The brain disease model of addiction: challenging or reinforcing stigma?

Abstract

In their critical analysis of the brain disease model of addiction (BDMA), Wayne Hall and colleagues1Hall WD Carter A Forlini C The brain disease model of addiction: is it supported by the evidence and has it delivered on its promises?.Lancet Psychiatry. 2015; 2: 105-110Summary Full Text Full Text PDF Scopus (133) Google Scholar have elegantly shown that the BDMA is insufficiently supported by animal-model and neuroimaging evidence; has not contributed to the development of more effective treatments; and has had a modest effect on public policies toward drugs and drug addiction. However, one of the key aspirational claims of advocates for the BDMA is left unaddressed—even though alluded to—by Hall and colleagues:1Hall WD Carter A Forlini C The brain disease model of addiction: is it supported by the evidence and has it delivered on its promises?.Lancet Psychiatry. 2015; 2: 105-110Summary Full Text Full Text PDF Scopus (133) Google Scholar the BDMA's potential to undermine the stigmatisation of addiction and people with drug addiction.Together with a few theoretical papers,2Buchman DZ Illes J Reiner PB The paradox of addiction neuroscience.Neuroethics. 2011; 4: 65-77Crossref Scopus (28) Google Scholar a paucity of empirical studies has explored this issue. Recently, an Australian survey on public attitudes has shown that considering addiction as a so-called brain disease is not associated with a reduced stigmatisation or with reduced support for coerced-treatment or punishment for addiction.3Meurk C Carter A Partridge B Lucke J Hall W How is acceptance of the brain disease model of addiction related to Australians' attitudes towards addicted individuals and treatments for addiction?.BMC Psychiatry. 2014; 14: 373Crossref PubMed Scopus (34) Google Scholar In this line, a newly published experimental study has concluded that strengthening belief in a BDMA does not reduce feelings of stigma and shame in mild-to-moderate alcohol-dependent individuals, but even weakens some of their perceptions of agency over addiction-related behaviours (eg, locus of control, coping style, and controlled drinking self-efficacy).4Wiens TK Walker LJ The chronic disease concept of addiction: helpful or harmful?.Addict Res Theory. 2014; (published online Dec 11.)https://doi.org/10.3109/16066359.2014.987760Crossref Scopus (39) Google Scholar The more extensive literature linking stigma and the conceptualisation of psychiatric diagnoses in terms of brain disease seems to point in the same direction.5Haslam N Genetic essentialism, neuroessentialism, and stigma: commentary on Dar-Nimrod and Heine.Psychol Bull. 2011; 137: 819-824Crossref PubMed Scopus (116) Google Scholar, 6Kvaale EP Haslam N Gottdiener WH The ‘side effects’ of medicalization: a meta-analytic review of how biogenetic explanations affect stigma.Clin Psychol Rev. 2013; 33: 782-794Crossref PubMed Scopus (245) Google ScholarTherefore, as Hall and colleagues1Hall WD Carter A Forlini C The brain disease model of addiction: is it supported by the evidence and has it delivered on its promises?.Lancet Psychiatry. 2015; 2: 105-110Summary Full Text Full Text PDF Scopus (133) Google Scholar have questioned the evidence base for—and potential benefits from—the BDMA, it would have been desirable that their critical analysis has also addressed BDMA's stigma-related issues. In any case, so far, the claim that framing addiction as a brain disease will lead to stigma reduction seems to be an unrealistically rosy picture or at least an unsubstantiated desideratum of BDMA's advocates.I declare no competing interests. In their critical analysis of the brain disease model of addiction (BDMA), Wayne Hall and colleagues1Hall WD Carter A Forlini C The brain disease model of addiction: is it supported by the evidence and has it delivered on its promises?.Lancet Psychiatry. 2015; 2: 105-110Summary Full Text Full Text PDF Scopus (133) Google Scholar have elegantly shown that the BDMA is insufficiently supported by animal-model and neuroimaging evidence; has not contributed to the development of more effective treatments; and has had a modest effect on public policies toward drugs and drug addiction. However, one of the key aspirational claims of advocates for the BDMA is left unaddressed—even though alluded to—by Hall and colleagues:1Hall WD Carter A Forlini C The brain disease model of addiction: is it supported by the evidence and has it delivered on its promises?.Lancet Psychiatry. 2015; 2: 105-110Summary Full Text Full Text PDF Scopus (133) Google Scholar the BDMA's potential to undermine the stigmatisation of addiction and people with drug addiction. Together with a few theoretical papers,2Buchman DZ Illes J Reiner PB The paradox of addiction neuroscience.Neuroethics. 2011; 4: 65-77Crossref Scopus (28) Google Scholar a paucity of empirical studies has explored this issue. Recently, an Australian survey on public attitudes has shown that considering addiction as a so-called brain disease is not associated with a reduced stigmatisation or with reduced support for coerced-treatment or punishment for addiction.3Meurk C Carter A Partridge B Lucke J Hall W How is acceptance of the brain disease model of addiction related to Australians' attitudes towards addicted individuals and treatments for addiction?.BMC Psychiatry. 2014; 14: 373Crossref PubMed Scopus (34) Google Scholar In this line, a newly published experimental study has concluded that strengthening belief in a BDMA does not reduce feelings of stigma and shame in mild-to-moderate alcohol-dependent individuals, but even weakens some of their perceptions of agency over addiction-related behaviours (eg, locus of control, coping style, and controlled drinking self-efficacy).4Wiens TK Walker LJ The chronic disease concept of addiction: helpful or harmful?.Addict Res Theory. 2014; (published online Dec 11.)https://doi.org/10.3109/16066359.2014.987760Crossref Scopus (39) Google Scholar The more extensive literature linking stigma and the conceptualisation of psychiatric diagnoses in terms of brain disease seems to point in the same direction.5Haslam N Genetic essentialism, neuroessentialism, and stigma: commentary on Dar-Nimrod and Heine.Psychol Bull. 2011; 137: 819-824Crossref PubMed Scopus (116) Google Scholar, 6Kvaale EP Haslam N Gottdiener WH The ‘side effects’ of medicalization: a meta-analytic review of how biogenetic explanations affect stigma.Clin Psychol Rev. 2013; 33: 782-794Crossref PubMed Scopus (245) Google Scholar Therefore, as Hall and colleagues1Hall WD Carter A Forlini C The brain disease model of addiction: is it supported by the evidence and has it delivered on its promises?.Lancet Psychiatry. 2015; 2: 105-110Summary Full Text Full Text PDF Scopus (133) Google Scholar have questioned the evidence base for—and potential benefits from—the BDMA, it would have been desirable that their critical analysis has also addressed BDMA's stigma-related issues. In any case, so far, the claim that framing addiction as a brain disease will lead to stigma reduction seems to be an unrealistically rosy picture or at least an unsubstantiated desideratum of BDMA's advocates. I declare no competing interests. The brain disease model of addiction: is it supported by the evidence and has it delivered on its promises?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. Full-Text PDF The brain disease model of addiction: challenging or reinforcing stigma?–Authors' replyWe thank Dr Joan Trujols for his comments on our review. Full-Text PDF