs and health and specific health professional and addiction subjects are made anew in these encounters. These notions of drugs, health, and subjectivity shape how alcohol and other drug professionals engage with substance-related addictions. In concluding, we consider the implications of new addictions for professional practice.

Q: Is Addiction a Brain Disease or a Moral Failing? A: Neither

This article uses Marc Lewis' work as a springboard to discuss the socio-political context of the brain disease model of addiction (BDMA). The claim that promotion of the BDMA is the only way the general public can be persuaded to withhold blame and punishment from addicts is critically examined. After a discussion of public understandings of the disease concept of addiction, it is pointed out that it is possible to develop a scientific account of addiction which is neither a disease nor a moral model but which the public could understand. Evidence is reviewed to suggest that public acceptance of the disease concept is largely lip-service and that the claim the BDMA removes stigma among the public and professionals is unsupported by evidence. Further, there is good evidence that biogenetic explanations of mental/behavioural disorders in general have been counterproductive in the attempt to ally stigma. A model of addiction as a disorder of choice may attract special problems in public-facing communications and risks being misunderstood. However, ways of presenting this model to the public are suggested that may avoid such risks. Lastly, the claim that the BDMA is the only way of ensuring access to treatment and of maintaining research funding for addiction is disputed and a way in which these benefits can be retained under a disorder-of-choice model proposed. The article concludes by enthusiastically endorsing Lewis' call for a third stage in the governing image of addiction.

The Neurobiology of "Food Addiction" and Its Implications for Obesity Treatment and Policy

There is a growing view that certain foods, particularly those high in refined sugars and fats, are addictive and that some forms of obesity can usefully be treated as a food addiction. This perspective is supported by a growing body of neuroscience research demonstrating that the chronic consumption of energy-dense foods causes changes in the brain's reward pathway that are central to the development and maintenance of drug addiction. Obese and overweight individuals also display patterns of eating behavior that resemble the ways in which addicted individuals consume drugs. We critically review the evidence that some forms of obesity or overeating could be considered a food addiction and argue that the use of food addiction as a diagnostic category is premature. We also examine some of the potential positive and negative clinical, social, and public policy implications of describing obesity as a food addiction that require further investigation.

Scepticism and hope in a complex predicament: People with addictions deliberate about neuroscience

BACKGROUND

According to the 'brain disease model of addiction', addiction is a chronic condition the symptoms of which reflect persistent changes in neural functioning produced by long-term drug use. Scholars have argued both for and against the validity and usefulness of this way of conceptualising addiction, which has been variously described as emancipatory and detrimental to addicted persons. In this paper we explore how people with addictions make sense of the brain disease concept and the extent to which they find it useful.

METHODS

We conducted 44 semi-structured interviews with persons in treatment for drug and alcohol addiction recruited through a variety of channels. Transcripts were analysed by combining a health identity approach with thematic analysis.

RESULTS

We describe participants' understandings of how they became addicted and what role, if any, neurobiological conceptions play in their explanations. Our findings highlight the hopeful and sceptical viewpoints of addicted individuals on the value of addiction neuroscience ideas and neurotechnologies.

CONCLUSIONS

These viewpoints shed some light on the diverse and divergent ways that people with addictions make sense of neurobiological ideas and technologies. It also describes when, and how, neurobiological explanations and the 'brain disease' model can be helpful to addicted persons. Some of the limitations of the brain disease model become apparent in the complex ways in which neurobiological explanations and labels are incorporated into lay understandings. In order to be more useful to addicted persons, neurobiological explanations should be provided as part of a more complex explanation of addiction and the brain than the BDMA offers, and should not be given a 'disease' label.

Views about responsibility for alcohol addiction and negative evaluations of naltrexone

BACKGROUND

Moral philosophers have debated the extent to which persons are individually responsible for the onset of and recovery from addiction. Empirical investigators have begun to explore counselors' attitudes on these questions. Meanwhile, a separate literature has investigated counselors' negative attitudes towards naltrexone, an important element of medication-assisted treatment for alcohol addiction. The present study bridges the literature on counselor views about responsibility for addiction with the literature on attitudes towards naltrexone. It investigates the extent to which a counselor's views of individual responsibility for alcohol addiction are related to that counselor's views of naltrexone.

METHODS

Using a vignette-based survey of 117 addiction treatment professionals, the study analyzes the relationship between an addiction counselor's views about individual responsibility for alcohol addiction and using naltrexone to treat it.

RESULTS

We find a significant difference in counselors who assign greater responsibility to a person for the onset of alcohol addiction. They agreed more strongly with several objections to naltrexone, including worries about compliance, naltrexone's side effects outweighing its benefits, naltrexone treating symptoms but not underlying causes, and the idea that medication may undermine a person's motivation to recover. Combined views of greater responsibility for addiction's onset and recovery also significantly predicted stronger agreement with objections.

CONCLUSIONS

We conclude that there is a strong relationship between a counselor assigning higher individual responsibility for addiction and holding more negative views about naltrexone. The study also sheds light on one reason why the model of addiction as a brain disease has had limited impact on clinical practice.