By Steve K.
In this essay I will be specifically referring to alcohol and other drug addiction, or severe alcohol/substance use disorder, which is the terminology used in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
The medical and scientific community, particularly in the USA, currently views addiction as a brain disease, and the following description taken from the US ‘Recognizing Addiction as a Disease Act of 2007’, outlines the general mainstream view:
Addiction is a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences. It is considered a brain disease because drugs change the brain’s structure and manner in which it functions. These brain changes can be long lasting, and can lead to harmful behaviors seen in people who abuse drugs. The disease of addiction affects both brain and behavior, and scientists have identified many of the biological and environmental factors that contribute to the development and progression of the disease. (1)
This description fits well within general dictionary definitions of the term disease, for example:
“A disorder of structure or function in a human, animal, or plant, especially one that produces specific symptoms or that affects a specific location and is not simply a direct result of physical injury.”
“A pathological condition of a body part, an organ, or a system resulting from various causes, such as infection, genetic defect, or environmental stress, and characterized by an identifiable group of signs or symptoms.”
Within the field of addiction treatment and research there is a long history of polarizing views in terms of the nature of addiction. On one side those who focus upon the neurobiological aspects of addiction, and on the other side those who favor environmental and behavioral explanations.
These different models are viewed as important in terms of how addiction is treated; with the neurobiological perspective comes a focus upon medicalization and drug treatments, and with the environmental and behavioral viewpoints comes social and psychotherapeutic interventions.
Some researchers in the field, those who favor environmental and behavioral learning explanations of addiction, don’t consider it to be a disease. In his book The Biology of Desire, the developmental psychologist and neuroscientist Marc Lewis argues that addiction is not a disease, but the consequence of the brain’s natural capacity to change its structure and function in response to repeated behavior that offers reward. These changes in the brain then stimulate the anticipation of reward (ie desire or craving), that leads to compulsive patterns of alcohol and other drug use.
“But is addiction really a disease? This book makes the case that it isn’t. Addiction results, rather, from the motivated repetition of the same thoughts and behaviours until they become habitual. Thus, addiction develops – it’s learned – but it’s learned more deeply and often more quickly than most other habits, due to a narrowing tunnel of attention and attraction. A close look at the brain highlights the role of desire in this process. The neural circuitry of desire governs anticipation, focused attention and behaviour.”
Introduction, p.x The Biology of Desire: Why Addiction Is Not A Disease. By Marc Lewis, 2015.
Lewis’s view of addiction not being a disease seems to rely on the changes in the brain’s structure and function being part of a natural process. I personally don’t find his reasoning that convincing. Yes, changes in the brain are the result of repeated behavior, which is motivated by the euphoric high obtained from using alcohol or other drugs. His viewpoint in the book seems to ignore the actual substances taken, suggesting they are not that important in the process, and offers examples of other powerful addictions such love and gambling.
I would suggest that the chemically induced high produced by alcohol and other drugs, in some individuals, causes extremes in terms of learning and changes in the brain’s structure and function, to the extent that the brain becomes disordered. Lewis’s view also ignores the potential for physical dependency with alcohol and some other drugs, which compounds the process of addiction.
Lewis doesn’t seem that convinced that addiction is not a disease in the following passage taken from an interview in the Guardian newspaper with Journalist Melissa Davey about his book.
(ML)“The parts of the brain that become activated when craving is triggered by cues changes. So there’s something going on that makes it hard to stop for very good neurological reasons. So then, do you want to call addiction a disease? Well, maybe, then you’re getting close I think, because you could call it a pathology I guess. Because obsessive compulsive disorder, that’s a pathology right? So yeah, I think there is a point at which the line between those definitions starts to blur.”
(MD) “So it sounds like it comes to a point where perhaps addiction does fall into disease territory then?”
(ML)“I wouldn’t say disease. I would call it disorder. Or even the adjective, “pathological”. But I just don’t like those words because there’re all part of this particular framework, and that’s the dominant framework in the US and parts of Europe, that this is in fact a chronic brain disease. It’s hard to talk about it as if sometimes it’s a disease or sometimes it’s not. Then the argument starts to get kind of mushy. But when you are in the grips of compulsion, yeah, there is a process going on that of course isn’t healthy and requires a certain amount of cognitive and emotional and probably therapeutic work to get out of. So yeah, OK, I’ll grant you that you could call that, certainly, a disorder.”
Marc Lewis: the neuroscientist who believes addiction is not a disease. Interviewed by Melissa Davey, the guardian, Sunday 30th August 2015.
“Pathological”: relating to, involving, or caused by disease. Collins Concise Dictionary.
It seems to me as though the difficulty in accepting alcohol and other drug addiction as a disease lies in its complexity. There are various causal factors at play in the formation of addiction, such as: genetic inheritance in relation to biology and character traits, upbringing and environmental influences, developmental difficulties and psychological trauma, co-occurring illnesses, availability, and cultural influences. All of which can make an individual more or less vulnerable to developing an addiction.
The fact that addiction is not caused by purely physical disorder doesn’t stop it from becoming a disease in the opinion of Dr Nora Volkow, Director of the National Institute on Drug Abuse:
“The non-inevitability of addiction is a point frequently emphasized by people challenging the brain disease model, with the faulty reasoning that it cannot be a disease because the condition is initiated by a decision to take a drug, which is viewed as a voluntary behavior, and also because most individuals never escalate their drug taking. However, this is no different from many other diseases that also have complex genetic, environmental, and developmental origins, may be triggered by voluntary behaviors or their omission, and may only affect a small subset of those at risk.
