This article reviews scientific advances in the prevention and treatment of substance-use disorder and related developments in public policy. In the past two decades, research has increasingly supported the view that addiction is a disease of the brain. Although the brain disease model of addiction has yielded effective preventive measures, treatment interventions, and public health policies to address substance-use disorders, the underlying concept of substance abuse as a brain disease continues to be questioned, perhaps because the aberrant, impulsive, and compulsive behaviors that are characteristic of addiction have not been clearly tied to neurobiology. Here we review recent advances in the neurobiology of addiction to clarify the link between addiction and brain function and to broaden the understanding of addiction as a brain disease. We review findings on the desensitization of reward circuits, which dampens the ability to feel pleasure and the motivation to pursue everyday activities; the increasing strength of conditioned responses and stress reactivity, which results in increased cravings for alcohol and other drugs and negative emotions when these cravings are not sated; and the weakening of the brain regions involved in executive functions such as decision making, inhibitory control, and self-regulation that leads to repeated relapse. We also review the ways in which social environments, developmental stages, and genetics are intimately linked to and influence vulnerability and recovery. We conclude that neuroscience continues to support the brain disease model of addiction. Neuroscience research in this area not only offers new opportunities for the prevention and treatment of substance addictions and related behavioral addictions (e.g., to food, sex, and gambling) but may also improve our understanding of the fundamental biologic processes involved in voluntary behavioral control. In the United States, 8 to 10% of people 12 years of age or older, or 20 to 22 million people, are addicted to alcohol or other drugs. 1 The abuse of tobacco, alcohol, and illicit drugs in the United States exacts more than $700 billion annually in costs related to crime, lost work productivity, and health care. 2-4 After centuries of efforts to reduce addiction and its related costs by punishing addictive behaviors failed to produce adequate results, recent basic and clinical research has provided clear evidence that addiction might be better considered and treated as an acquired disease of the brain (see Box 1 for definitions of substance-use disorder and addiction). Research guided by the brain disease model of addiction has led to the development of more effective methods of prevention and treatment and to more informed public health policies. Notable examples include the Mental Health Parity and Addiction Equity Act of 2008, which requires medical insurance plans to provide the same coverage for substance-use disorders and other mental illnesses that is provided for other illnesses, 5 and the proposed bipartisan Senate legislation that From the National Institute on Drug Abuse (N.D.V.) and the National Institute of Alcohol Abuse and Alcoholism (G.F.K.) — both in Bethesda, MD; and the Treatment Research Institute, Philadelphia (A.T.M.). Address reprint requests to Dr. Volkow at the National Institute on Drug Abuse, 6001 Executive Bld., Rm. 5274, Bethesda, MD 20892, or at nvolkow@ nida . nih . gov.

Review Article: Neurobiologic Advances from the Brain Disease Model of Addiction

Academically Adrift: Limited Learning on College Campuses Richard Arum and Josipa Roksa University of Chicago Press, 2011 This book has much to say that is perceptive about today's undergraduate higher education in the United States. It will be valuable to review the authors' insights. At the same time, it will be as instructive to note the book's weaknesses, and especially what is omitted from the discussion. It is a discussion that is truncated intellectually by the authors' close adherence to the selective awareness that so greatly typifies the mindscape of the contemporary American "establishment" in academia and throughout the commanding heights of American society. That mindscape allows a recognition of many things, but not of others. The authors are both faculty members at major American universities. Richard Arum is a sociology professor at New York University with a tie to the university's school of education. He is the author of several books on education and director of the Education Research Program sponsored by the Social Science Research Council. His co-author, Josipa Roksa, is an assistant professor of sociology at the University of Virginia. That the book is published by the University of Chicago Press attests to its presumptive merit. Academically Adrift furnishes an example of something that has long been common in social science writing: a rather thin empirical study serving as the work's own contribution, combined with considerable additional material coming out of the literature on whatever subject is being explored. The function of the authors' own research is thus often to serve more or less as scientistic windowdressing. The reason we say the empiricism for this book is "thin" is that the "longitudinal data of 2,322 students," while seemingly ample, involves students spread over "a diverse range of campuses," including "liberal arts colleges and large research institutions, as well as a number of historically black colleges and universities and Hispanic-serving institutions," all "dispersed nationally across all four regions of the country." This must necessarily mean that the "sample" from any given institution or program was quite small. We are told that the authors didn't concern themselves with the appropriateness of each sample, but left the recruitment and retention of the sample's students to each of the respective institutions. The authors acknowledge that the study included fewer men than women, and more good students than those of "lower scholastic ability." So far as this book is concerned, however, the thinness doesn't particularly hurt the content, since so much of what is said doesn't especially depend upon anything unique found by the authors' own research. A brief summary is provided when the authors say that "we will highlight four core 'important lessons' from our research." These are that the institutions and students are "academically adrift" (which is the basis for the book's title), that students gain surprisingly little from their college experience, that there is "persistent and growing inequality" in the students' learning, and that "there is notable variation both within and across institutions" so far as "measurable differences in students' educational experiences" is concerned. Following the lead of former president Derek Bok of Harvard and of the Council for Aid to Education, the authors' ideal for higher education is that it will enhance students' "capacity for critical thinking, complex reasoning, and writing." These are the three ingredients measured by the Collegiate Learning Assessment (CLA), which the authors value most among the various assessment tools. The CLA results, they say, show that "growing numbers of students are sent to college at increasingly higher costs, but for a large proportion of them the gains in critical thinking, complex reasoning and written communication are either exceedingly small or empirically nonexistent. …

