In particular, we reflect on the fact that these dominant narratives are both abstinence focused and therefore exclude many drinkers who are not willing and may not need, to consider lifelong sobriety to reduce their risk or experience of harms. We present an argument that these two dominant narratives alone do not capture the wide and heterogeneous experience of alcohol harms, and as such a more diverse range of relatable narratives are required to reach and resonate with the broader community of people with AUDs. The first is the historically embedded narrative of alcoholism as disease, and the second is the more recent narrative of positive or new sobriety. We argue that there are two dominant narratives that relate to how alcohol use disorder (AUD) is identified and addressed. Narratives draw on common representations that are subject to influences including historical and normative influences. Narratives around alcohol are important in determining how people decide who or what qualifies as problematic alcohol use. Either way, addiction stigma can be combatted by fighting moralism about drugs and moralistic drug policies directly, as opposed to resting hopes on the brain disease label. Further studies are necessary to determine their effect compared with other possible variables, such as, e.g., alternative reinforcers.ConclusionsĬonceptual clarification and preliminary empirical assessment of the BDMA recommends agnosticism about its validity and an openness to heterogeneity in some cases addiction may be a brain disease, in others not. Using this method, the causal significance of brain states, such as, e.g., extensive gray matter loss and/or neuroadapations in the mesocorticolimbic dopamine system, is not yet fully demonstrated. Although there exist competing analyses of causation, there is a relatively standard method used to establish it within experimental science: intervention. The theoretical and empirical challenges to developing such an account are not insurmountable, but they are substantial.
It is necessary to have an account of normal brain function by which to measure it. Evaluation of the BDMA therefore requires analysis of the concepts of brain dysfunction and causation, and their application to addiction science.ResultsBrain dysfunction cannot be analyzed merely as brain changes or brain differences nor can it be inferred merely from the presence of personal-level signs and symptoms. This means that underlying brain pathology is hypothesized to be the cause of the personal-level observable signs and experienced symptoms characteristic of addiction. I then distinguish strong, minimal, network, and mismatch models of disease, and I argue that the BDMA aligns with a strong disease model. To address this barrier, I begin with discussion of what we know about the effects of the brain disease label on addiction stigma, and why labelling effects should have no bearing on the validity of the BDMA. A barrier to such consideration is belief that the BDMA is necessary to combatting addiction stigma. The aim of this review is to conceptually clarify what it would mean for the BDMA to be true, rather than to argue decisively for or against it.ObjectivesĬonceptual clarification of the BDMA requires consideration of possible models of disease and their relationship to the BDMA. Yet few advocates or critics of the BDMA have provided an account of what a brain disease is. RationaleAlthough increasingly subject to criticism, the brain disease model of addiction (BDMA) remains dominant within addiction science. Importantly, this possibility requires the availability of social support and material resources that are all too frequently absent in the lives of those who struggle with addiction. I conclude by considering how it is nonetheless possible to overcome addiction despite this identity, in part by imagining and enacting a new one. Given that an addict identification carries expectations of continued consumption despite negative consequences, there is therefore a parsimonious explanation of why people who identify as addicts continue to use drugs despite these consequences: they self‐identify as addicts and that is what addicts are supposed to do. For people who lack a genuine alternative sense of self and social identity, recovery represents an existential threat. Against this characterization, I argue that many cases of addiction cannot be explained without recognizing the value of drugs to those who are addicted and I explore in detail an insufficiently recognized source of value, namely, a sense of self and social identity as an addict.
Addiction is standardly characterized as a neurobiological disease of compulsion.
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