The Brain Disease Model of Addiction: is it Supported by the Evidence and has it Delivered on its Promises?

Dr. Allwissend 01

The brain disease model of addiction: is it supported by the evidence and has it delivered on its promises?

Prof Wayne Hall, PhD
Adrian Carter, PhD
Cynthia Forlini, PhD

Sign up for Lancet Psychiatry to read the full article. An overview is below.

We need a similar critique of the American Society of Addiction Medicine (ASAM)  and its affiliates on this side of the Atlantic as “addiction medicine” is slated to be approved  by the  American Board of Medical Specialties in 2016 even though the discipline falls far short of the educational and professional standards for quality practice developed and implemented by all other ABMS member boards.    According to the ABMS these 24 boards are:

“committed to the principle of examining doctors based on six general competencies designed to encompass quality care: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice.”

These areas have been collectively identified by the ABMS, the American College of Graduate Medical Education (ACGME) and the Institute of Medicine (IOM) in order to standardize graduate medical education.

Any critique of the ASAM would find a number of issues antithetical to the six general competencies which stress “learning and improvement.”   In contrast the ASAM rests on the conviction that their views are absolutely certain and patently rejects open-minded inquiry.  An academic analysis of addiction medicine  from the vantage point of the ASAM would reveal false assumptions, bias, dogmatism, and data-dredging.  It would also reveal that those claiming expertise are in fact illegitimate and irrational authority who believe in an ends-justifies-the-means approach to push forth the chronic relapsing brain disease with lifelong abstinence an d imposed 12-step recovery. These are false experts who rationalize unethical, unprofessional and even criminal behavior as zeal for the faith if it aligns with the brain disease model of addiction (BDMA)   Their viewpoints are fixed and final.

They have not been held to truly objective judging, analysis, evaluation or outside critique.  The purpose of critique is the same as the purpose of critical thinking: to appreciate strengths as well as weaknesses, virtues as well as failings. Critical thinkers critique in order to redesign, remodel, and make better. This direly needs to be done.  The evidence-base for both the BDMA and the drug and alcohol testing, assessment and treatment is poor.     They are claiming physician health programs are the crown jewel of addiction treatment– a replicable model to be replicated in other populations.  It is all hyperbole and propaganda.  In reality they are using medical assessment and treatment as tools to repress and punish doctors.  Those running the state physician health programs are typically morally disengaged bullies with Machiavellian egocentricity.   And all the congratulatory backslapping is based on a singe poorly designed opinion piece.

Science and medicine need to be predicated on competence, thoughtfulness, good faith, civility, honesty, and integrity. This is universally applicable.  What they are doing betrays the trust of society and breaches the most basic ethical obligations of not only doctors but human beings.

But no one seems to be challenging them. Why is no one questioning this self-appointed authority. If people do not start talking, writing, discussing and debating the current paradigm then what Robert Dupont describes in the ASAM White Paper on Drug Testing will be ushered in.  As with doctors you won’t know it until it hits you.    If the ASAM becomes an ABMS medical specialty then it will be too late. They will impose their authority on you as a patient and their won’t be a damn thing you will be able to do about it.

Once illegitimate and irrational authority are sanctified by the American Board of Medical Specialties there will be nothing left to do except watch the profession of medicine go up in flames.

Right now it’s just doctors and pilots.   What you need to see is that you are next.  I base that prediction on past public-policy, regulatory, administrative and medical practice tinkering as well as the documented paper trail of “research” and opinion. And even though all of this can be explained using documentary evidence, fact and critical analysis no one seems alarmed.

If you map it out you will see the trajectory is aimed at the transportation industry,  students with federal loans,  high school athletes, schools, gun owners, and eventually schools.

If you have something to lose that is affiliated with a state or federal agency they will hold it hostage if you get a positive hair, nail, sweat blood, or urine test at your doctors visit.    The positive test is the golden ticket for them and a ticket to an assessment facility in Kansas, Arkansas, Mississippi and some other places for you on your dime.    And these are one-way tickets. No return to normality available.  One way ticket.    No return flight.

