The NIDA brain disease paradigm: History, resistance and spinoffs

Resistance to the biomedicalization of mental illness through peer support: The case of peer specialists and mental health

Certified peer specialists (CPS) are mental health professionals who draw their expertise from lived experience with mental illness and mental distress. They tale a nonmedical, nonclinical approach to providing support to community members with mental health difficulties and in doing so, emphasize the role of social environmental factors that contribute to mental distress. Their perspectives are contrary to the biomedical perspective of mainstream psychiatry. While there is a significant body of literature on CPS, there is a dearth of research on how CPS engage in and perceive the broader mental health system. They resist the biomedicalization of mental illness by moving past labels and the language of pathology to facilitate recovery from mental illness and to resist stigma. Drawing from in-depth interviews with peer specialists, participant observation of a peer-run organization, and a survey of peer specialists across the United States, I ask the following research questions: How and why are CPS challenging the medical model of mental illness? How do CPS consider social environmental factors in the etiology of distress and what are the potential implications for resistance to both biomedicalization and stigmatization? My data suggest that CPS, in their critiques of the medical model and the mental health system, are actively resisting the biomedicalization of mental illness and focus on social environmental factors that contribute to experiences of distress. This research has meaningful implications for research on CPS and hope for recovery from mental illness.

Causal complexity in human research: On the shared challenges of behavior genetics, medical genetics, and environmentally oriented social science

We received 23 spirited commentaries on our target article from across the disciplines of philosophy, economics, evolutionary genetics, molecular biology, criminology, epidemiology, and law. We organize our reply around three overarching questions: (1) What is a cause? (2) How are randomized controlled trials (RCTs) and within-family genome-wide association studies (GWASs) alike and unalike? (3) Is behavior genetics a qualitatively different enterprise? Throughout our discussion of these questions, we advocate for the idea that behavior genetics shares many of the same pitfalls and promises as environmentally oriented research, medical genetics, and other arenas of the social and behavioral sciences.

Making addicts: critical reflections on agency and responsibility from lawyers and decision makers

Various activities are increasingly characterised as 'addictions', including within the law, and raise important questions. Do 'addicts' have agency? Do addictions shape social problems such as family and sexual violence? And how do those involved in legal systems perceive addictions? This paper explores these questions. Drawing on qualitative interviews with lawyers and decision makers (N = 48), it explores addiction in law. Lawyers and decision makers see themselves as playing important roles in making addiction and 'addicts'. Addiction is an effect principally of legal strategy, and other forces. Legal processes bring differing conceptions of agency and responsibility into being, problematising understandings of agency as an 'effect' of addiction, or as pre-existing legal processes. There are also important variations in approach regarding different addictions. Alcohol or other drug addiction is seen as 'genuine', and a major factor in family violence, while sex addiction lacks credibility. I explore some implications of these approaches.

Not You: Addiction, Relapse, and Release in Uganda

In recent years, alcohol abuse and dependence have become topics of increasing concern in Uganda, but the chronic relapsing brain disease model of addiction remains only one of many ways of understanding and addressing alcohol-related problems there. For many Ugandan Pentecostals and spirit mediums to be addicted is to be under the control of a being that comes from outside the self. Where these two groups differ, and here they differ strongly, is in regard to the moral valence of these external spirits and what ought to be done about them. This article draws on four years of collaborative ethnographic fieldwork to explore the affordances of these ways of viewing and experiencing addiction and recovery for Ugandans attempting to leave alcohol behind. While the idioms of bondage, dedication, and possession are at times severe, this article argues that they contain within them concepts and practices that point away from models of addiction as a chronic relapsing brain disease and towards the possibility of release.

