Why the “Disease Model” Fails to Convince Americans That Addiction Is a Health Issue

Mar 14 2016

Why the “Disease Model” Fails to Convince Americans That Addiction Is a Health Issue

These days, everyone from Obama’s “drug czar” Michael Botticelli to former Republican presidential candidate Chris Christie strenuously emphasizes that addiction is a disease, not a sin.

Such proclamations have been earnestly made for over two centuries now, starting with physician and Declaration of Independence signer Benjamin Rush in the early 1800s. Indeed, the American Medical Association declared alcoholism a disease in 1956 and did the same for other drug addictions in 1989.

But these declarations have a hollow ring to them: They wouldn’t need to be remade constantly if the idea were truly accepted. No one goes around issuing statements about how “cancer is a disease” or “AIDS is a disease” or even “schizophrenia is a disease,” because it’s pretty obvious that they are.

From my perspective, addiction is clearly a health and medical problem—no different from depression or attention deficit/ hyperactivity disorder (ADHD), both of which are influenced by biological, social, cultural and developmental factors. However, in America, the D-word in the context of addiction has come to mean something much different from the word “disease” used for any other condition—something that unfortunately is more moral than medical.

So why don’t Americans really buy the idea that addiction is no different from “diseases” (if we choose to use that word) like depression?

I think there are two fundamental problems that undermine the way arguments about treating addiction as a health issue are made: The first involves the criminalization of drug possession; the second, the 12-step model of treatment.

Neither of these issues actually has anything to do with whether or not addiction is a medical condition—but both deeply undermine the case for medicalization. Indeed, I think that disease model supporters have often, inadvertently, been their own worst enemies.

Lack of acceptance of the disease model can be seen everywhere—from the “let them die” (and worse) comments on articles about people with addiction, to the War on Drugs, to the segregation of addiction treatment from mainstream healthcare. Although there isn’t much polling on the question, the research that has been done suggests that despite all the proclamations, many, if not most, people still don’t see addiction as genuinely medical.

A 2006 study, for instance, which looked at alcoholism, found that 65 percent of 630 people polled in a general population sample said that the condition was due to “bad character.” Only 47 percent saw it as a problem of brain chemistry and/or genetics. (People were allowed to endorse more than one cause).

And research published in 2014 found strong moral stigma associated with addiction: 90 percent of respondents, for example, would not want someone with addiction to marry into their family, and 78 percent did not want to work alongside addicted people. Those rates are far higher than those who would similarly reject people with mental illness.

So what’s behind the ongoing prejudice? Let’s return to those two main factors that I believe are responsible.

The first is criminalization. There is no other illness that can get you arrested simply for displaying symptoms; but it is impossible to be addicted to illegal drugs without breaking the law. This matters here because one of the key purposes of criminalization is to create moral stigma: The idea is that this behavior is so bad, we will put you in prison with murderers, rapists and others whose actions are terrible enough that society must isolate and cage them to protect itself and punish the evildoers.

As a result, criminalization itself undermines the disease model. We don’t treat anyone else who has a “disease” with punitive incarceration simply for being affected. While our jails have unfortunately become warehouses for people with mental illness, if you have psychiatric problems and are not at risk of harming anyone or violating other laws (and this is the case for the majority of us who have such diagnoses), the police do not have cause to arrest you. If you are addicted to drugs, however, you must possess them in order to take them.

Also, when the public portrayal of addiction is almost always in the context of crime, it’s hard to take medical claims seriously. Images of arrests, handcuffs, prisons, jail cells, courts and police officers standing in front of large quantities of drugs undermine medicalization by promoting the idea that drug use is itself criminal and that therefore, drug users are sinful by nature. In addition, criminalization in and of itself creates greater connections between people with addictions and illegal or immoral behavior: The high prices caused by prohibition, the marginalization of people with criminal records, and the fact that it is necessary to hide illegal activity all combine to make it difficult for even the most ethical people who are addicted to avoid deception and criminality.

What’s more, there is no other disease for which a judge can dictate which medications are allowed or banned: If you have cancer, the standard of care entitles you to the therapy that is linked with the greatest survival rate, even if you are in prison (whether you actually get it or not, of course, is another question). But if you have addiction, the only treatment known to reduce mortality by 70% or more—maintenance with methadone or buprenorphine—can be denied to you either by a drug court judge, or by a jail or prison.

