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Drug and Alcohol Review (May 2014), 33, 272–279 DOI: 10.1111/dar.12115
Public attitudes in Australia towards the claim that addiction is a (brain) disease CARLA MEURK, BRAD PARTRIDGE, ADRIAN CARTER, WAYNE HALL, KYLIE MORPHETT & JAYNE LUCKE UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia
Abstract Introduction and Aims. We investigated the Australian public’s understandings of addiction to alcohol and heroin and the factors predicting support for the idea that these types of addiction are ‘diseases’ and specifically ‘brain diseases’. Design and Methods. Data were collected as part of the 2012 Queensland Social Survey, a computer-assisted telephone interview of 1263 residents of Queensland, Australia. Participants were presented with scenarios of two addicted persons, one who was addicted to heroin and the other addicted to alcohol. Participants were asked a series of questions about different definitions and causes of addiction for both characters. Results. Over half of the respondents thought that addiction is a disease (alcohol: 67%, heroin: 53%), but fewer (alcohol: 34%, heroin: 33%) believed that addiction is a brain disease. Belief that addiction has biological causes predicted agreement that addiction is a disease [alcohol: odds ratio (OR) = 3.05 (2.15–4.31), heroin: OR = 3.99 (2.82–5.65)] and a brain disease [alcohol: OR = 4.97 (3.42–7.22), heroin: OR = 14.12 (9.23–21.61)].Women were more likely than men to agree that addiction is a disease [alcohol: OR = 1.79 (1.35–2.38), heroin: OR = 1.40 (1.09–1.81)] as were those 35 years of age and older [alcohol: OR = 2.25 (1.50–3.40), heroin: OR = 1.50 (1.01–2.24)]. Discussion and Conclusions. There is more public support for the idea that addiction is a ‘disease’ than for the more specific claim that it is a ‘brain disease’. Support for a biological aetiology of addiction predicted higher levels of agreement with both disease concepts. [Meurk C, Partridge B, Carter A, Hall W, Morphett K, Lucke J. Public attitudes in Australia towards the claim that addiction is a (brain) disease. Drug Alcohol Rev 2014;33:272–279] Key words: public attitude, brain disease model of addiction, neuroethics, alcohol, heroin.
Introduction In the USA, directors of the National Institute on Drug Abuse have argued that addiction is a ‘chronic relapsing brain disease’ and that ‘attending to the brain’ should be a core part of dealing with addiction [1,2]. However, the advantages of labelling addiction as a (brain) disease have been hotly contested by philosophers, sociologists, scientists and clinicians [3–7] who have expressed concern about the social, cultural and political implications of a ‘brain disease’ model [6–10]. If its advocates are correct, acceptance of the brain disease model of addiction will have social benefits by encouraging more addicted individuals to seek treatment and enhancing tolerance towards addicted
persons because addiction will be seen as something outside the control of those affected [1,2]. Critics, on the other hand, are sceptical that neuroscience research supports the view that addiction is a brain disease [11,12] and identify possible negative social consequences of accepting the brain disease view: it may encourage fatalism [13]; increase stigmatisation of addicted persons; promote coercive addiction treatment and/or the overuse of pharmacological treatments; and de-emphasise the role of social factors in the aetiology and treatment of addiction [4,14]. The likelihood of these competing claims about the social consequences of the brain disease model depends on how members of the public understand addiction. Are members of the public aware of the brain disease
Carla Meurk PhD, Postdoctoral Research Fellow, Brad Partridge PhD, NHMRC, Research Fellow, Adrian Carter PhD, NHMRC, Research Fellow, Wayne Hall PhD, Australia Fellow, Professor, Kylie Morphett BPsych (Hons), PhD Candidate, Jayne Lucke PhD, Associate Professor, Principal, Research Fellow. Correspondence to Dr Carla Meurk, UQ Centre for Clinical Research, The University of Queensland, 71/918 Royal Brisbane and Women’s Hospital Site, Herston, Qld. 4029, Australia. Tel: 07 3346 5477; Fax: 07 3346 5598; E-mail: [email protected] Received 18 September 2013; accepted for publication 18 December 2013. © 2014 Australasian Professional Society on Alcohol and other Drugs
Is addiction a (brain) disease?
model of addiction? If so, do they accept it? Do they accept what its advocates (or detractors) take to be its social entailments? Understanding the social meanings of addiction can assist in formulating health education about addiction and its treatment and inform debates about the social and ethical implications of labelling addiction as a brain disease. Understanding the meanings of addiction also contributes to scholarship on the medicalisation of addiction and shifting ideas about personhood, the body and its governance [7,15,16]. Addiction is a complex construct, and numerous discourses circulate publically [17]. In a previous qualitative investigation, we found that members of the Australian public understand addiction to be caused by multiple overlapping factors that included social environmental factors, emotional and experiential drivers, biology, rationality and education, the drug itself, and personal character [18]. There was a general acceptance of the idea that addictive drugs acted on brain mechanisms, but many people were ambivalent about accepting that addiction was a ‘brain disease’ [18]. The ‘brain disease’ notion evoked a diverse, and diffuse, set of meanings and uncovered multiple conceptualisations about the structure and function of the brain. The present study’s aim was to investigate the specificity and generalisability of these qualitative findings. We investigated the attitudes of Australian adults towards the concept of addiction as a brain disease for two addictive substances, one legal (alcohol) and one illegal (heroin).We attempted to quantify the following:
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cally as a ‘brain disease’; and the sociodemographic and experiential predictors of these beliefs. Methods Sampling and recruitment Data were collected as part of the 2012 Queensland Social Survey (QSS), a computer-assisted telephone interview of 1263 residents of the state of Queensland, Australia. QSS is administered by the Population Research Laboratory at Central Queensland University Australia, and the inclusion of our questions was approved by the Human Ethics Research Review Panel at that university. Households were randomly selected using a database of randomly generated telephone landline numbers. Within each household participants were selected who lived at the place of residence; were at least 18 years old; and were either male or female, depending on a gender selected randomly before the call was made. If the household contained more than one individual of the selected gender, then the participant who had the most recent birthday was selected. If no one in the household fits these criteria, the household was disqualified from the sample. The survey had a response rate of 35.34%. The profile of QSS respondents (Table 1), compared with the Australian Bureau of Statistics 2011 census data for Queensland, indicated that residents over the age of 55 were over-represented, and those under the age 35 were under-represented [19,20]. The under-representation of younger persons partly reflects shifts among younger people towards cellular phones [21]. Descriptive statistics were estimated to have a sampling error of plus or minus 2.7% at a 95% confidence level.