‘Making Ground’: An Ethnography of ‘Living With’ Harmful Methamphetamine Use and the Plurality of Recovery

The trajectories of people attempting to reduce harmful methamphetamine use are frequently understood within a binary framework of transitioning between states of health and disease. This framework can often be reinforced by service interactions informed by these dominant narratives of recovery and addiction. In this paper, we draw on a critical interactionist analysis of ethnographic fieldwork conducted with people who use methamphetamine, to examine how their experiences could undermine this binary, observing the ways participants experienced growth, change, and progress, without necessarily maintaining abstinence. These findings support a more diverse understanding of drug use trajectories, and we explore the concept of ‘living with drug use’, similar to how people live with other chronic conditions by finding ‘health in illness’. Participant experiences are also interpreted within the context of counter public health, arguing for the recognition and integration of values and goals which are divergent from the implicit aims of public health practice.

Police Officers' addiction frameworks and policy attitudes

Police officers have frequent encounters with people who use drugs, either by making an arrest for a drug-related offense or responding to a drug overdose call. Yet, little is known about how police officers view drug addiction - as a disease, a moral failure, or something else - and how their frameworks for conceptualizing addiction impact their attitudes toward drug policies, including the use of naloxone. This research examined police officers' adherence to a moralistic addiction framework in relation to their support for treatment-oriented drug policies. Officers (N = 618) were surveyed about their beliefs on drug policy and the extent to which drug addiction was a product of one's morals or related to social or biological reasons. Results found that approximately 22% of the variance in drug policy attitudes could be explained by addiction frameworks and control variables. Officers who embraced a biological perspective of addiction were more supportive of policies that expanded treatment, including access to naloxone, and less punitive sanctions. Those with stronger moralistic views were less supportive of expanding treatment initiatives and endorsed expanding punitive sanctions. Officer age and education was positively related with expanding treatment and naloxone use while exposure to overdoses was negatively related to policy support. These results demonstrate that officers' frameworks about drug addiction play an important role in drug policy attitudes and, by extension, how they might interact with people who use drugs.

Does Addiction Have A Subject?: Desire in Contemporary U.S. Culture

This paper traces the emergence of a new figure of the desiring subject in contemporary addiction science and in three other recent cultural developments: the rise of cognitive-behavior therapy, the self-tracking movement, and the dissemination of ratings. In each, the subject's desire becomes newly figured as a response to objects rather than a manifestation of the soul, measured numerically rather than expressed in language and rendered impersonal rather than individualizing. Together, these developments suggest a shift in the dominant form of the desiring subject in contemporary U.S. culture, one that breaks with the subject-form that Foucault theorized five decades ago.

Drug overdose deaths, addiction neuroscience and the challenges of translation

In this article, we argue that the rapid rise in drug overdose deaths in America is a tragedy that draws attention to fundamental conceptual and experimental problems in addiction science that have significant human consequences. Despite enormous economic investment, political support and claims to have revolutionised addiction medicine, neurobiological models are yet to produce a treatment for substance addiction. This is partly, we claim, because neurobiology is unable to explain essential features of addiction and relapse that neurobehavioral models of addiction are better placed to investigate. We show how addiction neuroscience turned to long-term memory to explain the chronicity of addiction and persistent relapses long after neurochemical traces have left the body. The turn to memory may in time help to close the translational gap facing addiction medicine, but it is our view in this article that the primary value of memory theory lays in its potential to create new critical friendships between biological and social sciences that are attuned to the lived experience and suffering of stigmatised people. The value of the memory turn may rest upon the capacity of these critical friendships to wean addiction science off its long-term dependence on disease concepts of human distress.

