How the Brain Disease Paradigm Remoralizes Addictive Behaviour

In recent decades, addiction has been medicalized anew through the rise of an influential ‘brain disease paradigm’. This questions the equivalence of addiction to drug dependence by re-emphasizing loss of self-control over unhealthy impulses as the disease locus. While showing continuities with the nineteenth-century vision of addictions as ‘diseases of the will’, neurobiology objectifies disease as disrupted neurochemical transmission and lasting neuroadaptation. The brain disease paradigm emerged together with rapid advances in neuroimaging technology as well as intensified research efforts to confirm cigarette smoking as nicotine addiction. After smoking achieved such recognition in the late 1980s, numerous other unhealthy impulses and appetites have likewise come under neurobiological investigation as prospective cases of addiction. Despite its technoscientific sophistication, neurobiology's biomedicalization of addiction remains as partial and ambiguous as past medicalizations. By confirming moral self-transformation anew as an indispensable component of treatment and recovery, neurobiology revives addiction as a moral disease in the process of its objectification. Furthermore, through its rediscovery of a classic nineteenth-century ‘liberal disease’ at the molecular level, the neurobiology of addiction is acting as a vital moralizing resource in the biomedicalization of health and illness more generally today.     

Drugs as instruments: a new framework for non-addictive psychoactive drug use

Most people who are regular consumers of psychoactive drugs are not drug addicts, nor will they ever become addicts. In neurobiological theories, non-addictive drug consumption is acknowledged only as a "necessary" prerequisite for addiction, but not as a stable and widespread behavior in its own right. This target article proposes a new neurobiological framework theory for non-addictive psychoactive drug consumption, introducing the concept of "drug instrumentalization." Psychoactive drugs are consumed for their effects on mental states. Humans are able to learn that mental states can be changed on purpose by drugs, in order to facilitate other, non-drug-related behaviors. We discuss specific "instrumentalization goals" and outline neurobiological mechanisms of how major classes of psychoactive drugs change mental states and serve non-drug-related behaviors. We argue that drug instrumentalization behavior may provide a functional adaptation to modern environments based on a historical selection for learning mechanisms that allow the dynamic modification of consummatory behavior. It is assumed that in order to effectively instrumentalize psychoactive drugs, the establishment of and retrieval from a drug memory is required. Here, we propose a new classification of different drug memory subtypes and discuss how they interact during drug instrumentalization learning and retrieval. Understanding the everyday utility and the learning mechanisms of non-addictive psychotropic drug use may help to prevent abuse and the transition to drug addiction in the future.     

Methodological, ethical, and legal considerations in drug court research

Since their inception in the late 1980s, drug courts have become the most prevalent specialty court in the United States. A large body of outcome research conducted over the past two decades has demonstrated that drug courts effectively reduce drug use and criminal recidivism, which has led to the rapid proliferation of these courts. Importantly, drug court research has flourished despite the many challenges faced by researchers when working with a vulnerable population of justice-involved substance users. In this article, we highlight the most common methodological, ethical, and legal challenges encountered in drug court research, and discuss ways in which researchers can overcome these challenges to conduct high-quality research. Drug court research exemplifies how rigorous empirical investigation can be accomplished in the criminal justice system, and it can serve as a useful model for researchers working in other parts of the judicial system.     

Drogenabhängige Patienten im Maßregelvollzug gemäß § 64 StGB: Verbesserung der Quote erfolgreicher Behandlung durch suchtspezifische Medikation?

In Germany, addicted offenders can be sentenced to compulsory addiction treatment in forensic mental hospital departments (Art. 64 of the penal code). A presupposition to such a sentence is a fair chance of successful treatment and rehabilitation. Commonly, an expert witness is asked by the court to assess this point in the trial. To date, the treatment in forensic mental hospitals aims at total abstinence from any kind of drugs. But in at least half of the cases, a fair chance of successful treatment is no longer seen after a period of therapy. In most cases, these patients are returned to prison. The paper pleads that in offenders addicted to illegal drugs, a drug specific medication – in particular methadone maintenance treatment or naltrexone medication – might be a useful option. The rate of “treatment failure” might be reduced slightly by using this option with some of the patients.     