Further, in no other condition do we see allowing patients to suffer the worst possible symptoms—AKA “hitting bottom”—as appropriate, let alone effective care. And in no other disorder is denying access to symptom-relief seen as acceptable medicine.

With addiction, however, jails, prisons and even hospitals routinely deny access to medical care that could relieve suffering because of the misguided idea that suffering itself will help solve the problem. Some programs even deliberately inflict emotional pain and humiliation.

This brings us to the second main reason Americans resist the current disease model: the ubiquitous influence of 12-step programs.

From the 1980s to the 2000s, 90 percent of US addiction treatment was based on getting patients to buy the ideas of 12-step programs and become members; now that is apparently down to 80 percent, but the approach is still overwhelmingly dominant. Indeed, the position is so entrenched in the addiction treatment establishment that the American Society of Addiction Medicine actually defines addiction as a disease with “characteristic bio-psycho-socio-spiritual manifestations.”

The “spiritual” part is something no other medical specialty feels compelled to mention in its official documents.

While 12-step programs claim to be “spiritual, not religious,” they aren’t like any other mainstream medical or psychological treatment. Do oncologists ask cancer patients to find a Higher Power? Do psychiatrists suggest that people with depression must to take “a searching and fearless moral inventory”? Do any other patients routinely get told by the medical professionals that their problem involves “defects of character”

While this language—taken directly from 12-step programs—remains a fundamental part of treatment, why would anyone believe it is a medical issue, rather than a problem only bad people have?

Indeed, if you sought any other type of medical care and were informed that the best treatment is meeting others with your condition, praying, confession and restitution, you’d likely rapidly conclude that you were seeing a quack—or at the very least, had wandered outside of mainstream medicine.

In addictions, however, this profoundly moralizing treatment is mainstream. And that leaves many disease model folks arguing out of both sides of their mouths.

“It’s a disease like any other,” they insist—while touting a treatment that would be considered faith-healing in general medicine and psychiatry, one that also implies moral failure. As a result, it’s no surprise that the public, seeing the prominence of the 12-step approach, thinks the word “disease” belongs in scare quotes for addiction, and hides a wink and a nod because the “treatment” is really either incarceration or God.

None of this is to say that some people don’t find the Steps helpful—it’s just that they really aren’t an argument for the disease model.

Read more from The Influence:

The Anatomy of a Heroin Relapse

How Placebos Prove That People Conquer Addiction With Their Minds

Do We Overstate the Role Trauma Plays in Addiction?

If addiction is a disease, the treatment should be evidence-based and led by doctors, not patients—sure, there are spiritual support groups for people with cancer and depression, but these do not replace chemotherapy or appropriate use of antidepressants. If I get brain surgery, I am not entitled, 90-days-to-one-year later, with no education beyond my own experience, to perform it on someone else.

If we really want people to see addiction as the health problem that it is, we can’t have treatment in which most—or really any—of the content is aimed at getting people to uncritically accept the Steps. And we also can’t criminalize drug possession and allow the courts to dictate what medical care is acceptable, in ways that they aren’t allowed to do for any other disorder.

Both the dominance of 12-step-based rehabs and counseling and the integration of the current treatment system with the criminal justice system undermine claims that addiction is a disease.

You can’t simultaneously criminalize addiction and destigmatize it. Nor can you call it medical at the same time as you treat it like a moral issue—at least if you want to convince anyone that you actually believe what you say. To move forward, we need to separate self-help and social support from medical care. We need to get punishment and prayer out of treatment.

Then we can create a health model of addiction that genuinely informs effective treatment and policy, rather than undermining them.

Maia Szalavitz is a columnist for The Influence. She has written for TimeThe New York TimesScientific American Mind, the Washington Post and many other publications. She has also authored six books, including Help at Any Cost: How the Troubled-Teen Industry Cons Parents and Hurts Kids (Riverhead, 2006). Her latest book is Unbroken Brain: a Revolutionary New Way of Understanding Addiction. Her last column for The Influence was “The Rehab Industry Needs to Clean Up Its Act. Here’s How.” You can follow her on Twitter: @maiasz

  • Also NIDA pumps out disease theory propaganda to impressionable school kids. I remember my own teacher chuckling when he said, “It’s a disease characterized by denial.” And I thought it was funny too, though I didn’t make anything of it at the time.