See full article through the following link:

http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(14)00126-6/fulltext

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Proponents of the brain disease model of addiction (BDMA) have been very influential in setting the funding priorities of NIDA, and by extension the bulk of publicly supported research on addiction. In 1998, Leshner testified that NIDA supports more than 85% of the world’s research on drug abuse and addiction.3 The American Society of Addiction Medicine has defined addiction as a “primary, chronic disease of brain reward, motivation, memory, and related circuitry”.4 In July, 2014, newly appointed Acting Director of US National Drug Control Policy, Michael Botticelli, launched a reformist strategy nationally, claiming decades of research have demonstrated that addiction is a brain disorder—one that can be prevented and treated.5 The BDMA has also been widely discussed in leading scientific research journals3, 6 and most recently in a positive editorial in Nature.7

In the USA, proponents of the BDMA have argued that it will help to deliver more effective medical treatments for addiction with the cost covered by health insurance, making treatment more accessible for people with addictions.1, 2, 6 An increased acceptance of the BDMA is also predicted to reduce the stigma associated with drug addiction by replacing the commonly held notion that people with drug addiction are weak or bad with a more scientific viewpoint that depicts them as having a brain disease that needs medical treatment.

In this Personal View, we critically assess the scientific evidence for the BDMA reported in leading general scientific journals and the extent of the social benefits that advocates of the BDMA claim it has produced, or is likely to produce, with its widespread acceptance among clinicians, policy makers, and the public. The BDMA is not co-extensive with neuroscience-based explanations of addiction. This review is not intended as a critique of all neuroscience research on addiction. We focus instead on the popular simplification of work in this specialty that has had a major influence on popular discourse on addiction in scientific journals and mainstream media.


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Considerable scientific value exists in the research into the neurobiology and genetics of addiction, but this research does not justify the simplified BDMA that dominates discourse about addiction in the USA and, increasingly, elsewhere. Editors of Nature were mistaken in their assumption that the BDMA represents the consensus view in the addictions specialty,7 as shown by a letter signed by 94 addiction researchers and clinicians (including one of the authors of this Personal View).74Understanding of addiction, and the policies adopted to treat and prevent problem drug use, should give biology its due, but no more than it is due. Chronic drug use can affect brain systems in ways that might make cessation more difficult for some people. Economic, epidemiological, and social scientific evidence shows that the neurobiology of addiction should not be the over-riding factor when formulating policies toward drug use and addiction.

The BDMA has not helped to deliver the effective treatments for addiction that were originally promised by Leshner and its effect on public health policies toward drug addiction has been modest. Arguably, the advocacy of the BDMA led to overinvestment by US research agencies in biological interventions to cure addiction that will have little effect on drug addiction as a public health issue. Increased access to more effective treatment for addiction is a worthy aim that we support but this aim should not be pursued at the expense of simple, cost effective, and efficient population-based policies to discourage the whole population from smoking tobacco and drinking heavily. Nor should the pursuit of high technology cures distract from the task of increasing access to available psychosocial and drug treatments for addiction, which most people with addictive disorder are still unable to access.

Our rejection of the BDMA is not intended as a defence of the moral model of addiction.65 We share many of the aspirations of those who advocate the BDMA, especially the delivery of more effective treatment and less punitive responses to people with addiction issues. Addiction is a complex biological, psychological, and social disorder that needs to be addressed by various clinical and public health approaches.65 Research into the neuroscience of addiction has provided insights into the neurobiology of decision-making, motivation, and behavioural control in addiction. Chronic use of addictive drugs can impair cognitive and motivational processes and might partly explain why some people are more susceptible than others to developing an addiction. The challenge for all addiction researchers—including neurobiologists—is to integrate emerging insights from neuroscience research with those from economics, epidemiology, sociology, psychology, and political science to decrease the harms caused by drug misuse and all forms of addiction.46

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The Aging Physician—Goodbye Dr. Welby!

IMG_8901The methodology is not new–witches are real, witches are dangerous and witches need to be identified and exterminated at all costs. Convince the authorities to assist you in protecting the public from harm and advance the greater good

In this manner the Federation of State Physician Health Programs (FSPHP)  has convinced the Federation of State Medical Boards state medical boards (FSMB)  to adopt and enforce policies that have incrementally and systematically increased their own  autonomy, scope and power.   This began in 1995 when the FSPHP first cultivated a relationship with the FSMB and subsequently took an uninvited seat at the table of power by offering a non-disciplinary “safe harbor” as an alternative to discipline for doctors impaired by drugs or alcohol.IMG_8900

Since then they have increased their scope from the “impaired” to the “disruptive” to everything else. Arising from the “impaired physicians movement” as “addiction specialists” these doctors whose specialty of addiction is not even recognized by the American Board of Medical Specialties have now become the “experts” in all matters related to physician health. Jacks of all trades covering neurology, psychiatry, geriatrics, and occupational medicine.

