Is Freedom a Disease?

I first heard about the Brain Disease Model of Addiction(BDMA) theory at a meeting of the Milwaukee City-County Heroin, Opioid and Cocaine (MCCHOC) Task Force.   One of their goals is to: “Develop programs in collaboration with the criminal justice system that treat addiction as a disease, while actively working to reduce the availability of illicit substances.”  My goal for drug policy is the complete and total decriminalization of all substances, so the idea of classifying addiction as a disease struck me as just another step being taken away from freedom and liberty.

As I was beginning to study the BDMA theory, I heard  Dr. George Lee Morris, the Chair of the Wisconsin Medical Society’s Opioid Task Force, adding genetics to the mix at another Task Force meeting: “Addiction is just another disease.  There are at risk people: there’s nothing to do with their personal fortitude, this is a genetic event.”, and “The majority of this is genetic.   The majority of the risks for addictions are genetic.  So, they’re sitting out there just waiting for the exposure.   If they don’t get the exposure, then they don’t get addicted.”  Now, the BDMA theory does not include a genetic component, but it provides a stepping stone from addiction as vice to addiction as disease; and everyone knows there is a genetic cure for everything -- Right?  Dr. Morris advocated for more research money to be spent to find the genetic causes of addiction along the lines of that spent to investigate the Zika virus.

Addiction as disease or addiction caused by genetics, either way, these approaches shift attention from the core issues of freedom and liberty to debates about scientific research.   Although both approaches hold out the hope of ultimately destigmatizing the “victims”, decriminalizing all substance abuse/vice is not part of their agenda.  This is definitely true in the case of government entities like the National Institute on Drug Abuse (NIDA), or private entities who are receiving grants from the government.  The idea of acknowledging that people are inherently free to inoffensively possess and consume any substance they want to, is being occulted by scientism.

Is the BDMA theory supported by the evidence?  When a person develops an addiction to a substance, is this a “genetic event”?  What are the implications of accepting these propositions?  Do they imply a redefinition or dilution of the meaning of the word “disease”?  If addiction is really a disease, then why are the people suffering from it stigmatized as criminals?  Do we incarcerate diabetics?  Do we confiscate donuts from obese people (Obesity Is Now A Disease, American Medical Association Decides)?

Substance abuse/addiction was, until relatively recently, considered a vice.  But over the last 100 years, this vice has been arbitrarily criminalized for some substances, while at the same time it morphed into a disease – one with genetic origins no less.  Lysander Spooner, in his essay: "Vices are not Crimes", summarizes the distinction and the implications:  

The Harrison Narcotic Act of 1914 was one of the first salvos in the War on Drugs.  The analysis of its impacts in the article linked above includes:

"The provision protecting physicians, however, contained a joker hidden in the phrase, "in the course of his professional practice only."  After passage of the law, this clause was interpreted by law-enforcement officers to mean that a doctor could not prescribe opiates to an addict to maintain his addiction. Since addiction was not a disease, the argument went, an addict was not a patient, and opiates dispensed to or prescribed for him by a physician were therefore not being supplied "in the course of his professional practice." Thus, a law apparently intended to ensure the orderly marketing of narcotics was converted into a law prohibiting the supplying of narcotics to addicts, even on a physician's prescription.”

Back then addiction was still considered a vice, albeit potentially criminal.  How was the “addiction as disease” metaphor promulgated to the point where this new definition is now being written into “law”?

The progression of addiction from vice to disease was facilitated via 2 major vectors: the American Psychiatric Association and the National Institute on Drug Abuse, National Institutes of Health.  The former being normative and the later purporting itself to be scientific.

Psychiatry's Master Plan for Control

"Here are actual recordings of a prominent English psychiatrist by the name of Colonel J R Rees addressing the National Council of Mental Hygiene in October 1940 and his colleague G. Brock Chisholm, the co-founder of the World Federation for Mental Health setting the agenda for psychiatry's influence and control of every sector of your life. Today it's becoming more a reality with mental illness being diagnosed for all and any of life's inherent difficulties"

Rees: “We must aim to make it [psychiatry] permeate every educational activity in our national life… Public Life, Politics and Industry should, all of them, be within our sphere of influence…. We have made a useful attack upon a number of professions.  The two easiest of them naturally are the teaching profession and the Church.  The most difficult are law and medicine.”

