Disease Model Proponents Are the Climate Change Deniers of Our Field

December 2, 2019

Our cognitive biases, per Nobel-winner Daniel Kahneman and colleague Amos Tversky, cause us to value short-term benefits over staving off future catastrophes. This tendency to give precedent to the present (“hyperbolic discounting”) evolved to meet survival needs at early stages in human development.

These biases join other common dysfunctional ways of thinking, such as “privilege protects against all dangers,” “devil take the hindmost” and premature consensus-seeking (groupthink).

Taken together, these biases are disastrously counterproductive in the face of the impendingperhaps already passedenvironmental point of no return. The same is true when it comes to finding a sustainable societal approach to addiction and drug-related harms, like our current drug-deaths crisis.


Climate-Emergency Paralysis

A series of UN climate reportsextending from the 2018 Intergovernmental Panel on Climate Change Report to its even more frightening 2019 report on the destruction of our oceans and frozen regionsare among many indicators that the earth is hurtling towards ruin.

Not only are we unable to halt this disaster, we are worsening it. A third UN report, issued in November, found: “Four years after countries struck a landmark deal in Paris to rein in greenhouse gas emissions in an effort to avert the worst effects of global warming, humanity is headed toward those very climate catastrophes,” with the richest nations “having expanded their carbon footprints last year.”

In the face of these dangers, meanwhile, a survey of 11,000 scientists recently concluded: “the climate crisis has arrived and is accelerating faster than most scientists expected.” 

These reports raise terrifying questions about our collective thinking and behavior:

* Why have governments around the world failed to counteract this crisis? 

* As a recent New York Times op-ed asked, why did scientists get it so wrong for so long? (The short answer: consensus-seeking)

* More generally, how have human beings been able to disregard their own self-destruction? 


Failure to react appropriately is as severe at the individual level as it is with governments. For example, Americans have abandoned sedans en masse in favor of SUVs and pick-up trucks. This trend is worldwide, in what the Times notes is “bad news for the climate.”

In a review of Rachel Maddow’s Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth, the Times notes that “While the tone throughout is one of shock, amazement and condemnation, the book is not as radical in its conclusions as readers might have anticipated”:

The caution is perhaps because Maddow knows that, whatever we might say about the oil and gas business, we are all eagerly consuming its products … “I like driving a pickup and heating my house as much as the next person,” Maddow writes.


Maddow isn’t going to give up her pickup truck and several residences, any more than privileged suburbanites will their SUVs and large homes. They will do anything to maintain the comfort of surrounding their families with costly metal, masonry and technology. This urge outweighs their vague awareness that the earth is being ruined for their children, which they see as occurring down the road, and which they feel their privilege can help them mitigate.


Our Self-Fulfilling Drug Death Crisis

Our policy on drugs and addiction accomplishes something similar. It provides elites with the sense that they are doing the best for themselves and their children while the world at large burns.

The drug death crisis has seen a leap of 600 percent since the 1990s—and 350 percent between 2013 and 2017. These leaps correspond with the rise of the chronic relapsing brain disease theory presented by Alan Leshner when he was director of the National Institute on Drug Abuse (NIDA).

Leshner’s hugely influential article, “Addiction Is a Brain Disease—And It Matters,” appeared in Science in 1997. Nora Volkow has expanded this view worldwide since her ascendancy to the NIDA’s leadership in 2003. In 2007, NIDA under Volkow created the HBO Addiction Project to bring the HBO brain disease documentary into every school curriculum in America. Volkow’s theme for the NIDA, “Addiction is a Disease of Free Will” (built on Leshner’s popular “hijacked brain” meme) was published in 2015.

Convincing us that addiction is inevitable and inescapable—in the face of ubiquitous evidence that it is culturally and cognitively inculcated and very escapable—is a self-fulfilling prophecy.

Meanwhile, according to the CDC, “From 1999 to 2017, more than 702,000 people have died from a drug overdose.” That number continues to grow apace.

