Addiction: Current Criticism of the Brain Disease Paradigm

Substance use Attitudes, Beliefs, Experience, and Knowledge Among Nursing and Nursing Assistant Students

Stigma is a public health concern. Stigmatizing attitudes toward persons with substance use disorders (SUDs) can adversely impact clinical care and outcomes. Beliefs about SUD, prior experience and familiarity to persons with SUD, and educational curricula drive attitudes among health-care workers. In 2019, nursing and nursing assistant students were recruited through an online survey platform. Participants completed an SUD knowledge test and a survey assessing education, beliefs, personal experience, and confidence in recognizing the signs and symptoms of SUD. One hundred and ten health-care students (nursing students, n = 67 and nursing assistant students, n = 43) completed the survey. Among nursing assistant students, endorsing a disease model of addiction (F(2, 40) = 5.83, p < .001, R2 = .23), and personal familiarity with SUD (F(2, 40) = 4.46, p < .001, R2 = .18), were significantly positively predictive of positive regard toward working with persons with SUD. For nursing students, endorsing a disease model of addiction, educational curricula involving persons with SUD, and personal familiarity were significantly positively predictive of positive regard toward working with persons with SUDs (F(2, 61) = 11.52, p < .001, R2 = .36). Interventions to mitigate drug-related stigma among health-care students should center students with personal familiarity, promote the disease concept of addiction, and incorporate contact-based training.

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.

Media framings of the role of genomics in "addiction" in the United States from 2015 to 2019: Individualized risk, biomedical expertise, and the limits of destigmatization

News coverage of the opioid epidemic is a useful site for examining genomic framings of addiction. Qualitative analysis of 139 articles published in the United States from 2015 to 2019 discussing genomics, addiction, and the opioid epidemic found an emphasis on both a postgenomic framing in which genetics operates in relation to social and environmental factors, and a molecularized understanding of addiction which highlighted the role of neurobiology and individual-level genetic risk. Discussions of genetics were often intertwined with calls for a biomedicalized approach that frames addiction as a chronic disease in need of medication, and thus under the purview of medical experts. Finally, while genomic discourses were invoked to reduce stigma, genomics was at times used to describe addicts as biologically distinct from other people, reflecting the possibility that genetics-even in the postgenomic context-can be used to promote a biologically essentialized understanding of people with addiction.

A comparative review on neuroethical issues in neuroscientific and neuroethical journals

This study is a pilot literature review that compares the interest of neuroethicists and neuroscientists. It aims to determine whether there is a significant gap between the neuroethical issues addressed in philosophical neuroethics journals and neuroscience journals. We retrieved 614 articles from two specialist neuroethics journals (Neuroethics and AJOB Neuroscience) and 82 neuroethics-focused articles from three specialist neuroscience journals (Neuron, Nature Neuroscience, and Nature Reviews Neuroscience). We classified these articles in light of the neuroethical issue in question before we compared the neuroethical issues addressed in philosophical neuroethics with those addressed by neuroscientists. A notable result is a parallelism between them as a general tendency. Neuroscientific articles cover most neuroethical issues discussed by philosophical ethicists and vice versa. Subsequently, there are notable discrepancies between the two bodies of neuroethics literature. For instance, theoretical questions, such as the ethics of moral enhancement and the philosophical implications of neuroscientific findings on our conception of personhood, are more intensely discussed in philosophical-neuroethical articles. Conversely, neuroscientific articles tend to emphasize practical questions, such as how to successfully integrate ethical perspectives into scientific research projects and justifiable practices of animal-involving neuroscientific research. These observations will help us settle the common starting point of the attempt at "ethics integration" in emerging neuroscience, contributing to better governance design and neuroethical practice.

Conflicting theories on addiction aetiology and the strengths and limitations of substance use disorder disease modelling

A lack of cross-disciplinary unanimity prevails within addiction research. Theories conceptualizing addiction through the three-stage brain disease model contest other theories that substance use disorder is of behavioural or genetic origin. The reverberations of this lack of consensus are noticeable throughout addiction research and within the foundations of disease modelling. The availability of methods to investigate substance use disorder are inconsistent and sometimes unrepresentative. This review discusses theories of addiction aetiology, available models for addiction research and the strengths and limitations of current practical experimental methods of study.