Behavioral perspectives on the neuroscience of drug addiction

Neuroscientific approaches to drug addiction traditionally have been based on the premise that addiction is a process that results from brain changes that in turn result from chronic administration of drugs of abuse. An alternative approach views drug addiction as a behavioral disorder in which drugs function as preeminent reinforcers. Although there is a fundamental discrepancy between these two approaches, the emerging neuroscience of reinforcement and choice behavior eventually may shed light on the brain mechanisms involved in excessive drug use. Behavioral scientists could assist in this understanding by devoting more attention to the assessment of differences in the reinforcing strength of drugs and by attempting to develop and validate behavioral models of addiction.     

工作记忆训练对药物成瘾者认知功能的改善及其机制

对处于戒断期的各类药物成瘾群体进行认知训练，训练后药物成瘾个体认知能力得到改善，成瘾症状也得到了一定缓解。认知训练能够加速药物成瘾者大脑受损区域的自发性恢复，尤其是使影响个体抑制控制能力的中脑边缘多巴胺系统和前额叶系统发生功能性和结构性的积极变化，实现药物成瘾个体高级认知能力的改善。今后可以从不同类别的药物成瘾是否全部具有可逆性，设置的认知训练任务能否起到改善认知能力的效果，药物成瘾个体训练的性别差异以及训练效果的保持时间等角度进行研究。     

Cocaine addiction and personality: A mathematical model

The existence of a close relation between personality and drug consumption is recognized, but the corresponding causal connection is not well known. Neither is it well known whether personality exercises an influence predominantly at the beginning and development of addiction, nor whether drug consumption produces changes in personality. This paper presents a dynamic mathematical model of personality and addiction based on the unique personality trait theory (UPTT) and the general modelling methodology. This model attempts to integrate personality, the acute effect of drugs, and addiction. The UPTT states the existence of a unique trait of personality called extraversion, understood as a dimension that ranges from impulsive behaviour and sensation‐seeking (extravert pole) to fearful and anxious behaviour (introvert pole). As a consequence of drug consumption, the model provides the main patterns of extraversion dynamics through a system of five coupled differential equations. It combines genetic extraversion, as a steady state, and dynamic extraversion in a unique variable measured on the hedonic scale. The dynamics of this variable describes the effects of stimulant drugs on a short‐term time scale (typical of the acute effect); while its mean time value describes the effects of stimulant drugs on a long‐term time scale (typical of the addiction effect). This understanding may help to develop programmes of prevention and intervention in drug misuse.     

干预胆碱M受体对药物成瘾的影响及其与多巴胺的关系

药物成瘾是一类精神及行为障碍, 涉及到中枢神经系统的病变。毒蕈碱受体(Muscarinic receptor, M受体)属于胆碱能受体, 分5种亚型。行为学研究表明, 干预M受体能有效影响药物成瘾行为, 但其神经机制还亟待探索。阿片类药物与精神活性药物均能激活中枢多巴胺系统, 而M受体与多巴胺系统在多个脑区产生了交互作用。其中激动M2及M4受体抑制了多巴胺系统功能, 而激动M5受体增强了多巴胺系统功能, 与干预M2、M4、M5受体对药物成瘾行为的影响相对应。以上证据提示, 干预M受体可能通过影响多巴胺系统对药物成瘾起作用。     

Aberrant learning and memory in addiction

Over the past several years, drug addiction has increasingly been accepted to be a disease of the brain as opposed to simply being due to a lack of willpower or personality flaw. Exposure to addictive substances has been shown to create enduring changes in brain structure and function that are thought to underlie the transition to addiction. Specific genetic and environmental vulnerability factors also influence the impact of drugs of abuse on the brain and can enhance the likelihood of becoming an addict. Long-lasting alterations in brain function have been found in neural circuits that are known to be responsible for normal appetitive learning and memory processes and it has been hypothesized that drugs of abuse enhance positive learning and memory about the drug while inhibiting learning about the negative consequences of drug use. Therefore, the addict's behavior becomes increasingly directed towards obtaining and using drugs of abuse, while at the same time developing a poorer ability to stop using, even when the drug is less rewarding or interferes with functioning in other facets of life. In this review we will discuss the clinical evidence that addicted individuals have altered learning and memory and describe the possible neural substrates of this dysfunction. In addition, we will explore the pre-clinical evidence that drugs of abuse cause a progressive disorder of learning and memory, review the molecular and neurobiological changes that may underlie this disorder, determine the genetic and environmental factors that may increase vulnerability to addiction, and suggest potential strategies for treating addiction through manipulations of learning and memory.     

