Envisioning a Path Forward: A Critical Narrative Review of the Brain Disease Model of Addiction (BDMA) after Three Decades of Debate

Abstract

For nearly three decades, the Brain Disease Model of Addiction (BDMA) has strongly influenced scientific, clinical, and public understandings of addiction while remaining the focus of sustained debate. This critical narrative review reassesses the BDMA by integrating evidence from addiction neuroscience, genetics, neuroimaging, behavioural economics, recovery research, stigma studies, and philosophical critique. The review examines evidence supporting a neurobiological basis for addiction alongside concerns regarding causation, agency, responsibility, social context, treatment implications, and stigma. The synthesis indicates that much of the continuing disagreement reflects differing definitions of “brain disease” rather than wholly incompatible evidence. Neurobiological findings demonstrate consistent involvement of reward, motivation, learning, and control systems, but they do not by themselves establish that addiction can be fully explained at a biological level. Conversely, psychosocial and choice-based accounts do not negate the relevance of neurobiological mechanisms. The reviewed literature therefore supports an integrative interpretation in which addiction emerges from interactions among biological vulnerability, learning history, socioeconomic conditions, environmental contingencies, and individual agency. This perspective has practical implications for prevention and treatment, favouring approaches that combine mechanism-specific and precision-oriented interventions with psychosocial support, recovery resources, and attention to stigma and social disadvantage. The review concludes that future progress depends less on defending a single explanatory label than on clarifying the meaning and limits of the brain-disease concept and applying multiple levels of explanation to research, clinical care, and public health.