Grayken lessons: between a rock and a hard place? A 37-year-old man with acute liver injury while enrolled in a managed alcohol program for severe alcohol use disorder

Managed alcohol programs aim to reduce health and social harms associated with severe alcohol use disorder. Here, we describe a young man with severe alcohol use disorder enrolled in a managed alcohol program, who was admitted to hospital with acute liver injury. Fearing that alcohol was contributing, the inpatient care team discontinued the managed alcohol dose in hospital. He was ultimately diagnosed with cephalexin-induced liver injury. After consideration of risks, benefits, and alternative options, the patient and care team jointly decided to restart managed alcohol after hospital discharge. With this case, we describe managed alcohol programs and summarize the emerging evidence-base, including eligibility criteria and outcome measures; we explore clinical and ethical dilemmas in caring for patients with liver disease within managed alcohol programs; and we emphasize principles of harm reduction and patient-centered care when establishing treatment plans for patients with severe alcohol use disorder and unstable housing.

Getting "clean" from nonsuicidal self-injury: Experiences of addiction on the subreddit r/selfharm

BACKGROUND & AIMS

Previous studies have shown that nonsuicidal self-injury (NSSI) has addictive features, and an addiction model of NSSI has been considered. Addictive features have been associated with severity of NSSI and adverse psychological experiences. Yet, there is debate over the extent to which NSSI and substance use disorders (SUDs) are similar experientially.

METHODS

To evaluate the extent that people who self-injure experience NSSI like an addiction, we coded the posts of users of the subreddit r/selfharm (n = 500) for each of 11 DSM-5 SUD criteria adapted to NSSI.

RESULTS

A majority (76.8%) of users endorsed at least two adapted SUD criteria in their posts, indicative of mild, moderate, or severe addiction. The most frequently endorsed criteria were urges or cravings (67.6%), escalating severity or tolerance (46.7%), and NSSI that is particularly hazardous. User-level addictive features positively predicted number of methods used for NSSI, number of psychiatric disorders, and particularly hazardous NSSI, but not suicidality. We also observed frequent use of language and concepts common in SUD recovery circles like Alcoholics Anonymous.

DISCUSSION & CONCLUSION

Our findings support previous work describing the addiction potential of NSSI and associating addictive features with clinical severity. These results suggest that NSSI and SUD may share experiential similarities, which has implications for the treatment of NSSI. We also contribute to a growing body of work that uses social media as a window into the subjective experiences of stigmatized populations.

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.

The Impact of Stigma on People with Opioid Use Disorder, Opioid Treatment, and Policy

Illicit drug use disorders are the most stigmatised health conditions worldwide, and stigma acts as a meaningful barrier to treatment entry and treatment provision. In the context of dramatically rising opioid-related harms, it is critical that we understand the drivers of stigma and how it affects opioid use disorder treatment and policy. The aim of this narrative review is to discuss how opioid-related stigma impacts treatment provision and harm reduction, and provide potential strategies to reduce stigma at a social and structural level. We used the Framework for Integrating Normative Influences on Stigma (FINIS) to identify sources of opioid-related stigma at the macro (structural stigma), meso (public stigma) and micro (internalised stigma) levels. Reducing stigma requires strategies that target multiple levels, however addressing inequity in the laws, regulations, and rules that segregate people with opioid and other substance use disorders from mainstream society is essential.

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.