• The extent to which participants agreed with the view that addiction is (i) a disease and (ii) a ‘brain disease’. • Their beliefs about the importance of different putative causes of alcohol or heroin addiction. • The relationship between their beliefs about the aetiology of alcohol and heroin addiction and their acceptance of addiction as a ‘disease’ and specifi-
The survey instrument QSS is a large omnibus survey that includes questions from multiple research bodies and other organisations
Table 1. Profile of QSS respondents Male 49.7%
Gender Age
18–24 4.3%
Years of education
1–10 24.9%
25–34 7%
Female 50.3% 35–44 16.5% 11–12 21.5%
45–54 18.6% 13–14 11.3%
55–64 22.6%
65+ 30.6% 15+ 41.6%
QSS, Queensland Social Survey. © 2014 Australasian Professional Society on Alcohol and other Drugs
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on a range of topics. The survey collected basic sociodemographic characteristics and explored participants’ opinions on the causes of addiction and their familiarity with the two drugs of abuse—either their own or that of others. Alcohol and heroin were chosen because they differ in prevalence, social acceptability and method of administration. They are also well known to be examples of legal and illegal drugs. Beliefs about the causes of addiction were examined using a series of questions about two hypothetical men: John was addicted to alcohol and Peter was addicted to heroin (Supporting Information Appendix S1). Participants rated their agreement on a 5-point scale (strongly agree, agree, disagree, strongly disagree, do not know) to each of seven possible causes of each type of addiction, namely (i) bad character; (ii) addictive personality; (iii) psychological problems; (iv) chemistry in the brain; (v) the way he was raised; (vi) stress; and (vii) a genetic or inherited problem. These options were based on the explanations offered by participants in our qualitative interviews [18,22]. Participants were asked about the extent of their agreement that each type of addiction is (i) a disease and (ii) a brain disease. Finally, they were asked whether they, or someone they knew personally, had ever had a problem with (i) alcohol or (ii) heroin. The response options were (i) no; (ii) yes, I have; (iii) yes, someone close to me has; and (iv) yes, both myself and someone close to me has.
Data analysis Data were analysed using spss v.20 [23], with χ2-tests performed in r v.2.15.2 [24]. Demographic variables included as predictors were gender (male = 0, female = 1); age (18–34 years = 0, age 35+ years = 1); and education (1–12 years = 0, 13–14 years = 1, 15+ years). The variable ‘familiarity’ classified those who had themselves or knew someone who had had a problem with alcohol/ heroin use (no = 0, yes = 1). We re-coded the seven questions exploring beliefs about the aetiology of addiction into the following three themes to take into account the findings from our qualitative investigations on the topic [18,22], thematic categories used in the literature [15,25] and results of exploratory analyses of beliefs about the aetiology of addiction. We re-coded the themes as follows (disagree = −1, neutral/do not know = 0, agree = 1): 1. ‘Biological’ aetiology combined participants’ agreement that (i) addiction is caused by chemistry in the brain, and (ii) addiction is genetic/ inherited; © 2014 Australasian Professional Society on Alcohol and other Drugs
2. ‘Socio-environmental’ aetiology combined (i) the way he was raised and (ii) stress; 3. ‘Personal qualities’ aetiology combined (i) psychological problems; (ii) addictive personality; and (iii) ‘bad character’. We conducted four logistic regression analyses to discover what characteristics and beliefs predicted agreement with the following statements: (i) addiction to alcohol is a disease; (ii) addiction to heroin is a disease; (iii) addiction to alcohol is a ‘brain disease’; and (iv) addiction to heroin is a ‘brain disease’. Participants who responded ‘do not know or unsure’ were excluded. The dependent variable in each model was re-coded as a binary variable (disagree/strongly disagree = 0, agree/ strongly agree = 1). Results Public attitudes about whether addiction is a disease versus brain disease More people thought that addiction to alcohol is a disease than is heroin addiction (alcohol: 67% agree, heroin: 53% agree, χ2 = 49.07, P < 0.001). There were no significant differences in the proportions who agreed that heroin or alcohol is a brain disease (alcohol: 34%, heroin: 33%). For both alcohol and heroin addiction, significantly fewer participants agreed that addiction is a brain disease than thought it was a disease (alcohol: χ2 = 281.77, P < 0.001, heroin: χ2 = 127.45, P < 0.001). Participants were more uncertain about whether alcohol and heroin addiction are brain diseases (alcohol: 25% unsure/do not know, heroin: 23% unsure/do not know) than they were about whether alcohol and heroin addiction are diseases (alcohol: 9% unsure/do not know, heroin: 11% unsure/do not know). Public beliefs about addiction’s causes Stress, psychological problems and addictive personality were the three most prevalent causes of alcohol and heroin addiction that participants identified (Table 2). Sixty-five per cent of participants said that stress is a cause of alcohol addiction, 64% selected psychological problems and 62% nominated an addictive personality. In the case of heroin addiction, the ranking was addictive personality (63%) followed by psychological problems (62%) and stress (48%). The belief that addiction is caused by brain chemistry was the fourth most prevalent cause for both alcohol and heroin addiction; it also elicited the highest proportion of ‘do not know/unsure’ responses (23% for alcohol and 24% for heroin). The three least prevalent causes of addiction were genetic/inherited traits, bad character and the way the
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Table 2. Beliefs about the causes of addiction to alcohol and heroin Alcohol (%)
Stress Psychological problems Addictive personality Brain chemistry The way he was raised Genetic/inherited Bad character
Heroin (%)
Agree
Disagree
Do not know
Agree
Disagree
Do not know
χ2
65 64 62 54 52 49 31
21 18 26 23 34 34 58
15 18 12 23 14 17 11
48 62 63 47 40 33 36
36 20 21 29 43 47 48
16 18 16 24 17 20 16
80.56***a 3.27 13.74** 14.66*** 37.92*** 66.85*** 26.42***
**P < 0.01; ***P < 0.001. aχ2-test comparing proportions who ‘agree’, ‘disagree’ and ‘do not know’ across alcohol and heroin.
