The parents of a 13-year-old middle school student brought their son to a counselor of my acquaintance. “He spends all of his time after school—night after night—playing Mortal Kombat,” they said. “He has no friends and has fallen behind in all of his courses.” They were beside themselves with worry.
It’s a familiar tale. And our analysis of such behaviors pervades modern addiction theory—raised once again by Evaluating the Brain Disease Model of Addiction, a monumental collective work published this month.
Non-substance addictions are important to understand and mitigate in their own right. But they are also central to the case against a reductive concept of drug addiction that hampers recovery and underpins the drug war.
Archie Brodsky and I first refuted what was then a heroin-centric, biological model of addiction in Love and Addiction in 1975. We then deduced:
If addiction is now known not to be primarily a matter of drug chemistry or body chemistry, and if we therefore have to broaden our conception of dependency-creating objects to include a wider range of drugs, then why stop with drugs? Why not look at the whole range of things, activities, and even people to which we can and do become addicted? We must, in fact, do this if addiction is to be made a viable concept once again.
Our model was built on people’s attachment to an experience that felt essential for them but became harmful. Such experiences were powerful and immediate, provided crucial though temporary feelings of wellness and relief, but eroded the person’s coping skills and other interests and outside relationships.
Obviously, if the characteristics of addiction are routinely exhibited with non-drug behaviors, the notion that addiction is a unique property of drugs doesn’t hold up.
In the years since, the “list” of addictive drugs according to various sources has been expanded piecemeal to include cigarettes, cocaine, methamphetamines, benzodiazepines, sleep medications including Ambien and others, painkillers, alcohol of course, marijuana and more.
Among the non-drug involvements now described as addictive by a range of sources are love, sex (including pornography), electronic media (games, iPhones), social media, gambling, eating, shopping and more.
Obviously, if the characteristics of addiction are routinely exhibited with non-drug behaviors, the notion that addiction is a unique property of drugs doesn’t hold up.
But basing “addiction” on something other than drugs’ properties is crucial to a string of developments in our field. Among these are the recognition of natural recovery (people usually believe that they can outgrow love addictions); harm reduction (people aren’t expected to abstain from love and sex and eating to recover from those addictions); and the central roles of cognition, coping skills, social resources and environmental factors—which are more obvious without the presence of drugs.
The recognition of non-substance addictions also underlies the mission of normalizing drug use.
Resistance to Expanding “Addiction” Beyond Drugs
Some opponents of the disease model oppose any model of addiction. If, as Brodsky and I noted, the key “truths” of addiction—use of opioids/drugs is inevitably addictive; addiction is irreversible and lifelong; external life factors and individual psychological dispositions don’t impact addiction—are false, why should we expand the concept? Instead, they argue, we should discard it entirely.
Dr. John Davies made this argument in The Myth of Addiction (1993). For Davies, addiction is misattributed to the object of addiction (drug use), rather than identifying the factors that are actually at work. These include psychological (personal attitudes), social (group beliefs), and situational (such as socio-economic) factors. Why, he reasoned, repeat such misattributions about non-drug activities and involvements?
Dr. Carl Hart may be a contemporary example of such thinking. Hart’s important highlighting of normalized drug use, outlined in Drug Use for Grown-Ups (2021), is that drugs don’t create negative consequences for most people. Rather, the opposite is true—people usually welcome and benefit from the drugs’ effects. That’s why people use drugs.
Hart’s work presenting a rational, scientific view of drugs is invaluable. But he has shown less interest in identifying and understanding compulsive non-drug behaviors. While agreeing with much of Davies’ and Hart’s reasoning, I have defended the reconceptualization of addiction—in large part because it can create a critical link between drug use and non-drug behaviors.
The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) meanwhile eschews “addiction” in favor of “substance use disorders” (from mild to severe). To its credit, these are defined by negative life impacts, not types or quantities of drugs consumed. Yet the term deliberately separates drugs from other involvements.
Establishing a Human Concept of Addiction
Dr. Bruce Alexander, whose famous “Rat Park” studies of the 1970s and ‘80s did much to inform the understanding of human involvements with drugs, wrote with me in The Meaning of Addiction (1985):
A successful addiction model must synthesize pharmacological, experiential, cultural, situational, and personality components in a fluid and seamless description of addictive motivation … The model must [also] make sense out of the essentially similar behavior that takes place with all compulsive involvements.
Real-world examples demonstrate the truths of Rat Park with humans. As Zach Rhoads and I described in Outgrowing Addiction (2019) and in Filter, most of the US soldiers in Vietnam who used heroin did not become addicted. Well over 90 percent of those who reported being addicted in Vietnam ceased the addiction within a short period on their return, almost always without treatment, even though half used an opioid stateside. Those veterans who used heroin again were no more likely to use it addictively than those using any other drug. And the minority who remained addicted or became re-addicted were immersed in negative social environments.
The Vietnam heroin experience simply reiterated the general rules of human behavior.
The Vietnam experience demonstrated that people move past addiction when their surroundings improve, that they are no more likely to use one drug compulsively than any other, and that having fewer positive life options obstructs natural recovery.