药物成瘾理论的新进展

成瘾过程伴随着一系列脑机能和心理机能的改变,但对药物滥用如何导致这些改变以及它们如何诱发成瘾却存在着不同的解释。近年来,由于认知心理学和认知神经科学研究技术在该领域的应用,研究者对药物成瘾过程的认知机能及其脑机制获得了新的认识,且基于对负性生活事件及外部压力在维持药物滥用及诱发复吸行为中的作用的测量学研究和动物实验研究而提出的成瘾理论为该领域的研究开辟了新的思路。本文重点评述了药物成瘾的认知加工模型和以压力或负性情绪为核心的相关理论模型及其研究,并提出进一步研究的方向。     

Drugs, Environment, Brain, and Behavior

Abstract— The effects of psychoactive drugs are not just a function of their pharmacological actions, but are due to complex interactions among pharmacological, psychological, and environmental factors. We discuss here how drug-environment interactions determine the likelihood that addictive drugs produce a persistent form of neurobehavioral plasticity (sensitization) thought to be involved in the pathophysiology of addiction and relapse.     

基于门户理论视角下的青少年物质成瘾

青少年物质成瘾行为受到普遍的关注, 成瘾物质滥用的机制一直是学者们探讨和研究的焦点。门户理论提出青少年发展成严重药物滥用者的过程存在顺序和阶段特征, 合法物质的使用会增加发展为非法药物使用的风险, 这种顺序效应得到了实证研究的支持。本研究在综述以往研究的基础上发现, 基于门户理论视角下青少年药物使用存在顺序效应, 但以往研究仍然存在一些不足, 例如药物使用顺序的不固定, 解释范围有限, 内在机制不清楚以及各种影响因素缺乏整合等。未来可以扩展研究对象和范围, 以深入研究顺序效应的内在机制。     

基于啮齿类动物的决策行为研究及其脑机制

介绍了近年来以啮齿类动物为对象,关于决策的行为表现及其内在脑机制的研究进展。首先介绍了决策的概念,以及啮齿类动物的决策模型。在这些模型的基础上,总结了不同决策模型的共同的心理过程：计算、动机和记忆,并且介绍了业已发现的参与这些心理机制的脑机制。最后,还从决策的角度探讨了其与药物成瘾之间的关系,包括成瘾药物对决策行为的影响以及决策个体差异与药物成瘾易感性之间的关系     

Follow the Bird—A Story of Survival in the Treatment of Addictions Commentary on Paper by Lisa Director

Lisa Director proposes a relational model with an emphasis on enactment for the treatment of chronic drug and alcohol use. She illustrates her thesis with an extensive case report. The story of her patient's addiction, and of the embroiled analytic developments, is engaging, disturbing, and rewarding. I suggest that the telling of this inspiring story, and the narration of her theoretical framework, is a response to the devastation involved in the encountering of addictions and that this story unintentionally obscures some basic issues about addiction and the psychoanalytic treatment of it. I believe that the survival of patient and analyst was achieved with the help of three underemphasized factors: Director is an expert in the assessment and treatment of chemical dependency problems, and her patient, Helena, knew this; despite her chronic addiction, Helena brought exceptional resources for survival to the analysis; and the authority of the analyst was used for leverage to help replace Helena's reliance on drinking and drugs.     

