International Journal of Drug Policy
Volume 145, November 2025, 105015 by Shane O’Mahony
Abstract
The brain disease model of addiction (BDMA) is a dominant, if highly contested, model of drug addiction globally. Over many decades, researchers have marshalled evidence from animal studies, neuroimaging scans, and genome wide association studies to argue that addiction is a brain disease. However, critics have argued that the model de-emphasises social and economic contexts, downplays the phenomenon of spontaneous or natural recovery, and over-interprets neuroscientific findings. Building on this critical tradition, the current paper asks a related question: Has the claim that addiction is a brain disease helped or harmed those experiencing drug-related harm epistemically? While no definitive answer to this question is offered, the current paper argues that overall, the claim that addiction is a brain disease advanced by proponents of the BDMA has harmed substance users already experiencing multiple disadvantages epistemically.
Drawing on the concept of epistemic injustice, the current paper argues that the category ‘drugs’ creates an artificial and harmful dichotomy between those who use licit medicines and experience harm and those who use illicit substances and experience harm. Furthermore, this artificial dichotomy is compounded by racist and colonial discourses central to the war on drugs, and a rigid biological reductionism that de-emphasises social, economic, and cultural harm. The paper concludes by sketching an alternative approach rooted in epistemic justice, and a discussion of the implications of this concept for research and theory.
Introduction
Academic literature has witnessed significant debate over the past thirty years concerning whether addiction is best thought of as a brain disease. While the framing of addiction as a disease has a much longer history (see Levine, 1978), the claim that addiction is specifically a brain disease and the debates around this claim began in earnest when Leshner (1997) categorically claimed that neuroscientific advances had shown that drug addiction is a chronic, relapsing disease resulting from the prolonged effects of drugs on the brain. This framing centres the illness or disorder firmly in the realm of the brain’s structure and functioning, as opposed to a lack of meaning and purpose (i.e. a spiritual disease/malady) as per proponents of AA’s spiritual disease model (see O’Mahony, 2019), a disease of the will as per Benjamin Rush (see Seddon, 2010), or a highly heterogeneous disorder from which more homogeneous, qualitatively distinct subtypes might be derived, only some of which constitute a disease, as E.M. Jellinek and colleagues have argued (see Kelly, 2018).
Despite multiple sustained critiques of the BDMA from criminologists (O’Mahony, 2019), anthropologists (Bourgois, 2009), psychologists (Alexander, 2008), and some within neuroscience (Heilig, 2021, Kalant, 2014) have reiterated that, despite valid criticism, the claim that addiction has a firm neurobiological basis remains strongly supported by the best scientific evidence. Most recently, Heather et al. (2022) have produced a volume evaluating the BDMA through contributions from supporters, opponents, and undecided scholars. While the editors entertain arguments from many different perspectives and models, they argue that addiction is undergoing a revolutionary change—from being considered a brain disease to a disorder of voluntary behaviour (Heather et al., 2022)—though this is contested by advocates of the BDMA (see Heilig, 2021).
While some have examined the emergence of the BDMA from a social constructionist perspective (Keane et al., 2014), and criticised its relative ignorance of social and cultural context (Reinarman, 2005), the current paper asks a different question: has the claim that addiction is best thought of as a brain disease helped or harmed those suffering from harmful substance use epistemically? While critical scholars have approached this question from many angles, there has been little reflection among supporters of the model, where it is often assumed that framing addiction as a brain disease will reduce stigma, increase access to treatment, and lead to better outcomes in general for those experiencing harmful drug use (see Volkow & Koob, 2010). Yet many critical scholars argue that disease understandings commit people to a lifetime of reduced autonomy (Hart, 2021), as they are perceived—by themselves and others—to lack control and free will in important ways. This, in turn, can stigmatise them as disordered and constitutionally different from others. Moreover, clinical treatment providers appear ambiguous in their support of the BDMA. While some believe it can reduce stigma, others argue it may foster hopelessness within clients (Barnett et al., 2018).
