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Why We Need to Stop Nora Volkow From Taking Over the World

The head of the National Institute on Drug Abuse uses brain scans to propagate the disease model of addiction. I say she's wrong—and the dominance of her theory causes great harm.

16 Substance

The disease theory of addiction, which has always been with us in one form or another, now boasts Nora Volkow, the director of the National Institute on Drug Abuse (NIDA), as its principal representative. Volkow holds worldwide sway with her approach, which focuses exclusively on neuroscience and the brain and which is increasingly seen as the key to eliminating addiction.

“Groundbreaking discoveries about the brain have revolutionized our understanding of drug addiction, enabling us to respond effectively to the problem,” trumpets the White House website, beneath a video of Volkow proselytizing her theory.

Yet there are no diagnoses or treatments based on neuroscientific research pegged to the brain scans so avidly pursued and enthusiastically presented by Volkow and her school. We are told to be patient because the new scientific paradigm must mature before it produces real-life applications. Until then, we have a glut of super-high-tech pictures of the living brain to distract us. They distract us above all from the major truth revealed by addiction epidemiology: Most people overcome alcoholism and drug addiction on their own. Finally, belief in the disease theory—to the extent that it persuades you of your powerlessness to control your substance use—has been shown to increase relapse and diminish the prospects for recovery.

But Volkow and her neuroscience campaign reign supreme in the US, and appear to be conquering the world, with the result that addiction will only grow worse.

Consider the following five facts.

1. Since the mid-19th century, the US has subscribed to the disease theory of addiction; it is a key American cultural meme.

In the second half of the 20th century, Alcoholics Anonymous was presented as a non-moralistic, modern disease view of addiction to replace the failed Temperance model.  But Temperance anticipated the essential elements not only of the 12 Steps but also of the new “chronic, relapsing brain disease” theory: that addiction is a progressive, irreversible disease state that must end in death or institutionalization unless you take a religious pledge (in Temperance terms), join AA or (now) undergo medical treatment. Although AA apologists argue that a belief that “a Power greater than ourselves could restore us to sanity” is not religious, the 12 Steps fall short of what most people regard as modern medicine. It was as a supposedly scientifically valid way to fill this addiction-disease niche that the neuroscience vision of addiction has become our ruling paradigm.

2. Nora Volkow has reinvented the disease theory of addiction as a function of neuroscience and positioned herself as the international go-to source on addiction. 

Appointed in 2003 by President George W. Bush to head NIDA, Volkow has been a tireless crusader for the neuroscience of addiction. She has used her bully pulpit to brilliant effect. Volkow is always available to the press. She cuts a most mediagenic figure: a neuroscientist who is stylish, quotable and on a mission. On top of this, she is Trotsky’s great granddaughter!

The New York Times presents her not only as the embodiment of addiction science but also as the spokesperson for the age-old anti-drug/anti-alcohol vision: The Times’ accolade to Volkow is titled “A General in the Drug War.” Volkow’s attention was urgently demanded, according to the Times, in the fight against the prescription painkiller “epidemic”: “Eight years into her tenure at the institute, the pace of addiction research is accelerating, propelled by a nationwide emergency that has sent her agency, with a $1.09 billion budget, into crisis mode.”

In a recent major editorial, the world’s leading scientific journal, Nature, declared that neuroscience has settled all questions about addiction: “Drug addiction is a disease. Images of the brains of addicts show alterations in regions crucial to learning and memory, judgment and decision-making, and behavioral control. Drugs imitate natural neurotransmitters, resulting in false or abnormal messages being sent around neural circuits. The brain’s central reward system is overstimulated and flooded with dopamine. The brain adapts to this flood by turning down its ability to respond to dopamine—so addicts take more and more of the drug to push dopamine levels higher.”

Lamenting that this revolution has lagged in Europe, the journal advised “Europe [to] look to the United States and to inspirational figures such as Nora Volkow…who has the scientific clarity of vision, and the relentless patience, to be able to argue for the promise of research effectively year in, year out.”

