Addiction and Brain Disease: Intertwined but Not One and the Same

by Vignesh Subramanian, October 18, 2021

Today, nearly every major medical organization in the United States defines drug addiction as a primary brain disease – a progressive, relapsing disorder driven not by choice, but rather by neural dysfunction. From patient advocacy organizations like the American Medical Association and the American Society of Addiction Medicine to top research organizations like the National Institutes of Health and the National Institute on Drug Abuse, this characterization of compulsive substance misuse is believed to effectively counter stigmatization of treatment while still accounting for biological and psychological realities. Yet if one is to evaluate other possible classifications and the present state of diagnostic protocols in fair measure, it could be reasonably asserted that a discussion is still to be had about the addict’s role in their own entrapment. The degree to which addiction may be considered a chronic illness is therefore contingent on not just the relativity of its prognosis, but also on what physicians believe to be appropriate recourse. 

The scientific tenets of addiction agreed on by psychologists, neurobiologists, and practitioners alike are key to judging the applicability of the brain disease model. Unwarranted assumptions about either the appositeness of a standard of comparison or a propensity for self-domestication can derail precedents set and determinations previously made by the discipline in question. It is fair to accept the medical discipline’s rhetoric on the need for restrictiveness in exposition, defining “chronic illness” as controllable but hitherto incurable conditions often identifiable by long periods of latency and protracted clinical course [3].

Proponents and opponents of the brain disease model also concur on the neurochemistry behind addiction. It starts with unregulated surges of the neurotransmitter dopamine in response to drug consumption occurring in the basal ganglia, the area of the brain tasked with executive functions that, among other behavior, enable learning from the ‘reward’ of brief ecstasy [5]. An affinity for a substance leading to increased use will cause neural circuits to adapt by restructuring receptors, by scaling back sensitivity to the drug’s effects – requiring more consumption to attain the same euphoric “high” – and by increasing tolerance of the substance as this subconscious demand is satisfied, completing the cycle [8]. The patient eventually develops dependence (inability to function without the substance) and dysphoria (a state of unease in the drug’s absence), fomenting cravings that prioritize reducing pain over experiencing pleasure [11]. The cycle is ultimately difficult to break, for reasons that demonstrate the true interplay of biology and behaviorism: parallel remodeling of the extended amygdala – tasked with controlling responses to stress – and the prefrontal cortex, which manages decision making, drives the user to form associations between increased consumption and decreased stress, causing inhibitory pathways to shut down as short-term reward is favored and sought after [5].

At no point in this slippery slope beyond the first ‘gateway’ use is the chemical compulsion of a drug resistible or reversible; indeed, the same reward circuits that drive addiction account for most human physiological needs, including reproductive activities [2]. In that regard, addiction is not just subconscious, but natural, solely dangerous in excess; patients of more socially sanctioned chronic illnesses – diabetes, heart disease, skin cancer – are victims of similar bet-hedging, whether it be by consumption of processed carbohydrates and meats, lack of exercise, or even sun exposure. Opponents of the brain disease model argue that the problem is initial awareness of risk: addicts must understand that intoxication is a precursor of worse to come, and addiction has a spectrum of severity, making accurate diagnosis difficult if not impossible [4]. With no physical measures of identifying mental health disorders (such as objective lab tests using biomarkers) yet deployed in medical practice, physicians must rely on neuropsychological assessments and dissociated imaging scans to compare a patient’s cognitive impairment with normal executive function and processing abilities. Such measures have found that neural changes associated with addiction matched those of “deep habits, Pavlovian learning, and prefrontal disengagement”, but did not match the “development-learning orientations” of various mental illnesses [1]. In other words, addiction stimulates synaptic pruning and neuroplasticity (the ability of neurons in the brain to change connections and reorganize) just as a conventionally developed brain does, but in atypical patterns poorly reflecting normal maturation and psychological tendencies. This information only sharpens the question of whether addiction is truly an aberration of the mind’s development or simply a collection of varying and even rectifiable effects elicited by the drug itself; to put it metaphorically, would a stabbing through the heart be considered cardiovascular illness? The concept of placing addiction on par with the likes of Alzheimer’s and Parkinson’s disease – surrounded by questions of whether all manipulated neuroplasticity is pathogenic, whether addicts can be responsible for consciously committed actions, and what even constitutes a problem with the brain – is thus far from conclusive. 

