A great deal of the research we cover here at AddictionNews concerns the efforts to trace the path of addiction, primarily through the brain’s reward system, and then to design agonists that intervene in that process, and therapies that repair the damage. However, this is a very individualistic and mechanistic way of looking at addiction and recovery, the theory being to devise an intervention that works for anyone.

But there is another element to addiction — a social component — that is left out of this equation. The factors that drive addiction include pain, poverty, abuse, fear, anxiety, family dynamics, housing stability, poor diet, unsafe working conditions, and unsafe living conditions, to name some of the factors cited in a new report in The Lancet: Psychiatry.

An international group of psychologists from Italy, Netherlands, Switzerland, and the U.K. submitted the piece, “Reevaluating the Brain Disease Model of Addiction,” in the “personal view” section of the respected journal. In the expensive search for drugs and procedures “that often result in a small advantage for a limited subgroup of patients,” the researchers challenge funders to address the social barriers that lead to addiction:

[…] [T]he real challenge lies in confronting and dismantling the systemic barriers that prevent us from effectively leveraging existing knowledge to address patients’ living situations, including material conditions, families, social networks, and all other factors that give meaning to people’s lives.

“The empirical evidence for addiction as brain disease is weak,” write the researchers (their emphasis). The researchers go on to recite a litany of failures for research into substance use disorders (SUDs):

• No prognostic biomarkers for addiction have been found
• No significant improvements in medical treatments have been found
• Labeling addiction as a brain disease has not reduced the stigma of addiction
• The brain disease model causes people to believe they can’t get better

Ouch! That’s some harsh criticism for research that brought us lifesaving naloxone and buprenorphine, that mapped the dopamine cycle, and discovered psychiatric medications. 

The authors cite myriad studies that argue addiction is not a brain disease but a brain disorder. They reject the “hijacked reward system” metaphor so common in scientific research. They point to contingency management as evidence that the permanently-damaged reward system is a myth:

[D]rug use in people with SUDs was shown to be highly responsive to environmental factors, as for example demonstrated by the effectiveness of contingency management interventions.

Contingency management is basically paying people to stay in treatment and meet thresholds of sobriety, such as clean urine and blood tests. Enough compensation is provided to sustain housing and medical care. Using a community reinforcement program to address substance use disorders also helps strengthen recovery outcomes, disproving the brain damage theory of addiction.

The researchers do not deny that addiction is difficult to treat, but they point out that “there is also growing evidence that many people with SUDs recover spontaneously without medical intervention and many of those who achieve recovery do not experience relapse.” 

That is the same conclusion reached by renowned European addiction researcher, Reinout W. Wiers, in his book, A New Approach to Addiction and Choice: Akrasia and the Nature of Free Will. The majority of people with a serious addiction will eventually recover without treatment. Thus, addiction is not a chronic brain disease but a difficult-to-treat disorder that people can and do recover from.

The authors point out repeatedly that parental divorce is a bigger marker for SUDs than genetics. However, studying the impacts of changing any one of the social components of addiction in isolation is not realistic:

These social and environmental factors include poverty, unemployment, job insecurity, housing instability, discrimination, low educational attainment, and poor access to health care, among others.

Programs such as community reinforcement and contingency management prove that if we address all these issues together, at the same time, we get the best possible outcomes.

Written by Steve O’Keefe. First published May 12, 2025.

Sources:

“Reevaluating the Brain Disease Model of Addiction,” The Lancet: Psychiatry, March 25, 2025.

“Disease Model of Addiction Lacks Empirical Support, New Study Finds,” Mad In America, May 7, 2025.

Image courtesy of Pixabay, used under Creative Commons licence.