3. Neuroscience’s chronic brain disease model has produced no useful diagnostic or treatment tools for addiction, even as it expands endlessly before us.

In 1977, celebrating the discovery of the first family of neurochemicals—the endogenous opioid-like endorphins—prominent neurologist Richard Restak declared, “It’s hard to leave out the exclamation points when you are talking about a veritable philosopher’s stone—a group of substances that hold out the promise of alleviating, or even eliminating, such age-old medical bugaboos as pain, drug addiction and… schizophrenia.”

Restak was never held accountable for what have proved to be overblown, unfounded claims. Nor have the media, from the most prestigious medical journals to TimeNewsweek and Scientific American, had to issue a correction, let alone an apology, for regular depictions of the brain’s addictive structure and chemistry—even though nothing of therapeutic significance has been forthcoming. Americans seem to find these schemas rewarding in themselves, as “proof” that our faith in “better living through technology” is being fulfilled.

Ignoring this 35-year losing track record, Nature’s editorial predicts that neuroscience’s promises to alleviate addiction will come true: “It is likely that demand [for drugs] can be reduced by developing treatments for the self-destructive cravings that drive drug addiction. Given the technical tools now available for looking deep inside the brain, there is realistic hope that such treatments will emerge from research in the coming decades.”

Nature’s projection is notably far off in the future. We lack anything like a basic biomarker to diagnose the “disease.” But the more fundamental problem is pegging the neuroscience vision of addiction to the brain’s pleasure centers or reward systems in the first place.

To begin with, the people whose brains are the material for Volkow & Co.’s research have been identified—and self-identify—as addicts. By contrast, we know very little about the brains of the people who use cocaine but don’t become addicted or who overcome their addictions, including the many who cut back their use. Instead, comparisons are made to brain scans of people who have never (or rarely) used drugs. But without seeing how the brains of casual, former or moderating users respond to cocaine, we lack the relevant control groups that science requires. Without these comparisons, it is not even theoretically possible to use a brain scan as a diagnostic tool to distinguish a person who has the “disease” of addiction from the person who does not.

Also, brain scans only reflect a moment in time. They do not have any predictive value. Maybe those whose brains spell out “I’m addicted!” (or, more accurately, “I have taken a hell of a lot of cocaine!”) in marquee light bulbs will moderate as they mature. Many will, after all, concentrate on more productive things—like taking care of children—that will cause them to restrain themselves.

Most important, these images cannot depict why people become addicted—or differentiate between those who keep using in the face of grievous consequences and those whose values cause them to desist or cut back their use. And this—the science of quitting addiction—is the crucial scientific question.

The limitations of brain scans fold into a larger theoretical limitation of the theory that people become addicted to pleasure. Don’t we all experience more or less pleasure from many different things? And doesn’t how we handle such pleasure depend on many factors?

Dopamine is not limited to drug use. Larry Young and Brian Alexander write in The Chemistry Between Us, “Dopamine is involved in reward and motivation for everything we do in life—whether we’re eating good food, drinking good wine or interacting with our kids and family.” All of us are exposed to many pleasure-causing activities, and most of us have experienced excesses in these areas. But only rarely do excesses become chronic. Why is that? The regulation of dopamine-mediated pleasure is a fundamental aspect of life, just as the experience of pleasure is. Yet, according to Volkow, anything that activates the same parts of the brain and brain chemicals that drugs do will be irresistibly addictive.

The new edition of American psychiatry’s bible, DSM-5, for the first time recognizes as addictive a non-drug-taking activity—gambling. In addition, the DSM committee is contemplating adding gaming as an addiction. But why stop there? Volkow’s brain revolution could presumably enter every serious area of our lives.

4. Natural recovery from drug addiction and alcoholism is the norm, often without abstinence, completely undercutting the “chronic, relapsing brain disease” meme.