These are not special features of drug use. They are operational keys to all human functioning. The Vietnam heroin experience simply reiterated the general rules of human behavior.
Where Are We in 2022?
In reviewing Evaluating the Brain Disease Model of Addiction, I wrote its senior editor, Nick Heather, about its focusing on drugs rather than establishing a general model of addiction. Heather explained that “the issue is not directly addressed but is implied in the more general criticism of the brain disease model.”
Actually, the argument goes the opposite way: The fact that addiction carries beyond drugs disproves the brain disease model of addiction (BDMA).
The brain disease model was developed in the service of establishing the inherent dangers of drug use. This is the motivating vision of the National Institute on Drug Abuse, embedded in its name. For NIDA to consider normal or positive drug use is impossible—to do so would defy its defined mission.
The Heather et al. volume reprints the views of the prior and current directors of NIDA. Neither they, nor other BDMA theorists, were willing to contribute any new writing. Since BDMA is the ruling paradigm, they didn’t need to bother.
Meanwhile, as indicated by its title, Evaluating defines itself in terms of the BDMA, which most of its contributors critique. (Bruce Alexander’s two chapters, including the final one, “Replacing the BDMA: a paradigm shift in the field of addiction,” stand out for their cultural-social-psychological-experiential portrayal of addiction.) In this way, it reflects the superior position the disease theory occupies.
The current epidemic of drug-related deaths, which has accelerated over the quarter century that BDMA has been dominant, should have finally discredited the disease theory, a belief in which has been shown to impede recovery from addiction. Instead, its opponents still are shouting into the wind.
The Way Forward
There can be no advancing addiction theory, treatment or policy without placing drug use and addiction within the firmament of all human behavior.
A group of European psychologists observed in a 2013 review titled “Motivation and Self-Regulation in Addiction: A Call for Convergence”:
[as] Peele (1985) summarized, ‘addiction may occur with any potent experience’ . . . Until recently, mainstream addiction research has greatly departed from this broad definition of addiction that can encompass any kind of behavior whatsoever. Instead, there has been a clear tendency to over-identify addiction with substance abuse and to distinguish drug addiction in particular as a unique phenomenon, quantitatively and qualitatively distinct from behaviors and habits of everyday life. However, recent evidence in psychology, behavioral economics, and neuroscience increasingly suggest that the qualitative dichotomy is unwarranted and that addiction to drugs shares essential commonalities with motivated or goal-directed behaviors in general.
We can note the change in the substance use disorders section in the fifth edition of the DSM (2013). DSM-5 labels no drugs, but only compulsive gambling, as “addictive” in the section titled “Substance Use Disorders and Behavioral Addictions.” Its first acceptance of the existence of a non-drug addiction was a step forward; its limiting of the category to gambling alone is nonsensical.
Other non-substance addictions will surely be added in time, however. In fact, DSM-5 placed sex addiction and (electronic) gaming addiction on hold for further consideration. Meanwhile, the 2019 edition of the World Health Organization’s International Classification of Diseases (ICD-11) included both conditions (without labeling them “addictions”).
DSM doesn’t deconstruct its diagnosis of Obsessive Compulsive Disorder (OCD) into separate categories for washing hands, checking locks, lining up shoes, etc. Instead, the disorder is identified by the severity of the negative consequences of these and similar activities.
For substance use disorders, DSM enumerates 10 types of drugs—alcohol; caffeine; cannabis; hallucinogens; inhalants; opioids; sedatives, hypnotics or anxiolytics; stimulants (amphetamines and cocaine); tobacco (i.e., nicotine); and “other or unknown substances.” It then uses 11 criteria for categorizing them as disorders, from mild to severe.
American psychiatry still feels obligated to specify which activities, as if their identities form the dominant component of the condition.
These criteria all contribute to a portrait. Per the DSM:
“If substance use causes significant problems in someone’s life, such as health issues, disability, and/or not meeting responsibilities at work, home, or school, the person may have a substance use disorder.”
Using the same criteria, we could say that any immersive activity can be addictive. Yet American psychiatry still feels obligated to specify which activities, as if their identities form the dominant component of the condition.
The 13-year-old boy at the beginning of this article was able—like most children, and most people who experience addiction—to move forward into a positive new phase of his life.
His counselor worked calmly with him to find out more about his concerns and interests. With the agreement of his school, the boy took on a new classroom role of sharing his computer skills with less tech-savvy classmates.
This built his confidence, helping him to become more popular with his peers. All of this made him happier, leading him naturally to end his addictive relationship with gaming and to engage more with his schoolwork and other areas of his life.
No drug or activity is inherently, unavoidably or inescapably “addictive.” Addiction is a negative state in which some people become enmeshed for shorter or longer periods. Recognizing this truth—with both drugs and other behaviors—is necessary in order not only to advance treatment and related societal changes, but to cease the demonization of drugs.
Photograph via PxHere
Archie Brodsky is a member of the board of directors of The Influence Foundation, which operates Filter.
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