Acceptance – or lack thereof – of substance addiction as a brain disease has had and will continue to have wide-ranging implications for patient protections under law and avenues of treatment. Distinguishing between the public perceptions of users’ behavior and the intimate worldviews of addicts as shaped by their battles for recovery help sustain the idea that addiction medicine can be entirely recontextualized into being a centerpiece of public health. For example, even if addiction is not to be considered a disease of the brain, its contribution to the later development of chronic illnesses such as lung disease, stroke and HIV/AIDS makes addiction treatment itself a form of preventative medicine rather than rehabilitation alone [10]. Conversely, if classification of addiction as a brain disease remains the status quo, it might justify dependence as a ‘side effect’ of self-medication started because of lack of access to care, much the way it is for some substances with addictive potential – like selective serotonin reuptake inhibitors (SSRIs) and opiates – that are used and abused as antidepressants and for pain management, respectively [2][7]. As is clearly evident, proponents and opponents of the brain disease model ultimately do not disagree on the facts of addiction, but simply emphasize different contexts that, when taken to their conclusions, have different implications for diagnosis and stigmatization; both camps have proven willing, however, to oversee an explosion of medicalization that address those biological and psychological realities [6]. Today, trained physicians can administer pharmaceutical agonists and antagonists in clinics and other outpatient settings; the importance of psychosocial therapy, monitoring and follow-up in addiction treatment has been amplified; and the establishment of drug courts and diversion and harm reduction programs attests to the idea that drug consumption is not inherently a moral failing and that natural reactions to its effects can be less painfully anticipated and controlled [9]. 

Addiction is a convoluted condition: it has an onset influenced by environmental conditions but no infection agent, has little known pathological prognosis but a tendency to run in families, and displays outward behavioral changes but is not anatomically degenerative. A disease model that assumes partial responsibility on the part of the addict but recognizes the extent to which addiction rewires the brain is perhaps the best road on which to pursue a patient freedom-centric means of battling dependency and decay.


Works Cited

  1. Lewis, Mark. “Addiction and the Brain: Development, Not Disease.” Neuroethics, vol. 10, 2017, pp. 7–18, doi:10.1007/s12152-016-9293-4.
  2. Hammer, Rachel, et al. “Addiction: Current Criticism of the Brain Disease Paradigm.” AJOB Neuroscience Journal, vol. 4, no. 3, 2013, pp. 27–32. doi:10.1080/21507740.2013.796328.
  3. “Is Addiction a Disease?” Partnership to End Addiction, July 2020, drugfree.org/article/is-addiction-a-disease.
  4. Levy, Neil. “Addiction is not a brain disease (and it matters).” Frontiers in Psychiatry, vol. 4, no. 24, 2013. doi:10.3389/fpsyt.2013.00024.
  5. United States, Department of Health and Human Services. “The Neurobiology of Substance Use, Misuse, and Addiction.” The Surgeon General’s Report, 2016. addiction.surgeongeneral.gov/sites/default/files/chapter-2-neurobiology.pdf.
  6. NIDA. “Preventing Drug Misuse and Addiction: The Best Strategy.” National Institute on Drug Abuse, 10 July 2020, http://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/preventing-drug-misuse-addiction-best-strategy.
  7. Satel, Sally, and Scott O. Lilienfeld. “Addiction and the Brain-Disease Fallacy.” Frontiers in Psychiatry, vol. 4, no. 141, 2014. doi:10.3389/fpsyt.2013.00141.
  8. “The Science of Drug Use and Addiction: The Basics.” National Institute of Drug Abuse, 25 June 2020, http://www.drugabuse.gov/publications/media-guide/science-drug-use-addiction-basics.
  9. Smith, David E. “The Evolution of Addiction Medicine as a Medical Specialty.” AMA Journal of Ethics, vol. 13, no. 12, 2011, pp. 900–905. doi:10.1001/virtualmentor.2011.13.12.mhst1-1112.