My work in helping people recover from addiction is dedicated to the idea that there is some ineluctable element in human experience centering on values, purpose and free will driving people to recovery. This idea is supported by an abundance of evidence.

The vast majority of addicts recover, frequently be moderating use on their own. In 2002, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) studied 43,000 randomly sampled Americans’ lifetime history of alcohol and drug abuse. Called the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), it concluded: “Twenty years after the onset of alcohol dependence, three-fourths of individuals are in full recovery; more than half of those who have fully recovered drink at low-risk levels without symptoms of alcohol dependence.” Only a quarter had any treatment, and only half of those who did—13% of the entire sample—attended AA or rehab.

NESARC found that the same held for drug addicts. Gene Heyman has analyzed NESARC and other major drug surveys. He summarized these results in the Times: “Since 1991 four major national surveys of psychiatric disorders and their correlates have been published. Each found that most of those ever addicted to illicit drugs were ‘ex-addicts’ by about age 30. Moreover, most of those who quit did so without professional help.”

Several studies have tracked people who developed alcoholism or drug addiction, following them for decades. In one such study, Kenneth Sher found that “people mature out of addictions at all ages.” In another, Madeline Meier reported that “relapse does not appear to be as ubiquitous as one might expect based on estimates from clinic samples (i.e., those in AA and treatment).” This leads Meier to “the view that alcoholism, at least in most cases, represents a changeable habit rather than a brain disease.”

But the neuroscience-based American Board of Addiction Medicine (ABAM)—like NIDA itselfhas declared the “chronic, relapsing brain disease” model to be its official policy. (Volkow is a central figure in both organizations). “The management of folks with addiction becomes very much like the management of other chronic diseases, such as asthma, hypertension or diabetes,” said ABAM’s Daniel Alford. “It’s hard necessarily to cure people, but you can certainly manage the problem to the point where they are able to function through a combination of pharmaceuticals and therapy.” In other words, as with AA, addicts and alcoholics never get better, but must rely on these groups, experts and medications to function.

5. The disease view is associated with higher addiction rates and longer-lasting addictions.

There is good evidence that the disease theory is not only wrong but bad for you. William Miller and his colleagues at the University of New Mexico tracked subjects following outpatient treatment for their drinking problems. They found that two primary factors predicted the likelihood of relapse: “the lack of coping skills and belief in the disease model of alcoholism.”

If you believe that you are powerless, you are at much higher risk of relapsing and of then throwing in the towel on your efforts to quit than if you feel that quitting is within your own power. In other words, the disease-cum-powerlessness view is self-fulfilling. A study of smokers trying to quit found that people who were heavily dependent and used nicotine replacement therapy were twice as likely to relapse as those who quit cold turkey. And obese subjects presented with the idea that obesity is a disease ate significantly worse diets—based on their learning that they couldn’t control themselves—than those not given this information.

Our growing reliance on the recovery-world idea of addiction, now cloaked in neuroscience, as a disease that is, at best, manageable is hurting us badly. As new brain discoveries “uncover” new addictions all the time, we congratulate ourselves on our medical progress. Yet we likely have many more addicts today than we had a century ago. Why, then, are we so confidently embracing this neuroscientific worldview?

Nora Volkow has pulled off a remarkable coup in the field of addiction. She has built an international reputation—and mission—by persuading us that we can’t do what we have been doing for centuries: resolve addictions through our values, purposes and life experiences. Studies following addicts and alcoholics over the course of their lives show this to be a regular occurrence. By denying this naturally occurring phenomenon so as to fit substance use and many other activities into an institutionalized, medical framework, Volkow and her expanding neuroscience legions are effectively reducing natural recovery while prolonging otherwise-transient addictive behavior. And they are glorying in this achievement.

Stanton Peele has been at the cutting-edge of addiction theory and practice since writing, with Archie Brodsky, Love and Addiction in 1975. He has developed the on-line Life Process Program, and has published a new book, with Ilse Thompson, Recover! Stop Thinking Like an Addict and Reclaim Your Life with The PERFECT Program.