Crisis, what crisis? Addiction neuroscience and the challenges of translation

In this article we interrogate the claim that there is an opioid crisis: a dramatic rise in drug overdose fatalities in the United States over the past two decades that is also spreading to other countries.  The usual argument is that this crisis is largely explained by errant prescription practices leading to an oversupply of opioids, leading to addiction, premature mortality and drug overdose deaths, both among those prescribed opioids for pain relief, and those obtaining them on the illegal market.  We argue, that this view is highly problematic and that it is likely to entrench deeper problems with how substance addiction has been perceived and known. In this article, we develop an alternative picture of the addiction crisis based on four years of research and collaboration with addiction neuroscientists. Drug overdose deaths, we claim, are symptoms of what we term the ‘structural distribution of social despair.’ We argue that this is compounded by a translation crisis at the heart of addiction neuroscience. For all its dominance, the ‘dopamine hypothesis’ of addiction that shaped understandings for some three decades, has still not produced a single effective treatment. However, this translation crisis also represents an opportunity for ‘the memory turn’ in addiction neuroscience as it seeks to translate its emerging conception of addiction as a problem of memory into effective forms of treatment. We conclude by arguing that, for the ‘memory turn’ to underpin effective interventions into ‘the opioid crisis’, a new relation between neuroscientists and social scientists of addiction is needed, one that proceeds from the lived experience of human beings.

What We're Not Talking about When We Talk about Addiction

The landscape of addiction is dominated by two rival models: a moral model and a model that characterizes addiction as a neurobiological disease of compulsion. Against both, I offer a scientifically and clinically informed alternative. Addiction is a highly heterogenous condition that is ill-characterized as involving compulsive use. On the whole, drug consumption in addiction remains goal directed: people take drugs because drugs have tremendous value. This view has potential implications for the claim that addiction is, in all cases, a brain disease. But more importantly, it has implications for clinical and policy interventions. To help someone overcome addiction, you need to understand and address why they persist in using drugs despite negative consequences. If they are not compelled, then the explanation must advert to the value of drugs for them as an individual. What blocks us from acknowledging this reality is not science but fear: that it will ignite moralism about drugs and condemnation of drug users. The solution is not to cleave to the concept of compulsion but to fight moralism directly.

Addiction from the harmful dysfunction perspective: How there can be a mental disorder in a normal brain

Is addiction a medical disorder, and if so, what kind of disorder is it? Addiction is considered a brain disease by NIDA, based on observed brain changes in addicts that are interpreted as brain damage. Critics argue that the brain changes result instead from normal neuroplasticity and learning in response to the intense rewards provided by addictive substances, thus addiction is not a disorder but rather a series of normal-range if problematic choices. Relying on the harmful dysfunction analysis of medical disorder to evaluate disorder versus nondisorder status, I argue that even if one accepts the critics' reinterpretation of NIDA's brain evidence and rejects the brain disease account, the critics' conclusion that addiction is not a medical disorder but is rather a matter of problematic nondisordered choice does not follow. This is because there is a further possible account of addiction, the evolutionary "hijack" view, that holds that addiction is due to the availability of substances and stimuli that were unavailable during human species evolution and that coopt certain brain areas concerned with human motivation, creating biologically undesigned peremptory desires. I argue that if the hijack theory is correct, then it opens up the possibility that addiction could be a true motivational medical disorder for which there is no underlying neurological-level dysfunction. Finally, I explore the implications of this account for how we see the social responsibility for addiction and how we attempt to control it.

The (in)Significance of the Addiction Debate

Substance addiction affects millions of individuals worldwide and yet there is no consensus regarding its conceptualisation. Recent neuroscientific developments fuel the view that addiction can be classified as a brain disease, whereas a different body of scholars disagrees by claiming that addictive behaviour is a choice. These two models, the Brain Disease Model and the Choice Model, seem to oppose each other directly. This article contends the belief that the two models in the addiction debate are polar opposites. It shows that it is not the large amount of addiction research in itself what sets the models apart, but rather their extrapolated conclusions. Moreover, some of the most fiercely debated aspects - for instance, whether or not addiction should be classified as a disease or disorder - are irrelevant for the conceptualisation of addiction. Instead, the real disagreement is shown to revolve around capacities. Discussing addiction-related capacities, especially regarding impaired control, rather than the assumed juxtaposition of the two models can be considered the true addiction debate. More insight into the extent to which the capacities of the addicted individual were affected would be highly useful in various other areas, especially legal responsibility.