Academically Adrift: Limited Learning on College Campuses

refugee children, Watters’ book provides more generally significant insights into a wide array of issues relevant to contemporary refugees. Rather than concentrating on those who receive refugee status from host societies, Watters asserts “the focus of this book is not restricted to legal and administrative definitions of refugee children, but instead accords with what Zolberg has referred to as a ‘sociological’ definition ‘grounded in observable social realities’” (p. 2). In addition, Watters draws extensively from contemporary theorists of inequality, exclusion and domination—Michel Foucault, Aihwa Ong, Pierre Bourdieu, Homi Bhabha, Liisa Malkki among them—to create a refined appreciation of the ways that states and bureaucracies affect refugees’ understandings of themselves, their social position and their ability to act in their own interest. Refugee Children is based upon the analysis of refugees in several (mostly European) countries of settlement, including Germany, the Netherlands, Belgium, France and especially the U.K., which according to the author is regarded by many stateless persons as the most desirable point of settlement. In addition, the book examines populations originating from and travelling through multiple world regions. Drawing from his own research as well as his reviews of journalistic and academic literature, Watters gives readers numerous first-hand accounts of the settings, interactions and assistance programs that refugee youth encounter. The author carefully attends to the origins of refugees, considering their history, religion and cultural background. Based on this, he questions both the assimilationist approach to refugee resettlement that would compel recent arrivals into the acceptance of host society practices in order to facilitate access to jobs and health care, as well as multicultural models that see refugees as inextricably immersed in the cultural and religious patterns of their country of origin, and as such, fundamentally unlike persons native to the host society. Championing neither, he regards both as paternalistic and potentially limiting to refugee children’s ability to make choices based upon their own outlooks, goals and understandings. In a like manner, Watters assesses models of resettlement in terms of their allocation of resources. He critiques both tight-fisted programs that fail to provide minimal levels of support as well as therapeutic regimes that assume all forced migrants to be deeply wounded and as such, in immediate need of culturally alien and sometimes unwanted rehabilitation. Despite its impressive scholarship, Refugee Children: Towards the Next Horizon is not simply an exercise in academic analysis. Rather, it offers valuable information with many practical examples drawn from successful programs devoted to refugee youth. If there is one downside to this book, it is that the volume is so rich in theories, examples, case studies, suggestions for practice and evaluations of the political and ethical implications of various approaches to working with young refugees, that readers may become overwhelmed. Its scholarly exuberance notwithstanding, Refugee Children: Towards the Next Horizon is a thought-provoking and sophisticated resource for scholars and practitioners interested in the experience of forced migrants in general and refugee youth in particular. The book does an impressive job of filling the conceptual, contextual and theoretical gaps that have, until recently, limited the breadth and quality of research on forced migrants.