Chisholm: “The reinterpretation and eventually eradication of the concept of right and wrong, are the objectives of all psychotherapy.  To achieve World Government, it is necessary to remove from the minds of men their individualism, loyalty to family traditions, national patriotism and religious dogmas."

The American Psychiatric Association played a prominent role in the evolution of vice to disease thus extending its “sphere of influence” into law and medicine.  It’s Diagnostic and Statistical Manual of Mental Disorders (DSM–5) has become the standard resource for defining and categorizing Mental Disorders as diseases.  Its language was incorporated into law by the Wisconsin Legislature in 2017 via its passing of Wisconsin Act 34 which defines drug dependence as a disease: ““Drug dependence" means a disease that is characterized by a person's use of one or more drugs that is beyond the person's ability to control to the extent that the person's physical health is substantially impaired or his or her social or economic functioning is substantially disrupted. “ 

Where did the language equating drug dependence with disease in Wisconsin Act 34 come from?  Below is section 292.9 (F18.99) page 747 of DSM V.5: Opioid Use Disorder:

Diagnostic Criteria

1. A problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:
   1. Opioids are often taken in larger amounts or over a longer period than was intended.
   2. There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
   3. A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.
   4. Craving, or a strong desire or urge to use opioids.
   5. Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home.
   6. Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.
   7. Important social, occupational, or recreational activities are given up or reduced because of opioid use.
   8. Recurrent opioid use in situations in which it is physically hazardous.
   9. Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
   10. Tolerance, as defined by either of the following:
       1. A need for markedly increased amounts of opioids to achieve intoxication or desired effect.
       2. A markedly diminished effect with continued use of the same amount of an opioid.

   Note: This criterion is not considered to be met for those taking opioids solely under appropriate medical supervision.

   11. Withdrawal, as manifested by either of the following:
       1. The characteristic opioid withdrawal syndrome (refer to Criteria A and B of the criteria set for opioid withdrawal, pp. 547–548).
       2. Opioids (or a closely related substance) are taken to relieve or avoid withdrawal symptoms.

   Note: This criterion is not considered to be met for those individuals taking opioids solely under appropriate medical supervision.

We can clearly see that the Wisconsin Legislature drew its definition of “Drug Dependence” as a disease from the DSM, although they cite no references to the DSM or anything that might support their making this association.  And they go beyond the conclusions drawn in the DSM: the DSM does not use the terms disease or addiction in its description of Opioid Use Disorder or in the criteria used to define it. 

DSM page 671:

“Note that the word addiction is not applied as a diagnostic term in this classification, although it is in common usage in many countries to describe severe problems related to compulsive and habitual use of substances. The more neutral term substance use disorder is used to describe the wide range of the disorder, from a mild form to a severe state of chronically relapsing, compulsive drug taking. Some clinicians will choose to use the word addiction to describe more extreme presentations, but the word is omitted from the official DSM-5 substance use disorder diagnostic terminology because of its uncertain definition and its potentially negative connotation."

Notwithstanding this disavowal, others (governments, legislators, physicians, psychiatrists, mental health professionals, the media etc…) have used the normative criteria in the DSM to define addiction and disease and promulgate the metaphor that equates the two.

Similar to the Harrison Narcotics Act of 1914, the DSM diagnostic criteria for drug abuse disorder contains a “Joker”; two of them in fact.  Under criteria 10 and 11 they get the last laugh with the caveats: “Note: This criterion is not considered to be met for those taking opioids solely under appropriate medical supervision.”

