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Scott Kellogg Scott Kellogg

Why Stanton Peele Got Nora Volkow All Wrong

Peele's anti-science attack on the head of NIDA—and the brain-disease model of addiction—reveals how inadequate his own "natural recovery" approach is when it comes to addressing the immense complexity of addiction.

9 Substance

The world of drugs and drug addiction is like the sea—filled with mystery, power and complexity, but also suffering and grief. There are no experts; we are all students trying to understand and learn. As an addiction psychologist and psychotherapist, I know that we must have humility as we proceed with determination and creativity to assist those who are living in the prison of addiction. It is from this perspective that I found Stanton Peele’s recent Substance.com article, titled “Why We Need to Stop Nora Volkow From Taking Over the World,” which attacked both Nora Volkow, MD, the director of the National Institute on Drug Abuse (NIDA), and the brain-disease model of addiction itself, deeply disturbing.

Two things struck me as I read his piece. The first is that there was no sense of the tragic nature of drug addiction—of the oceans of pain, loss, guilt and anguish that are an essential part of the journey. The second is that Peele showed no apparent understanding of the history of contemporary addiction treatment or the bitter struggles among the traditionalists, the scientist-humanists, and the harm reductionists or the work that many of us have done to develop more compassionate and effective systems of care. I suspect that his conflation of the “disease” model of the 12-step fellowships and the brain disease model of NIDA stems, in part, from this lack of historical perspective.

Addictions are best understood as multifactorial experiences. People use substances for many different reasons: to experience pleasure, to medicate internal states of pain, to address brain-based cravings and dysphoria, to affirm their membership in valued groups, and to cope with oppression and poverty, medical illness and social degradation. Likewise, there are many paths that lead to change, healing and recovery. To say that addiction is only a brain disease is simplistic. However, to create, as Peele does, a model of addiction and recovery that does not give a significant role to the brain is anti-scientific.

Peele’s main point is that most people overcome their addictions and problematic use of substances without the benefit of treatment or self-help groups. This is neither new nor controversial information. These people have a great deal to teach us—not only with their creativity and resilience, but also with their sorrow and regret. Yet others are unable to do this on their own—and their numbers are legion.

A central question that runs through contemporary discussions of addiction is this: Are these bad people who need to be punished or are they sick people who need to be healed? In fact, many treatment and recovery programs blend both perspectives. The “disease” model of Alcoholics Anonymous (AA), on the one hand, and the brain-disease model of Nora Volkow, NIDA and the entire field of neuroscience, on the other, are two profoundly different ways of trying to understand (1) why some people relapse repeatedly and never seem to achieve durable stability, and (2) why other people maintain abstinence, sobriety and moderation for long periods and then return to drug and alcohol use in ways that are dramatic and, sometimes, catastrophic.

AA’s approach says that it is impossible for people to recover on their own; Volkow’s approach says that it may be difficult for them to recover on their own. The difference between “impossible” and “difficult” is huge, but somehow Peele fails to see it. And by conflating the two models, he also condemns both for promoting “powerlessness” rather than empowerment. This is a fair charge to make against AA but not against NIDA.

The 12 Steps employ the concept of addiction as a disease but do not actually believe in it. The “disease” they refer to is a metaphor rather than a medical condition. It is a way of acknowledging that some people repeatedly have trouble using substances with intention and control; it is also a way of helping their members remain vigilant about their own vulnerabilities. That AA does not truly view addiction as a medical condition is evident in is longstanding opposition to the use of medications that is manifest not only in the meetings but also in programs based on this model. If you do not allow people the use of medications, then you fundamentally do not believe that they are sick or have a disease.

AA’s approach says that it is impossible for people to recover on their own; Volkow’s approach says that it may be difficult for them to recover on their own. The difference between “impossible” and “difficult” is huge, but somehow Peele fails to see it.

However, what is a strategic metaphor for one group is a medical imperative for another. The NIDA brain disease model is built on the seminal work done by physician-researchers Vincent Dole, Marie Nyswander and Mary Jeanne Kreek in their development of methadone maintenance in 1966. The essential discovery was that when some individuals use substances, they trigger a state of disruption in brain functioning experienced as symptoms of withdrawal, craving, tolerance and profound mood dysregulation. This deep discomfort and “drug hunger” makes it more likely that they will seek to relieve these symptoms by using the substance again. And again and again and again and again.

As NIDA itself says, most people who use drugs do not experience these changes, but some do. This variability may be due to the amount, frequency, duration and choice of drug; or it may be due to genetics, trauma and other medical, psychological and social problems. The question arising from these conditions is, With abstinence or a marked decrease in use, will the brain heal, remain deranged or leave the individual with lifelong vulnerabilities? All three outcomes are possible. To be clear, the patients are not automatons; they do have some capacity for choice or action even if the desire for pleasure, the longing for relief and the intensity of craving can, at times, be overwhelming.

We are just beginning to understand the nature of the addicted brain. Neuroscience is revealing the complex and damaging ways in which many of these substances work; tragically, neuroscience is also showing that the creation of medicines that undo the damage is a long and difficult process. Yet there has already been some progress, most notably with methadone and such opiate substitution medications as buprenorphine. At the First National Harm Reduction Conference in 1996, there was a meeting of methadone patients and their organizations.