Imprisoning Communities: How Mass Incarceration Makes Disadvantaged Neighborhoods Worse

American Apartheid: Segregation and the Making of the Underclass. Douglas S. Massey , Nancy A. Denton

existing political arrangements were threatened, anticipated effects failed to materialize quickly, or other budget priorities (chiefly the Vietnam war) surfaced. As with any large-scale conflict, the “fog or war” imposed a messy reality on wellintentioned plans. In signing the 1964 Economic Opportunity Act, Johnson asserted that he wanted to enhance ‘opportunity’ and not increase public ‘doles.’ Over time, however, the provision of cash and cash-like benefits to the poor increasingly came to dominate the policy landscape. And while a growing economy had made the elimination of poverty a seemingly reasonable goal to those launching this war, the problem proved more intractable than imagined. Was the War on Poverty won or lost? The authors offer no easy answer, simply because there is none to offer. The official poverty rate bottomed out in the early 1970s at 11.1%. The elderly have fared well, while children have not. Overall, it is difficult to see significant aggregate progress. While few today recall that a War on Poverty was declared in 1964 this volume documents how much subsequent social policies were shaped during this period. Clearly, victory has proved elusive. Yet, considering the trends that have driven income inequality to heights not seen since the onset of the Great Depression, arguably this war has done much to mitigate those trends’ worse consequences. This volume should be read by all students of public policy. It offers a cogent and clear examination of both the difficulties and necessity of addressing one of society’s most enduring problems.

Stuck in place: urban neighborhoods and the end of progress toward racial equality

This article builds on an existing body of scholarship on historical and intergenerational cultural trauma to elucidate deliberate attempts to eliminate Native Hawaiian cultural practices related to psychoactive drug use and replace them with the foreign (Western) tradition of alcohol use. This action, to instill alcohol as a component of colonial domination, was one example of the resulting assault on cultural identity that has often been overlooked, particularly in relation to transgenerational trauma in the history of Hawai'i and the Hawaiian context. In this article, we argue for the use of the term historical trauma, introduced by Brave Heart, which allows for a more inclusive consideration of the many aspects of trauma. Drawing on literature related both to alcohol use in indigenous Hawaiian society and to the wider historical context of Hawai'i since the late eighteenth century, we endeavor to demonstrate the correlation between the historical trauma experienced by the population and the incidence of alcohol consumption and alcohol use disorder. The article is intended to augment the existing paradigm on cultural trauma as it specifically relates to Hawaiians, and potentially to widen the explanatory power of this paradigm with regard to present-day psychoactive drug use among Hawaiians as well as the implications for treatments.

Indigenous Hawaiian Psychoactive Drug Use: Before European Contact, and after 1778.

This article reviews multidisciplinary literature to propose a structurally traumatized communities theoretical framework relating to three major topics: (a) addiction as an equal opportunity disease, (b) the psychology of marijuana use, and (c) anger and rage. From an ecological and structural perspective, the socially defined themes of stigma and stereotypes interplay with sociopolitical, historical, and cultural forces that contribute to substance use and addiction among African Americans and the treatment success gap that they experience in drug treatment. Empathy serves as an underlying mediating construct in clinical training and accreditation standards, inducing a systematic improvement in programmatic service delivery.

The intersection of structurally traumatized communities and substance use treatment: Dominant discourses and hidden themes

Too often, the unique needs of men that may jeopardize treatment and prevent full recovery are left unaddressed in the psychosocial space and cultural representational place of substance use disorder treatment. Helping men to address concerns related to fatherhood can strengthen their identities as fathers and aid in the recovery process. This article draws on symbolic interactionism, identity theory, structuration, and double consciousness to frame discourses on child support, visitation rights and custody, parenting, and masculinity/manhood. Clinical suggestions are offered within the scope of treatment for promoting fathering roles and engaging men in dialogues about issues that are integral to fatherhood in recovery.

Desilencing Fatherhood: Making the Invisible Visible Within Substance Use Disorder Treatment

The field of substance use disorder treatment has long been dominated by the influence of Alcoholics Anonymous’ (AA) Twelve Steps to alcohol addiction recovery. This article provides a conceptual d...

Inside the black box of traditional treatment programs: clearing the air on the original literary teachings of Alcoholics Anonymous (AA)

Native Hawaiian culture-based addiction treatment programs are disproportionately funded by federal entitlements exempt from treatment-as-usual and receive almost double the amount of fundi...

Izaak L. Williams

Papers

Indigenous Hawaiian Psychoactive Drug Use: Before European Contact, and after 1778.

The intersection of structurally traumatized communities and substance use treatment: Dominant discourses and hidden themes

Desilencing Fatherhood: Making the Invisible Visible Within Substance Use Disorder Treatment

Inside the black box of traditional treatment programs: clearing the air on the original literary teachings of Alcoholics Anonymous (AA)

Does Native Hawaiian culture-based treatment deserve more funding than treatment-as-usual?