 session will be Sheila Murphy with a question. Okay I first I wanted to thank Dr. Flanagan for a very thought-provoking, I'm still kind of you know in my head thinking about all that he brought forth. But what about the women? How do women fit into all this? The women fit in. Good that's it. Yeah so you notice certain features except for Morphe and Mary they were all men my examples and they're all white. So I'm aware of that. So here's here's roughly the idea I think the the answer is that women are out there but part of the sort of my aim behind this whole talk was to sensitize us actually following up on the your talk and then Carl's talk that the concept of addiction is it not just an individual level phenomenon. Now because I have substance abuse disorder either now depending on what you think it is a permanent disease or in my past I'm actually pretty good at speaking from my own personal experience about what it was like to be the kind of Irish Catholic male oldest kid in a large family six children. I can tell you about that I can also tell you read memoirs of men who are like me or listen to them at recovery meetings where I feel I really get it I can they can understand my experience and I can understand their experience. But I think that this is what's to me in one way the point I don't feel that I have the position to speak from authority about what it's like to be a woman addict. I've met plenty in my meetings over the years I would just say this here's a sociological observation more men come into meeting alcoholic meetings having gotten into sort of public trouble jail institutions police trouble they were also you know back when I did get sober some people I saw there were people I used to drink with but I didn't know they had a problem we just all drank together. There are more women who are likely to come in because of social stigmatization of female behavior in drinking who you find out as I said at lunch today and I made the minister nervous is the minister's wife and she's 65 years old and she's been drinking for a really long time and it's been painful so I partly you know my message today was really partly that the people who get permission to use in ways that we think of as abusive Keith Richard baby's the best example tend to be white rich and middle class or above men and I think there's a different profile depending on the way they a certain drug or substance runs through a community there are sort of sociological features of it and so I intentionally decided not to speak for women I don't know anything to say about I spoke about I know about like what it's like to be Keith Richard I wish that was yeah that makes sense yes very much but I guess I what I guess I wanted to take a moment to think about was in this notion of willing addiction women are left out of that picture and they're left out of that picture for very concrete and discernible reasons one of which is childbearing of course yeah and the other one is our you know patriarchy you know the fact that men get to do a lot of things that women don't get to do and get judged in a much harsher fat fashion and therefore it becomes you know you know that that all seems unfair and unequal but it also has real consequence for things like seeking treatment and if they want to quitting using drugs and and I think they're doubly punished doubly stigmatized for their behaviors and I think those are these are important things to keep to the forefront when we're talking about these things. Thank you all for really a really good talk and helping us to think about some of the important issues I just wonder if we could talk maybe further about two issues I mean the panel I know it's a difficult situation in with you or you find yourself right now because you just gave a talk a long-ass talk and now shorter than yours really but but now now but now you you're asked to like pay attention and answer these questions from all of us I know that's difficult so I want to maybe ask others to help out you know but thank you for raising these important issues two issues that you raise that I think needs some more clarification some more discussion deals with the issue of addiction is a brain disease and the issue of just the terminology particularly when I think about morphine Mary addiction as defined by the DSM of course the word isn't used and we think about clinicians the main thing is that people are distressed and you have these social dysfunctions disruptions not physical dependence the field moved away from that many years ago so physical dependence is not even that important we all know that at least in the field and so I wonder if we could talk more about that and the issue of brain disease it's kind of simple when we ask people can you show me in the brain where is addiction can you show me how addiction is a brain disease like other brain diseases Parkinson's disease Alzheimer's disease Huntington's disease brain diseases what evidence do we have that drug addiction is a brain disease can I speak to that one that's that's a topic that's close to my heart no pun intended and mark I'm just gonna ask to make sure you speak up clearly okay I'm gonna speak as loud as I can you know my whole my talk tonight is going to be about whether addiction is a brain disease and the answer is no so that's there you don't have to come to my talk thank you thank you but although and I agree with you call that you know that you can't point to an area and there's no spits okay let me let me say this