By Steve K.
In this essay I will be specifically referring to alcohol and 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 behaviours seen in people who abuse drugs. The disease of addiction affects both brain and behaviour, 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.” (Oxford Dictionary)
“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.” (Dictionary.com)
Within the field of addiction treatment and research there is a long history of polarising views in terms of the nature of addiction. On one side those who focus upon the biological aspects of addiction, and on the other side those who favour environmental and behavioural explanations.
These different models are viewed as important in terms of how addiction is treated; with the biological perspective comes a focus upon medicalization and drug treatments, and with the behavioural viewpoint comes social and psychotherapeutic interventions.
Some researchers in the field, who favour behavioural learning explanations of addiction, don’t consider it to be a disease. In his latest book The Biology of Desire, the 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 behaviour that offers reward. These changes in the brain then stimulate the anticipation of reward, (desire or craving) that leads to compulsive patterns of alcohol and 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 behaviour, which is motivated by the euphoric high obtained from using alcohol or 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 drugs, in some individuals, causes extremes in terms of learning and changes in the brain structure and function, to the extent that the brain becomes disordered. Also, his view ignores the potential for physical dependency with alcohol and some drugs which compounds matters.
Lewis himself doesn’t seem that convinced that addiction isn’t a disease in the following passage taken from an interview in the Guardian about his book.
“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.
So it sounds like it comes to a point where perhaps addiction does fall into disease territory then?
[Pauses]. I wouldn’t say disease. I would call it disorder. Or even the adjective, “pathological”. But I just don’t like those words because they’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)
The difficulty it seems to me of accepting alcohol and drug addiction as a disease is in its complexity. There are various components in the formation of addiction such as, genetic inheritance (in terms of 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.
Also, in terms of metabolism, it seems to me that some are more sensitive than others when it comes to processing alcohol and drugs. I am myself sensitive and affected by substances very easily compared to others. You only need to consider how GPs prescribe very different dosages of medications to their patients for the same illnesses, dependent upon their patients’ capacity to tolerate them. I accept that an individual’s psychology can play a part in these differences, but biology must do so as well. Admittedly, this is my layman’s view and of course I may be wrong on this issue.
The fact that addiction is not caused by purely physical disorder doesn’t stop it from becoming a disease in the opinion of 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 behaviour, 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 behaviours 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 behavioural 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 and drug addiction 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 drug problems, from mild to moderate and severe. I think once an alcohol or drug problem has developed into a severe and chronic addiction, it is more appropriate to use the language of disease. Maybe in the earlier stages the terms behavioural problem and disorder are 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 ‘spontaneously’.
“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 and severe the alcohol and 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).
These 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 in his book, 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.
Simply put 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 the individual’s predispositions and the 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 adolescents.
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 on any one particular viewpoint is not helpful and that a holistic approach towards the causes and treatment of addiction is best.
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 or other drug problems are probably better described as a behavioural problem or disorder. Alcohol or drug use starts with choices that are influenced by biopsychosocial factors relating to the individual, but as the habit or dependency develops, choice becomes increasingly impaired and instead becomes a compulsive disorder. Addiction 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 The Selected Papers of William L White.
About the Author, Steven K.
Steve K has been a member of AA for 24 years and lives in Cheshire, which is in the N. West region of England. He would describe himself as a humanist/agnostic. His home group is the Macclesfield Saturday morning AA group and he regularly chairs the meeting. He has a background in advice and counselling work, mainly in the areas of mental health and social welfare law. Steve enjoys swimming and going to the gym regularly at the local Leisure Centre and hill walking in the Cheshire countryside.
He’s recently started a recovery blog, 12stepphilosophy, and has self-published an eBook entitled “The 12 Step Philosophy of Alcoholics Anonymous: An Interpretation by Steve K.” The Third edition is available as both an eBook and a paperback at Lulu.
Tags: AddictionalcoholismDisease Concept
Is drug addiction a disease or a choice?
Have you in any way contemplated whether drug addiction is a disease or a choice? This topic has been very controversial and has brought about many debates to ascertain the whole thing. Many researchers have taken a stand that being a drug addict is completely a disease that only can be cured by taking drugs. On other side, there are other researchers who are for it not being a disease but just a matter of choice. Having considered and carried a lot of research on this controversial issue, my stand remains that drug abuse or drug addict is wholly a matter of choice and not a disease.
The time one is born, he/she does not know anything. You are introduced into the new world with your own will. The things that one chooses to do at any age are solely his or her own choice. There are many things that happen in this world that may directly or indirectly involve oneself. Everybody has the will to make his or her own decision, to say yes or no to indulgent into some activities. In whatever case, any time that these boundaries are crossed, it becomes a choice that has been made.
