We argue that when considering addiction as a disease, the lens of neurobiology is valuable to use. It is not the only lens, and it does not have supremacy over other scientific approaches. We agree that critiques of neuroscience are warranted [108] and that critical thinking is essential to avoid deterministic language and scientific overreach. Interpreting these and similar data is complicated by several methodological and conceptual issues. First, people may appear to remit spontaneously because they actually do, but also because of limited test–retest reliability of the diagnosis [31]. This is obviously a diagnosis that, once met, by definition cannot truly remit.
Collectively, the data show that the course of SUD, as defined by current diagnostic criteria, is highly heterogeneous. Accordingly, we do not maintain that a chronic relapsing course is a defining feature of SUD. When present in a patient, however, such as course is of clinical significance, because it identifies a need for long-term disease management [2], rather than expectations of a recovery that may not be within the individual’s reach [39]. From a conceptual standpoint, however, a chronic relapsing course is neither necessary nor implied in a view that addiction is a brain disease. Human neuroscience documents restoration of functioning after abstinence [40, 41] and reveals predictors of clinical success [42].
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The person we call an addict always monitors their rate of consumption in relation to relevant circumstances. For example, even in the most desperate, chronic cases, alcoholics never drink all the alcohol they can. They plan ahead, carefully nursing themselves back from the last drinking binge while deliberately preparing for the next one. This is not to say that their conduct is wise, simply that they are in control of what they are doing.
Epidemiological data are cited in support of the notion that large proportions of individuals achieve remission [27], frequently without any formal treatment [28, 29] and in some cases resuming low risk substance use [30]. These spontaneous remission rates are argued to invalidate the concept of a chronic, relapsing disease [4]. As briefly touched upon earlier, it is not inconceivable that the BDM and the CM are essentially referring to distinctly different ‘types’ of addicts.