What is a mental disorder? An exemplar-focused approach

The question of 'what is a mental disorder?' is central to the philosophy of psychiatry, and has crucial practical implications for psychiatric nosology. Rather than approaching the problem in terms of abstractions, we review a series of exemplars - real-world examples of problematic cases that emerged during work on and immediately after DSM-5, with the aim of developing practical guidelines for addressing future proposals. We consider cases where (1) there is harm but no clear dysfunction, (2) there is dysfunction but no clear harm, and (3) there is possible dysfunction and/or harm, but this is controversial for various reasons. We found no specific criteria to determine whether future proposals for new entities should be accepted or rejected; any such proposal will need to be assessed on its particular merits, using practical judgment. Nevertheless, several suggestions for the field emerged. First, while harm is useful for defining mental disorder, some proposed entities may require careful consideration of individual v. societal harm, as well as of societal accommodation. Second, while dysfunction is useful for defining mental disorder, the field would benefit from more sharply defined indicators of dysfunction. Third, it would be useful to incorporate evidence of diagnostic validity and clinical utility into the definition of mental disorder, and to further clarify the type and extent of data needed to support such judgments.

Voluntary decision-making in addiction: A comprehensive review of existing measurement tools

The notion of voluntariness, notably the inability to refrain from using an addictive substance, is central to addiction. This review examines different constructs measuring voluntariness in the context of drug addiction. We found 117 articles featuring 123 distinct scales for 11 of the 16 constructs initially searched. Self-efficacy was by far the construct with most scales. Most scales were not specifically developed with samples of people with addictions. From a methodological standpoint, current literature jeopardizes the validity of generalizations about how voluntariness functions and is measured in people with and without a drug addiction. From the standpoint of social psychology, the study of voluntariness remains anchored in an individualistic orientation to the study of cognition and behavior, thus calling for greater crosstalk between psychology subspecialties.

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.

"I Was Raised in Addiction": Constructions of the Self and the Other in Discourses of Addiction and Recovery

The aim of this article is to address how conceptualizations of addiction shape the lived experiences of people who use drugs (PWUDs) during the current opioid epidemic. Using a discourse analytic approach, we examine interview transcripts from 27 PWUDs in rural Appalachian Ohio. We investigate the ways in which participants talk about their substance use, what these linguistic choices reveal about their conceptions of self and other PWUDs, and how participants' discursive caches might be constrained by or defined within broader social discourses. We highlight three subject positions enacted by participants during the interviews: addict as victim of circumstance, addict as good Samaritan, and addict as motivated for change. We argue participants leverage these positions to contrast themselves with a reified addict-other whose identity carries socially ascribed characteristics of being blameworthy, immoral, callous, and complicit. We implicate these processes in the perpetuation of intragroup stigma and discuss implications for intervention.

Buprenorphine dispensing in an epicenter of the U.S. opioid epidemic: A case study of the rural risk environment in Appalachian Kentucky

BACKGROUND

Buprenorphine is a cornerstone to curbing opioid epidemics, but emerging data suggest that rural pharmacists in the US sometimes refuse to dispense this medication. We conducted a case study to explore buprenorphine dispensing practices in 12 rural Appalachian Kentucky counties, and analyze whether and how they were shaped by features of the rural risk environment.

METHODS

In this case study, we conducted one-on-one semi-structured interviews with 14 pharmacists operating 15 pharmacies in these counties to explore buprenorphine dispensing practices and perceived influences on these practices. Thematic analyses of the resulting transcripts revealed three features of the rural risk environment that shaped dispensing. To explore these three risk environment features, we analyzed policy documents (e.g., Attorney General lawsuits) and administrative databases (e.g., incarceration data). Textual documents were analyzed using thematic analyses and administrative data were analyzed using descriptive statistics; memoes explored relationships among risk environment features and dispensing practices.

RESULTS

Twelve of the 15 pharmacies limited dispensing, by refusing to serve new patients; limiting dispensing to known patients or prescribers; or refusing to dispense buprenorphine altogether. Concerns about exceeding a "Drug Enforcement Administration (DEA) cap" on opioid dispensing stifled dispensing. A legacy of aggressive and fraudulent marketing of opioid analgesics (OAs) by pharmaceutical companies and physician OA overprescribing undermined pharmacist trust in buprenorphine and in its prescribers. The escalating local war on drugs may have undermined dispensing by reinforcing stigma against people who use drugs.