In the world of today, it is very impossible for someone to say that they have never come across or know anybody who is in one way or the other involved in drug abuse or addiction. One could know a person who is a drug abuser, addict or is even contemplating usage of drugs. Though, nobody at any point gets involved with drugs when he/she has not chosen to do so at the startup. When the first decision to either test or use drugs, the decision leads to severe drug addiction or abuse. There are many people who do not know that there is a difference between being a drug addict and a drug abuser. The only fact is that neither of the two is better than the other. Drug addiction is when somebody uses any kind of a substance that is deemed to be dangerous or comes with many dangerous and negative effects. Carl L. et al. on the other hand, Drug abuse is when someone uses a substance or a drug excessively or when they apply it into the purposes that it was not medically intended to. (Hart, Ksir, Ray). According to the researches that have been carried, it is true that one can abuse drugs and he/she has not been addicted to the same but one cannot be addicted to drugs without being an abuser of the same. When a person makes a decision to first use a drug substance, the spiral downward trend begins to take effect on one’s life unless the involved person makes a decision to stop being an addict because also quitting drug usage is also another choice.
Like all the other choices, drug addiction or abuse is influenced by goals and preference. Drug addiction is not gender based and can affect anybody regardless of his/her economic status. The first decision that is made to first start abusing drugs leads to a direction of making decisions that are not right according to other people who are not drug addicts. These decision could involve making a decision to drive a car sometimes even in uncontrollable speed, indulging into unprotected sex, or even take part in some activities that one would not have done normally if they were not under the influence of drugs. The ones who are completely addicted fail to fulfill their obligations at work, home, at school and even to his/her friends. To cite an example of this I shall use a woman who indulged into drug addict only because she had a small fight with her husband. The woman has been a drug addict but now she has fully quitted to be one for more than twenty five years. In an interview, she recalls the time that she firstly made a decision to try cocaine. She states that because of the feeling that resulted from her and her husband she easily made a decision to let someone convince her to take cocaine. From that time, she wanted to try the drug again and again so that she could feel the highness that she had felt the first time she took the drug. For five years, she constantly chased the high feeling. For another one year, she was struggling with the idea of wanting to quit drug but still the high feeling drove her back into the trap. The woman remembers getting some money from her family member and blowing more than two thousand dollars on one day. She became very neglectful towards her kids and also the other family members. Due the circumstances she passed through, ranging from being involved in a drug raid many times, the fear that her kids were going through hard times, she decided to go for a rehab. This is a decision that she also made to herself without being forced by anyone to do so. In the interview with the woman, she was asked whether she believed that drug addiction was a matter of choice or a disease. She responded by saying that it was solely a matter of choice because on her case nobody had forced her to became an addict each time that she used the drug she knew of the adverse effect that comes with the same and also she realized how her family were being affected yet continued taking cocaine. When she was asked if she accepted the full responsibility for all her actions, she responded “yes”. She said that it could be wrong to blame other for her own choices and she put it clear that it was her choice to start using the drugs as it was in quitting.
The drug addiction support group suggests that no matter the drug of choice, counseling, treatments and other kind of intervention are necessary for any addict to return to their normal and healthy lifestyles. It is clear that there are some other factors that need to be considered by the drug addicts so that they can not only remain clean but also drug free. One should make it clear to choose on the friends that he/she hanged up with, the places that one spends his/her leisure time, and the things that one does that could lead them to become drug users or rather abusers and addicts.
In conclusion, drug use is a willful commitment or a choice just like choosing or dedicating oneself to complete a college education or choosing to join a certain club. Even though heavy consumption of drug is self destructive and foolish, it is a matter of choice. The addiction has no specific people who are affected, no matter whether a person is nice, weak, educated, rich or poor they can all be tempted to make the choice of becoming drug addicts by merely being convinced by what they may think is a high and good feeling but undermining the fact that they are destructing their bodies. When some individuals try to label the drug addict as the ones who have some kind of a brain disease, it is a big insult to the ones who truly have the disease but have not chosen to indulge in drug abusing activities. All the people that are drug abusers should accept the responsibility for their own choices. Every time that a person decides whether to acquire the drugs for money or by use of other means, they have not been forced by anybody, it is xjust their own choice and no one else should be blamed for this. The ones that have decided to stop drug addiction; they have done so because they chose to do so. Owing to all these arguments, my stand remains that drug addiction is a matter of choice and not a disease.
Hart, Ksir, Ray (2013) Drug, society, and Human Behavior: McGraw-Hill