person was raised. Half (52%) thought that a person’s upbringing could cause alcohol addiction, 49% considered it is caused by genetic or inherited traits and 31% considered that alcohol addiction is caused by ‘bad character’. The least prevalent identified causes of heroin addiction were the way a person is raised (40%), ‘bad character’ (36%) and genetic or inherited traits (33%). Familiarity with problematic alcohol and heroin use Overall, 62% of respondents had either personally experienced or had someone close to them who had experienced problematic alcohol use. Only 19% of respondents reported having experienced problematic heroin use. In both cases, it was mostly someone close to the participant who had a problem (54% for alcohol and 15% for heroin). Factors influencing the belief that addiction is a disease Respondents 35 years and older and females were more likely to agree that alcohol and heroin addiction are a disease (Table 3).Women were more likely than men to agree that addiction to alcohol is a disease [odds ratio (OR) = 1.79 (1.35–2.38)] and that addiction to heroin is a disease [OR = 1.40 (1.09–1.81)]. Those 35 years and older were more likely than those aged 18–34 to agree that addiction to alcohol is a disease [OR = 2.25 (1.50–3.40)] and that heroin addiction is a disease [OR = 1.50 (1.01–2.24)]. Level of education and familiarity with addiction were not significant predictors of beliefs that addiction is a disease. Those who agreed that addiction has biological causes were more likely to agree that addiction is a disease than those who disagreed [alcohol: OR = 3.05 (2.15–4.31), heroin: OR = 3.99 (2.82–5.65)]. Those who did not know or were neutral about the role of
biological causes were also more likely to believe that addiction to alcohol and heroin is a disease [alcohol: OR = 1.82 (1.28–2.61), heroin: OR = 1.63 (1.20– 2.23)]. Beliefs about the personal qualities of an individual did not significantly predict beliefs that addiction to alcohol or heroin is a disease. However, support for the view that addiction to heroin is caused by an individual’s social environment predicted agreement that heroin addiction is a disease [OR = 1.45 (1.03–2.04)]. Not knowing, or being neutral, as to whether heroin addiction has social environmental causes also predicted agreement that addiction to heroin is a disease [OR = 1.52 (1.11–2.08)]. Factors predicting the belief that addiction is a brain disease Age, gender and level of education did not predict agreement with the belief that heroin or alcohol addiction is a brain disease (Table 4). People with personal or vicarious experience of problem alcohol use were more likely to agree that addiction to alcohol is a brain disease than those who did not [OR = 1.49 (1.12– 1.99)]. This pattern did not hold for heroin addiction [OR = 1.12 (0.76–1.66)]. In the case of alcohol, participants who agreed that addiction has biological causes were more likely to agree that alcohol addiction is a brain disease [OR = 4.97 (3.42–7.22)] and so were those who were neutral or did not know if addiction has biological causes [OR = 1.88 (1.25–2.82)]. Participants who agreed that heroin addiction has biological causes were more likely to agree that addiction to heroin is a brain disease [OR = 14.12 (9.23– 21.61)], and so were those who were neutral or did not know if addiction to heroin has biological causes [OR = 3.92 (2.64–5.83)]. Those who agreed that alcohol addiction is caused by personal qualities were more likely to agree that addiction to alcohol is a brain © 2014 Australasian Professional Society on Alcohol and other Drugs
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Table 3. Factors predicting the belief that addiction is a disease Alcohol addiction is a disease Prediction of agreement Age Gender Years of Education Familiarity with addiction Biological causes Social environmental causes Personal qualities
OR 18–34 ≥35 Male Female 1–12 13–14 15+ No Yes Disagree Neutral/Do not know Agree Disagree Neutral/Do not know Agree Disagree Neutral/Do not know Agree
95% CI
1.00 2.25*** 1.00 1.79*** 1.00 0.76 1.12 1.00 1.27 1.00 1.82** 3.05*** 1.00 0.99 1.27 1.00 0.73 0.91
1.51–3.40 1.35–2.38 0.48–1.19 0.83–1.52 0.96–1.68 1.28–2.61 2.15–4.31 0.66–1.48 0.85–1.88 0.44–1.19 0.66–1.25
Heroin addiction is a disease OR 1.00 1.50* 1.00 1.40** 1.00 0.93 1.03 1.00 1.33 1.00 1.63** 3.99*** 1.00 1.52** 1.45* 1.00 1.19 1.02
95% CI
1.01–2.24 1.09–1.81 0.61–1.41 0.78–1.35 0.95–1.88 1.20–2.23 2.82–5.65 1.11–2.08 1.03–2.04 0.74–1.89 0.75–1.39
*P < 0.05; **P < 0.01; *** P < 0.001. CI, confidence interval; DK, do not know; OR, odds ratio.
Table 4. Factors predicting beliefs that addiction is a brain disease Alcohol addiction is a brain disease Prediction of agreement Age Gender Years of Education Familiarity with addiction Biological causes Social environmental causes Personal qualities
OR 18–34 ≥35 Male Female 1–12 13–14 15+ No Yes Disagree Neutral/DK Agree Disagree Neutral/DK Agree Disagree Neutral/DK Agree
*P < 0.05; **P < 0.01; ***P < 0.001. CI, confidence interval; DK, do not know; OR, odds ratio.
© 2014 Australasian Professional Society on Alcohol and other Drugs
1.00 1.35 1.00 1.08 1.00 0.96 1.08 1.00 1.49** 1.00 1.88** 4.97*** 1.00 1.04 1.29 1.00 1.14 1.40*
95% CI
0.85–2.14 0.82–1.44 0.60–1.54 0.80–1.46 1.12–1.99 1.25–2.82 3.42–7.22 0.69–1.58 0.87–1.93 0.66–1.95 1.02–1.92
Heroin addiction is a brain disease OR 1.00 1.20 1.00 1.00 1.00 1.25 1.16 1.00 1.12 1.00 3.92*** 14.12*** 1.00 1.02 0.87 1.00 0.94 1.27
95% CI
0.75–1.93 0.75–1.35 0.77–2.01 0.84–1.59 0.76–1.66 2.64–5.83 9.23–21.61 0.70–1.49 0.58–1.31 0.52–1.69 0.88–1.84
Is addiction a (brain) disease?