CONCLUSIONS

Initiatives to increase buprenorphine prescribing must be accompanied by policy changes to increase dispensing. Specifically, buprenorphine should be removed from opioid monitoring systems; efforts to de-escalate the war on drugs should be extended to encompass rural areas; initiatives to dismantle aggressive OA marketing should be strengthened; and efforts to re-build pharmacist trust in physicians are needed.

Intensive online videogame involvement: A new global idiom of wellness and distress

Extending classic anthropological "idioms of distress" research, we argue that intensive online videogame involvement is better conceptualized as a new global idiom, not only of distress but also of wellness, especially for emerging adults (late teens through the 20s). Drawing on cognitive anthropological cultural domain interviews conducted with a small sample of U.S. gamers (N = 26 free-list and 34 pile-sort respondents) (Study 1) and a large sample of survey data on gaming experience (N = 3629) (Study 2), we discuss the cultural meaning and social context of this new cultural idiom of wellness and distress. Our analysis suggests that the "addiction" frame provides a means for gamers to communicate their passion and commitment to online play, even furthering their enthusiasm for the hobby and community in the process, but also a way for players to express and even resolve life distress such as depression and loneliness. The American Psychiatric Association (APA) has recently included "Internet gaming disorder" (IGD) as a possible behavioral addiction, akin to gambling, warranting further consideration for eventual formal inclusion in the next iteration of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Our study leads us to suggest that clinicians only sparingly use IGD as a clinical category, given that medical and gamer understandings of "addictive" play differ so markedly. This includes better distinguishing positive online gaming involvement-also sometimes framed by gamers as "addictive"-from other play patterns more clearly entailing distress and dysfunction.

Mindsets of Addiction: Implications for Treatment Intentions

Introduction: The goal of the current work is to contribute to the critical dialog regarding consequences of different communications about the nature of addiction by offering a new theoretical approach. Specifically, we merge a mindset perspective, which highlights the importance of beliefs regarding the malleability of human attributes, with the attribution literature to explore how messages stressing the changeable vs. fixed nature of addiction influence beliefs and treatment intentions.

Method: We crafted a message about addiction designed to induce the belief in the potential to change without influencing self-blame (compensatory-growth mindset message) and compared it to a message focused on the fixed underpinnings of addiction (disease-fixed mindset message).

Results: In an online sample of probable substance users (N = 214), we found that the compensatory-growth, relative to the disease-fixed message, led to participants reporting stronger growth mindsets and efficacy without an impact on blame. Additionally, the compensatory-growth, relative to the disease-fixed message, led to stronger intentions to pursue counseling and cognitive behavioral treatment therapies.

Discussion: The current work finds support for an innovative theoretical approach for understanding motivation to seek treatment among individuals with probable substance use problems.

Current perspectives on the opioid crisis in the US healthcare system: A comprehensive literature review

INTRODUCTION

The administration of opioids has been used for centuries as a viable option for pain management. When administered at appropriate doses, opioids prove effective not only at eliminating pain but further preventing its recurrence in long-term recovery scenarios. Physicians have complied with the appropriate management of acute and chronic pain; however, this short or long-term opioid exposure provides opportunities for long-term opioid misuse and abuse, leading to addiction of patients who receive an opioid prescription and/or diversion of this pain medication to other people without prescription. Several reviews attempted to summarize the epidemiology and management of opioid misuse, this integrative review seeks to summarize the current literature related with responsible parties of this opioid abuse crisis and discuss potential associations between demographics (ethnicity, culture, gender, religion) and opioid accessibility, abuse and overdose.

METHODS

We performed an extensive literature search in Google Scholar and Pub Med databases that were published between December 7, 1999 and January 9, 2018 in accordance with the Preferred Reporting Items for Systematic Reviews and meta-Analysis (PRISMA) guidelines. Searches were referenced using medical subject headings (MeSH) that included "opioids", "over-prescription", "opioid consumption", or "opioid epidemic". The final review of all data bases was conducted on July 24, 2018.

