Research Paper

The brain disease model of addiction and epistemic injustice

Academic literature has witnessed significant debate over the past thirty years concerning whether addiction is best thought of as a brain disease. While the framing of addiction as a disease has a much longer history (see Levine, 1978), the claim that addiction is specifically a brain disease and the debates around this claim began in earnest when Leshner (1997) categorically claimed that neuroscientific advances had shown that drug addiction is a chronic, relapsing disease resulting from the prolonged effects of drugs on the brain. This framing centres the illness or disorder firmly in the realm of the brain’s structure and functioning, as opposed to a lack of meaning and purpose (i.e. a spiritual disease/malady) as per proponents of AA’s spiritual disease model (see O’Mahony, 2019), a disease of the will as per Benjamin Rush (see Seddon, 2010), or a highly heterogeneous disorder from which more homogeneous, qualitatively distinct subtypes might be derived, only some of which constitute a disease, as E.M. Jellinek and colleagues have argued (see Kelly, 2018).

Despite multiple sustained critiques of the BDMA from criminologists (O’Mahony, 2019), anthropologists (Bourgois, 2009), psychologists (Alexander, 2008), and some within neuroscience (Heilig, 2021, Kalant, 2014) have reiterated that, despite valid criticism, the claim that addiction has a firm neurobiological basis remains strongly supported by the best scientific evidence. Most recently, Heather et al. (2022) have produced a volume evaluating the BDMA through contributions from supporters, opponents, and undecided scholars. While the editors entertain arguments from many different perspectives and models, they argue that addiction is undergoing a revolutionary change—from being considered a brain disease to a disorder of voluntary behaviour (Heather et al., 2022)—though this is contested by advocates of the BDMA (see Heilig, 2021).

While some have examined the emergence of the BDMA from a social constructionist perspective (Keane et al., 2014), and criticised its relative ignorance of social and cultural context (Reinarman, 2005), the current paper asks a different question: has the claim that addiction is best thought of as a brain disease helped or harmed those suffering from harmful substance use epistemically? While critical scholars have approached this question from many angles, there has been little reflection among supporters of the model, where it is often assumed that framing addiction as a brain disease will reduce stigma, increase access to treatment, and lead to better outcomes in general for those experiencing harmful drug use (see Volkow & Koob, 2010). Yet many critical scholars argue that disease understandings commit people to a lifetime of reduced autonomy (Hart, 2021), as they are perceived—by themselves and others—to lack control and free will in important ways. This, in turn, can stigmatise them as disordered and constitutionally different from others. Moreover, clinical treatment providers appear ambiguous in their support of the BDMA. While some believe it can reduce stigma, others argue it may foster hopelessness within clients (Barnett et al., 2018).

Similarly, while access to treatment has increased in many countries, this has not always been due to the adoption of the BDMA or any disease model. For example, Ireland has expanded treatment access in the 21st century (see Butler, 2007), yet never explicitly adopted disease understandings. Sweden’s approach, while complex, accommodates both social and brain-based understandings of drug-related harm (Grahn et al., 2014). Meanwhile, the Islamic Republic of Iran has recently increased access to treatment despite its lack of commitment to disease framings (see Mirzaei et al., 2022). While one might argue that these increases were compelled by growing rates of drug-related harm, the case remains: representing addiction as a brain disease has not, in and of itself, played a decisive role in facilitating treatment access in these diverse contexts. This is not to say that the BDMA cannot support access, but that many culturally diverse countries have achieved this end without adopting it. Ultimately, the choice is not between viewing addiction as a moral failing or a brain disease, there are diverse ways to frame addiction to achieve stigma reduction and treatment uptake ends.

While much debate exists within the academic literature, the BDMA currently represents a dominant way addiction is understood in the United States (Barnett et al., 2018) and that the model is influential in Europe (see SStorbjörk, 2018; O’Mahony, 2019) and Australia (Keane et al., 2014). Given this position of influence, the current paper asks whether the model helps or harms those experiencing drug-related harm epistemically. That is, does the claim that they are suffering from a brain disease help them understand themselves and their experiences of drug-related harm and/or enable them to communicate this to others—or is it harmful in these respects? Before turning to this question, let us briefly examine the relevant literature.