The continuing search for an addiction vaccine

Inspired by advances in immunology, in the 1970s scientists began to study the possibilities of mobilizing the human immune system against intruders other than pathogenic viruses and bacteria. In 1972 the suggestion was first made that it might be possible to provoke immunity to narcotic dependence. Because molecules of narcotics such as heroin and cocaine are too small to stimulate an immune response, researchers sought ways of coupling them to immunogenic proteins. The substances they developed soon became known as addiction vaccines. However, despite fifty years of research, and despite the growing problem of addiction, no vaccine against heroin, cocaine, methamphetamine or nicotine addiction has yet been licensed for clinical use. This paper reviews the history of addiction vaccinology, seeks to explain the unique appeal of a vaccinological approach to addiction, and argues for broad discussion of how such vaccines should ultimately be used.

Psychosomatic subjects and the agencies of addiction

Addiction science and public policy have for some time been articulated in conformity with a broader antinomy in Western thought between biological reductionism and liberal voluntarism. Hence, mainstream debates have concerned whether and how addiction might be understood as a disease in the biomedically orthodox sense of anatomical or physiological pathology or whether and how addiction might be understood as a voluntary choice of some kind. The fact that those who staff these debates have appeared either unable or unwilling to consider alternatives to this antinomy has resulted in a rather unhappy and intransigent set of intellectual anomalies both on the biomedical and the social scientific sides of this divide. Perhaps more importantly, it has also resulted in a striking isolation of scientific debates themselves from the vicissitudes of therapeutically caring for those putatively suffering from addictions both within and outside clinical settings. After briefly demonstrating the conformity of debates in addiction science with the broader antinomy between biological reductionism and liberal voluntarism and the anomalies that thereby result, this article considers the scientific and therapeutic benefits of a psychosomatic framework for the understanding of both self-governing subjects and the experience of a loss of self-control to agencies of addiction.

Poly and Tricky Dick: The drug war origins of the term "polydrug use"

Polydrug use is presented as a particular drug-use phenomenon when the combination of substances is and always has been the practice. The origin of the term is found in the early years of the war on drugs under the Nixon administration in the US, when it was used to justify the intensification of repressive measures against drug users and to counter the growing accommodation and normalisation of cannabis. Only by presenting cannabis as the first step towards the use of harder drugs could the repression of this largely innocuous and widely used substance be justified. Drug users were presented as "polydrug users", which offered an explanation of problematic use as rooted in the drug user, the addict, who would switch substances in accordance with availability and price. Having become established for political reasons, the term has become entrenched because it resonates and vividly describes social practice. Yet it does not add to understanding of social reality but occludes and confuses because it presents "polydrug" as a particular and peculiar pattern of consumption and not as the norm.

When the Brain Leaves the Scanner and Enters the Clinic

Addiction neuroscience promises to uncover the neural basis of addiction by mapping changes in the “diseased brains” of people with “drug addictions.” It hopes to offer revolutionary treatments for addiction and reduce the stigma experienced by those seeking treatment for a medical, rather than moral, condition. While the promises of addiction neuroscience have received considerable attention, relatively few studies have examined how neuroscientific discourses and promises play out in drug treatment settings. Instead of asking how neuroscience might measure or treat a preexisting addiction “problem,” we draw on poststructuralist ideas to trace how neuroscientific discourses produce addiction as a certain type of “problem” and the effects of these particular problematizations. Based on interviews with a range of different types of treatment providers working in Victoria, Australia, we discuss three themes that reveal neuroscientific discourses at work: (1) constituting pathological subjects, (2) neuroplasticity and “recovery,” and (3) the alleviation of guilt and shame via references to the “diseased brain.” On the basis of our analysis, we argue that dominant neuroscientific discourses produce patients as pathologized subjects, requiring medical treatment. We also contend that the intersection of neuroscientific and recovery discourses enacts “recovery” in terms of brain “recovery” through references to neuroplasticity. Further, when neuroscientific and moral discourses intersect, addicted subjects are absolved from the guilt associated with immoral behavior emerging from a “hijacked brain.” We conclude by emphasizing the need for future critical work to explore the complex ways in which neuroscientific discourses operate in localized care ecologies.