Addiction: An Emergent Consequence of Elementary Choice Principles

ABSTRACT

Clinicians, researchers and the informed public have come to view addiction as a brain disease. However, in nature even extreme events often reflect normal processes, for instance the principles of plate tectonics explain earthquakes as well as the gradual changes in the face of the earth. In the same way, excessive drug use is predicted by general principles of choice. One of the implications of this result is that drugs do not turn addicts into compulsive drug users; they retain the capacity to say ‘no’. In support of the logical implications of the choice theory approach to addiction, research reveals that most addicts quit using drugs by about age 30, that most quit without professional help, that the correlates of quitting are the correlates of decision making, and, according to the most recent epidemiological evidence, the probability of quitting remains constant over time and independent of the onset of dependence. This last result implies that, after an initial period of heavy drug use, remission is independent of any further exposure to drugs. In short, there is much empirical support for the claim that addiction emerges as a function of the rules of everyday choice.     

Interpretive Phenomenological Analysis of the Spiritual Characteristics of Recovery Experiences in the Context of the Brain Disease Model of Addiction

Spirituality persists as a mechanism of behavior change for addiction recovery. The aim of this project was to carefully attend to how those in recovery construct meaning of their experience of addiction, regardless of the addiction treatment modality or ideological framework. Participant accounts reflected the increased public interest in and research funding based on the brain disease model of addiction (BDMA). The qualitative study used interpretive phenomenological analysis to investigate the experiences of six adults (age range from 24 to 72) with at least three years of sustained recovery from substance use disorders. In-depth key informant interviews tracked their construction of their experiences and their understanding of addiction. Participants who entered recovery after 2010 sought to integrate BDMA-related constructs into their understanding of addiction and recovery. Addiction recovery narratives featuring BDMA-related constructs integrated neuroscience-related ideas with spirituality-related constructs rather than completely replacing the latter. Notable innovations and paradoxical tensions were found within participant accounts. Such features echo the insights on secularity of Harvard philosopher Charles Taylor, particularly his notion of the “buffered self,” which offers a theoretical framework for understanding these shifts in meaning-making. For persons entering recovery in the twenty-first century, the brain disease model of addiction carries more explanatory authority than it does for previous generations, despite the lack of agreement across addiction-related neuroscientific findings. As a model, it engenders more mechanistic, agential, brain-centered (“buffered”) senses of self, ostensibly making it less compatible with spiritual understandings of addiction than other medical models of addiction. However, this study’s findings indicate that those in recovery are likely to devise complex narratives of the etiology of addiction that combine elements from various models.     

Children's Representations of the World of Drugs

The changing profile of drug use has highlighted the need for age-appropriate education which requires insight into children's representations of drugs. Representations were elicited from 134 children aged between 5 and 11 years, drawn from two schools, by asking them to draw and write their responses to questions relating to a story about losing and finding a bag of drugs. Relevant responses were generated by 119 children aged between 8 and 11 years. A content analysis of these responses revealed differences with school and age. Older children were more likely to recognize that drugs can be good or bad depending on type, quantity taken and reason for use. The children had firm ideas about who takes drugs and their motivations and were knowledgeable about methods of use. They recognized that drugs can be dangerous, but had little understanding of how or why. The children's representations were characterized by fear and uncertainty and most wanted to know more. These findings are used to argue that there is a need for child-centred constructivist approaches to drug education which seek to demystify drugs and drug use and to orientate children to the realities of the world of drugs in the 1990s.     

Helping behaviour among people who use drugs: Altruism and mutual aid in a harm reduction program

People who use drugs, and particularly people experiencing addiction, are rarely afforded the opportunity to have their voices heard when it comes to drug treatment or drug policy or even when attempting to define themselves and their life experiences. Of course, there is much more to a person than one area of their behaviour. The current study seeks to capture and understand the lived experiences of people who use drugs, with a focus on their relationships and helping behaviour. We interviewed 32 participants in a harm reduction program seeking to provide understanding beyond stigmatizing and criminalizing drug narratives, by exploring their motivation and context for helping behaviours. Grounded theory methodology was used to understand the patterns of helping behaviour, along with the contexts in which help is or is not given. We particularly focus on participants' distribution of syringes and carrying medicine to reverse overdose (naloxone). Participants shared stories of altruism and mutual aid, along with barriers and disincentives to helping others. We situate these behaviours within contrasting environments of a free harm reduction program and the competitive market system of the U.S. society. Implications for practice and public policy are discussed.