Rachel R. Hammer

Addiction: Current Criticism of the Brain Disease Paradigm

To deepen understanding of efforts to consider addiction a “brain disease,” we review critical appraisals of the disease model in conjunction with responses from in-depth semistructured stakeholder interviews with (1) patients in treatment for addiction and (2) addiction scientists. Sixty-three patients (from five alcohol and/or nicotine treatment centers in the Midwest) and 20 addiction scientists (representing genetic, molecular, behavioral, and epidemiologic research) were asked to describe their understanding of addiction, including whether they considered addiction to be a disease. To examine the NIDA brain disease paradigm, our approach includes a review of current criticism from the literature, enhanced by the voices of key stakeholders. Many argue that framing addiction as a disease will enhance therapeutic outcomes and allay moral stigma. We conclude that it is not necessary, and may be harmful, to frame addiction as a disease.

The experience of addiction as told by the addicted: incorporating biological understandings into self-story.

How do the addicted view addiction against the framework of formal theories that attempt to explain the condition? In this empirical paper, we report on the lived experience of addiction based on 63 semi-structured, open-ended interviews with individuals in treatment for alcohol and nicotine abuse at five sites in Minnesota. Using qualitative analysis, we identified four themes that provide insights into understanding how people who are addicted view their addiction, with particular emphasis on the biological model. More than half of our sample articulated a biological understanding of addiction as a disease. Themes did not cluster by addictive substance used; however, biological understandings of addiction did cluster by treatment center. Biological understandings have the potential to become dominant narratives of addiction in the current era. Though the desire for a “unified theory” of addiction seems curiously seductive to scholars, it lacks utility. Conceptual “disarray” may actually reflect a more accurate representation of the illness as told by those who live with it. For practitioners in the field of addiction, we suggest the practice of narrative medicine with its ethic of negative capability as a useful approach for interpreting and relating to diverse experiences of disease and illness.

Students as Resurrectionists--A Multimodal Humanities Project in Anatomy Putting Ethics and Professionalism in Historical Context.

Because medical students have many different learning styles, the authors, medical students at Mayo Clinic, College of Medicine researched the history of anatomical specimen procurement, reviewing topic‐related film, academic literature, and novels, to write, direct, and perform a dramatization based on Robert Louis Stevensons The Body‐Snatcher. Into this performance, they incorporated dance, painting, instrumental and vocal performance, and creative writing. In preparation for the performance, each actor researched an aspect of the history of anatomy. These micro‐research projects were presented in a lecture before the play. Not intended to be a research study, this descriptive article discusses how student research and ethics discussions became a theatrical production. This addition to classroom and laboratory learning addresses the deep emotional response experienced by some students and provides an avenue to understand and express these feelings. This enhanced multimodal approach to“holistic learning” could be applied to any topic in the medical school curriculum, thoroughly adding to the didactics with history, humanities, and team dynamics. Anat Sci Educ 3:244–248, 2010.

The Media and Behavioral Genetics Alternatives Coexisting with Addiction Genetics

To understand public discourse in the United States on genetic causation of behavioral disorders, we analyzed media representations of genetic research on addiction published between 1990 and 2010. We conclude first that the media simplistically represent biological bases of addiction and willpower as being mutually exclusive: behaviors are either genetically determined, or they are a choice. Second, most articles provide only cursory or no treatment of the environmental contribution. A media focus on genetics directs attention away from environmental factors. Rhetorically, media neglect the complexity underlying the etiology the addiction and direct focus back toward individual causation and responsibility.