RESULTS

A total of 7160 articles were originally identified. After 3340 duplicate articles were removed, 3820 manuscripts were removed after title and abstract screening. Following this, 120 manuscripts underwent eligibility selection with only 70 publications being selected as reliable full-texts addressing related factors surrounding the opioid crisis.

CONCLUSION

With approximately 100 million people suffering from both chronic and acute pain in the United States (US) in 2016, opiates will continue to remain a prominent class of medication in healthcare facilities and homes across the US. Over 66% of total overdose episodes in 2016 were opioid-related, a figure that attests to the severity and wide-spread nature of this issue. A three-point approach accentuating the prevention, treatment, and rehabilitation of both those currently affected and at-risk in the future may be the comprehensive solution.

Addiction Mindsets and Psychological Processes of Quitting Smoking

BACKGROUND

Lay belief systems about the malleability of human attributes have been shown to impact behavior change in multiple domains. Addiction mindset-i.e., beliefs about the permanence (vs. malleability) of addiction - may affect cigarette smokers' ability to quit, but this has never been examined.

OBJECTIVES

The aims of the present research were to develop a measure of addiction mindset (study 1) and examine its associations with various psychological aspects of quitting smoking (study 2).

METHODS

In Study 1, using factor analysis of current smokers' and nonsmokers' (n = 600) responses to 22 items designed to measure addiction mindset, we developed a reliable six-item Addiction Mindset Scale (AMS). In Study 2, adult smokers (n = 200) completed the AMS, and measures of a number of psychological processes related to smoking.

RESULTS

Higher scores on the AMS, indicative of the belief that addiction is malleable (referred to as a growth mindset), were positively and significantly associated with greater motivation to quit, greater commitment to quitting, greater self-efficacy to abstain, less attribution of failure to lack of ability to change addiction, and fewer self-reported barriers to cessation (all p's < .05).

CONCLUSIONS

The results of this study show a relationship between the beliefs about the permanence of addiction and psychological processes relevant to quitting smoking. The findings underscore the potential of future research exploring how addiction mindsets relate to successful smoking cessation as well as other types of addictive behavior and how they can be applied to change people's behavior.

Withdrawal symptoms predict prescription opioid dependence in chronic pain patients

BACKGROUND

The last version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes substantial changes for prescription opioid-use disorder (POUD). After its removal as a criterion, the goal of this study was to estimate the prevalence of withdrawal symptoms in long-term users of prescription opioids and its association with the new DSM-5 POUD classification.

METHODS

Data were collected from 215 long-term consumers of opioid medication who were chronic non-cancer pain patients. Participants completed sociodemographic, Adjective Rating Scale for Withdrawal (ARSW), opioid treatment characteristics, POUD criteria (DSM-5), and pain intensity measurements.

RESULTS

26.6% of the participants were classified with moderate to severe POUD. Higher intensity of withdrawal symptoms was found in patients with moderate/severe POUD, younger age, and higher pain intensity (p < .01). Anxiolytics (p < .01) and antidepressants use (p < .05) and percentage of smokers (p < .05) were significantly higher in patients with severe withdrawal. Logistic regression analyses suggested moderate [odds ratio (OR) = 3.25] and severe (OR = 10.52) withdrawal as the strongest predictor of POUD. Age, anxiolytics use, and smoking were also associated with POUD, but multilevel analysis showed that these variables do not moderate the association between withdrawal intensity and POUD.

CONCLUSION

Escalation of withdrawal intensity during opioid treatment can be used to identify patients with POUD. Further studies are needed to assess the clinical implications of these findings during long-term opioid therapy for chronic pain.