Keeping secrets: Leslie E. Keeley, the gold cure and the 19th-century neuroscience of addiction

BACKGROUND AND AIMS

Dr Leslie E. Keeley was perhaps the world's most famous addiction cure doctor at the turn of the 20th century, but mainstream medicine dismissed him as a quack because he dispensed a secret cure. This paper aims to describe Keeley's now largely forgotten story and to draw attention to the role of contextual issues in the acceptance or rejection of any theory of addiction, particularly the neuroscientific theories of the early 21st century.

METHODS

This study is a qualitative assessment and contextualization of historical documents. Its main sources are archival and are, for the most part, unknown to historians. The paper also offers intellectual and historical context that is drawn from leading historical and sociological analyses.

RESULTS

Keeley's addiction cure was dismissed as quackery because it failed to meet the changing standards of late 19th-century professional medicine. This begs us to consider contextual issues in any assertion of the viability of addiction therapeutics, in the present as well the past.

CONCLUSIONS

Keeley's near erasure from the historical record was a consequence of a broader, late 19th-century medical power struggle that took precedence over the testimony of tens of thousands of satisfied patients who claimed that Keeley's cure worked. Context matters in the assessment of the viability of theories of addiction from the past, but also from the present. Historians and social scientists are well placed to make those assessments.

"I don't have to know why it snows, I just have to shovel it!": Addiction Recovery, Genetic Frameworks, and Biological Citizenship

The gene has infiltrated the way citizens perceive themselves and their health. However, there is scant research that explores the ways genetic conceptions infiltrate individuals' understanding of their own health as it relates to a behavioral trait, like addiction. Do people seeking treatment for addiction ground their self-perception in biology in a way that shapes their experiences? We interviewed 63 participants in addiction treatment programs, asking how they make meaning of a genetic understanding of addiction in the context of their recovery, and in dealing with the stigma of addiction. About two-thirds of people in our sample did not find a genetic conception of addiction personally useful to them in treatment, instead believing that the cause was irrelevant to their daily struggle to remain abstinent. One-third of respondents believed that an individualized confirmation of a genetic predisposition to addiction would facilitate their dealing with feelings of shame and accept treatment. The vast majority of our sample believed that a genetic understanding of addiction would reduce the stigma associated with addiction, which demonstrates the perceived power of genetic explanations in U.S. society. Our results indicate that respondents (unevenly) ground their self-perception of themselves as an addicted individual in biology.

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.

Making visible the politics and ethics of alcohol policy research

Although research on alcohol policy has produced a huge international literature, alcohol research and policy itself-its cultural assumptions, methods, politics and ethics-has rarely been subject to critical analysis. In this article, I provide an appreciative review of an exception to this trend: Joseph Gusfield's 1981 classic, The Culture of Public Problems: Drinking-Driving and the Symbolic Order. I first outline Gusfield's argument that the 'problem of drinking-driving' is constructed as a 'drama of individualism' centring on the 'killer drunk'. The 'culture' of drinking-driving research and policy emphasizes alcohol as the problem and locates the source of car accidents in the moral failings of the individual motorist, rather than in social institutions or physical environments. For Gusfield, this construction of the problem is the outcome of political and ethical choices rather than of 'objective' conditions. In the second part of the article, I highlight the book's remarkable foresight in anticipating later trends in critical policy analysis, and argue that it should be regarded as a sociological classic and as required reading for those working in alcohol and indeed other drug policy research. I conclude by arguing that The Culture of Public Problems remains relevant to those working in alcohol and other drug policy research, although the reasons for its relevance differ depending on readers' theoretical commitments.

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.

From Boredom to Dependence: The Medicalisation of the Swedish Gambling Problem

Aims

The aim of this study is to investigate the medicalising of gambling problems by comparing the political discussions on gambling in the Swedish Parliament in the early 1970s and the early 2010s.

