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Dose of Reality: The Effect of State Marijuana Legalizations

It was promoted tirelessly by psychologist Alan I. The brain-disease model is a staple of medical school education and drug counselor training and even appears in the antidrug lectures given to high-school students 9. Rehab patients learn that they have a chronic brain disease. Bush, and Barack Obama have all endorsed the brain-disease framework at one time or another From being featured in a major documentary on HBO, on talk shows and Law and Order , and on the covers of Time and Newsweek , the brain-disease model has become dogma — and like all articles of faith, it is typically believed without question 12 — That may be good public relations, but it is bad public education.

We also argue that it is fundamentally bad science. The brain-disease model of addiction is not a trivial rebranding of an age-old human problem. Now introduce brain imaging, which seems to serve up visual proof that addiction is a brain disease. For over three centuries in the United States, physicians, legal scholars, politicians, and the public have debated the nature of addiction: is it a defect of the will or of the body?

A moral or a medical problem?

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After all, mountains of evidence attest to the fact that addiction entails both biological alterations in the brain and in personal agency. This is an opportune time to pause and clarify two potential sources of misunderstanding. We are more concerned with the very different issue of whether addiction is best construed as a brain disease or brain disorder. Moreover, although severe addictions are partly rooted in genetic predispositions that are themselves manifested in brain functioning, these conditions can be profitably understood at multiple levels of analysis e. That is, we do not believe that the mind and the brain are independent of each other or composed of different physical substances with consciousness existing in a spiritual world separate from the body.

Kayla Greenhalge

Few scientifically literate persons do. But, speaking of literacy, there is indeed value in examining the language people use when talking about the relationship between the brain and the mind. Every subjective experience, from the ache of nostalgia to the frisson of a Christmas morning, corresponds to physical events in the brain. The mind — the realm of feelings, desires, ideas, memories, intentions, and subjective experience — is produced by the action of neurons and brain circuits. How else could it work?

Yet the mind is not identical with the matter that produces it; one cannot use the physical rules from the cellular level to completely predict activity at the psychological or behavioral level. Put somewhat differently, there is a fundamental difference between substance dualism and property dualism: the latter acknowledges that everything mental is ultimately produced by physical matter but allows for the fact that certain mental phenomena have different properties than neural phenomena just as molecules themselves are not alive, but complex configurations of certain molecules can produce life.

At this time, one cannot rely on the brain alone to predict or understand everything important about human subjectivity or behavior. This is because many psychological phenomena are emergent properties of lower-order constituents such as neural circuits, neurons, proteins, and genes.

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In his book, An Argument for Mind , Harvard University psychologist Jerome Kagan notes that the appreciation of an impressionistic painting requires far more than the sum of its parts Some philosophers of mind take a different view. They speculate that such properties the painting in full will ultimately prove reducible to more basic elements the paint They may prove correct.

But for the foreseeable future, valuable information is often lost when descending from higher explanatory levels, such as mental states, to lower levels, such as neuronal systems. The distinctions between substance and property dualism and between constitutive and greedy reductionism may appear arcane, but overlooking them can lead us to overestimate the explanatory power of neuroscientific findings.

Take addiction, for example.

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Without a doubt, chronic drug exposure often changes the brain, but knowledge of the neural mechanisms underlying addiction typically has less relevance to the treatment of drug addiction and alcoholism than the psychological and social causes. To be sure, intervening directly on the brain, say with medications such as methadone, can sometimes be of value too.

But understanding the brain of addicts gives us only partial insight into why they become addicted and how they recover. So, what exactly makes addiction a brain disease? Every experience changes the brain — from learning a new language to navigating a new city. It is certainly true that not all brain changes are equal; learning French is not the same as acquiring a crack habit. In addiction, intense activation of certain systems in the brain makes it difficult for users to quit. Genetic factors influence the intensity and quality of the subjective effect of the drug, as well as the potency of craving and the severity of withdrawal symptoms Normally, dopamine surges in the so-called reward pathway, or circuit, in the presence of food, sex, and other stimuli central to survival.