A 2011 updated FSMB Policy on Physician Impairment states that Medical Boards should recognize the state Physician Heath Program (PHP) as their experts in all matters relating to licensed professionals with “potentially impairing illness,” and these include those potentially impairing maladies that increase as we age.  This has gone too far.  Isn’t it time we take back the profession of medicine from illegitimate and irrational authority?Slide15

Disrupted Physician

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As a specialist in geriatric medicine I have experience in taking care of a number of  doctors who were referred to me for suspected memory problems. Still operating and teaching residents in his 70s, my first was a well-respected surgeon, a pioneer or Maverick who had made advances in his particular subspecialty.  Known for his detailed knowledge of the history of medicine and sharp clinical acumen, he had not seemed himself for a while.  His colleagues noted he appeared slower,  fatigued and forgetful at times (not remembering his keys, having trouble finding the right word).  An internist friend and co-worker who knew him for 50 years curb-sided me and asked if I would see him.  He did not have a primary care physician or even seen a doctor professionally for decades (a common phenomenon in this age cohort of doctors).

I met him the next week and he readily admitted to having difficulty concentrating and having trouble with his short term…

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How False Constructs Come to Be Regarded As Irrefutable Truth: The Malleus Maleficarum, Demonologists and Witch-Prickers–Let’s See if She Floats!

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“The belief that there are such things as witches is so essential a part of the faith that obstinately to maintain the opposite opinion manifestly savors of heresy.”  

So begins Malleus Maleficarum , a witch hunters manual published in 1486 that  launched a new paradigm for all those concerned with the identification and extirpation of witches.  Used as a judicial case-book the Malleus set forth definitions of witchcraft, rules of evidence, and the canonical procedures by which suspected witches were tortured and put to death.   Written by Inquisitors for Inquisitors, the Malleus construct came to be regarded as irrefutable truth and contributed to the identification and execution of as many as 60,000 “witches”, predominantly women.  The 29th and last edition was published in 1669.

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Although there was a general belief in witches at the time the Malleus was published they were not regarded as evil or life threatening.  Society did not fear them and Church and Political authority  certainly did not feel the need to hunt them down.   There were many scholars who publicly doubted the existence of witches at the time.  That would soon change.

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After being snubbed by secular and ecclesiastical authorities in his witch-hunting pursuits, the  Dominican friar and German Inquisitor Heinrich Kramer told Pope Innocent VIII of a  dangerous outbreak of witches that had occurred in the region.    This diabolical conspiracy hell-bent on destroying humanity needed to be identified and destroyed for the public good, but church authorities were not cooperating.

On December 5th, 1484 Pope Innocent VIII issued the papal bull Summis Desiderantes affectibus giving full authority to proceed with “correcting, imprisoning, punishing, and chastising” such persons “according to their deserts,”  and threatening to sanction or excommunicate those who hindered the pursuit.

images-18From the late 15th century through the early 17th century a confederacy of “authorities” calling themselves demonologists assisted in identifying witches. Shaping ecclesiastical orthodoxy they set the standards that cooperating political authorities could follow in criminalizing, persecuting and punishing heretics.

Behavioral manifestations  included living alone, cultivating strange herb and saying hello to a neighbors cat.Witches were blamed for everything—plague, crop failure, and erectile dysfunction.

Using the nebulous “witch label” anyone with a grudge or suspicion could accuse anyone of witchcraft .

Propaganda, threats, misinformation, guilt assumed from the start.

male31Physician oversight of witch persecution was standard.

During the European witch-hunts the  legal notion of crimen exceptum (an exceptional and most dangerous crime] allowed for the suspension of normal rules of evidence to punish the guilty.

Because of the nature of the enemy the evidentiary bar was lowered and any witness, no matter what his credentials, could testify against the accused.

Belief in the seriousness of the situation rationalized cruelty.

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The Devil’s mark (Stigmata diaboli) was taken as the mark of a witch entailing close inspection.

Professional witch-prickers used  needles, pins and bodkins to poke the skin with lack of bleeding confirming the accusation.   The accused did not bleed due to retractable needles and sleight of hand.   False accusations, if exposed, were excused if they were a result of “zeal for the faith.”

The consequences of being branded a heretic  by questioning the existence of witches essentially silenced any dissenting voices and the notion of crimen exceptum freed the consciences of those involved.

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Sanctimony, feigned piety and  hypocritical devoutness was used as justification.  After all–Torture and torment are a small price to pay when it comes to protecting the public and saving souls.

Through the witch trials clerics, doctors, and lawyers used their expertise as witnesses to increase their prestige.  Witch hunts developed into a means of economic profit.  Some gained a lot of money from the witch trials.  The witch or her relatives paid for the salaries of those who worked the witch trials including judges, court officials, torturers, physicians, clergymen, scribes, guards, attendants. Even the people who made the stakes and scaffolds for executions gained from the conviction and death of each witch.

matthew“Witch hunting,” wrote the historian Rossell Hope Robbins, “was self-sustaining and became a major trade, employing many people, all battening on the savings of the victims.”