Design

Against a theoretical background on medicalising processes in general, and medicalisation of gambling problems in particular, we have analysed discussion protocols and parliamentary bills in the Swedish Parliament from the years 1970–1975 and 2012–2013.

Results

The problem descriptions of the 1970s and 2010s are, in certain respects, strikingly similar, identifying proactive operators such as the gambling companies and highlighting an inadequate legal framework. But where the MPs of the 1970s put some effort into describing the drab society which fed the need for gambling, the elected representatives of the 2010s shortcut to individual dependence.

Conclusions

EU membership and the development of the Internet have made effective control and regulation impossible in the early 2010s and the political handling of the Swedish gambling problem is therefore a clear example of how market liberalisation can pave the way for individualisation, medicalisation and depoliticisation of social problems.

Addiction in the Making

This review traces the literatures in cultural anthropology and neighboring disciplines that are focused on addiction as an object of knowledge and intervention, and as grounds for self-identification, sociality, and action. Highlighting the production of disease categories, the staging of therapeutic interventions, and the ongoing work of governance, this work examines addiction as a key site for the analysis of contemporary life. It likewise showcases a general movement toward accounts of addiction that foreground complexity, contingency, and multiplicity.

Politics of prevention: The emergence of prevention science

BACKGROUND

This article critically examines the political dimension of prevention science by asking how it constructs the problems for which prevention is seen as the solution and how it enables the monitoring and control of these problems. It also seeks to examine how prevention science has established a sphere for legitimate political deliberation and which kinds of statements are accepted as legitimate within this sphere.

METHODS

The material consists of 14 publications describing and discussing the goals, concepts, promises and problems of prevention science. The analysis covers the period from 1993 to 2012.

RESULTS

The analysis shows that prevention science has established a narrow definition of "prevention", including only interventions aimed at the reduction of risks for clinical disorders. In publications from the U.S. National Institute of Drug Abuse, the principles of prevention science have enabled a commitment to a zero-tolerance policy on drugs. The drug using subject has been constructed as a rational choice actor lacking in skills in exerting self-control in regard to drug use. Prevention science has also enabled the monitoring and control of expertise, risk groups and individuals through specific forms of data gathering. Through the juxtaposition of the concepts of "objectivity" and "morality", prevention science has constituted a principle of delineation, disqualifying statements not adhering to the principles of prevention science from the political field, rendering ethical and conflictual dimensions of problem representations invisible.

CONCLUSION

The valorisation of scientific accounts of drugs has acted to naturalise specific political ideals. It simultaneously marginalises the public from the public policy process, giving precedence to experts who are able to provide information that policy-makers are demanding. Alternative accounts, such as those based on marginalisation, poverty or discrimination are silenced within prevention science.

A Thousand Contradictory Ways

Neuroscientific accounts of addiction are increasingly influential in health and medical circles. At the same time a diverse, if equally scientifically focused, opposition to addiction neuroscience is emerging. In this struggle over the merits of addiction neuroscience are elements of a uniquely 21st-century public engagement with science. No longer trusted by the public as the unerring source of objective knowledge about the world, science is, at least in some contexts, increasingly treated as just one voice among many. Observing the difficulties this loss of faith in science poses for effective action on pressing issues such as climate change, philosopher Bruno Latour develops a different (ecological) approach to scientific knowledge, one that for the first time allows scientists (and other “moderns”) to understand it for what it really is and locate it “diplomatically” alongside other modes of knowing. In this article, I ask whether a similar innovation is needed to allow more effective understanding of addiction. I explore this question by analyzing two recent, widely discussed, popular books (Marc Lewis’s Memoirs of an Addicted Brain: A Neuroscientist Examines His Former Life on Drugs, 2011 and Carl Hart’s High Price: A Neuroscientist’s Journey of Self-discovery that Challenges Everything You Think You Know About Drugs and Society, 2013) as well as reviews of these books. Written by neuroscientists, and drawing heavily on personal memoir to illustrate and ratify their competing views on drugs and addiction, both books crystallize contemporary dilemmas about science, empiricism, and the nature of evidence and truth. How are we to understand their mix of “scientific fact” and individual self-observation, what does this mix suggest about scientific knowledge, and what are its implications for dominant notions of “evidence-based” drug policy and treatment? I argue that these books both trouble and reinforce our taken-for-granted distinctions between science and personal stories, between objectivity and subjectivity, and note the lost opportunities the books represent for a more searching and productive (Latour might say “ecological”) engagement with science.