disease than those who did not [OR = 1.40 (1.02– 1.92)]. Belief that addiction reflects personal qualities did not predict agreement with the view that heroin addiction is a brain disease. Discussion Disease label reflects a biological conception Those surveyed believed that addiction has multiple causes. Older persons, females and those who believed addiction is caused by biological factors were more likely to support the view that addiction to heroin and alcohol is a disease and a brain disease in particular. Our sample did not appear to endorse biological reductionism.Their endorsement of multiple causes suggested the sample see addiction as a syndrome, as was the case in our earlier qualitative interviews. In the case of heroin addiction, social environmental causes predicted support for the belief that addiction is a disease. Factors predicting whether addiction is a brain disease differed according to the drug in question. In the case of alcohol addiction, familiarity with addiction and belief that addiction was caused by personal factors predicted agreement with the claim that it is a brain disease. Despite this variability, the consistency of the biological variable as a predictor of agreement with disease concepts suggests that when people think of addiction as a disease, they invoke a biological conception even though biological causes were among the least commonly identified causes of addiction. The fact that agreement with disease concepts were not, overall, significantly associated with beliefs about personal qualities or social environmental factors, either positively or negatively, suggests that the disease concept does not completely encompass what people think addiction is. The relationship between beliefs, formal learning and personal experience is complex Gender and age differences predicted support for the belief that addiction to alcohol or heroin is a disease but not the belief that addiction is a brain disease. Women were more likely than men to agree that addiction is a disease, and those 35 years of age and older were more likely than those 18–34 to agree that addiction is a disease. There were no educational differences in support for the views that addiction to alcohol and heroin is a disease, and no sex, age or educational differences in degree of support for the view that addiction to alcohol or heroin is a brain disease. The gender differences in support for disease models of heroin and alcohol addiction accord with findings that women are more likely to be aware of, and medicalise, mental illnesses than men [26,27]. Greater
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support for a disease model in older participants may reflect broader historical and cultural influences. The disease concept of alcoholism has a long history of being promoted in Australia through the efforts of the 12-step self-help movement alcoholics anonymous (AA). AA first appeared in Australia in the late 1940s and dominated alcohol addiction treatment until relatively recently [28]. The brain disease model is of more recent origin and, although it has been heavily promoted in North America, it is ambivalently supported by Australian addiction experts [13]. The brain disease model has also been less often promulgated in the Australian media than in the USA [8,29,30]. Personal or vicarious experience of alcohol addiction predicted support for the belief that alcohol addiction is a brain disease. This may be because those with alcohol problems were more likely to have been exposed to this idea via their experiences of treatment by health professionals. They may also find that this idea resonates with their subjective experiences, a hypothesis supported by findings from our qualitative research on the pathways to acceptance of the brain disease model of addiction [22]. Absence of any relationship between familiarity and beliefs about heroin addiction probably reflects much lower rates of familiarity with heroin addiction. Limitations The overall low response rate and bias in the sample towards older and better educated individuals is a limitation of this study. This is an increasingly common limitation of surveys conducted via landline telephones given the greater adoption of cellular phones by younger people [21]. A second limitation is that familiarity with addiction in our sample was mostly vicarious and of uncertain depth. Given that the lower bound of 95% confidence intervals for familiarity hovered near 1 regarding whether addiction is a disease, more detailed measures of familiarity might find it is a predictor of support for disease models. We hypothesise that variability in beliefs about addiction to alcohol versus beliefs about heroin is because of low incidence of respondents’ personal or vicarious experience with heroin addiction in our sample. The generalisability of these findings should also be considered in relation to the male gender of the addicted individuals used to contextualise survey questions. Finally, χ2-tests for differences in beliefs about alcohol addiction versus heroin addiction may be biased because questions relating to John and Peter were not randomly assigned to different groups within our sample. Conclusion Those we surveyed were more likely to accept a disease concept of addiction than a brain disease concept. This © 2014 Australasian Professional Society on Alcohol and other Drugs
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was more likely to be the case for alcohol than for heroin addiction. The patterns of response suggest that members of the public acknowledge that the causes of addiction are multiple and complex and are ambivalent towards reductionist labels for addiction. Framing addiction as a syndrome may resonate more with the Australian public than disease concepts as it allows multiple causes of addiction to be acknowledged. Further research is needed on the impact these beliefs have on beliefs about the most appropriate treatment of addiction, attitudes towards addicted individuals’ responsibility for their addiction and empathy/stigma [31–34]. Research on the perspectives of addicted individuals on these issues is also a priority. Acknowledgements The authors would like to thank staff at the Population Research Laboratory, Institute for Health and Social Science Research, CQ University who administered this study. This research was funded by an Australian National Health and Medical Research Council Australia Fellowship (Grant ID: 569 738) awarded to Professor Wayne Hall. Drs Brad Partridge and Adrian Carter are both recipients of Australian National Health and Medical Research Council Postdoctoral Fellowships. References [1] Volkow N, Li T-K. Drug addiction: the neurobiology of behaviour gone awry. Nat Rev Neurosci 2004;5:963– 70. [2] Leshner A. Addiction is a brain disease, and it matters. Science 1997;278:45–7. [3] Blaxter M. Diagnosis as category and process: the case of alcoholism. Soc Sci Med 1978;12:9–17. [4] Dingel M, Karkazis K, Koenig B. Framing nicotine addiction as a ‘disease of the brain’: social and ethical consequences. Soc Sci Q 2011;92:1363–88. [5] Foddy B. Addiction and its sciences-philosophy. Addiction 2010;106:25–31. [6] Heyman G. Addiction: a disorder of choice. USA: Harvard University Press, 2009. [7] Kaye K. De-medicalizing addiction: toward biocultural understandings. In: Netherland J, ed. Critical perspectives on addiction. UK: Emerald Publishing, 2012:27–51. [8] Vrecko S. Birth of a brain disease: science, the state and addiction neuropolitics. Hist Human Sci 2010;23:52–67. [9] Rusch N, Evans-Lacko S, Thornicroft G. What is a mental illness? Public views and their effects on attitudes and disclosure. Aust N Z J Psychiatry 2012;46:641–50. [10] Hammer R, Dingel M, Ostergren J, Partridge B, McCormick J, Koenig B. Addiction: current criticms of the brain disease paradigm. AJOB Neuroscience 2013;4:27–32. [11] Levy N. Addiction is not a brain disease (and it matters). Front Psychiatry 2013;4:1–7. [12] Kalant H. What neurobiology cannot tell us about addiction. Addiction 2009;105:780–9. © 2014 Australasian Professional Society on Alcohol and other Drugs
[13] Bell S, Carter A, Mathews R, Gartner C, Lucke J, Hall W. Views of addiction neuroscientists and clinicians on the clinical impact of a ‘brain disease model of addiction. Neuroethics 2013;1–9. [14] Carter A, Hall WD. Addiction neuroethics: the promises and perils of neuroscience research on addiction. London: Cambridge University Press, 2012. [15] Netherland J. We haven’t sliced open anyone’s brain yet’: neuroscience, embodiment and the governance of addiction. In: Pickersgill M, Van Keulan I, eds. Sociological reflections on the neurosciences. UK: Emerald Publishing Group Limited, 2011:153–77. Online. [16] O’Connor C, Joffe H. How has neuroscience affected lay understandings of personhood? A review of the evidence. Publ Underst Sci 2013;22:254–68. [17] Keane H. What’s wrong with addiction? Australia: Melbourne University Press, 2002. [18] Meurk C, Carter A, Hall W, Lucke J. Public understandings of addiction: where does neurobiological information fit? Neuroethics 2013;1–12. [19] ABS. Census of Population and Housing: 2011 Census Tables: Queensland B04 AGE BY SEX (Population greater than or equal to 18 years). Australian Bureau of Statistics, 2011. [20] Duncan O, Duncan B. Residential distribution and occupational stratification. Am J Sociol 1955;60:493–503. [21] Hu S, Balluz L, Battaglia M, Frankel M. Improving public health surveillance using a dual-frame survey of landline and cellphone numbers. Am J Epidemiol 2011;173:703– 11. [22] Meurk C, Hall W, Morphett K, Carter A, Lucke J. What does ‘acceptance’ mean? Public reflections on the idea that addiction is a brain disease. BioSocieties 2013;8:491– 506. [23] IBM Corp. IBM SPSS Statistics for Windows. [program]. Armonk, NY: IBM Corp., 2011 [24] R Core Team. R: A language and environment for statistical computing. [program]. Vienna, Austria: R Foundation for Statistical Computing, 2012. [25] Broer C, Heerings M. Neurobiology in public and private discourse: The case of adults with ADHD. Sociol Health Illn 2012;25:49–65. [26] Holzinger A, Floris F, Schomerus G, Carta M, Angermeyer M. Gender differences in public beliefs and attitudes about mental disorder in western countries: a systematic review of population studies. Epidemiol Psychiatr Sci 2012;21:73– 85. [27] Holzinger A, Matschinger H, Angermeyer M. What to do about depression? Help-seeking and treatment recommendations of the public. Epidemiol Psychiatr Sci 2011;20: 163–9. [28] Lewis M. A Rum State: alcohol and state policy in Australia 1788–1988. Canberra: Australian Government Publishing Service, 1992. [29] Courtwright D. The NIDA brain disease paradigm: history, resistance and spinoffs. BioSocieties 2010;5:137–47. [30] Keane H. Adventures of the addicted brain. Aust Fem Stud 1999;14:63–76. [31] Jorm A, Griffiths K. The public’s stigmatizing attitudes towards people with mental disorders: how important are biomedical conceptualizations. Acta Psychiatr Scand 2008;118:315–21. [32] Breheny M. Genetic attribution for schizophrenia, depression, and skin cancer: impact on social distance. NZ J Psychol 2007;36:154–60.