Together they created the Methadone Patients’ Manifesto, which stated that “heroin addiction is a medical condition. Methadone treatment must…be considered a legitimate medical treatment that is delivered with dignity and respect. Methadone is not a substitute; rather, it is a replacement therapy for a deranged opiate receptor-ligand system.…Recipients of methadone treatment shall be called ‘patients.’ It is denigrating for a methadone patient to be called a ‘client.’ We are patients like everyone else who goes to a doctor.…Methadone is health care.…Methadone is recovery and methadone shall be considered drug-free.” Using insights from NIDA’s neuroscientific work, these patients claimed empowerment while challenging traditionalists about the nature of healing and recovery.

A grim alternative is Russia’s defiant refusal to allow methadone or buprenorphine to be used in the treatment of heroin addiction. This kind of antipathy is based on the fact that Russian Narcology has separated itself from psychiatry and has, in practice, replaced a medical model with a moral one. Punishment and religion are now the favored interventions. One of the more terrible consequences of this anti-science approach to addiction is a rising tide of death due to drug use and HIV. Some have called these practices human rights violations.

I have no doubt that Stanton Peele would not support the importation of Russian-style treatment to the US. But Peele’s anti-science approach, if widely adopted, would have dire results. By first conflating AA’s moral model with Volkow’s scientific model in order to delegitimize the brain-disease approach to addiction, and then arguing instead that addiction treatment should be built on a foundation of natural recovery and waiting for people to “mature out” rather than treating them with the full armamentarium of available psychological and biological treatments, Peele abandons all those people for whom natural recovery—that is, no treatment—does not work.

I have no doubt that Stanton Peele would not support the importation of Russian-style treatment to the US. But Peele’s anti-science approach—that addiction treatment should be built on natural recovery—would have dire results if it were widely adopted.

Attacking Volkow for supposedly turning NIDA into a war room of neuroscientists bent on taking over the world of addiction is absurd. NIDA and the National Institute on Alcoholism and Alcohol Abuse (NIAAA) have spent millions of dollars championing major psychological and behavioral approaches centered on principles of empowerment and choice, such as Relapse Prevention, Motivational Interviewing and Contingency Management. They are one of the leading proponents of empowerment treatments in the world.

Relapse Prevention (RP), the work of psychologist Alan Marlatt, is a training in mastery. Working with a therapist, the patient seeks to understand their pattern of use, assess their risks and develop coping methods to help manage craving. Motivational Interviewing (MI), which was created by psychologists William Miller and Stephen Rollnick, is based on the idea that all people who use substances in problematic ways are ambivalent about doing so. MI seeks to clarify the internal forces, expand the capacity for choice and empower patients to create and pursue action plans. Contingency Management (CM), which has been championed by Maxine Stitzer and fellow psychologists, involves the creation of positive reinforcement systems to counteract the reinforcing power of drugs and to strengthen their determination and efficacy.

I use these NIDA-supported principles in my own addiction psychotherapy practice, which I see as a form of warrior work. I tell my patients that recovering from an addiction means that they are fighting for their life. I tell them that we are in a liberation struggle with a formidable enemy. I also tell them that we can win.

Is there a way to resolve this conflict between different approaches to addiction? Taking a simplistic stance—and a highly speculative one—I believe that there is. Instead of viewing the brain as a monolithic entity, we might consider the possibility that the brain itself may be of “two minds” about drug use. The limbic system, a center for emotion, motivation and pleasure, is a critical target of drugs and alcohol. The prefrontal cortex (PFC) is the center for executive cognitive function—which includes such tasks as goal setting, planning and the delay of gratification. There may be an ongoing state of conflict between the present-focused, pain-and-pleasure-oriented limbic system that seeks the drugs, and the future-oriented, goal-driven PFC. Interventions that soothe or balance the limbic system and those that strengthen the PFC can both be helpful.

Attending an emotionally evocative, hope-inducing meeting at a self-help group—whether AA, SMART Recovery or Moderation Management—could have a positive effect on the limbic system. Developing a pattern of reading or using affirmations, slogans and program materials during a time of stress could help strengthen the PFC. The behavioral treatments could also be recast in this light: MI as a kind of dialogue between the limbic system and the PFC; RP, which involves strategizing, acting purposefully and learning skills, as activating the PFC.

Some harm reduction interventions, such as using clean needles, involves working with drug users to pause and think rather than act on automatic pilot. CM and positive-reinforcement systems reward behaviors that involve the PFC. Mindfulness training empowers people to observe their thoughts and feelings rather than simply act on them. Meditation can also be calming and soothing—so it is likely that both of these areas of the brain could be positively affected.

Further research is necessary, of course, but it may be that those people who, on their own, successfully moderate or leave drugs behind—those who are the model for recovery that is at the center of Peele’s vision—may have actually found ways to better stimulate their PFC and calm their limbic system.

Because addiction is multifactorial (and not simply a matter of brain chemicals and regions), we need to develop a wide array of treatments that help patients cope with cravings, urges and high-risk situations; heal their traumas, inner anguish, and psychopathology; find meaningful existential and spiritual answers; engage in vision work and processes of re-creation to discover new and viable identities; be empowered in their struggles with social, economic and other oppression; and rebalance and restore brains that have suffered insults from drugs, trauma or poverty. This is the great quest. I hope that Stanton Peele will join us on it.

Scott Kellogg, PhD, is the former president of the Division on Addictions of the New York State Psychological Association, a Schema Therapist, and a clinical assistant professor in the New York University Department of Psychology. His websites are Transformational Chairwork and Gradualism and Integrative Addiction Psychotherapy. His email is scott.kellogg@nyu.edu.