oh the one thing you said that I disagreed with is that you say addiction is not a natural kind now it's not a one of not a natural kind I say that natural I said oh and oh and oh I'm gonna get back to you that addiction is not a natural kind you said and a natural kind for non philosophers I guess is means something that is like definable as a unitary separate independent thing like a zebra a zebra is a zebra okay and and so forth and there's no there's no different ways to be a zebra you're either a zebra or you're not so but I think addiction is a natural kind but I don't think it's a brain disease so that's where I want to draw a line normally when we think it's a natural kind I it's a disease no it's not a disease but it's a very specific phenomenon that's got really specific characteristics to it and such as itself perpetuating itself building it feeds on itself you know and all there's there's a number of different things I think of it as an attractor in a state space which some of you might know what that kind of language means but I mean it's it's a place that people often end up in because different paths lead to it like different paths lead to Rome and then you're there and then it's very distinct and you know like people say about an orgasm you there's no question about whether you must have one or not you know if you had an orgasm what are you faking it I take it there's a question to Owen here about the natural kind what we mean so let me so I mean why don't I just finish yeah and then I will stop so yeah so I think it is a very specific phenomenon but it's not a disease so that's why it's difficult that's why it's confusing that's why we have such a hard time that's why we continue to argue whether it's a disease or not is because it is a natural kind it's a very specific thing but it's not a disease I'm just going to leave it there but you think it takes place hold on let's give you a chance to response what I took to be the question so yeah this is where I think so three three points helpful so you heard that I I claim that it can't possibly be a brain disease for reasons that Carl just indicated no one's able with lots of work to show the distinctive brain profile but even if they were if you think about the logic the sort of social logic of the way we describe whether someone's an addict or not it depends on all kinds of features independent of the person's brain and even body and that's why I think what car I'm not sure of Carl and I Carl might have think he disagrees with me about morphine Mary the reason I like morphine Mary is if there was suppose a squiggle squaggle that every morphine heavy morphine user's brain did then morphine Mary would show up that way but the reason no one is going to attribute to her the normative scar of being an addict is because she's not on the street scoring street drugs and causing trouble or potentially causing trouble so she gets permissions because of features that have nothing to do with her or her use but as I as I tried to say yesterday I think some of us know here who hang around in the addiction talk circuit that there are a lot of people who just want to say it is a brain disease the simple solution is just to say of addictive use or abusing drugs involves features of the brain that might be one location of intervention for different drugs with different other drugs perhaps or different kinds of therapy it's just as an aspect just as the normative and political structures of society which say this is a really bad drugs that there's black drug fiends on the streets in 1914 or whatever it was in the south or the cocaine I remember the year in which I read in the must have been about 1981 I was still in the northeast that crack cocaine was an epidemic and no one in the history universe who ever used crack had ever recovered from crack addiction and that was the rhetoric that was out there with regard to the quick other point about natural kinds the way philosophers of science would usually use natural kinds it would apply as Mark said to like when you go into a chemistry room and you see the periodic table of elements you know gold is a substance with atomic number 79 that's a natural kind and some people say zebra is a natural kind I pretty much think that social kinds are never natural kinds because we sometimes say a natural kind is a kind that cars nature at its joints and I think that any kind like something like addiction substance abuse all these things have so many political cultural gender related how the society is viewing them treating them which are so politicized and economically and in every other way that you're not carving nature at any joint that I know about that's all Mark Willenbrink was a couple things first of all in some ways it doesn't matter whether we call it a disease you know in terms of where to intervene is really the the the question and that's on multiple levels I mean the reason tuberculosis is no longer highly prevalent has had very little to do with antibiotics had almost everything to do with public health measures to get better water and sewage so and taxation is a way to reduce alcohol use for example so one of things I wanted to do well first of all I just like to offer in to try to I mean the issue of whether whether something is a disease is fundamentally to my mind definitional and that's a lengthy and complex discussion I guess I just like to offer one conceptualization I have of it which is from George Kub who's the head of the alcohol Institute