Over time, drugs come to mimic these natural stimuli. With every puff of a Marlboro, injection of heroin, or swig of Jim Beam, the learning signal in the reward pathway is strengthened, and in vulnerable users, these substances assume incentive properties reminiscent of food and sex. The development of salience has been traced to the nerve pathways that mediate the experience as they emerge from the underside of the brain, in an area called the ventral tegmentum, and sweep out to regions such as the nucleus accumbens, hippocampus, and prefrontal cortex, which are associated with reward, motivation, memory, judgment, inhibition, and planning.

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Other nerve fibers travel from the prefrontal cortex, a region involved in judgment and inhibition, to parts of the brain that control behavior. The mere clink of a whiskey bottle, a whiff of cigarette smoke, or a glimpse of an old drug buddy on the corner can set off an unbidden rush of yearning, fueled by dopamine surges. For the addict who is trying to quit, this is a tense feeling, not pleasurable at all. Because the rush of desire seems to come out of the blue, users may feel blindsided, helpless, and confused In a very impressive display of brain technology, scientists have used PET and fMRI scans to observe the neural correlates of craving.

In a typical demonstration, addicts watch videos of people handling a crack pipe or needle, causing their prefrontal cortices, amygdala, and other structures to bloom with activity 25 videos of neutral content, such as landscapes, induce no such response. Even in users who quit several months previously, neuronal alterations may persist, leaving them vulnerable to sudden, strong urges to use.

To illustrate how drugs affect the brain, an egg representing the brain was cracked on a sizzling frying pan representing drugs. Result: fried brain]. Nowadays, however, the brain itself often substitutes for the fried egg. But that egg is not always sizzling. There is a surprising amount of lucid time in the daily life of addicts. Most of their time is spent either working or hustling 27 — The same is true for many cocaine addicts In the grip of such hunger, an addict cannot be expected blithely to get up and walk away.

But in the days between binges, cocaine users worry about a host of everyday matters: should I find a different job? Enroll my kid in a better school? Kick that freeloading cousin off the couch for good? Attend a Narcotics Anonymous meeting, enter treatment, or register at a public clinic? It is during these stretches of relative calm that many addicts could make the decision to get help or quit on their own — and many of them do. But the decision to quit can be long in coming, far too long for those who destroy their health, families, or careers in the meantime. The paradox at the heart of addiction is this: How can the capacity for choice coexist with self-destructiveness? Aristotle noted this paradox as well. He used the term Akrasia to denote an appetite or strong desire for pleasure that leads to actions that are harmful to our conscious wishes for our well-being Indeed, how many of us have ever come across a heavy person who exercised his or her freedom expressly toward the goal of becoming fat?

Many undesirable outcomes in life arrive incrementally. In the early phase of addiction, drugs or alcohol become ever more appealing, while once-rewarding activities, such as relationships, work, or family, decline in value. The attraction of the drug starts to fade as consequences accrue — spending too much money, disappointing loved ones, attracting suspicion at work — but the drug still retains its allure because it blunts psychic pain, suppresses withdrawal symptoms, and douses intense craving [ 35 , p.

Addicts find themselves torn between the reasons to use and reasons not to Sometimes a spasm of self-reproach or a flash of self-awareness tips the balance toward quitting. William S. Lawford 38 , himself in recovery from drugs and alcohol, edited a collection of essays called Moments of Clarity in which the actor Alec Baldwin, singer Judy Collins, and others recount the events that spurred their recoveries. Some quit on their own; others got professional help.

These are not the sentiments of people in helpless thrall to their diseased brains. Nor are these sentiments the luxury of memoirists. Among those who had become dependent on drugs by age 24, more than half later reported not a single drug-related symptom. By comparison, people who were addicted within the year before the survey were more likely to have concurrent psychiatric disorders.

In other words, they are not representative of the universe of addicts. They are the hard cases — the chronic and relapsing patients. Yet these patients often make the biggest impressions on clinicians and shape their views of addiction, if only because clinicians are especially likely to encounter them. Researchers and medical professionals err in generalizing from the sickest subset of people to the overall population of patients. This caveat applies across the medical spectrum.

Advocates of the brain-disease paradigm have good intentions.

What Is drug addiction?

They hope that this portrayal will inspire insurance companies to expand coverage for addiction and politicians to allocate more funding for treatment [ 44 , p.