The costs of a witch trial were usually paid for by the estate of the accused or their family.

Far from the conventional image of a penniless hag, a significant proportion of accused witches, especially in Germany, were wealthy and male.

Their property was seized to pay the clergymen, judges, physicians, torturers, guards, scribes, and laborers who raked in increasingly large sums of money as well as other reliable assets.

With a single member accused, a moderately wealthy family could be ruined permanently.

In 1592 Father Cornelius Loos wrote:

Wretched creatures are compelled by the severity of the torture to confess things they have never done and so by cruel butchery innocent lives are taken; and by new alchemy, gold and silver are coined from human blood.

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 Context, characters and circumstances may differ but the mechanics do not.

The mosaic remains the same.

The Malleus shows how false constructs come to be regarded as irrefutable and the creation and chains of causation are timeless.

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A paranoid is someone who knows a little of what’s going on.

“A paranoid is someone who knows a little of what’s going on”
–William S. Burroughs
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In his 1969 novel The Wild Boys, William S. Burroughs writes “Under pretext of drug control suppressive police states have been set up throughout the Western world…. The police states maintain a democratic façade from behind which they denounce as criminals, perverts and drug addicts anyone who opposes the control machine.”

15 years earlier Dr. Ruth Fox formed the New York City Medical Society on Alcoholism. This organization subsequently became the American Medical Society on Alcoholism and eventually the American Society of Addiction Medicine (ASAM). The organizational goal of this group has always been to convince the medical establishment of the chronic relapsing brain disease model of alcoholism (and subsequently all addictions) and that 12-step spiritual recovery as defined by Bill Wilson and the Big Book as not only a valid medical treatment, but the one and only treatment.

The American Medical Association had previously reviewed the Big Book in 1939 aptly finding it “a curious combination of organizing propaganda and religious exhortation” that “contains instructions as to how to intrigue the alcoholic addict into acceptance of divine guidance in place of alcohol.” The reviewer concludes that other that the “recognition of the seriousness of addiction to alcohol” the “book has no scientific merit of interest.”

Unable to successfully convince doctors of their ideology by swaying them intellectually due to an absence of any solid scientific methodology or genuine evidence-base, they decided on a more effective tactic.   By gaining political power, promoting themselves with propaganda, spreading misinformation, and suppressing truths that don’t fit in their world view, they created a faux “medical specialty” requiring not knowledge or competence just authoritative dogma and allegiance.

They have convinced medical societies, medical boards, regulatory agencies, parole boards and others to not only accept them as experts, but to write legislation in states to declare them “the” experts in addiction medicine. They did this with a torrent of strategic lobbying efforts on behalf of the 12-step addiction treatment industry towards the AMA (and indirectly through the FSPHP towards the AMA), ABMS, APA, FSMB, ABIM, JCAO, CSAT, consumer groups, presidential candidates, state medical societies, congress, corrections agencies, social service agencies, faith-based community centers, the media and many other targets.

By proclaiming themselves “experts” and  bestowing phony “Board Certification” not recognized by the American Board of Medical Specialties, (ABMS) they have created the myth of expertise at the expense of real experts. And in doing so they have effectively lobotomized evidence-based thought and critical thinking.

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This group has essentially created a despotism in addiction medicine treatment. A no choice one-size-fits-all take-it-or-leave-it pretend panacea of what’s good for the goose is good for the gander.   They have additionally created a tyranny in regulatory medicine.   Unsupervised and opaque, they have gained stranglehold control over individual doctors and gained sway over the culture and practice of organized medicine.

They have influenced the DSM-V, are trying to gain control of MRO education and regulation, and pose a great danger to us all.  This front-group for AA and the 12-step drug testing industry is fulfilling Burrough’s prediction of a police state. As medical Robber Barons by imposition of force in numbers and money they have assumed unqualified authoritarian control and influence that is posed to create irremediable harm to both society and individual freedoms and liberty.

Alarmist call to arms about the dangers of drugs and hidden addicts protected by others and posing danger to create untrue hype is propaganda and misinformation to further the ASAM drug-testing 12-step inpatient rehab agenda and gain control.

Drug war sloganeering designed to get everyone aboard. Logical fallacy, deceptive facts, pseudoscience, and misinformation is obvious if anyone cares to look a little deeper. The conflicts-of-interest are immense. The ASAM is a front group for AA that uses ends-justifies-the-means coercion and deception to get public recognition of the righteousness of the twelve steps of recovery.

