The Harms of Constructing Addiction as a Chronic, Relapsing Brain Disease

As an international network of historians and social scientists who study approaches to the management of drugs across time and place, we have noticed the effort to redefine addiction as a chronic, relapsing brain disease (CRBD). The CRBD model is promoted as a route to destigmatize addiction and to empower individuals to access treatment that works within that model's terms.1 CRBD usefully recognizes that brain-based neural adaptations place individual brains in chronic states of readiness to relapse. But brains are housed inside of people. Substance use is biological, social, and political; our concepts and approaches to complex questions surrounding substance use must be, too.2,3 By overlooking the sociopolitical dynamics and inequalities bound up with substance use, the CRBD model can paradoxically further marginalize people who use drugs by positing them as neurobiologically incapable of agency or choice. We are concerned that the CRBD model paints drug users as individuals whose exclusion from social, economic, and political participation is justified by their biological flaws and damaged brains.This view of people who use drugs has resulted in special emphasis on medications developed to limit propensity to relapse and to manage the neurophysiological elements of problem substance use. Although medications can be empowering to people with problem substance use and can enhance social, economic, and political participation, they do not always or necessarily do so. The social and political contexts within which a biomedical model such as the CRBD model is implemented matter, but the model is not designed to address such contexts or questions of justice. In this editorial, we explore prospects of doing better by comparing US policies with a brief historical survey of Western European countries that have adopted medications for problem substance use while remaining skeptical of or agnostic toward the CRBD model. These examples show that the CRBD model is not the only or best way to fight stigma and provide treatment. Policies in these countries provide support and push back against stigma in a range of ways, the most effective of which incorporate aspects of harm reduction. We can learn from these successes and continuing challenges as we work to achieve effective policies in the United States.We believe that a historical and socially rooted analysis offers an especially powerful lens to reassess the CRBD model's value and implications.4,5 Our goal is no