Stigma and the addiction paradigm for obesity: lessons from 1950s America

AIMS

To discuss an historical episode in which obesity was conceptualized as an addictive disorder and declared to be a major epidemic in the early postwar United States. This history illuminates past consequences of framing obesity as an addiction in ways that may inform constructive policy responses today.

METHODS

Review of secondary and primary sources, including archival documents, relating to obesity in biomedical and popular thought of the 1940s and 1950s.

RESULTS

In the United States in the late 1940s and 1950s, new medical thinking about obesity reinterpreted overweight and obesity as chiefly the consequence of addiction (understood in the then dominant psychodynamic theory as a psychological defect, oral fixation). This new conception was rapidly taken up in popular discourse and clinical practice, with adverse effects through amplification of weight stigma. Further, in the conservative political context, the addiction concept contributed to an ineffective policy response to the alarming new epidemiological evidence about obesity's consequences. Despite a lack of evidence for efficacy of the intervention, public health efforts focused on correcting individual eating behaviour among obese people by encouraging self-help in lay groups modelled, in part, on Alcoholics Anonymous. Population-level intervention was neglected.

CONCLUSIONS

Current public health policy initiatives must be mindful of the risks of reframing obesity as an addiction. These include inadvertently reinforcing stigma, narrowing responses to those aiming to modify individual behaviour and biology and neglecting population policies aiming to reduce the consumption of energy-dense foods, as all occurred in the 1950s United States.

The brain disease model of addiction: is it supported by the evidence and has it delivered on its promises?

Since 1997 the US National Institute on Drug Abuse has advocated a brain disease model of addiction (BDMA). We assess the strength of evidence for the BDMA in animals, neuroimaging studies of people with addiction, and current research on the role of genetics in addiction. We critically assess claims about the medical and social benefits of use of the BDMA because the social implications are often implied as a reason to accept this model. Furthermore, we argue that the BDMA is not supported by animal and neuroimaging evidence to the extent its advocates suggest; it has not helped to deliver more effective treatments for addiction; and its effect on public policies toward drugs and people with addiction has been modest. The focus of the BDMA is on disordered neurobiology in a minority of severely addicted individuals, which undermines the implementation of effective and cost-effective policies at the population level to discourage people from smoking tobacco and drinking heavily. The pursuit of high technology direct brain interventions to cure addiction when most individuals with addiction do not have access to effective psychosocial and drug treatments is questionable.

Contingencies of the will: Uses of harm reduction and the disease model of addiction among health care practitioners

The concept of addiction as a disease is becoming firmly established in medical knowledge and practice at the same time as the logics of the harm reduction approach are gaining broader acceptance. How health care practitioners understand and intervene upon drug use among their patients is complicated by these two models. While harm reduction can be understood as a form of governmentality wherein drug-taking individuals express their regulated autonomy through self-governance, the notion of addiction as a disease removes the option of self-governance through negating the will of the individual. Through analysis of qualitative interviews conducted with 13 health care practitioners who provide care for economically marginalized people who use drugs in New York City, it was found that the absence of will articulated in constructions of addiction as disease offered a gateway through which health care practitioners could bring in ideological commitments associated with harm reduction, such as the de-stigmatization of drug use. Despite differences in the attribution of agency, sewing together these two approaches allowed health care practitioners to work with drug-using patients in practical and compassionate ways. This resembles the strategic deployment of diverse subjectivities found in feminist, post-structural liberatory projects wherein differential subjectification proves tactical and productive. Although drug-using patients may enjoy the benefits of practical and compassionate health care, the conjoint facilitation and denouncement of their will occasioned by the use of both harm reduction and the disease model of addiction imply their management by both pastoral and disciplinary technologies of power.