    • Learning64

      How sad for you and the other kids. It is not a laughing matter, and you should not have been influenced by this man’s ignorance.

  • Addiction isn’t the only medical condition treated this way – pain is too.

    Pain is treated as irrationally as addiction: medicines are restricted by government agencies and politics, questionable treatments are recommended (acupuncture, chiropractic, psychotherapy), and suffering is considered appropriate (they now say that decreasing pain intensity shouldn’t be the goal of care).

    • April Smith

      I was just thinking that ! People are punished for having pain. Especially women and people of color.

    • Gina

      Probably because pain patients are often seen as, or assumed to be, addicts—or well-intentioned doctors want to prevent them from become one?

      • TrishRan

        Also contributing to this: people caught for crimes who go to court and say, “It all started when I got Percocet after a car accident…”

  • Kenneth Anderson

    How many American’s would want to de-stigmatize church going by calling religion a disease? One does not de-stigmatize a behavior such as drug use by calling it a disease. Homosexuality was de-stigmatized by recognizing it as a human rights issue. Drug use will only be de-stigmatized when we acknowledge the people have a right to use drugs. Drug use is neither a sin nor a disease–it is a right. As with all rights it carries the responsibility to not harm others.

    • Chris Baldwin

      So I have a right to be addicted to alcohol????

      • Gina

        You have the right to drink alcohol—without punishment. If you happen to develop an addiction to it, you have the right to get help for it—-again, without punishment. Kenneth is saying the same should be true when it comes to the use of other drugs. Why should drug use in and of itself be a criminal act?

    • Gina

      Good point, Ken. I think that’s what Maia’s saying when she’s advocating for the decriminalization of all drug use.

      • TrishRan

        Really? They why didn’t she say that?

  • Lucy Rizzetta Lantz

    Oh, how this article makes my hair stand on end. I, like many others have had and still have addicts as family members. A disease? really, a disease, like alcohol that is chosen. The cancer patient, the diabetic did not choose to have their disease. I am assuming is drug addition is a disease that the same would apply to pedophiles, after all no one in their right mind would harm a child.
    To say that the addict technically doesn’t commit a crime when he robs the bank because of his sickness, what if the cancer patient robbed the same store to buy his/her meds? Better yet what if the cancer patient had Narcan to bring them back to life!!!!
    Sorry no sympathy here, been there done that lived as a member of an addicts family. Your choice, then pay the consequences don’t blame society and don’t say its a disease. This of course is my opinion and in the USA I am entitled to my own opinion and you are allowed to disagree.

    • Terrie Best

      He robs a bank because he needs his drug. That is a problem of prohibition not a moral failing. When drugs are illegal it causes problems. You can trace the harms of most drugs back to prohibition. My opinion.

      • Support the first amendment

        Drugs are illegal because many times being under the influence of certain drugs people commit crimes and have criminal behavior and to help keep the drugs away from children

        • Gina

          Most people who use drugs (or drink alcohol) do not commit crimes and use them without issue. Interestingly, the drug that causes the most people to commit crimes, like vehicular manslaughter, and violent ones, like assault and battery (and even murder), is alcohol, which is legal (but not sold to children).

          • TrishRan

            If drug use made people into antisocial maniacs, why do so many workplaces go tot he trouble & expense of drug testing their employees? You’d think that they could follow the path of destruction to the cubicle of the person who has created such a mess of his/her life.

      • TrishRan

        Really? Do you think he has a budget spreadsheet where he assigns money from a minimum wage job to pay for rent, food and clothes and a line item for proceeds of crime to pay for drugs?

        No, criminals pay for whatever they need or want with proceeds of crimes – whatever they need or want might include drugs, but is not limited to drugs.

        I have known many people in my life who pay for, say, a bag of weed, they way they’d pay for, say movie tickets and popcorn. If they have cash left after paying their bills, they might buy weed, they might go to the movies. But if they’re broke, they don’t indulge in smoke or the latest blockbuster.

    • April Smith

      The shame and blame approach just doesn’t work to get people well. It’s been tried. I’m sorry that you’ve been hurt but your emotions don’t make for rational or effective public policy. Addiction is hell – nobody chooses it. Would you deny treatment to diabetics who are too much? Obesity is the main risk factor. Or lung cancer patients who smoked?