I often compare drug addiction to another chronic, relapsing disease, diabetes. In diabetes, the pancreas is not able to make the insulin necessary for our cells to use glucose as fuel. No one thinks that, with sufficient willpower, a person with this condition could push through without medication. Their disease, even if it had behavioral antecedents and may have involved free choices in a person’s past — such as decisions about food or exercise — has a physical basis and requires medical management once it has developed.”
Advances In Addiction and Recovery. P17. Vol.3, No.3, 2015
I think that the degree of alcohol or other drug dependence is relevant in terms of language used, how it is considered, and the treatment or interventions offered. The DSM-5 uses the terms alcohol use disorder and substance use disorder in an attempt to represent the wide spectrum of alcohol and other drug problems; which can range from mild to moderate to severe. I think that once an alcohol or other drug problem has developed into a severe and chronic addiction, it can be appropriate to use the language of illness and disease, certainly as a metaphor (even if not technically true) in order to convey the serious and corrupting nature of the disorder. In the earlier stages of misuse, though, the terms behavioral problem or disorder are probably more fitting.
Lewis and others cite the research that in community populations most with addictions resolve them without help from treatment services. According to William L White (the addictions researcher), in an email to me, they fail to mention the difference between community and clinical populations in respect of addictions ending naturally.
“People often note my reference to resolution of alcohol and other drug problems without professional treatment or recovery mutual aid involvement, but they often fail to mention (because it doesn’t support their argument) the tandem conclusion that the probability of this sharply declines as problem severity, complexity, and chronicity increases—this is the major difference between follow-up studies of community samples and follow-up studies of clinical samples.”
Bill White. November 6th 2015.
In other words, the more established, complex, and severe the alcohol or other drug problem, the more likely the need for interventions clinically and in terms of recovery mutual aid groups.
In his blog article ‘Predicting Addiction/Recovery Trajectories’(2), Bill White suggests several high risk factors that make it more likely a person will develop a chronic, complex, and severe problem with alcohol and other drugs (AOD), such that they will require treatment or interventions. These risk factors include:
* Family history of AOD-related problems
* Early age of onset of AOD use
* Euphoric recall of first AOD use
* Atypically high or low drug tolerance from onset of use
* Historical or developmental trauma: cumulative adverse experiences with traumagenic factors (e.g., early onset, long duration, multiple perpetrators, perpetrators from within family or social network, disbelief or blame following disclosure)–without neutralizing healing opportunities
* Adjustment problems in adolescence that contribute to adult transition problems, e.g., instability in education, employment, housing, and intimate and social relationships
* Multiple drug use
* High risk methods of drug ingestion (e.g., injection)
* Co-occurring physical/psychiatric challenges
* Enmeshment in excessive AOD-using family and social environments, and
* Low levels of recovery capital (internal and external assets that can be mobilized to initiate and sustain recovery).
The above risk factors don’t necessarily mean an individual will develop a chronic and severe addiction problem, but make them more vulnerable to doing so, particularly when the factors are combined.
Choice and Self-Medication models.
When considering the different viewpoints in relation to the causes and nature of addiction, Marc Lewis narrows them down to three broad categories: the disease model, choice model, and self-medication model. All three are influenced by social and psychological factors. I have already mentioned the disease model.
The ‘choice model’ suggests that people make decisions about payoffs and pleasure, particularly in the short term, and the decision to use alcohol or other drugs is often most attractive at the time and in the circumstances. It’s a view that’s given to explain people’s decision to stop using when the consequences of doing so become too unpleasant, or when their circumstances change.
In my view, while there is some truth in this understanding of alcohol and other drug use, it’s far too simplistic and denies an individual’s predispositions and changes in the brain’s neurobiology that strongly influence choice. This viewpoint also encourages an attitude of moral judgement towards those with addictions, and is a return to the concept of moral failure of character prevalent in the past.
The ‘self-medication model’ of addiction suggests that people use alcohol and other drugs to relieve emotional or psychological distress. The model suggests that some individuals are more vulnerable to self-medicating due to trauma, particularly trauma experienced in childhood and adolescence. This viewpoint is supported by the influential ACE study in relation to adverse childhood experiences.
I see truth in all three of the above models of addiction and would suggest that there is a complex interplay between them, and that this interaction is unique to each person who develops an alcohol or other drug problem. I think that an over emphasis upon any one particular viewpoint is reductionist and not helpful, and that a holistic approach towards the causes and treatment of addiction is best.
Returning to the question: Is addiction a disease? It seems to me a matter of interpretation, and when considering the current definitions of the term disease, my view is that addiction, in its severe form, can legitimately be classed as such. However, in the earlier stages, alcohol and other drug problems are probably better described as a behavioral problem or disorder.
Alcohol and other drug use begins with choices that are influenced by bio-psycho-social factors relating to the individual, but as habit or dependency develops, choice becomes increasingly impaired and can instead become a compulsive disorder. Addiction then takes over to a large degree and has the capacity to make a person very ill, both mentally and physically (the symptoms of the disease), and quite often kills.
The quoted disease model description is taken from; p.11, ‘The Biology of Desire: Why Addiction Is Not A Disease’. By Marc Lewis, 2015.
‘Predicting Addiction/Recovery Trajectories’, Blog Post, Nov’ 21st 2014. The Selected Papers of William L White.