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Appendix S1. This material supplements the paper Meurk, C et al. Public attitudes in Australia towards the claim that Addiction is a (Brain) Disease. It outlines the information given to participants of the Queensland Social Survey (QSS) 2012 along with relevant survey questions with response formats.
Supporting information Additional Supporting Information may be found in the online version of this article at the publisher’s web-site:
© 2014 Australasian Professional Society on Alcohol and other Drugs
R E V I E W
Drug and Alcohol Review (May 2014), 33, 272–279 DOI: 10.1111/dar.12115
Public attitudes in Australia towards the claim that addiction is a (brain) disease CARLA MEURK, BRAD PARTRIDGE, ADRIAN CARTER, WAYNE HALL, KYLIE MORPHETT & JAYNE LUCKE UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia
Abstract Introduction and Aims. We investigated the Australian public’s understandings of addiction to alcohol and heroin and the factors predicting support for the idea that these types of addiction are ‘diseases’ and specifically ‘brain diseases’. Design and Methods. Data were collected as part of the 2012 Queensland Social Survey, a computer-assisted telephone interview of 1263 residents of Queensland, Australia. Participants were presented with scenarios of two addicted persons, one who was addicted to heroin and the other addicted to alcohol. Participants were asked a series of questions about different definitions and causes of addiction for both characters. Results. Over half of the respondents thought that addiction is a disease (alcohol: 67%, heroin: 53%), but fewer (alcohol: 34%, heroin: 33%) believed that addiction is a brain disease. Belief that addiction has biological causes predicted agreement that addiction is a disease [alcohol: odds ratio (OR) = 3.05 (2.15–4.31), heroin: OR = 3.99 (2.82–5.65)] and a brain disease [alcohol: OR = 4.97 (3.42–7.22), heroin: OR = 14.12 (9.23–21.61)].Women were more likely than men to agree that addiction is a disease [alcohol: OR = 1.79 (1.35–2.38), heroin: OR = 1.40 (1.09–1.81)] as were those 35 years of age and older [alcohol: OR = 2.25 (1.50–3.40), heroin: OR = 1.50 (1.01–2.24)]. Discussion and Conclusions. There is more public support for the idea that addiction is a ‘disease’ than for the more specific claim that it is a ‘brain disease’. Support for a biological aetiology of addiction predicted higher levels of agreement with both disease concepts. [Meurk C, Partridge B, Carter A, Hall W, Morphett K, Lucke J. Public attitudes in Australia towards the claim that addiction is a (brain) disease. Drug Alcohol Rev 2014;33:272–279] Key words: public attitude, brain disease model of addiction, neuroethics, alcohol, heroin.
Introduction In the USA, directors of the National Institute on Drug Abuse have argued that addiction is a ‘chronic relapsing brain disease’ and that ‘attending to the brain’ should be a core part of dealing with addiction [1,2]. However, the advantages of labelling addiction as a (brain) disease have been hotly contested by philosophers, sociologists, scientists and clinicians [3–7] who have expressed concern about the social, cultural and political implications of a ‘brain disease’ model [6–10]. If its advocates are correct, acceptance of the brain disease model of addiction will have social benefits by encouraging more addicted individuals to seek treatment and enhancing tolerance towards addicted
persons because addiction will be seen as something outside the control of those affected [1,2]. Critics, on the other hand, are sceptical that neuroscience research supports the view that addiction is a brain disease [11,12] and identify possible negative social consequences of accepting the brain disease view: it may encourage fatalism [13]; increase stigmatisation of addicted persons; promote coercive addiction treatment and/or the overuse of pharmacological treatments; and de-emphasise the role of social factors in the aetiology and treatment of addiction [4,14]. The likelihood of these competing claims about the social consequences of the brain disease model depends on how members of the public understand addiction. Are members of the public aware of the brain disease
Carla Meurk PhD, Postdoctoral Research Fellow, Brad Partridge PhD, NHMRC, Research Fellow, Adrian Carter PhD, NHMRC, Research Fellow, Wayne Hall PhD, Australia Fellow, Professor, Kylie Morphett BPsych (Hons), PhD Candidate, Jayne Lucke PhD, Associate Professor, Principal, Research Fellow. Correspondence to Dr Carla Meurk, UQ Centre for Clinical Research, The University of Queensland, 71/918 Royal Brisbane and Women’s Hospital Site, Herston, Qld. 4029, Australia. Tel: 07 3346 5477; Fax: 07 3346 5598; E-mail: [email protected] Received 18 September 2013; accepted for publication 18 December 2013. © 2014 Australasian Professional Society on Alcohol and other Drugs
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model of addiction? If so, do they accept it? Do they accept what its advocates (or detractors) take to be its social entailments? Understanding the social meanings of addiction can assist in formulating health education about addiction and its treatment and inform debates about the social and ethical implications of labelling addiction as a brain disease. Understanding the meanings of addiction also contributes to scholarship on the medicalisation of addiction and shifting ideas about personhood, the body and its governance [7,15,16]. Addiction is a complex construct, and numerous discourses circulate publically [17]. In a previous qualitative investigation, we found that members of the Australian public understand addiction to be caused by multiple overlapping factors that included social environmental factors, emotional and experiential drivers, biology, rationality and education, the drug itself, and personal character [18]. There was a general acceptance of the idea that addictive drugs acted on brain mechanisms, but many people were ambivalent about accepting that addiction was a ‘brain disease’ [18]. The ‘brain disease’ notion evoked a diverse, and diffuse, set of meanings and uncovered multiple conceptualisations about the structure and function of the brain. The present study’s aim was to investigate the specificity and generalisability of these qualitative findings. We investigated the attitudes of Australian adults towards the concept of addiction as a brain disease for two addictive substances, one legal (alcohol) and one illegal (heroin).We attempted to quantify the following:
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cally as a ‘brain disease’; and the sociodemographic and experiential predictors of these beliefs. Methods Sampling and recruitment Data were collected as part of the 2012 Queensland Social Survey (QSS), a computer-assisted telephone interview of 1263 residents of the state of Queensland, Australia. QSS is administered by the Population Research Laboratory at Central Queensland University Australia, and the inclusion of our questions was approved by the Human Ethics Research Review Panel at that university. Households were randomly selected using a database of randomly generated telephone landline numbers. Within each household participants were selected who lived at the place of residence; were at least 18 years old; and were either male or female, depending on a gender selected randomly before the call was made. If the household contained more than one individual of the selected gender, then the participant who had the most recent birthday was selected. If no one in the household fits these criteria, the household was disqualified from the sample. The survey had a response rate of 35.34%. The profile of QSS respondents (Table 1), compared with the Australian Bureau of Statistics 2011 census data for Queensland, indicated that residents over the age of 55 were over-represented, and those under the age 35 were under-represented [19,20]. The under-representation of younger persons partly reflects shifts among younger people towards cellular phones [21]. Descriptive statistics were estimated to have a sampling error of plus or minus 2.7% at a 95% confidence level.