Homophobia as Epistemic Justice in Japan

by Marie Yamamoto, October 14, 2021

While it is considered relatively safe for gay and bisexual individuals to live in compared to other East Asian countries, Japan still does not protect LGBTQ+ individuals from hate crimes on the national level, allow for same-sex marriages, recognize same-sex marriages performed abroad, or allow same-sex partners to adopt children or undergo IVF, among other refusals to recognize their human rights (“Japan”). Recently, there was an attempt to pass national legislation that would have at least granted LGBTQ+ people protection against discrimination on the basis of sexuality and gender. However, the legislation was watered down to instead “promote understanding” towards this group.  The legislation was ultimately tabled in the summer of 2021 (Holmes). 

Those who are in favor of maintaining this status quo insist that homosexuality is a Western ideal imported into Asia as a result of globalization (Wong). Those within the largely conservative National Diet have also allegedly argued that protecting gay and transgender individuals is too radical of a change and would hinder the country’s growth (Holmes). However, exploring the historical stances Japan has taken towards sexual fluidity reveals how deeply-entrenched colonialist ideas are within the Diet’s outward lack of compassion towards LGBTQ+ individuals. Homophobia within Japan is a result of epistemic injustice that arose as Japan faced pressure to conform to the West during the Meiji Era, and leaders within Japan should take steps to mend it from an epistemological perspective.

Colonization can have deep, long-lasting implications for the culture being colonized due to its ability to impose outside knowledge while undermining local knowledge. After all, colonization not only involves the exploitation of the resources and labor of the colonized but also involves the destruction and warping of the colonized culture to the point that it becomes “inferiorized, marginalized, and anonymized” so that the colonizer’s treatment is viewed as “beneficial and fair” (Collste). Often, this involves the addition of foreign epistemic frameworks into the colonized culture, which can destabilize old knowledge that has worked effectively in the past. In “Cultural Pluralism and Epistemic Injustice,” Goran Collste defines an epistemic framework as a means by which one within a given culture may “interpret, understand, and categorize [one’s] impressions and experiences so that they are manageable and possible to communicate and assess” (Collste). Quoting Rajeev Bhargava, he also emphasizes that any given epistemic framework relies on “‘historically generated, collectively sustained” lenses that inform both one’s individual identity and the culture’s collective identity (Collste).

From a religious standpoint, the introduction of the Judeo-Christian concept of shame surrounding sex—and homosexuality in general—fueled the suppression of the open expression of same-sex relationships. Neither Shintoism nor Japanese Buddhism—the two major religions in Japan up until the present day—decried homosexuality. In the Kojiki, the first written compilation of mythos considered sacred in Shinto practices, homosexuality is not decried; in fact, it is not even mentioned (Koichi). While male-female sexual activity is considered more corrupting to the soul, overall, Shintoism does not engrain ideas of shame into sex (Koichi). Likewise, among Buddhist monks sworn to celibacy, male-female sexual activity has been seen as innately defiling, whereas homosexual activity is not offensive enough to be considered punishable (Koichi). Shintoism and Buddhism’s more sex-positive ideas allowed Japan to found its ideologies regarding sex as separated from morality. Because their fundamental ideals regarding these topics contrasted so starkly, encroaching Western powers looked upon this aspect of Japanese culture with surprise and disgust. Outward expressions of sexuality and male-male relationships were decried in newspapers overseas, which ultimately led to Japan’s ruling elite deeming it as something meant to be left in the past (Koichi). In this sense, Japan’s swiftly-changing moral attitudes were not a result of Japan’s free will, rather they were a result of the constant, looming threat of a loss of respect from more powerful countries. The sudden change arose as Japan was “disrespected and considered as inferior” by Western powers, which instilled in them an “enduring sense of inferiority among the adherents of the old culture.” Homophobia followed (Collste). Shame towards these aspects of Japanese culture stemmed in part from how incompatible these local and imported epistemic frameworks were. With the looming fear of colonization, sexual freedom and fluidity were increasingly pushed out of Japan’s mainstream epistemic framework in order to harmonize with its oppressors (Collste).

