In 1997, a one-page article entitled “Addiction is a Disease of The Brain, and It Matters” was published in the journal Science. The paper, written by Alan Leshner, Director of the National Institute on Drug Abuse (NIDA), was the first time someone made the case that addiction is a disease of the brain. Leshner based his claim on recent advances in neuroscience, citing research that “virtually all drugs of abuse (have) common effects, either directly or indirectly, on a single pathway deep within the brain.”
He wrote that the “activation” of this pathway, known as the reward pathway, “appears to be a common element in what keeps drug users taking drugs.” He also pointed out that “prolonged drug use cause(s) pervasive changes in brain function that persist long after the individual stops taking the drug.” These changes, he said, have been identified on “molecular, cellular, structural, and functional” levels.
Leshner’s theory came to be known as “the brain disease model of addiction.” And it can be summed up by the belief, as Leshner wrote, “that addiction is tied to changes in brain structure and function is what makes it, fundamentally, a brain disease.”
Proclaiming addiction was a medical problem in 1997 was like comparing alcoholism to diabetes. This understanding did not—and still does not—conform to commonly held beliefs that addicts are immoral persons lacking an ability to control oneself, people who just can’t “say no.”
Leshner confronted this issue in his landmark article. “The gulf in implications between the ‘bad person’ view and the ‘chronic illness sufferer’ view is tremendous,” wrote Leshner. “There are many people who believe that addicted individuals do not even deserve treatment.”
Twenty years have passed since the brain disease model for addiction was introduced. It remains largely unknown to the general public, the medical community and those making public policy. But the implications are indeed tremendous: We are in the midst of an Opiate Crisis in America, and it’s still far easier for a doctor to write a prescription for opiate painkillers than Methadone, an opiate that does not get addicts “high,” but is used to help them get off of addictive drugs like heroin.
Addiction remains so poorly understood that in 2016 the president of the Philippines, Rodrigo Duterte, vowed to kill 3 million addicts (having already killed an estimated 3,000 in the first few months of his presidency). NIDA has focused their addiction research not just on the brain, but on genetics—looking for a genetic explanation for addiction and on the behavioral and social mechanisms involved in it. But their core research remains focused on the brain and finding targets for treatment in the brain.
Baclofen, a generic medication used to treat muscle spasms, was accidentally found to treat cocaine addiction by a paralyzed cocaine-addicted patient at the University of Pennsylvania in the late 1990s. The efficacy of Transmagnetic Stimulation to treat cocaine addiction was also stumbled upon by chance by a researcher in Padua, Italy. These treatments work by actions on the Dopamine Reward Pathway and related circuitry in the brain, but there’s much more work needed to fully understand them.
Another major area of focus is the Prefrontal Cortex. Through neuroimaging, researchers have found that disruption of the Prefrontal Cortex—the area of the brain involved in judgment and decision-making—contributes to compulsive drug-taking.
There is a reason why addicts make poor decisions for themselves. A crucial, if not necessary, part of current addiction research must be to eliminate the stigma of addiction and promote wider recognition of addiction as a chronic, relapsing brain disease. When this happens, a new era of addiction treatment and how we view addicts will be upon us.