      • Support the first amendment

        If this is true why is it that many addicts won’t go to treatment instead they are continually using drugs – why will they not go to treatment?

        • April Smith

          Because treatment is usually punitive, stigmatizing, humiliating and ineffective. Would you subject yourself to invasive body cavity searches, being cut off from the rest of the world, traumatic invasions of your emotional privacy, all for the hope of a pathetic success rate? Until treatment is humane and effective most will hope to go it alone. I will write more and post a link. Thank you for your question.

          • TrishRan

            Not to mention that the only reading matter permitted in these places is 12 step hogwash.

      • TrishRan

        I think Lucy has the right to be angry at people in her family who commit crimes and to be angry when criminal activities are blamed on the supposed disease of addiction.

        I would say that conflating the use of drugs with the crimes is the problem. Crime is crime, drinking/drug use for non-medical reasons is another. Some criminals even avoid drugs during their crimes to keep their minds sharp so they won’t get caught.

        Look at it this way – cigarets are often reported to be harder to quit than heroin. Yet nobody goes to court and claims that they robbed a bank or kited checks or committed identity theft or assaulted an ex lover because of their terrible addiction to nicotine. By conflating drug use and crime, the issue is completely muddied (but it’s great for certain careers – politicians who vote for increasingly harsh punishments for drug possession or making it harder to get opiate pain meds, cops can chase after nonviolent marijuana users and inflate their stats for arrests and convictions, “treatment” centers can make bank by renting rooms to adults for $35K a month and having a place where these people are made to sit and listen to 12 step sales pitches all month)

        Here’s an example of how conflating drug use with crime is bogus: A few years ago a couple started hanging out with an older, single woman, and eventually moved into her home and mooched off her to pay for their vehicles, insurance, groceries, etc. When they were caught for some crime they’d committed, the newspapers said the couple “used this woman to pay for their drugs”. Not exactly – they used her for *all* their monetary needs – rent, food, clothing, gas, car insurance, as well as recreational drugs, which were a small portion of the spending they did of this woman’s money.

    • Support the first amendment

      I think drug addiction is a little of both of these things once a person gets addicted it does become a medical problem but I have lived with addicts in my family also and I understand what you are saying – it seems as if there is some amount of personal choice when a person continually chooses to use addiction, unhealthy substances

    • Gina

      The point of the article was not to absolve anyone, including people with addictions, of responsibility for harm they may cause others. Both the cancer patient and the addiction patient who rob a store to buy his/her meds should be punished appropriately. To the extent anyone causes harm to another or commits a crime—regardless of whether they’re under the influence or not—they are responsible for their actions. And we have laws in place to address that. The point is that neither drug or alcohol use (so long as the user is not harming anyone else) nor an addiction to either should be a crime. By the way, nearly all chronic diseases include a behavioral component. Type 2 diabetics most certainly “cause” their disease to develop through lifestyle choices over time (poor diet, lack of exercise, excessive weight, smoking, etc.) which combine with genetic and environmental factors to create the disease. Same is true of hypertension, heart disease and even, to some extent, many cancers. And, yes, the same is true of addictions. In nearly all these cases, the conditions can often be reversed by lifestyle changes alone, including addictions, though in many cases, people are unwilling or unable to make sufficient changes to improve their health outcomes. If I were you, in order to avoid being a complete hypocrite, I would make sure you have no sympathy for any type 2 diabetic who fails to make sufficient lifestyle changes to reverse his or her condition (like my friend) or the lung cancer patient who fails to stop smoking (like my sister-in-law). Or the bypass patient who refuses to stop eating fatty foods (like another friend). Because aren’t we all paying for the poor choices of others on some level?

  • April Smith

    Best article ever. I am sending to everyone I’ve ever met.

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  • Dougie

    “The “spiritual” part is something no other medical specialty feels compelled to mention in its official documents.”
    Not entirely true, apart from a lot of Psychologists dealing with depression considering the spiritual aspect, many recognised and respected cancer treatments such as those at The Mayo Clinic include a spiritual component.

    • TrishRan

      Yeah, and a lot of medical facilities where people go for cancer treatment (chemo, radiation and so forth) also have “alternative” medicine on premises. That doesn’t make homeopathy, reiki, flower remedies, etc., into part of medicine.