Chronic Addiction, Compulsion, and the Empirical Evidence

Pickard (2012) provides a strong critique of the definition of addiction as a “chronic, relapsing, neurobiological disease characterized by compulsive use of drugs or alcohol.” We agree with Pickard that framing addiction as a “disease of the brain” may have unintended consequences; for example, the model deemphasizes the influences of culture and environment, needlessly narrowing our understanding of addiction (Dingel, Karkazis, and Koenig 2011). However, we do not support her analysis fully. Pickard assumes that researchers and patients suffering from addictive disorders make literal use of the “disease of the brain” metaphor. She seriously overstates its influence. Based on five years of ethnographic fieldwork with addiction researchers, clinicians, and patients, we conclude that empirical realities are not consistent with Pickard’s position. The strong definition of compulsion Pickard refers to, and also associates with a neurobiological understanding of addiction—”an urge, impulse or desire that is irresistible: so strong that it is impossible for it not to lead to action”—implies that there is no choice (Pickard 2012). However, just because something is biological or a “disease” does not mean there is no choice or a loss of choosing capacity. Indeed, as noted by Ho and colleagues (2010), “The voluntary initiation and continuation of a behavior that is harmful to health is an important aspect of the etiology of many common diseases, including cardiovascular disease and metabolic syndrome” (779, emphasis added). Nora Volkow, the current head of the National Institute on Drug Abuse, has endorsed a theory in which addiction is thought to result from problems of motivation of choice—a framing that implies that “choosing,” though difficult, is still possible (Kalivas and Volkow 2005). While Pickard suggests that most scientists consider compulsion an all-or-none thing, we disagree. Data from our current study support what others have noted: Scientists are focused on enhancing our understanding of biological factors involved in addiction, which they hope will encourage policy changes that emphasize treatment; the basic assumption is that drug addicts have free will and can recover. As addiction researcher Griffith Edwards (2003) writes, alcoholism “is best approached through a framework of the

