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28 Oct. 2019

360Edge: Why ‘addiction’ is NOT a ‘brain disease’

The following article is written by Director of 360Edge Professor Nicole Lee. She discusses the brain disease model in the USA for AOD issues, and how mental health and AOD services do not belong together.  You can read the original article as posted on the 360Edge website here.

The USA-led push to view alcohol and other drug problems as a ‘brain disease’ was in part to try to provide a counter to the prevailing moral view at the time.

But, while the use of alcohol and other drugs clearly has a (mostly temporary) impact on the structure and function of the brain, there is no evidence that an alcohol or other drug problem is a brain disease in the same way that Huntington’s or Parkinson’s are diseases of the brain, for example.

The fact that relatively few people who use drugs develop a problem with them is also evidence that it is not a brain disease.

We still can’t distinguish between the brain of someone who is dependent on alcohol or other drugs and someone who is not. broader social determinants of health, such as low socio-economic status, lack of education, homelessness, and unemployment; as well as early trauma and mental health issues.

The social consequence of viewing alcohol and other drug dependence as a function of the interaction between an ‘addictive brain’ and a specific drug is prohibition. We either need to eliminate drugs from society (and hence more law enforcement is needed)  or we need protect the brain from drugs (and hence abstinence is required). But emerging research shows that a prohibition approach is not effective in reducing harms or use.

The reality is there are many complex factors that impact on the development of alcohol and other drug issues, including family history; socio-demographic factors and

Alcohol and other drug problems are more aligned to the definition of a mental health issue, with multiple factors in both their development and maintenance. We don’t typically refer to mental health disorders as a ‘disease’, even though there is evidence that there is associated impact on the structure and function of the brain.

Alcohol and other drug services don’t belong with mental health

Alcohol and other drug use has historically been seen first as a moral deficit, and then a criminal issue, and only relatively recently has there been a broader shift in thinking about it as a mental health issue.

But understanding where alcohol and other drug problems fit into mental health is not straight forward.

Not all alcohol and other drug use is problematic. Very few people go on to develop long term problems (overall the estimate is around 10%), so our understanding of alcohol and other drug use as a mental health issue only applies to the end of the use spectrum where people are experiencing significant problems.

Taking that further, alcohol and other drugs have another unique dimension to them.

Most people with depression and anxiety don’t enjoy those feelings, even when they are not at the problematic end of the spectrum. Alcohol and other drugs on the other hand…

With alcohol and other drugs, use does not equal problems. So we need to take a broader view that encompasses both a health and a human rights perspective.

Unlike most other clinical health areas, our AOD service sector spans prevention, harm reduction and tertiary intervention. Sometimes that means we aren’t all peas in a pod, but it is also one of the strengths of the sector.

We philosophically view alcohol and other drug use on a continuum, and understand that merely (non-problematic) use of a drug does not necessarily constitute a problem.

Jim Orford’s idea of alcohol and other drug problems as an ‘excessive appetite’ captures the idea nicely – use is generally fun and purposeful, and only becomes a problem when it is excessive.

So while some alcohol and other drug problems might be viewed from mental health perspective, the issues for our sector are much broader. Under some circumstances alcohol and other drug use might be viewed as a mental health problem but they shouldn’t be integrated into the mental health system.

In many ways it maintains the stigma around (especially illicit) drug use by perpetuating the idea that use is a mental health issue.

Professor Nicole Lee is 360Edge’s Director and an international leader on alcohol and drug policy and practice.