Likewise, the medicalization of homosexuality is one such example of the addition of an epistemic framework that warped Japan’s local knowledge and led to the “othering” of gay individuals. In practice, same-sex relationships were normalized up until the beginning of the Meiji Era in the late 19th century. Sexuality was regarded as both fluid and something that was done as opposed to something that was an innate part of oneself. Men of all classes were able to engage in nanshoku and wakashudo culture, forms of love between men, and this did not prevent them from engaging in joshoku, or love between men and women (McLelland). Wim Lunsing further indicates that it was believed that “anybody could ‘slip’ (ochiiru) into pseudo-homosexuality for a variety of reasons” (Lunsing). The concept of a fixed sexual identity, therefore, did not exist within Japan’s epistemic framework regarding sexuality. Rather, it was perceived to be a result of one’s environment or a desire to experiment in one’s youth, or simply just love (Lunsing). 

Into the early 1900s, Japanese scholars studied in the West. They took with them both the concept of homosexuality as a fixed identifier, as evinced by the creation of the words dōseiai and iseiai to embody the concept of homosexuality and heterosexuality respectively within the binary sexuality spectrum (McLelland). After World War II, they adopted the Western belief that homosexuality was a mental illness and therefore an abnormality to be studied (McLelland). Despite Japan’s long-standing cultural perspective and practices, the insertion of pseudoscientific ideals framed by Western empirical thinking into Japan’s concept of sexuality resulted in the deeming of homosexuality as inferior compared to heterosexuality (McLelland). It is more difficult to compare with cultural practices without such evidence, even though said evidence may be heavily influenced by the biases of the scholars (Mao). Since Western empiricism positions itself as absolute based on its emphasis on the need for scientific evidence, Japan’s historical lens regarding sexuality was largely discarded and replaced with one that was less suited to capture its nuances and normalcy.

As a result of the adoption of these Western ideals, gay people in Japan have a more difficult time being accepted by society, and their experiences are distorted and obscured. There lacks an adequate epistemic framework for them to make sense of their sexuality largely within the context of their own history, and there still exists a subtle prejudice against gay individuals in their lack of serious representation in mainstream media and the pressure to conform to traditional, heteronormative standards (Wong). 

It must be said that it is entirely possible to slowly mend this epistemic injustice. Especially within its cities, the Japanese public is largely supportive of LGBTQ+ rights, and there have been ongoing efforts by advocacy groups towards more legislation to protect LGBTQ+ people and addressing misconceptions regarding homosexuality (Holmes). Queer Japanese people should not only be given the opportunity and resources to reconnect with their rich culture on their own terms, but also the opportunity to productively voice their own needs and concerns. In “Reflective Encounters: Illustrating Comparative Rhetoric,” LuMing Mao suggests that groups with opposing viewpoints or cultures listen to each other with an open mind with the purpose of self-reflection and understanding. If conversations like these occur within this context, those with biases against gay people—especially those within the government—can differently understand their viewpoints regarding homosexuality with the intent of social progress. The means by which homophobic biases manifest in the everyday lives of gay people must be restricted in order for healing to occur.

It is inherently wrong to call homosexuality a Western concept; the truth is that Japan’s fear of occupation by the Western imperial powers applied immense pressure to conform to Western ideals, which included shame associated with gay relationships and sex in general. This distancing from Japan’s rich queer culture and customs has resulted in homosexuality being seen as a result of globalization as sexuality began to be defined by Western terminology. Moving forward, the Japanese public should be educated on Japanese queer history and more rights must be afforded to queer individuals. It is entirely possible for the public to reconnect with these roots in their history with an open mind and work towards justice for gay individuals.


Works Cited

Collste, Göran. “Cultural Pluralism and Epistemic Injustice.” Journal of Nationalism, Memory & Language Politics, vol.13, no.2, 2019, pp.152–163. ResearchGate, https://www.researchgate.net/publication/335431712_Cultural_Pluralism_and_Epistemic_Injustice.

Holmes, Juwan J. “Japanese Politicians Refuse to Pass LGBTQ Rights Bill as Olympics Approach.” LGBTQ Nation, 25 May 2021, http://www.lgbtqnation.com/2021/05/japanese-politicians-refuse-pass-lgbtq-rights-bill-olympics-approach/.

“Japan.” Out Leadership, 21 Mar. 2019, outleadership.com/countries/japan/.