Addiction: Current Criticism of the Brain Disease Paradigm

To deepen understanding of efforts to consider addiction a "brain disease," we review critical appraisals of the disease model in conjunction with responses from in-depth semistructured stakeholder interviews with (1) patients in treatment for addiction and (2) addiction scientists. Sixty-three patients (from five alcohol and/or nicotine treatment centers in the Midwest) and 20 addiction scientists (representing genetic, molecular, behavioral, and epidemiologic research) were asked to describe their understanding of addiction, including whether they considered addiction to be a disease. To examine the NIDA brain disease paradigm, our approach includes a review of current criticism from the literature, enhanced by the voices of key stakeholders. Many argue that framing addiction as a disease will enhance therapeutic outcomes and allay moral stigma. We conclude that it is not necessary, and may be harmful, to frame addiction as a disease.

Framing Nicotine Addiction as a "Disease of the Brain": Social and Ethical Consequences

OBJECTIVES

In this article, we seek to better understand how a genomic vision of addiction may influence drug prevention and treatment. Though social influences on substance use and abuse (e.g., peer and family influence, socioeconomic status) are well documented, biomedical intervention is becoming increasingly technoscientific in nature. We wish to elucidate how emphasizing biological influences on substance use may lead to a vision of addiction as a phenomenon isolated within our bodies and neurochemistry, not lived daily within a complex social web of relationships and a particular political economy, including the tobacco industry, which aggressively markets products known to cause harm.

METHODS

We explore the emerging view of addiction as a "disease of the brain" in open-ended interviews with 86 stakeholders from the fields of nicotine research and tobacco control. Interview data were analyzed using standard qualitative techniques.

RESULTS

Most stakeholders hold a medicalized view of addiction. Though environmental variables are understood to be a primary cause of smoking initiation, the speed and strength with which addiction occurs is understood to be a largely biological process. Though stakeholders believe that an increased focus on addiction as a disease of the brain is not likely to lead to widespread unrealistic expectations for cessation therapies, they remain concerned that it may reinforce teenagers' expectations that quitting is not difficult. Finally, stakeholder responses indicate that genetic and neuroscientific research is unlikely to increase or decrease stigmatization, but will be used by interest groups to buttress their existing views of the stigma associated with smoking.

CONCLUSION

We argue that the main potential harms of focusing on biological etiology stem from a concept of addiction that is disassociated from social context. Focusing on genetic testing and brain scans may lead one to overemphasize pharmaceutical "magic bullet cures" and underemphasize, and underfund, more traditional therapies and public health prevention strategies that have proven to be effective. Genetic research on addiction may fundamentally change our conception of deviance and our identities, and may thus transform our susceptibility to substance use into something isolated in our biology, not embedded in a biosocial context.

Weight stigma, addiction, science, and the medication of fatness in mid-twentieth century America

Obesity and overweight are today recognised as subject to harmful stigma. Through an analysis of discussions of obesity in major American newspapers, the medical literature, and pharmaceutical advertising in the 1930s, 1940s and 1950s, I document a significant shift in medical thinking about overweight and obesity based in psychiatry, and explore the relationship of that shift to changes in popular understandings of fatness after the Second World War. I argue that the psychiatrically-oriented postwar medical thinking about obesity was more stigmatising as compared with the endocrinologically-oriented thinking of the interwar period, in that the newer biomedical theory linked fatness to the already stigmatised condition of addiction and authorised attribution of moral blame to the fat. I further argue that the pharmaceutical industry cannot be assigned the lead role in medicalisation in this period that some authors attributed to it. These events cast doubt on the received view of fatness as subject to decreasing stigma and increasing medicalisation over the course of the twentieth century, and call for exploration of the social factors influencing specific forms of medicalisation.