New Year’s resolutions, dry January, credit card debt, divorce, insomnia and anxiety—running over fragments of what was said during the office Christmas party or the family get together. This is the life of an alcoholic. Struggling with the consequences of chaos, grasping at the opportunities to find order. But there’s a catch: everyone else was drinking, weren’t they? The holiday parties were fun, right? The alcoholic acknowledges they may have taken it too far, but they never asked to be this way. They might want things to change, but that requires accountability, life change. Comparatively, that’s the easy part. Next, they need to rewire their biology, change their genes.
It’s well-established that certain genes are commonly inherited by people with addiction disorders. A major driver of genetic research is to create a pipeline of drug therapies that can help people treat their illness. Understanding genetics is important. It influences how someone’s brain works. There’s excellent work being done to inform the societal debate around neurodiversity—protecting employees, showcasing the value of neurodivergent perspectives, and hearing neurodiverse voices. Neurodiversity is a non-medical concept that regards differences in brain function and behavioral traits as part of a normal variation of the human population.
Although society is moving in the right direction to include and protect individuals with neurodiversity, the extent of promoting inclusion for alcoholics is limited. An invite (maybe) to the office party or Thanksgiving dinner with the hope they don’t go overboard, this time.
Perhaps since drinking is so widely accepted, the alcoholic’s disease is already normalized. Sure, they are included, but this leaves them in a bad spot—asked to make a choice, fighting biology, and surrounded by a world that embraces their condition, only from a different level of the spectrum. Yes spectrum. Alcoholics drink with everyone else, but they do it differently because they are wired differently. They should be considered neurodivergent and accommodated, included.
Or is it personal choice? It’s all a slap in the face for alcoholics, really.
In Ohio, the Alcohol, Drug and Mental Health Board identified 1 in 3 Ohioans struggle with addiction. As a result, they ran a series of TV ads from 2021 to 2024 through a “Beat the Stigma” campaign.
A major theme was to bring to light the notion that fifty percent of an individual’s risk for developing addiction is determined by their genes. Stigma, then, is inappropriate. The definition of stigma includes:
- a set of negative and unfair beliefs that a society or group of people have about something
- a mark of shame or discredit
- an identifying mark or characteristic; specifically : a specific diagnostic sign of a disease
As such, beating the stigma associated with addiction is a noble cause—we shouldn’t shame someone for something they’re born with, should we? This question brings up challenging words: fault, blame, choice, agency, free will. And what happens to the meaning of these words when targeted therapies are developed?
When science identifies the root cause of alcoholism and develops treatments, the responsibility will shift.
There’s an emerging field of science focused on ‘neuroplasticity’; the brain’s ability to reorganize itself by forming new neural connections through life. It’s critical during early development and impacted by learning and environmental changes (like lots of alcohol). And it’s not always permanent. In other words, there is plasticity—malleability. And there is a new field of drugs called neuroplastogens that do the reorganizing. But they’re not so new; much of this emerging field is centered around the capabilities for psychedelic drugs.
Age-old psychedelics like psilocybin (magic mushrooms) and LSD are being studied for their ability to rewire a person’s brain to reduce alcohol consumption. There’s at least ten psychedelics being studied in clinical (human) or pre-clinical (animal) studies currently for the treatment of alcohol use disorder. Some of these are considered ‘neuroplastogens’ which basically means they can do the rewiring without causing hallucination. A drug that can do the rewiring without the “trip”.
That’s a big deal. Especially for the alcoholic who was born with faulty wiring and has been fixing the situation with more faulty wiring for decades. Like a bad electrician in a bad analogy.
So, when will these new drugs be available? Soon, maybe. It’s hard to do a placebo-controlled clinical trial when the active drug treatment causes hallucinations. That challenge aside, artificial intelligence is the hot topic in neuroscience and drug discovery right now. It speeds up how quickly pharmaceutical researchers can find new drug treatments. If that goes very well, we may have our first alcohol-use-disorder-targeting-drugs available in the US in five to ten years. How will that look?
It depends on the usual suspects: pricing, access, insurance, policy, marketing, consumer demand.
This new class of drugs will likely take two paths, depending on what level of psychedelic experience the patient faces. Consider the recovering alcoholic undergoing therapy: one drug causes vivid hallucinations, which are notoriously unpredictable, and the other drug causes scantly noticeably mental change. Theoretically, both are doing the rewiring in the background.
If these mind-altering drugs reach the market, they will require an altogether new support structure for administration and oversight by clinicians. That strongly influences pricing and access. Then insurance is needed to cover the high cost. That brings in policy, pulling regulatory levers to make sure the right people can get the treatment paid for. High prices lead to insurance, lead to policy, and this all leads to concerns with equity. And there are also very unique considerations for demand. Will alcoholics want to rewire their brains? Marketing will be important.
It’s a clash of the titans. The alcohol industry spends $7 Billion in marketing each year with $1.9 Trillion sales, the pharmaceutical industry spends $122 Billion in marketing with $1.5 Trillion in sales. The figures are slippery to track (think, difference between sponsoring a cardiology conference or a professional futbol match). But if they are directionally close to accurate, the math points to a drug industry that will really need to make its case for new treatments. Afterall, humans are quite comfortable with the value proposition alcohol offers—it’s been consumed for thousands of years and essentially advertises itself.
When treatments are available, science organizations, medical societies, and the pharmaceutical industry will need to raise awareness that alcohol use disorder is not a moral failing, but rather a complex disease of biology. Marketing will push insurance coverage and policymaking. Society will need to consider next steps. And what a conundrum.
Will this new future look upon the alcoholic as a neurodivergent individual whose characteristics should be accommodated? Did they bring unique perspectives to the workplace, or should their disease be treated, and only those seeking medical treatment, brain rewiring, be accommodated? Do they want, wish, desire to be rewired? How do they decide? Should it be expected, required, demanded? Who pays for it?
Neurodiversity is not a medical classification; it’s a societal construct. It’s not a question of whether alcoholics, or more broadly, people with addiction, are neurodiverse—of course they are. No one would choose chaos over order for their daily life, willingly. And the question is not whether alcoholism will be seen as a complex disease of genetics and biology. The pharma industry will address this during product launch.
The question is deeper than that; a matter of agency, free will, consciousness itself. Will people knowingly agree to change how their brain works, or in other words, change their self? Anyone who has ever attempted to quit drinking understands the difficulty, the peer pressure, the normalization. Alcohol is very much ingrained in modern society. The struggle will continue. The decision will persist for the alcoholic who is asked: which version of yourself do you want to be? Most people are not asked to make choices about their consciousness—at a minimum we should understand the alcoholic as a neurodivergent individual. It’s not an easy struggle.
To be too conscious is an illness; ordinary human consciousness would be more than sufficient for everyday human needs.
— Fyodor Dostoyevsky, Notes from Underground (1864).