Addiction begins with the voluntary decision to use drugs. No one starts out hoping to become an addict, but as one uses a drug repeatedly over time, control over its use decreases dramatically. The individual who is initially a voluntary user can become a compulsive drug user, an addict.
An ever-increasing body of scientific evidence suggests that the transition from voluntary user to addict occurs through a combination of processes, including a series of brain changes or neuroadaptations that result from repeated drug exposure. Because changes in brain structure and function are fundamental to the development and expression of addiction, it qualifies as a brain disease--a brain disease expressed as compulsive behavior. It's the quintessential biobehavioral disorder.
This concept has generated substantial controversy, and the conversation is still polarized in some circles. Unfortunately, this polarized thinking can characterize virtually all aspects of the drug issue. Discussions frequently devolve into arguments pitting drug supply control strategies against demand control strategies--interdiction versus prevention and treatment. Some people have reverted to the old argument that we should simply incarcerate addicted criminal offenders, whereas others say we only need to treat them. The true answer, of course, is much more complicated and requires that we do "all of the above."
Polarized thinking also surrounds the brain disease concept of addiction. People who object to it frequently say addiction is simply a failure of will; it is only about behavior, not about biology. Other people argue the reverse. However, a century of psychobiological research has taught us never to pit biology against behavior. We have finally learned that we do not have separate minds and bodies--dualism is dead. We understand biology and behavior to be inextricably intertwined. Addiction epitomizes that link.
How does this biobehavioral view of addiction relate to the tougher drug issues our society must face? First, the fact that addiction is a brain disease does not mean the patient is a hapless victim with no responsibilities. Addiction begins with the decision to use drugs, and the patient must be actively involved in his or her own treatment for it to work. But we do need to rise above the moral outrage that the addict became ill as a result of his or her own behavior and deal with the brain disease once it is there.
The best treatments for addiction
That leads to the second issue, treatment. That addiction is a brain disease helps explain why people need treatment at all--why most cannot just stop. They're in a different brain state. Because addiction is a complex biobehavioral disorder whose development and expression depend heavily on social context, addiction treatment inevitably has many different components. The symptoms of this brain disease go beyond simply using a lot of drugs. Addiction has diverse medical, behavioral and social consequences that affect one's ability to function in virtually every life domain. Thus, the target outcome for treatment cannot be just reducing drug use; it must be restoring the individual to full functioning in the family, at work and in society. For these reasons, the best treatments combine--as appropriate to the individual--medications, behavioral therapies and necessary psychosocial services.
Understanding the bio-behavioral nature of addiction also helps in thinking about strategies to deal with addicted criminal offenders. That they have this brain disease helps explain why untreated addicted offenders have such high post-incarceration rates of recidivism both to drug use and criminality. Untreated, the illness takes over as soon as they are released back into the community. On the other hand, numerous studies have shown that treating addicted offenders while they are under criminal justice control dramatically reduces later criminality and drug use. The conclusion is obvious, and these findings are actually fueling a national trend to blend public health and public safety approaches when dealing with addicted offenders. Examples abound, including diversion to treatment programs, drug courts and prison-based treatment programs.
A vital role to play
Since addiction is the quintessential bio-behavioral illness, a true brain disease, psychologists have a vitally important role to play in both increasing understanding of and dealing with addiction. Moreover, because psychologists are particularly able to see mind/body relationships in their full complexity, they are well-positioned to help explain drug abuse and addiction to our broader society.
We have done it before with brain diseases that are expressed in behavior, like schizophrenia and depression. Let us do it again with addiction. The payoffs to society will be immense.