at NIH where some a system that's in homeostasis shifts into a different stable configuration called allostasis that's less adaptive and whatever levels of the system you're talking about everything from social to as Ken Kenler says you know if we want to get really reductionistic it's all about particle physics but I think one of the key aspects is so there's two things about this fundamentally I think that we it's often about a biological reductionism to say it's just a brain disease and I believe it was Stephen Jay Gould who said who wrote that biological reductionism politically is always reactionary because you blame an individual for their problems that may well have been caused because of social policies and and and other things like that family situations and so forth so and but I wanted to kind of circle back then to one of the very first things you said Ellen which was at the very beginning is that and it took me 40 years as a clinician and a researcher to finally get it that there's only one thing happening there's only one it's not we we we have so much trouble getting away from linear oh it's caught this causes this and then that causes that whereas in fact the whole system is constantly interacting we are complex dynamical systems and it's very hard to model that but it's only one thing happening at once and they're just different levels of analysis yes thank you I think this is a very rich discussion and I agree with my colleagues we could go on and on and on but I'd like to bring us to the other part of it as a humanist first and foremost in this work I follow the adage and forgive the word disease replace it with condition or whatever you want don't ask what disease the person has ask what person the disease has let's talk about the person who needs our help because we all know someone who has the condition the disease the biopsychosocial disorder and I'd like to bring us there because we know that how we interact with people with whatever level of issue they report affects whether they're willing resigned motivated or not so I think I'd like to move us in that direction how do we talk with these folks to help them find what they need I work at an outpatient program it's innovative unlike any I've ever seen and we almost never have this conversation it almost never comes up because it's irrelevant to whether or not they get well so I agree with Michael I'd like to ask a question from a student he asked many people that I look look up to and when considered to be role models fall into the category of willing addict do you think this is either positive or negative or neither and he signs it a white male artist slash student well I would first say let's not assume that they're a willing addict let's figure out what that is I mean that that was very useful in terms of the talk but it's not something that really in any empirical way defines the person if that person I wouldn't even call that person an addict I don't use the word addict alcoholic clean or dirty I use these more disease-like terms because they take it away from the person that they're not pejorative so don't assume they're a willing addict there's some issue do they want some help ask them if they want some help why they might want some help so the more labeling we do even if we feel empirically accurate I think the more difficult it is to motivate people to change just a quick response to it that's a very moving question that the student asks and yeah just I think it's tricky I think actually the class of people that I was willing to trying to ask us to think about who might fit might fit the profile of people who are okay with their addiction because I think it's important to like realize that this is a really complicated spectral phenomenon or set a phenomenon but I was thinking of people who like a Keith Richard would just say with impunity I do this the people who love me are fine with it and I'm just gonna do I do this yeah and I'm fine with it right certainly don't meet criteria for addiction social disruptions no disruptions no distress right right but I mean there are people here tonight who will go out and drink their alcohols and their usual ways right that's right there's one clarification just one just that quick but I thought the very moving question is you know one never knows and it goes back to some things that were said earlier about that we've all been trying to say I think about the complex system level one might be looking up to adults that one thinks have a problem as opposed to someone who people who are fine with whatever and that and there are lots of family rules on this Sunday night on 60 minutes Patrick Kennedy Ted Kennedy's son spoke about a 1993 intervention with his dad about his his dad senator Kennedy's drinking and he reported that his father opened the door and went out and wrote his son a mail letter saying don't ever do that again and they never talked about it again so these things are very very complicated situation specific I don't think there's any general algorithm for knowing what you're dealing with exactly or what the system is like it's very complicated and individual I would caution us to be very careful if we're listening to Patrick Kennedy about anything related to this issue I just just a quick clarification is that in terms of the diagnosis it requires clinically significant impairment or distress so if somebody is using and they're neither distressed nor impaired then they don't have a disorder disorder yeah all right