  • Dougie

    Oh, and it is spiritual, not religious, try not to mix them up 🙂

    • TrishRan

      AA created the “spiritual not religious” false distinction in the 1930s because the Catholic church was not happy with Catholics getting religion from people like Bill Wilson.

  • Lenny Singleton

    Addiction is a health issue and not a criminal issue. Science has now proven that addiction is a disease of the brain where the brain actually becomes “high-jacked” by the drug. In the 80’s and 90’s with the epidemic of crack cocaine within the African American communities, mass incarceration and harsher sentencing was the name of the game. Now, as the heroin epidemic takes precedence in white society, the name of the game has changed to finding more help for these people and lighter sentencing. There are many casualties in the war on drugs and the mass incarceration craze. Let me give you just one example that illustrates how we are all paying for it…Lenny Singleton (shown in the profile pic).

    committed 8 “grab & dash” robberies in a 7 day period while high on
    alcohol and crack to fund his crack addiction. He did not have a gun. He did not murder anyone.
    In fact, he didn’t even physically injure anyone and not one person
    filed as a “victim.” He stole a total
    of less than $550 and these were his first felonies. He earned a
    college degree and served in our Navy before he allowed his addiction to
    destroy his life. He needed some help with his addiction.

    he got was 2 Life Sentences plus 100 years with no chance of parole.
    The judge, without any explanation to Lenny or the courtroom as
    documented by his court transcripts, sentenced Lenny to more time than
    repeat violent offenders, rapists, child molesters, or murderers. There are murderers who will walk free in the state that Lenny is incarcerated in while he remains in prison.

    while incarcerated, works every business day in a position of
    authority, lives in the Honor’s Dorm, takes every available class for
    self-improvement offered, and in his spare time, has co-authored a book
    to help others called, “Love Conquers All,” available now on Amazon.
    It is a cautionary tale targeting the African American culture sharing his struggles with addiction. During the entire 20+ years he has been in prison so far he has not received a
    single infraction for anything – rare for lifers. Lenny is deserving of
    a second chance.

    How does this have an impact on you? American taxpayers will pay well
    over a million dollars to keep Lenny in prison for the rest of his life –
    for stealing less than than $550 in crimes where no one was physically
    injured? This makes absolute no sense. Justice will not have been served if Lenny dies in prison. Would we lock up someone with cancer? If it has been scientifically proven that addiction is a disease of the brain, why are we incarcerating people who obviously have committed crimes because of their addictions? Lenny has done a significant amount of time to pay for his crimes – over 20 years. It is time for people like Lenny to be released.

    Please learn more and sign Lenny’s petition at http://www.justice4lenny.org.

    • Marilee Odendahl

      Lenny – signed, donated & posted on my FB page. Peace to you.

      • Lenny Singleton

        Thank you Marilee – we genuinely appreciate it! God Bless!

  • Chris Whitelaw

    It doesn’t matter if the rest of society accepts alcoholism or drug addiction as a disease. All that matters is that the alcoholic/addict recognizes that their illness is a spiritual malady which can only be cured by taking a few simple solutions on how to live life, twenty-four hours a day, one day at a time.

    The Twelve Steps have changed and saved many lives. But it is not the responsibility of the AA/NA community to get people to understand what they have been through. As long as someone is focused on their current journey in maintaining their sobriety, that’s all that matters. One less alcoholic/addict on the streets makes the world a safer place to live for everyone else who doesn’t suffer from this terrible affliction.

    • April Smith

      So few people really need to maintain abstinence after an initial period. AA Mayes people convinced that they can’t control their drinking. You’re just passing on lies instead of teaching people how to live in the real world

    • ez

      spiritual malady? malarky.

  • Olmy Olm

    That might be why some people aren’t “convinced” by it. The reason others aren’t “convinced” by it is because it’s false. Like Lance M. Dodes, M.D.:

    “Addiction has long been deeply misunderstood in both our culture and
    clinical practice. Rather than being a reflection of impulsivity or
    self-destructiveness, or a result of genetic or physical factors,
    addiction can be shown to be a psychological mechanism that is a subset
    of psychological compulsions in general. Correspondingly, for many
    people addiction is best understood and treated in psychodynamic
    psychotherapy. Over the past thirty-five years progress has been made
    in understanding addictions from a psychological perspective, and in the
    past 15 years I’ve developed a new model of addiction that permits a
    comprehensive view of the nature of addictive behavior.”