DSM page 671:

Symptoms of tolerance and withdrawal occurring during appropriate medical treatment with prescribed medications (e.g., opioid analgesics, sedatives, stimulants) are specifically not counted when diagnosing a substance use disorder. The appearance of normal, expected pharmacological tolerance and withdrawal during the course of medical treatment has been known to lead to an erroneous diagnosis of “addiction” even when these were the only symptoms present. Individuals whose only symptoms are those that occur as a result of medical treatment (i.e., tolerance and withdrawal as part of medical care when the medications are taken as prescribed) should not receive a diagnosis solely on the basis of these symptoms. However, prescription medications can be used inappropriately, and a substance use disorder can be correctly diagnosed when there are other symptoms of compulsive, drug-seeking behavior." (This qualifier is especially relevant to the discussion of the Brain Disease Model of Addiction discussed below).

But Wisconsin Act 34 doesn’t consider this qualification.  They rely on all of the other criteria from the DSM for defining drug dependence as “disease” without acknowledging the “dependence” and “withdrawal” criteria in the DSM and the caveats it associates with them.

If I develop a tolerance to heroin or opioids or experience withdrawal symptoms as a result of my personal choice to consume these substances, and I exhibit at least one additional criteria from the list over a 12 month period – I have an abuse disorder per the DSM, and an addiction disease per the BDMA theory.  But if I develop a tolerance to heroin or opioids or experience withdrawal symptoms while under appropriate medical supervision, and I exhibit at least one additional criteria from the list over a 12 month period – I do not have a disorder per the DSM.  But, do I still have a disease per the BDMA?  Do I still have a disease per Wisconsin Act 266?  If I get hepatitis from sharing a dirty needle with a heroin addict on the street, its generally recognized that I have a disease. But, if I contract hepatitis in a hospital while “under appropriate medical supervision”, then, I guess, everybody would say that — I don’t have the disease.  Right?

The DSM criteria defining Opioid Use Disorder has provided the cover used by others to equate substance abuse with addiction and disease — despite the APA’s explicit disavowal of that intent.  Although they do not proscribe others from making the correlation, the APA eschews it.  The arbitrary/normative criteria it established for substance abuse disorders has contributed to the dilution of the meaning of the word disease, and its association with addiction. 

Psychiatry the fraud

"Dr. Jeffrey Schaler Professor of Psychology describes psychiatry as a pseudo science. He highlights how psychiatry is being used as a social weapon." He says: “Every disorder in the DSM is invented.  Every disease listed in a pathology textbook is discovered." "Real disease is found in a cadaver at autopsy, mental illness is not.  Mental illness refers to something that a person does.  Real disease refers to something that a person has.“"Diagnosis is a tool, a weapon, that people use against one another."

While the DSM uses the APA’s normative criteria for defining substance abuse disorder, the National Institute of Drug Abuse’s Brain Disease Model of Addiction (BDMA) theory is scientific.   But what does the science show? Is the BDMA theory supported by evidence?  This question is the subject of a lot of debate and the exchange below is just a sample.

The Brain Disease Model of Addiction (BDMA) was first described in 1997 by Alan I. Leshner, who, at the time, was the Director of the National Institute on Drug Abuse, National Institutes of Health, in his article: "Addiction Is a Brain Disease, and It Matters"

“Scientific advances over the past 20 years have shown that drug addiction is a chronic, relapsing disease that results from the prolonged effects of drugs on the brain. As with many other brain diseases, addiction has embedded behavioral and social-context aspects that are important parts of the disorder itself. Therefore, the most effective treatment approaches will include biological, behavioral, and social-context components.  Recognizing addiction as a chronic, relapsing brain disorder characterized by compulsive drug seeking and use can impact society’s overall health and social policy strategies and help diminish the health and social costs associated with drug abuse and addiction.”

In 2013 Neil Levy, who, at the time of writing the article, was associated with the Florey Institute of Neuroscience and Mental Health, wrote in Frontiers in Psychiatry: "Addiction is not a brain disease (and it matters)"

"Addiction is a disorder of a person, embedded in a social context.  If the judgment that addiction is a disease is unashamedly normative, and the norms in question are not norms of brain function, then addiction is not a brain disease. Addiction is a brain disease only if pathological deviations from norms of brain function are (in almost any accessible environment) sufficient for being impaired."