Neither doctors nor US citizens should be subject to the whims of a religion based political group composed of unqualified, inexperienced, paternalistic and biased individuals who are truncheons of dogmatic ideology and refuse to accept evidence based treatment, transparency, and accountability as important. These are self-proclaimed specialists–great pretenders. Fake it til u make it.

The problem is that regulatory agencies, politicians, medical boards, law enforcement and others have either bought into the lie or live in willful ignorance.   Blinkered, ambivalent or unconcerned, most people, including those in health-care, take them at face value resulting in the misperception that they are the experts.

Indeed, they are well on the way to becoming the only experts.  Within the next couple of years this will become a reality. The ASAM will eventually gain ABMS specialty certification and when this comes to fruition they will undeniably be the only recognized experts  in the field of Addiction Medicine.

The Addiction Psychiatry subspecialty (the only specialty currently recognized by the ABMS) has already been pushed into a corner and will most likely have to join in rather than fade away–similar to what happened to proctology as gastroenterology evolved as a specialty. That analogy doesn’t quite work however as gastroenterology swallowing proctology represents an advancement in science based on valid methodology and evidence base.  It represents evolution in medicine not monopolization in sales.

This situation is more like anti-vacciners proclaiming themselves immunologists and gaining enough support to run the real ones out. Pseudoscience, groupthink, deception, and coercion. A framework not built on the scientific method, evidence based decision making, autonomy and benevolence; but based unproven ideological dogma, righteous inflexible worldview, rigid rules, obedience, and control.

Drug testing of  physicians and others will be done by ASAM, FSPHP physicians. They will demand prohibition, testing and treatment at their facilities. Complete control. Absolute power.  . Even with 100% specificity and sensitivity there are valid arguments against this. But if you throw in the corruption and other issues that are obvious if one peers inside this Potemkin ASAM village, both medicine and society as we know it is going to be emasculated  by dabblers and clowns.  It will come in a whimper not a bang,  and by then it will be too late.

They have already taken over Physician Health Programs  (PHPs) by removing competent and virtuous doctors who did not conform to A.A. groupthink and held them under threats of litigation with “gag orders” not to speak of the abuse and crimes they witnessed.  Claiming success with these programs they now want to move outward and onward as “Professionals Health Programs.”  Any one with any sort of license will be at risk.

PHP’s function to monitor and control. . Mandating coercive 12-step ideology onto physicians is standard operating procedure. The marked rise in physician suicide over the past decade is directly correlated with the FSPHP (an arm of ASAM)  taking over state impaired physician programs. A front-group for a front-group unrecognized in the sea of acronyms involved.

And the “kill em all let God sort em out” logical fallacy of saving doctors and protecting patients is propaganda with no evidence base.

This system, that encourages referring doctors confidentially for evaluation, is a nearly foolproof means to silence any physician they feel the need to. An accusation of substance abuse is made relatively easy. Then recommend an evaluation to one of your own people who will confirm the problem and force the victim into a 5 -year monitoring program with mandatory adherence to the 12-step road to salvation.

The FSPHP colludes with a list of around two dozen inpatient drug treatment centers such as Hazelden, Talbott, Marworth, and Bradford where  co-conspirators will engage in “confirmatory bias” and “confirmatory distortion” to make the assessment fit the diagnosis.  This provides a nearly perfect system to remove any physician from practice.

The ASAM claims an 80% success rate with the PHPs. If you look at the data on which this is based , however, it is as illusory as they are—-sheer sloganeering and propaganda with no substance or soul.

The ASAM and FSPHP are gaining power and expanding in scope. They have effectively muscled forth the “war on drugs’ agenda to further their goals by establishing a system of coercion, control, secrecy, and misinformation.  With doctors the first wave was substance abusers, they then added any psychiatric diagnoses, and are now after the “disruptive physician.”  The next target is the “aging physician” who will inevitably be diagnosed with “character defects.”    And by calling this the “New Paradigm” of addiction medicine they want to expand their scope to other professions.

This is a system that oppresses physicians and is about to enter the domain of others including students.  It will impact individual freedom, destroy the Bill of Rights, erode freedom of religion, stifle freedom of speech, and take us back decades..

By convincing others of their expertise they have strategically placed themselves in a position of power that includes the ability to remove any doctor from practice.

And unless something is done soon, every physician in the US will be at risk of losing everything at the whim of of a 12-step front group that places ideology above evidence base and dogma above virtue.

Claiming success they now want to bring it to you.

http://medicalwhistleblowernet…

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