Koichi. “The Gay of the Samurai.” Tofugu, 30 Sept. 2015, http://www.tofugu.com/japan/gay-samurai/. 

Lunsing, Wim. “Discourses and Practices of Homosexuality in Japan: Recent Contributions to the Literature.” Social Science Japan Journal, vol. 4, no. 2, 2001, pp. 269–73. JSTOR, www.jstor.org/stable/30209329.

Mao, LuMing. “Reflective Encounters: Illustrating Comparative Rhetoric.” Style, vol. 37, no. 4, Penn State University Press, 2003, pp. 401–24. JSTOR, http://www.jstor.org/stable/10.5325/style.37.4.401.

McLelland, Mark J. “Japan’s Queer Cultures.” The Routledge Handbook of Japanese Culture and Society, edited by Theodore and Victoria Bestor, Routledge, 2011, p. 140–149. University of Wollongong Australia Digital Commons, ro.uow.edu.au/artspapers/265.

Wong, Brian. “Column: Homophobia Is Not an Asian Value.” Time, 17 Dec. 2020,  time.com/5918808/homophobia-homosexuality-lgbt-asian-values/.

The Mental Conundrum

by Ali Ahmad, October 8, 2021

We all have faced a feeling of regret at some point in our lives. Regret is a human condition that I am sure all of us have faced at least once in our lifetime. The feelings of hopelessness and regret positively reinforce each other as we look back on the past and fixate on the problems we have faced. The more we begin to fixate on these problems, the more we begin to deviate from taking action and instead begin to imagine hypotheticals in our mind. These replays of alternate scenarios in our heads induce  feelings of accomplishment and triumph where there is none to begin with. This fantasy is our mind methodology of expunging negative emotions and mutating it into something bright and positive. This at first does not sound like a problem at first, given that we normally associate feelings of positivity with fulfillment. However, I believe that the motivation that drives us to excel and learn is stifled by feelings of positive emotions that overshadow negative feelings. 

I was once at a house party and a friend of mine from high school was in attendance. They had just accepted an offer of admission from Dartmouth College, a prestigious ivy league university. I was just a junior in High School studying for a retake of the SAT exam hoping to get into a good school. Naturally, I felt that I had fallen behind in my studying and went to bed at night dreaming that I had attained a perfect score through hours of desiccated study. I instantly felt better afterwards and unfortunately I never put in the hours of studying I had initially envisioned myself doing. If I had set up initial negative feelings of having fallen behind or of feeling inferior, I might have had the push I needed to put in the hours of studying and to make a meaningful change in my life.

In a study conducted on cocaine addiction treatment success, the emotional processing of addicts was measured to see if there is any correlation between motivation and goal directed behaviors. The study found that brain areas activated in early treatment for cocaine addiction were also active during  emotional activation. These brain regions included the amygdala, accumbens, and fusiform gyrus (Contreras-Rodriguez et al.). This might sound surprising at first, considering that we all strive to cultivate positive emotions. On the contrary, we all purposefully have a built in “negativity bias,” that we actively use to create adverse scenarios to contrast against to better digest information. This bias is an evolutionary feature unique to humans. In fact the early origin of these negative emotions can be clearly observed in infants, where infants “look at angry faces for a shorter duration due a recognition of aversive stimulus,” (Vasih et al.) All of this suggests that our brains are hardwired from the beginning to attend to negative or threatening stimulus in the environment more so than happy or positive stimulus.

So what are the practical takeaways from this finding? We can first begin by redirecting our negative cognitive energy to moving forward. By grounding ourselves in the present moment we can begin to break through this mental trap and begin to take small steps towards a slightly more positive future.


Works Cited

Contreras-Rodriguez, Oren, et al. “The neural interface between negative emotion regulation and motivation for change in cocaine dependent individuals under treatment.” Drug and Alcohol Dependence, vol. 208, 2020. doi.org/10.1016/j.drugalcdep.2020.107854

Vaish, Amrisha, et al. “Not all emotions are created equal: The negativity bias in social-emotional development.” Psychological Bulletin, vol. 134, no. 3, 2013, pp. 383–403. doi.org/10.1037%2F0033-2909.134.3.383