"If we are to show that addiction is a brain disease, we shall need to show that the underlying pathology is a pathology of the brain.  We need to show that the brain is dysfunctional, in much the same way as medical scientists establish that an organ is diseased by showing that it is dysfunctional. The canonical example in medical science is heart disease: heart disease counts as a disease because it threatens to interfere with the function of the heart. The heart’s functional role is pumping blood; because heart disease interferes with that role, it is a disease."

"I claimed earlier that addiction is a brain disease only if two conditions are satisfied: its neural correlates are pathological, and that pathology is sufficient for the person to be suffering from a disease in almost any accessible environment. This second condition is necessary to rule out conditions in which the appropriate response to suffering is to alter the environment and not to “treat” the person."

"The conjunction of causation by dysfunction plus impairment is not sufficient for disorder, when the impairment is due to social conditions that can relatively easily be altered; that is, when the alterations necessary to remove the impairment are not alterations we have good reason to refuse to make (because they would impose significant costs on third parties, for instance). I express this claim by saying it is a necessary condition of a condition being a disease that it causes suffering in almost any accessible environment. If it is the case that there is an accessible environment – where accessibility is a function not merely of physical possibility, but also of the costs (economic, social, moral) of actually accessing that environment — in which a dysfunction does not cause an impairment, then the dysfunction is not sufficient for a disease."

The fact that the DSM discounts tolerance and withdrawal if they occur under a doctor’s supervison is right in line with Levy’s conclusions — in that case there is an accessible environment in which the dysfunction does not cause impairment and thus, Opioid Use Disorder is not a "real" disease.

Another challenge to Leshner’s BDMA theory came in 2015.   Wayne Hall, Adrian Carter and Cynthia Forlini responded to Leshner’s theory with their article in Lancet Psychiatry 2015: "The brain disease model of addiction: is it supported by the evidence?"

“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.”

Nora D. Volkow, MD [Office of Director] National Institute on Drug Abuse and George Koob [Office of Director] National Institute on Alcohol Abuse and Alcoholism responded with their article, also in the Lancet Psychiatry 2015: "Brain Disease Model of Addiction: why is it so controversial?"

“First, preclinical and clinical studies have consistently delineated specific molecular and functional neuroplastic changes at the synaptic and circuitry level that are triggered by repeated drug exposure...

Second, uncovering the molecular targets and circuits underlying addiction has already resulted in several effective medications (naloxone and acamprosate for alcoholism, buprenorphine-naloxone for opioid addiction; varenicline for tobacco addiction) and ongoing clinical trials are taking advantage of this knowledge to test new targets…

Finally, the statement that the effects of the BDMA framework on public policy are modest negates some major achievements, such as the passage in 2008 of the parity law (the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act, driven by the BDMA model) that requires medical insurance for the first time in the USA to cover costs associated with the treatment of addiction. Finally, the mere framework of BDMA has benefits in treatment as it significantly diminishes the stigma attached with addiction and gives hope for recovery to those fighting this devastating disease.”

In the next month’s Lancet Psychiatry, Hall, Carter and Forlini responded with: "Brain disease model of addiction: misplaced priorities?"

“We were disappointed by Nora Volkow and George Koob’s response to our critique of the brain disease model of addiction (BDMA) from the US National Institute on Drug Abuse (NIDA), which simply repeats the promise of future treatment advances and puts the most favourable spin on modest treatments that have been used since Alan Leshner first promulgated the BMDA in 1997.”

Conclusion

I confess that I am biased and that I do not have any credentials to give weight to my opinions regarding the validity of the science supporting the BDMA theory and possible genetic causation of the "disease", so take the following conclusions with a grain of salt.  The arguments raised against the BDMA theory are very reasonable and logical – they make sense even to a layman like myself.  I have not thoroughly researched the evidence for and against a genetic cause for addiction, but I’m very skeptical: before we start looking for a genetic cause for the “disease”, it should first be established that it is a disease.  I agree with Lysander Spooner that substance abuse is a vice that, nevertheless, depending on the substance, has been arbitrarily criminalized.  In my opinion, the focus of attention and resources on the BDMA theory and searching for genetic causes for substance abuse is misguided.  We should be focused on reducing the harms of the War on Drugs and leaving people free to possess and consume what they want to in peace and privacy.