From the Shade into the Sun: In Search of a Mentor

“H ow do you know which ones to select, Mizz Hammer?” my student David asked me, the teacher of his New Orleans high school plant lab. I stopped thinning the forest of sprouts stretching like green arms up from the soil. Hmm. I hadn’t given my selection process much thought. Sheer impulse is what it was. I plucked, absently humming “Killing Me Softly,” and wove through the lab benches, which in addition to plants, teemed with student papers I would later pluck, sort and spruce with feedback. Not all of the plants would have room to grow deeper roots, I explained. Sometimes, there aren’t enough resources to feed all the baby chicks in the nest, so you pick a few of the strongest and work with them. Nature can seem cruel and very random, can’t it?“How do you know which ones to select, Mizz Hammer?” my student David asked me, the teacher of his New Orleans high school plant lab. I stopped thinning the forest of sprouts stretching like green arms up from the soil. Hmm. I hadn’t given my selection process much thought. Sheer impulse is what it was. I plucked, absently humming “Killing Me Softly,” and wove through the lab benches, which in addition to plants, teemed with student papers I would later pluck, sort and spruce with feedback. Not all of the plants would have room to grow deeper roots, I explained. Sometimes, there aren’t enough resources to feed all the baby chicks in the nest, so you pick a few of the strongest and work with them. Nature can seem cruel and very random, can’t it? On a Monday Mystery Beer Night, I met a high-eyebrowed college senior excitedly gushing on about her summer research at the Mayo Clinic. “How did you get hooked up with that?” I asked, when I managed to hold steady her darting blue eyes. She recounted how a physician at Mayo posted a comment on her personal blog on health policy. The connection became a Facebook friendship. She was invited, or perhaps she invited herself, to visit the Clinic, had dinner with the physician’s family, developed even more passion for a summer project, and now plans to go to medical school. “Isn’t that amazing?!” she sang (to no one, everyone), while twittering, literally, like a techno hummingbird drunk on nectar. It really was, if that was the whole story. All of a sudden, I felt as if my body weighed three hundred extra pounds and that my feeble efforts at networking toward success were the equivalent of swimming laps in molasses with an anchor roped to my ankle. She launched all that from a blog post at 3:14 in the morning? Can we count on such lures? As I sat shackled to notebooks, snacks, technologies, and stress among the other heavy-burdened travelers waiting to fly from the San Diego airport, a Hawaiian man sat right next to me with nothing but his iPhone. “My life just blew up, like two days ago,” he soared, rocking on ischia. “What do you mean?” I was worried, curious. He was on his way to Cabo to attend the award ceremony for a fishing competition. The winning team had used his blown-glass lure to land two million dollars in prize money and offered him ten percent of the prize. He wiped salty mist from his brow. “I know. Whoa. I mean, it’s crazy. I just started making these lures, like, a month ago. And I was in line at Baskin Robbins, a couple of these dudes were talking about fishing, and I was, like, ‘Hey, take one of these babies with you for luck. Here’s my card.’ Forgot I even did that. And then, next thing I know, yesterday, I get this call.” Wide-eyed, he waved his phone at me like it was a Golden Ticket. He showed pictures of his artful lures to all us captives waiting to fly. You couldn’t help but catch his high. The lures were glass tubes swirled in silvers, reds, and spirals of gold. They shimmered and flashed. So did his eyes. Meeting him was like getting fin flap splashed with cold saltwater. I shiver at how baited and dazzled I am by possibility, the chance we all have for a bright future, and yet haunted by the dulling threat of selection. The forces that jostle medical students, or any of us for that matter, toward success, may as well be Brownian. A blog. Standing in the ice cream line. The books we open. How our parents’ sperm and egg happen to meet. In the tossing sea of opportunity, these, the most random of assets, can buoy equal if not greater weight than our degrees, curricula vitae, publications, and more formal qualifications. You can’t teach luck on the Rota Fortunae. But you can teach students to seek good mentors, though mentors can be the slipperiest fish. My medical school doesn’t have a “speed mentoring”1 program, which is an amalgamation of musical chairs and elevator speeches, and Facebook is hard on my suspected ADHD, so I personally resorted to good-ole’ barbecue buffet line networking at the Internal Medicine Interest Group potluck. Drawn to a guy with a lobster baseball hat and peculiar round eye frames no more than two centimeters in diameter, I met a physician who had lived a festive season of life on the Gulf Coast, as I had. We talked about Mardi Gras and crawfish boils. He knew how to get a hundred pounds of shrimp and crawfish delivered fresh from Louisiana to Minnesota, and in admitting so, won my respect. He had an idea for a play he’d wanted to organize with medical students. Later, we wrote the play. Later still, I published it, made a presentation in Scotland at a medical education conference, and decided to be a hospitalist, like him. The direction in which we grow is not such curious tropism, after all. I’m outgoing. I guffaw in packed lecture halls. I talk to fishing lure salesmen in airports, blonde, bright-eyed strangers in bars, and guys with lobster hats. My mother tells me that sometimes I stand too close to people. She is worse. She’s Lucille Ball, in color. But we get noticed, we get included, and I might argue, are often left to grow while others are weeded out. In contrast, a classmate and close friend of mine doesn’t asphyxiate a room. She’s a fresh breath of air. She’d rather listen to you. She’s not going to talk to a stranger, if she can help it. It embarrasses her that I do. With all her extroverted colleagues bragging about their research mentors in such and such a field that they met at the library counter reaching for the candy dish, she is frustrated for not yet having found someone special to mentor her. She’s brilliant, works hard, is interested in public health, but feels threatened and thwarted by the prospect of competing or professionally prostituting for attention. Exasperated by the search she says, “I just want to find someone that wants me!” A good match made between mentor and mentee is a romance, indeed. A curious chemistry, and hardly ever “speedy.” Maybe medical schools need Yentas. Mentoring relationships are critical in the cultivation of healthy, fruitful doctors. Eden born, I idealize. I wish the gardens were better organized; the fertilizer and soil more fairly distributed so there weren’t so many forlorn shoots among the grateful sprouts. That spring afternoon in my classroom after David’s comment, I looked into the expectant faces of my students as their teacher and mentor and worried about the choices I made every day out of necessity, impulsively, consciously, with limited resources, biases, and many Darwinian defenses. I know what a privilege it is to be found, to be pulled from the shade and into the sun. So even if we aren’t all crawling up walls and leaning hoggishly into the light, we all want to feel loved, to feel heard, and to feel a part of something greater than ourselves. What a duty, this creative challenge, to make room for healthy roots.