Similarly, while access to treatment has increased in many countries, this has not always been due to the adoption of the BDMA or any disease model. For example, Ireland has expanded treatment access in the 21st century (see Butler, 2007), yet never explicitly adopted disease understandings. Sweden’s approach, while complex, accommodates both social and brain-based understandings of drug-related harm (Grahn et al., 2014). Meanwhile, the Islamic Republic of Iran has recently increased access to treatment despite its lack of commitment to disease framings (see Mirzaei et al., 2022). While one might argue that these increases were compelled by growing rates of drug-related harm, the case remains: representing addiction as a brain disease has not, in and of itself, played a decisive role in facilitating treatment access in these diverse contexts. This is not to say that the BDMA cannot support access, but that many culturally diverse countries have achieved this end without adopting it. Ultimately, the choice is not between viewing addiction as a moral failing or a brain disease, there are diverse ways to frame addiction to achieve stigma reduction and treatment uptake ends.
While much debate exists within the academic literature, the BDMA currently represents a dominant way addiction is understood in the United States (Barnett et al., 2018) and that the model is influential in Europe (see SStorbjörk, 2018; O’Mahony, 2019) and Australia (Keane et al., 2014). Given this position of influence, the current paper asks whether the model helps or harms those experiencing drug-related harm epistemically. That is, does the claim that they are suffering from a brain disease help them understand themselves and their experiences of drug-related harm and/or enable them to communicate this to others—or is it harmful in these respects? Before turning to this question, let us briefly examine the relevant literature.
Section snippets
Background
The brain disease model of addiction has been championed for several decades by the US based National Institute of Drug Abuse (NIDA). While the model contains many complexities, at its most basic, the claim is that persistent drug use changes the brain’s structure and function to such an extent as to ‘hijack’ the brain’s motivational reward circuitry. Koob and Simon (2009) argue, for example, that a key element of drug addiction is how the brain’s reward system changes throughout the course of
Epistemic injustice
Epistemic injustice is a form of injustice ‘done to someone specifically in their capacity as a knower’ (Fricker, 2007: p.1). Put simply, an injustice that harms a person’s ability to know things and be seen by others to know things. Fricker (2007) distinguishes between two different forms of epistemic injustice: (1) Testimonial injustice (TI); and (2) Hermeneutical injustice (HI). TI occurs when a hearer’s prejudices about a person’s identity led them to treat what the person says more
The concept of drugs and hermeneutical injustice
The first issue relevant to this paper is the category of ‘drug’ itself. The question is whether this category—central to the Brain Disease Model of Addiction (BDMA)—is rooted in hermeneutic injustice. A useful starting point is the work of British drug historian Porter (1996). In a paper tracing the historical origins of the “drug problem” in Britain, Porter argues that the concept of a drug is historically contingent:
“If you had talked about the ‘drug problem’ two hundred years ago, no one
The war on drugs and hermeneutic injustice
The previous section argued that the concept of “drugs” is rooted in hermeneutic injustice (HI). This section demonstrates that, cross-culturally, the prohibition and criminalisation of certain types of substance use have been selective regarding which substances are targeted. Put simply, evidence from several jurisdictions indicates that substances used by marginalised populations are disproportionately criminalised. We begin with examples from the United States.
In a landmark study on the
Biological reductionism and epistemic injustice
The previous section demonstrated that substance use among marginalised groups is often labelled drug use, stigmatised and criminalised, while use among powerful groups often escapes these labels and is treated more benignly. This section will show how this tendency also obscures the social, cultural, historical, and economic forces underpinning harmful drug use among marginalised Indigenous populations. This occurs through the biological reductionism at the heart of the Brain Disease Model of
An alternative frame: epistemic justice
This paper argued that the influence of the BDMA (though heavily contested) leads to multiple instances of epistemic injustice (specifically hermeneutic injustices). If this is the case, it is plausible to ask how we might move away from this harmful framing of substance-related problems to a more epistemically just approach. Epistemic justice has been defined as ‘the proper inclusion and balancing of all epistemic sources’ (Geuskens, 2018: 2). Firstly, if we are to move towards a context where
Conclusion and discussion
The current paper asked the following question: Does the claim that addiction is a brain disease put forth by supporters of the BDMA help or harm those who are currently experiencing drug-related harm epistemically? The answer that has been developed is that the BDMA causes harm as it leads to various instances of epistemic injustice. The first instance of epistemic injustice relates to the concept of ‘drugs’ itself. Put simply, built into the very foundations of the concept ‘drugs’ is the
CRediT authorship contribution statement
Shane O’Mahony: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Software, Resources, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization.
Source: https://www.sciencedirect.com/science/article/abs/pii/S0955395925003111