  • abobinmn

    If addiction is a disease, it’s the only one I know that you go out and create yourself……and I’ve been to treatment. And I dare to to tell the dying cancer patient sitting next to you that your addiction is a disease. No, addiction is real but a disease I don’t think so.

    • Leona

      Can a cancer patient recover without the proper treatment? Probably not and addiction is a mental and physical disease, there is absolutely no doubt in my mind, my son was addicted and I know what they go through and how they just want to be normal again they need long-term treatment and unfortunately it’s not usally availability, if you think addiction is not a disease then you have never loved someone that is.

      • abobinmn

        I have been addicted and now I have cancer. I think people confuse the physical symptoms of addiction with a disease. Tell any cancer patient that your addiction is a disease and see how far you get.

  • AA is not treatment

    • TrishRan

      Correct – it is a religion. 6 steps mention God. 0 steps mention “I will quit drinking.”

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  • abobinmn

    I don’t buy the “disease” concept either and I’ve been badly addicted to opiates as the result of a severe chronic pain problem. Was it back in 1974 that the AMA against its better judgment declared addiction a disease? Whenever it was it sure paved the road for expensive treatment centers. Anyway, you just go sit down with someone dying from a horrible cancer or other painful terminal disease and tell them all about your addiction disease. See how far you get.

  • David Kerr

    I have been working with hardcore criminal addicts since 1965, founding the Integrity House drug treatment program in Newark, NJ in 1968. I have met with and listened to thousands of people with addiction and see addiction as both a disease and a learned behavior and lifestyle. To offer help to people with addiction is to identify and encourage their strengths.

    They will often need detox followed by long term residential treatment followed by years of coaching. After many months of treatment and years of coaching for 5 years, it is likely that the recovering person will begin to learn and practice an entirely new lifestyle and that’s the key to a durable recovery. An addiction lifestyle lasting 20 to 40 years won’t be changed by a few months of treatment and yet there are some who can stop on their own with the help of AA or NA. (People with addiction in their family genes will have a far more difficult time supporting a lasting recovery.)


    I can be reached at; dkerr.recoveryadvisorygroup@gmail.com

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  • penob

    Alcohol and drug use disorders are a complex mosaic of biopsychosocial factors that are unique to every individual. Reducing those factors to the highly-inaccurate notion that they constitute a disease is a convenient way to absolve the individual of true responsibility for their behavior. 12-step groups are riddled with impossible double-binds that keep people stuck in endless feedback loops directly caused by the disease model. Those of us who have been to thousands of meetings and “worked the program” while trying to suspend disbelief only to relapse yet again, know exactly what I’m talking about.

    It’s as if the “disease” is some kind of parasitic creature that lives inside us and dictates our thoughts and actions unless we adopt a quasi-Christian belief system that says we are powerless to do anything on our own. AA’s Big Book states matter-of-factly that we are doomed unless we turn our lives over to a higher power. That and the implicit requirement to perform a moral inventory of our “character defects” are enough to make any vulnerable person feel empty and worthless. Not exactly conducive to positive self-worth.

    AA and the other 12-step groups are fear-based and have been since Day 1. Insisting that we have no personal power and must place our will and lives in the hands of a higher power might benefit some who have always had an external locus of control, but for the majority of us, that approach is coercive, demeaning and ineffective. Telling a suffering person they need to have their ego deflated when their egos are already shattered is abusive and simply wrong. No wonder AA has such a dismal success rate.

    I’ve been there, folks. My first AA meeting was in 1981. I am fine with it working for some of us that buy into that belief system, but I grew out of it and now live the life that I’ve always wanted. And that was my personal choice. The “disease” was in my head all along. Those thoughts don’t rule my life any more, thank goodness.

    • Learning64

      Only 1 in 10 heavy drinkers are addicted. I’m glad you were not one.

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  • TrishRan

    Every thing a human body does is intertwined with brain activity. Trying to claim that “addiction” has causes or effects on the brain does not demonstrate that “addiction” is even a distinct collection of symptoms or behaviors.

    • Learning64

      Do you know how to read? I think you should try it!