• The extent to which participants agreed with the view that addiction is (i) a disease and (ii) a ‘brain disease’. • Their beliefs about the importance of different putative causes of alcohol or heroin addiction. • The relationship between their beliefs about the aetiology of alcohol and heroin addiction and their acceptance of addiction as a ‘disease’ and specifi-
The survey instrument QSS is a large omnibus survey that includes questions from multiple research bodies and other organisations
Table 1. Profile of QSS respondents Male 49.7%
Gender Age
18–24 4.3%
Years of education
1–10 24.9%
25–34 7%
Female 50.3% 35–44 16.5% 11–12 21.5%
45–54 18.6% 13–14 11.3%
55–64 22.6%
65+ 30.6% 15+ 41.6%
QSS, Queensland Social Survey. © 2014 Australasian Professional Society on Alcohol and other Drugs
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on a range of topics. The survey collected basic sociodemographic characteristics and explored participants’ opinions on the causes of addiction and their familiarity with the two drugs of abuse—either their own or that of others. Alcohol and heroin were chosen because they differ in prevalence, social acceptability and method of administration. They are also well known to be examples of legal and illegal drugs. Beliefs about the causes of addiction were examined using a series of questions about two hypothetical men: John was addicted to alcohol and Peter was addicted to heroin (Supporting Information Appendix S1). Participants rated their agreement on a 5-point scale (strongly agree, agree, disagree, strongly disagree, do not know) to each of seven possible causes of each type of addiction, namely (i) bad character; (ii) addictive personality; (iii) psychological problems; (iv) chemistry in the brain; (v) the way he was raised; (vi) stress; and (vii) a genetic or inherited problem. These options were based on the explanations offered by participants in our qualitative interviews [18,22]. Participants were asked about the extent of their agreement that each type of addiction is (i) a disease and (ii) a brain disease. Finally, they were asked whether they, or someone they knew personally, had ever had a problem with (i) alcohol or (ii) heroin. The response options were (i) no; (ii) yes, I have; (iii) yes, someone close to me has; and (iv) yes, both myself and someone close to me has.
Data analysis Data were analysed using spss v.20 [23], with χ2-tests performed in r v.2.15.2 [24]. Demographic variables included as predictors were gender (male = 0, female = 1); age (18–34 years = 0, age 35+ years = 1); and education (1–12 years = 0, 13–14 years = 1, 15+ years). The variable ‘familiarity’ classified those who had themselves or knew someone who had had a problem with alcohol/ heroin use (no = 0, yes = 1). We re-coded the seven questions exploring beliefs about the aetiology of addiction into the following three themes to take into account the findings from our qualitative investigations on the topic [18,22], thematic categories used in the literature [15,25] and results of exploratory analyses of beliefs about the aetiology of addiction. We re-coded the themes as follows (disagree = −1, neutral/do not know = 0, agree = 1): 1. ‘Biological’ aetiology combined participants’ agreement that (i) addiction is caused by chemistry in the brain, and (ii) addiction is genetic/ inherited; © 2014 Australasian Professional Society on Alcohol and other Drugs
2. ‘Socio-environmental’ aetiology combined (i) the way he was raised and (ii) stress; 3. ‘Personal qualities’ aetiology combined (i) psychological problems; (ii) addictive personality; and (iii) ‘bad character’. We conducted four logistic regression analyses to discover what characteristics and beliefs predicted agreement with the following statements: (i) addiction to alcohol is a disease; (ii) addiction to heroin is a disease; (iii) addiction to alcohol is a ‘brain disease’; and (iv) addiction to heroin is a ‘brain disease’. Participants who responded ‘do not know or unsure’ were excluded. The dependent variable in each model was re-coded as a binary variable (disagree/strongly disagree = 0, agree/ strongly agree = 1). Results Public attitudes about whether addiction is a disease versus brain disease More people thought that addiction to alcohol is a disease than is heroin addiction (alcohol: 67% agree, heroin: 53% agree, χ2 = 49.07, P < 0.001). There were no significant differences in the proportions who agreed that heroin or alcohol is a brain disease (alcohol: 34%, heroin: 33%). For both alcohol and heroin addiction, significantly fewer participants agreed that addiction is a brain disease than thought it was a disease (alcohol: χ2 = 281.77, P < 0.001, heroin: χ2 = 127.45, P < 0.001). Participants were more uncertain about whether alcohol and heroin addiction are brain diseases (alcohol: 25% unsure/do not know, heroin: 23% unsure/do not know) than they were about whether alcohol and heroin addiction are diseases (alcohol: 9% unsure/do not know, heroin: 11% unsure/do not know). Public beliefs about addiction’s causes Stress, psychological problems and addictive personality were the three most prevalent causes of alcohol and heroin addiction that participants identified (Table 2). Sixty-five per cent of participants said that stress is a cause of alcohol addiction, 64% selected psychological problems and 62% nominated an addictive personality. In the case of heroin addiction, the ranking was addictive personality (63%) followed by psychological problems (62%) and stress (48%). The belief that addiction is caused by brain chemistry was the fourth most prevalent cause for both alcohol and heroin addiction; it also elicited the highest proportion of ‘do not know/unsure’ responses (23% for alcohol and 24% for heroin). The three least prevalent causes of addiction were genetic/inherited traits, bad character and the way the
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Table 2. Beliefs about the causes of addiction to alcohol and heroin Alcohol (%)
Stress Psychological problems Addictive personality Brain chemistry The way he was raised Genetic/inherited Bad character
Heroin (%)
Agree
Disagree
Do not know
Agree
Disagree
Do not know
χ2
65 64 62 54 52 49 31
21 18 26 23 34 34 58
15 18 12 23 14 17 11
48 62 63 47 40 33 36
36 20 21 29 43 47 48
16 18 16 24 17 20 16
80.56***a 3.27 13.74** 14.66*** 37.92*** 66.85*** 26.42***
**P < 0.01; ***P < 0.001. aχ2-test comparing proportions who ‘agree’, ‘disagree’ and ‘do not know’ across alcohol and heroin.