In 2016, faced with soaring death rates and convinced that not yet enough Americans thought addiction was a brain disease, then-US Surgeon General Vivek Murthy launched a national campaign to drive the message home. Media joined in: In 2018 PBS’s NOVA created a new addiction documentary series which it spread throughout the nation’s schools. American students are now taught the brain disease theory of addiction as though it were Newtonian physics.

Leshner, Volkow and NIDA have succeeded in relegating drug addiction and death to the medical sphere. Even though their usurpation conveyed the promise that medicine will soon eradicate this brain disease, its failure to do so hasn’t harmed their franchise in the least. No Democratic or Republican administration dares to challenge the brain disease establishment.


The Anti-Disease Backlash

The discrepancy between promised outcomes and delivered results has made Volkow and her allies defensive. They enumerate, then counter, disease theory objections raised by people like Marc Lewis, Maia Szalavitz, Carl Hart and myself (for decades) in one remarkable 2018 NIDA article, which rightly notes:

* “medications cannot take the place of an individual’s willpower” [an argument Volkow has previously despised]

* “viewing addiction this way minimizes its important social and environmental causes”

* “addiction is not fundamentally different from other experiences that redirect our basic motivational systems” [like falling in love]

It also notes the most fundamental challenge of all:

Some critics also point out, correctly, that a significant percentage of people who do develop addictions eventually recover without medical treatment. It may take years or decades, may arise from simply “aging out” of a disorder that began during youth, or may result from any number of life changes that help a person replace drug use with other priorities.


Taken altogether, NIDA paradoxically outlines the critical fallacy in disease thinking: Convincing us that addiction is inevitable and inescapable—in the face of ubiquitous evidence that it is culturally and cognitively inculcated and very escapable—is a self-fulfilling prophecy. (Unlike addiction, people don’t generally escape diseases like cancer through developing an overriding purpose.)

In the 1970s, ‘80s and ‘90s, psychologists like Alan Marlatt, Nick Heather and Stephen Rollnick, Jim Orford, and William Miller conducted experiments and treatment assessments demonstrating that individual and cultural beliefs were critical to treatment outcomes such as controlled drinking versus abstinence and relapse.

But these results have gone by the wayside in the hypermedicalized 21st century. NIDA’s partial admissions are too little, too late. The agency’s fundamental direction is not changing, any more than the consequent self-defeating addiction beliefs of most Americans.


The Misuse of MAT

The primary tools activated in NIDA’s medicalized addiction model (although they existed before it) have been the “medication-assisted treatment” (MAT) drugs: methadone, buprenorphine and naltrexone. MAT has been embraced across the drug policy spectrum—from conservative medical groups like the American Medical Association’s Board of Addiction Medicine to drug policy reform groups like the Drug Policy Alliance and the Harm Reduction Coalition, as publicized by liberal publications from the Atlantic to the New York Times.

These medications have been shown to be useful tools in studies in which they greatly reduce mortality in specific targeted populations. But their promise has not been broadly borne out in their application at a whole-population level. Why?

The accompanying message doubles down on the damaging disease ideas that drive our cultural drug crisis.

Expanded across the country by policy reform groups as a “proven method of recovery,” MAT is now official government policy. There was a slight tick back in drug deaths in 2018, but this improvement is a drop in the ocean and has been spotty, to say the least.  (And factored into any improvement has to be the dispersal of naloxone, which instantly reverses narcotic drug effects.)

The Centers for Disease Control and Prevention announced a projected decline of 4 percent in overall drug deaths in 2018. Yet “some states actually saw double-digit increases.” Missouri, in which deaths increased 17 percent, was one of 18 such states: 

Over the last several years, Missouri has received $65 million in federal grants to address the opioid crisis, [researcher Rachel] Winograd says … They’ve focused on expanding access to medication-assisted treatment …

“The fact that the numbers didn’t go down and that people were dying at an even higher rate—it was devastating.”  