Portraying addiction as a disease: A phenomenological answer

This paper stems from the concern that, in certain situations, categorization may lead to the annihilation of the subject. It attempts to answer the question whether there is a way of framing addiction without necessarily putting the addicted persons in categories that hurt them. After showing, in the first section, how stigma is part of the process of becoming (and remaining) addicted, I will turn to the phenomenological tradition in order to re-consider the main descriptive categories that have been used so far to capture addiction as a "pathological" or "deviant" experience. The second section addresses addiction as an experience of hetero-transformation of the psycho-physical unity of the individual, which presupposes a genuine sense of the power of the bodily subject, while the third focuses on the modifications of temporality in addiction, especially in the horizon of trauma. The paper concludes that understanding addiction depends on framing the experience of addiction primarily as a non-pathological form of expression and looking at it as an attempt to restore the capabilities of a vulnerable subject.

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.

Addiction, Stress, and Relational Disorder: A Neuro-Informed Approach to Intervention

Substance use disorders are immensely costly economically and socially, but also in relational terms. The helping fields have struggled to arrive at consensus about substance use disorders and to endorse effective treatment approaches. We suggest that counselors will find it useful to frame substance use disorders as a type of relational disorder, a cycle wherein early nurturance disruption leads to brain function vulnerability and subsequent interpersonal difficulty. This difficulty in establishing and maintaining connections with others, in turn, can lead to susceptibility to substance use disorders. This article discusses basic neurophysiology surrounding substance use and relational disorders that can be used to inform efficacious counseling approaches for working with individuals facing substance use disorders. Such approaches explore the connection between substance use and relational disorders in terms of long-term exposure to nonnurturing environments. Our hope is that conceptualizing substance use disorders as relational disorder will assist clinicians in building more informed conceptualizations of their clients and reconsidering how they may work to rebuild this relational capacity, drawing on the brain's adaptive nature and potential for healing.

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.

Free Will and the Brain Disease Model of Addiction: The Not So Seductive Allure of Neuroscience and Its Modest Impact on the Attribution of Free Will to People with an Addiction

Free will has been the object of debate in the context of addiction given that addiction could compromise an individual's ability to choose freely between alternative courses of action. Proponents of the brain-disease model of addiction have argued that a neuroscience perspective on addiction reduces the attribution of free will because it relocates the cause of the disorder to the brain rather than to the person, thereby diminishing the blame attributed to the person with an addiction. Others have worried that such displacement of free will attribution would make the person with a drug addiction less responsible. Using the paradigmatic literature on the seductive allure of neuroscience explanations, we tested whether neuroscience information diminishes attributions of free will in the context of addiction and whether respondent characteristics influence these attributions and modulate the effect of neuroscience information. We performed a large-scale, web-based experiment with 2,378 German participants to explore how attributions of free will in the context of addiction to either alcohol or cocaine are affected by: (1) a text with a neurobiological explanation of addiction, (2) a neuroimage showing effects of addiction on the brain, and (3) a combination of a text and a neuroimage, in comparison to a control group that received no information. Belief in free will was measured using the FAD-Plus scale and was, subsequent to factor analysis, separated into two factors: responsibility and volition. The investigated respondent characteristics included gender, age, education, self-reported knowledge of neuroscience, substance-use disorder (SUD), and having a friend with SUD. We found that attributions of volition (in the cocaine-subsample) were reduced in the text and neuroimage-treatment compared to the control group. However, respondent characteristics such as education and self-reported knowledge of neuroscience were associated with lower attributions of responsibility for both substances, and education was associated with lower attribution of volition for the alcohol sub-sample. Interaction analyses showed that knowledge of neuroscience was found to generally decrease attribution of responsibility. Further research on attribution of free will should consider the effects of context and respondent characteristics, which appeared surprisingly larger than those induced by experimental treatments.

Involuntary Civil Commitment for Substance Use Disorder: Legal Precedents and Ethical Considerations for Social Workers

Although each state in the United States legally authorizes involuntary civil commitment on the grounds of severe mental illness, a considerable number do not have comparable laws to mandate drug addiction treatment. This discrepancy is due, in part, to differing ethical positions regarding whether a substance use disorder diagnosis provides sufficient justification to suspend individual liberty rights. This article chronicles some of the legal and ethical thinking on the subject and applies them to a social work-specific context.

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.

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.

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.