person was raised. Half (52%) thought that a person’s upbringing could cause alcohol addiction, 49% considered it is caused by genetic or inherited traits and 31% considered that alcohol addiction is caused by ‘bad character’. The least prevalent identified causes of heroin addiction were the way a person is raised (40%), ‘bad character’ (36%) and genetic or inherited traits (33%). Familiarity with problematic alcohol and heroin use Overall, 62% of respondents had either personally experienced or had someone close to them who had experienced problematic alcohol use. Only 19% of respondents reported having experienced problematic heroin use. In both cases, it was mostly someone close to the participant who had a problem (54% for alcohol and 15% for heroin). Factors influencing the belief that addiction is a disease Respondents 35 years and older and females were more likely to agree that alcohol and heroin addiction are a disease (Table 3).Women were more likely than men to agree that addiction to alcohol is a disease [odds ratio (OR) = 1.79 (1.35–2.38)] and that addiction to heroin is a disease [OR = 1.40 (1.09–1.81)]. Those 35 years and older were more likely than those aged 18–34 to agree that addiction to alcohol is a disease [OR = 2.25 (1.50–3.40)] and that heroin addiction is a disease [OR = 1.50 (1.01–2.24)]. Level of education and familiarity with addiction were not significant predictors of beliefs that addiction is a disease. Those who agreed that addiction has biological causes were more likely to agree that addiction is a disease than those who disagreed [alcohol: OR = 3.05 (2.15–4.31), heroin: OR = 3.99 (2.82–5.65)]. Those who did not know or were neutral about the role of
biological causes were also more likely to believe that addiction to alcohol and heroin is a disease [alcohol: OR = 1.82 (1.28–2.61), heroin: OR = 1.63 (1.20– 2.23)]. Beliefs about the personal qualities of an individual did not significantly predict beliefs that addiction to alcohol or heroin is a disease. However, support for the view that addiction to heroin is caused by an individual’s social environment predicted agreement that heroin addiction is a disease [OR = 1.45 (1.03–2.04)]. Not knowing, or being neutral, as to whether heroin addiction has social environmental causes also predicted agreement that addiction to heroin is a disease [OR = 1.52 (1.11–2.08)]. Factors predicting the belief that addiction is a brain disease Age, gender and level of education did not predict agreement with the belief that heroin or alcohol addiction is a brain disease (Table 4). People with personal or vicarious experience of problem alcohol use were more likely to agree that addiction to alcohol is a brain disease than those who did not [OR = 1.49 (1.12– 1.99)]. This pattern did not hold for heroin addiction [OR = 1.12 (0.76–1.66)]. In the case of alcohol, participants who agreed that addiction has biological causes were more likely to agree that alcohol addiction is a brain disease [OR = 4.97 (3.42–7.22)] and so were those who were neutral or did not know if addiction has biological causes [OR = 1.88 (1.25–2.82)]. Participants who agreed that heroin addiction has biological causes were more likely to agree that addiction to heroin is a brain disease [OR = 14.12 (9.23– 21.61)], and so were those who were neutral or did not know if addiction to heroin has biological causes [OR = 3.92 (2.64–5.83)]. Those who agreed that alcohol addiction is caused by personal qualities were more likely to agree that addiction to alcohol is a brain © 2014 Australasian Professional Society on Alcohol and other Drugs
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Table 3. Factors predicting the belief that addiction is a disease Alcohol addiction is a disease Prediction of agreement Age Gender Years of Education Familiarity with addiction Biological causes Social environmental causes Personal qualities
OR 18–34 ≥35 Male Female 1–12 13–14 15+ No Yes Disagree Neutral/Do not know Agree Disagree Neutral/Do not know Agree Disagree Neutral/Do not know Agree
95% CI
1.00 2.25*** 1.00 1.79*** 1.00 0.76 1.12 1.00 1.27 1.00 1.82** 3.05*** 1.00 0.99 1.27 1.00 0.73 0.91
1.51–3.40 1.35–2.38 0.48–1.19 0.83–1.52 0.96–1.68 1.28–2.61 2.15–4.31 0.66–1.48 0.85–1.88 0.44–1.19 0.66–1.25
Heroin addiction is a disease OR 1.00 1.50* 1.00 1.40** 1.00 0.93 1.03 1.00 1.33 1.00 1.63** 3.99*** 1.00 1.52** 1.45* 1.00 1.19 1.02
95% CI
1.01–2.24 1.09–1.81 0.61–1.41 0.78–1.35 0.95–1.88 1.20–2.23 2.82–5.65 1.11–2.08 1.03–2.04 0.74–1.89 0.75–1.39
*P < 0.05; **P < 0.01; *** P < 0.001. CI, confidence interval; DK, do not know; OR, odds ratio.
Table 4. Factors predicting beliefs that addiction is a brain disease Alcohol addiction is a brain disease Prediction of agreement Age Gender Years of Education Familiarity with addiction Biological causes Social environmental causes Personal qualities
OR 18–34 ≥35 Male Female 1–12 13–14 15+ No Yes Disagree Neutral/DK Agree Disagree Neutral/DK Agree Disagree Neutral/DK Agree
*P < 0.05; **P < 0.01; ***P < 0.001. CI, confidence interval; DK, do not know; OR, odds ratio.
