HJNO May/Jun 2022

HEALTHCARE JOURNAL OF NEW ORLEANS I  MAY / JUN 2022 21 ABSTRACT The view that substance addiction is a brain disease, although widely accepted in the neuroscience community, has become subject to acerbic criticism in recent years. These criticisms state that the brain disease view is deterministic, fails to account for heterogeneity in remission and recovery, places too much emphasis on a compulsive dimension of addiction, and that a specific neural signature of addiction has not been identified. We acknowledge that some of these criticisms have merit, but assert that the foundational premise that addiction has a neurobiological basis is fundamentally sound. We also emphasize that denying that addiction is a brain disease is a harmful standpoint since it contributes to reducing access to healthcare and treatment, the consequences of which are catastrophic. Here, we therefore address these criticisms, and in doing so provide a contemporary update of the brain disease view of addiction. We provide arguments to support this view, discuss why apparently spontaneous remission does not negate it, and how seemingly compulsive behaviors can co-exist with the sensitivity to alternative reinforcement in addiction. Most importantly, we argue that the brain is the biological substrate from which both addiction and the capacity for behavior change arise, arguing for an intensified neuroscientific study of recovery. More broadly, we propose that these disagreements reveal the need for multidisciplinary research that integrates neuroscientific, behavioral, clinical, and sociocultural perspectives. Close to a quarter of a century ago, then director of the US National Institute on DrugAbuseAlan Leshner famously asserted that “addiction is a brain disease”, articu- lated a set of implications of this position, and outlined an agenda for realizing its promise [1]. The paper, now cited almost 2000 times, put forward a position that has been highly influential in guiding the efforts of researchers, and resource allo- cation by funding agencies. A subsequent 2000 paper by McLellan et al. [2] examined whether data justify distinguishing addic- tion from other conditions for which a dis- ease label is rarely questioned, such as dia- betes, hypertension or asthma. It concluded that neither genetic risk, the role of personal choices, nor the influence of environmental factors differentiated addiction in a manner that would warrant viewing it differently; neither did relapse rates, nor compliance with treatment. The authors outlined an agenda closely related to that put forward by Leshner, but with a more clinical focus. Their conclusion was that addiction should be insured, treated, and evaluated like other diseases. This paper, too, has been excep- tionally influential by academic standards, as witnessed by its ~3000 citations to date. What may be less appreciated among sci- entists is that its impact in the real world of addiction treatment has remained more limited, with large numbers of patients still not receiving evidence-based treatments. In recent years, the conceptualization of addiction as a brain disease has come under increasing criticism. When first put for- ward, the brain disease viewwas mainly an attempt to articulate an effective response to prevailing nonscientific, moralizing, and stigmatizing attitudes to addiction. Accord- ing to these attitudes, addiction was simply Part II: Addiction as a brain disease revised: why it still matters, and the need for consilience © 2021 LLS. Printed with permssion. https://creativecommons.org/licenses/by/4.0/ Heilig, M., MacKillop, J., Martinez, D. et al. Addiction as a brain disease revised: why it still matters, and the need for consilience. Neuropsychopharmacol. 46, 1715–1723 (2021). https://doi.org/10.1038/s41386-020-00950-y INTRODUCTION