mark Lewis but my it's quick too I just want to say that zebra even though it's a natural kind zebra is very complex well more I mean so addiction can be a certain thing and still have many levels to it and yes I think a lot of them you I can point to in the brain but that doesn't mean that there's not a lot of very also important levels going on in the social realm that's all yeah I'm just a comment about the Kennedy interview I started out kind of with that reaction it's like oh here we go the old party line but I will say that one thing that I felt that he did in the interview by coming public coming forward in such a prominent way breaking the family rules in the taboo is that so many families who live with this have tremendous shame and I think that he helped to kind of break some of the rules about that and help some of those of us who have struggled with that feel better about you know we we should be able to talk about this publicly just the way we do about a family member with cancer or diabetes and I'd like that part of it thank you and thank you I just have to say something you know and point is well taken it's just that I've heard Patrick Kennedy say so many in name things on this subject that I'm biased well and what I was just gonna say is you know I think that some people in the audience are saying well what the hell are they talking about you know it's a brain disease it's not a brain disease who cares you know if I have somebody in my life who's losing their job you know wetting the bed doing whatever it is that's that's that's disrupting my family life what you know what do we care if it's a disease or not but it has real importance how we conceptualize yes it has importance with took for us as scientists as to what kind of questions we can address it has real importance for that person who is thinking about themselves and their drug use and saying well if I have a disease I haven't heard of any drugs that are gonna cure this disease and drugs are my problem maybe I should be a resigned person I mean what why should I try I've already ruined my brain and what we're saying is no no okay that's and and I think we have to think about that that's why this discussion is important because the way we as people who are trying to understand addiction treat addiction live with not addiction is the wrong word drug drug use and or drug abuse is has real import and real consequence Mike no good points excellent people can recover you know we haven't said that here people can recover they can get better well and if we bring in a doctor candell's work here in plasticity the brain can rebound whether it came from the brain or not it certainly affects the brain we all know that and so it can rebound people can get well I just wanted to make a point that about what we talked about before with the Patrick Kennedy you can come out and talk to your family members that you're concerned about I think that's a good part of that I want to those stress the message that traditional interventions and that approach to dealing with your loved ones does not work so that's not the way to talk to them and later on this afternoon we'll learn more ways of doing that right final comment from Mark Lewis and then we'll adjourn but we'll be back here at three o'clock with the panel discussion about okay not only people can recover they most often recover and you know there's I mean you hear stats between 60 and 75% do recover from real from real addiction without any treat and a lot of those a lot of us yeah recover without treatment like the majority you know people are not aware of that and it's really doesn't mean they have to do it that way it's a very painful no some people need treatment for some people it's very beneficial but some people don't a lot of people don't so it's just important to mention that you know and the funny thing about the brain disease issue which I will come back to in my talk is is and I really agree with what you just said that it really matters the first the first article that said that came up with the brain disease official designation said addiction is a brain disease and it matters that was the title of the article and that was in the 90s 1997 and it wasn't an article it was an opinion piece that's right in science right that's right it was an opinion piece by Alan Lester okay but that's like a short article but anyway and then recently a couple of pieces have come out saying addiction is not a brain disease and it matters like those of the title and and yeah because all that matter it matters because it really helps helps us with our thinking helps us know I would really encourage anyone who thinks it's a brain disease to read Alan Lester's 1997 science paper and evaluate it for evidence evaluate it for rigor it won't hold up I disagree what you haven't read it or you don't know what you're not I'm not defending the paper but but I I think that but I know we have to stop but we will be back at three o'clock at which point we will have Mark Willen Bray Mike Panalone and Anne Fletcher and then they'll all be joined by the Mary band again so back here at three thank you wonderful paper by Owen Flanigan thank you Anne Fletcher Mark Lewis and Carl Hart will be available for book signing in the forum unfortunately we're sold out of Dr. Hart's book but there are a hundred some copies floating out there that I think some people would like to have signed otherwise Anne's book and Mark's book will be available for purchase over in the forum