© 2014 Australasian Professional Society on Alcohol and other Drugs
1.00 1.35 1.00 1.08 1.00 0.96 1.08 1.00 1.49** 1.00 1.88** 4.97*** 1.00 1.04 1.29 1.00 1.14 1.40*
95% CI
0.85–2.14 0.82–1.44 0.60–1.54 0.80–1.46 1.12–1.99 1.25–2.82 3.42–7.22 0.69–1.58 0.87–1.93 0.66–1.95 1.02–1.92
Heroin addiction is a brain disease OR 1.00 1.20 1.00 1.00 1.00 1.25 1.16 1.00 1.12 1.00 3.92*** 14.12*** 1.00 1.02 0.87 1.00 0.94 1.27
95% CI
0.75–1.93 0.75–1.35 0.77–2.01 0.84–1.59 0.76–1.66 2.64–5.83 9.23–21.61 0.70–1.49 0.58–1.31 0.52–1.69 0.88–1.84
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disease than those who did not [OR = 1.40 (1.02– 1.92)]. Belief that addiction reflects personal qualities did not predict agreement with the view that heroin addiction is a brain disease. Discussion Disease label reflects a biological conception Those surveyed believed that addiction has multiple causes. Older persons, females and those who believed addiction is caused by biological factors were more likely to support the view that addiction to heroin and alcohol is a disease and a brain disease in particular. Our sample did not appear to endorse biological reductionism.Their endorsement of multiple causes suggested the sample see addiction as a syndrome, as was the case in our earlier qualitative interviews. In the case of heroin addiction, social environmental causes predicted support for the belief that addiction is a disease. Factors predicting whether addiction is a brain disease differed according to the drug in question. In the case of alcohol addiction, familiarity with addiction and belief that addiction was caused by personal factors predicted agreement with the claim that it is a brain disease. Despite this variability, the consistency of the biological variable as a predictor of agreement with disease concepts suggests that when people think of addiction as a disease, they invoke a biological conception even though biological causes were among the least commonly identified causes of addiction. The fact that agreement with disease concepts were not, overall, significantly associated with beliefs about personal qualities or social environmental factors, either positively or negatively, suggests that the disease concept does not completely encompass what people think addiction is. The relationship between beliefs, formal learning and personal experience is complex Gender and age differences predicted support for the belief that addiction to alcohol or heroin is a disease but not the belief that addiction is a brain disease. Women were more likely than men to agree that addiction is a disease, and those 35 years of age and older were more likely than those 18–34 to agree that addiction is a disease. There were no educational differences in support for the views that addiction to alcohol and heroin is a disease, and no sex, age or educational differences in degree of support for the view that addiction to alcohol or heroin is a brain disease. The gender differences in support for disease models of heroin and alcohol addiction accord with findings that women are more likely to be aware of, and medicalise, mental illnesses than men [26,27]. Greater
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support for a disease model in older participants may reflect broader historical and cultural influences. The disease concept of alcoholism has a long history of being promoted in Australia through the efforts of the 12-step self-help movement alcoholics anonymous (AA). AA first appeared in Australia in the late 1940s and dominated alcohol addiction treatment until relatively recently [28]. The brain disease model is of more recent origin and, although it has been heavily promoted in North America, it is ambivalently supported by Australian addiction experts [13]. The brain disease model has also been less often promulgated in the Australian media than in the USA [8,29,30]. Personal or vicarious experience of alcohol addiction predicted support for the belief that alcohol addiction is a brain disease. This may be because those with alcohol problems were more likely to have been exposed to this idea via their experiences of treatment by health professionals. They may also find that this idea resonates with their subjective experiences, a hypothesis supported by findings from our qualitative research on the pathways to acceptance of the brain disease model of addiction [22]. Absence of any relationship between familiarity and beliefs about heroin addiction probably reflects much lower rates of familiarity with heroin addiction. Limitations The overall low response rate and bias in the sample towards older and better educated individuals is a limitation of this study. This is an increasingly common limitation of surveys conducted via landline telephones given the greater adoption of cellular phones by younger people [21]. A second limitation is that familiarity with addiction in our sample was mostly vicarious and of uncertain depth. Given that the lower bound of 95% confidence intervals for familiarity hovered near 1 regarding whether addiction is a disease, more detailed measures of familiarity might find it is a predictor of support for disease models. We hypothesise that variability in beliefs about addiction to alcohol versus beliefs about heroin is because of low incidence of respondents’ personal or vicarious experience with heroin addiction in our sample. The generalisability of these findings should also be considered in relation to the male gender of the addicted individuals used to contextualise survey questions. Finally, χ2-tests for differences in beliefs about alcohol addiction versus heroin addiction may be biased because questions relating to John and Peter were not randomly assigned to different groups within our sample. Conclusion Those we surveyed were more likely to accept a disease concept of addiction than a brain disease concept. This © 2014 Australasian Professional Society on Alcohol and other Drugs
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was more likely to be the case for alcohol than for heroin addiction. The patterns of response suggest that members of the public acknowledge that the causes of addiction are multiple and complex and are ambivalent towards reductionist labels for addiction. Framing addiction as a syndrome may resonate more with the Australian public than disease concepts as it allows multiple causes of addiction to be acknowledged. Further research is needed on the impact these beliefs have on beliefs about the most appropriate treatment of addiction, attitudes towards addicted individuals’ responsibility for their addiction and empathy/stigma [31–34]. Research on the perspectives of addicted individuals on these issues is also a priority. Acknowledgements The authors would like to thank staff at the Population Research Laboratory, Institute for Health and Social Science Research, CQ University who administered this study. This research was funded by an Australian National Health and Medical Research Council Australia Fellowship (Grant ID: 569 738) awarded to Professor Wayne Hall. Drs Brad Partridge and Adrian Carter are both recipients of Australian National Health and Medical Research Council Postdoctoral Fellowships. References [1] Volkow N, Li T-K. Drug addiction: the neurobiology of behaviour gone awry. Nat Rev Neurosci 2004;5:963– 70. [2] Leshner A. Addiction is a brain disease, and it matters. Science 1997;278:45–7. [3] Blaxter M. Diagnosis as category and process: the case of alcoholism. Soc Sci Med 1978;12:9–17. [4] Dingel M, Karkazis K, Koenig B. Framing nicotine addiction as a ‘disease of the brain’: social and ethical consequences. Soc Sci Q 2011;92:1363–88. [5] Foddy B. Addiction and its sciences-philosophy. Addiction 2010;106:25–31. [6] Heyman G. Addiction: a disorder of choice. USA: Harvard University Press, 2009. [7] Kaye K. De-medicalizing addiction: toward biocultural understandings. In: Netherland J, ed. Critical perspectives on addiction. UK: Emerald Publishing, 2012:27–51. [8] Vrecko S. Birth of a brain disease: science, the state and addiction neuropolitics. Hist Human Sci 2010;23:52–67. [9] Rusch N, Evans-Lacko S, Thornicroft G. What is a mental illness? Public views and their effects on attitudes and disclosure. Aust N Z J Psychiatry 2012;46:641–50. [10] Hammer R, Dingel M, Ostergren J, Partridge B, McCormick J, Koenig B. Addiction: current criticms of the brain disease paradigm. AJOB Neuroscience 2013;4:27–32. [11] Levy N. Addiction is not a brain disease (and it matters). Front Psychiatry 2013;4:1–7. [12] Kalant H. What neurobiology cannot tell us about addiction. Addiction 2009;105:780–9. © 2014 Australasian Professional Society on Alcohol and other Drugs
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Appendix S1. This material supplements the paper Meurk, C et al. Public attitudes in Australia towards the claim that Addiction is a (Brain) Disease. It outlines the information given to participants of the Queensland Social Survey (QSS) 2012 along with relevant survey questions with response formats.
Supporting information Additional Supporting Information may be found in the online version of this article at the publisher’s web-site:
© 2014 Australasian Professional Society on Alcohol and other Drugs