MAT, dispensed as an option for people seeking to navigate drug use in rational ways, can be valuable. But dispensing it as the only viable option for people proposed to be struggling with a disease from which they cannot ever truly escape—certainly not through developing their own skills and resources—is dangerously counterproductive. The accompanying message doubles down on the damaging disease ideas that drive our cultural drug crisis at an individual and societal level.


Climate Change and Addiction Responses Fuel Inequality

The disease theory frames addiction as a result of the inherent properties of certain drugsabsurdly, when we consider the prevalence of addiction to many non-drug behaviors, from gambling to sex and love to video games. 

In doing so, the brain disease model serves a sinister purpose. It diverts people’s attention toward chemical solutions and away from the social roots of addiction and drug-related death. 

The disease theory has become  a societal excuse for neglecting the redistribution of resources needed to fully support education, housing and community-building. It instead implies that the solution lies in supporting ineffective and expensive—but nevertheless easier than structural change—addiction “treatment.”

As with climate change, where the poorest individuals and countries suffer the most immediate and devastating damage, the social implications of our wilful blindness are unavoidable. According to the Times:

People with lower incomes were less prepared for natural disasters and were more likely to live in homes vulnerable to them. Low-income Americans are also more likely to become homeless after a disaster and have more difficulty obtaining loans after one…


The relative self-perceived safety of better-off populations also explains the ever-expanding drug crisis—which likewise falls disproportionately on those in deprived settings. 

The theory enables them to believe that no significant sacrifices on their part will forestall such problems in those less fortunate. How convenient.

While PSAs emphasize that everyone is susceptible to drug addiction and death—the “equal-opportunity disease” mantra—the data instead show such deaths heavily discriminate on economic lines. Per one study this year: “Drug overdose deaths significantly declined with higher house prices.”

And according to the Institute for New Economic Thinking, in rural areas: 

[Death] rates varied widely from one region to another. Some rural counties have the highest opioid mortality rates in the country, while others enjoy the lowest. Among non-urban counties, drug mortality rates appear to spike in two types of places: economically beaten-down communities centered on mining and distressed areas where people increasingly depend on service jobs. 


But the most obvious example is smoking: While smoking has declined dramatically among better-off Americans, despite rising prices, it retains a strong hold on poorer Americans. For deprived people, smoking still provides a relatively cheap, harmful drug release.

The disease view of addiction allows Americans, including progressives, to avoid recognizing and dealing with this reality. While elites and liberals rarely encounter severe opioid harms in their own prosperous worlds, the theory enables them to believe that no significant sacrifices on their part will forestall such problems in those less fortunate—who are largely invisible to them. How convenient.


Climate Change and Addiction Demand the Same Unlikely Approach

The solution for mitigating both climate change and drug deaths is essentially the same—and unfortunately, highly unlikely.

Privileged people and nations would have to drastically change their ways of living to reduce their consumption of resources. In the case of climate change, this would be a goal in itself. In the case of drugs, offering, through a fairer share of resources, greater security, opportunity and purpose to poor populations would see addiction rates plummet.

But privileged people, like most human beings throughout history, aren’t willing to sacrifice their short-term interests. Therefore, we shouldn’t be surprised when environmental violence and drug deaths continue to grow. 

Yet while those of us in socially privileged positions may fend off some of the worst immediate effects of these assaults, we cannot do so forever. All of us will ultimately suffer the consequences of environmental and societal disasters.

As John Donne advised, “Never send to know for whom the bell tolls; it tolls for thee.”


Photo adapted from Alto Crew on Unsplash

Stanton Peele

Dr. Stanton Peele is a psychologist who has pioneered, among other things, the idea that addiction occurs with a range of experiences and recognition of natural recovery from addiction. He developed the Life Process Program for addiction. He has authored many books since the 1975 publication of Love and Addiction (co-authored by Archie Brodsky); his latest is A Scientific Life on the Edge: My Lonely Quest to Change How We See Addiction.

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