Addiction a disease? Really?

The debate about the nature of addiction has raged for decades. Is it disease? Is it a matter of choice? Is it a weakness of character? A moral failing? Today, the most widespread and prevalent view is that addiction is a chronic relapsing brain disease. The majority of addiction treatment centres in the US and the UK address addiction from a disease perspective, prescribing total abstinence from the offset and using the twelve Steps as their treatment method.

So why is there still a debate about the disease concept of addiction? it doesn’t happen with other diseases like Alzheimer’s, cancer, heart disease or multiple sclerosis. Well, basically because:

• addiction has  little in common with any disease that we know of
• the current methods of addressing it don’t make sense from a disease management point of view
• the foundational elements that the disease concept is based on, can be disproved by multiple sources of evidence.

First of all let’s look at some of the principles that drive the disease concept and the evidence the refutes it.

Addiction is a primary disease of drugs and alcohol consumption

This means that addiction is not due to other causes such as mental illness, emotional problems such as anxiety, depression, stress or trauma. It is the drugs and alcohol that are the problem, and this then leads to other social, emotional and psychological problems.  It is the addictive nature substances that make changes in the brain that result in addiction.

If this is the case, why doesn’t everyone who drinks or uses develop addictions? The famous study of Vietnam soldiers officially assessed as heroin addicts during the war, reported that on return home 95% did not return to using heroin. And the majority of these soldiers did not have any formal treatment. So it can’t hold true that it is the substances alone that cause the problem. If this were true then all the soldiers would return to active use on return to their home country.

This first principle also does not account for behavioural addictions such as gambling, internet, sex or food addictions. If addiction is a primary problem of only alcohol and drugs how can we explain the addictive behaviour of the compulsive gambler or over-eater? There is now evidence that addiction is not a result of a substance’s effects on the brain, but an aspect of normal human behaviour gone to extremes, and that any activity can become addictive.

Addiction is a chronic relapsing brain disease that needs life long management (or, once an addict always an addict)

Clearly the research on the Vietnam vets proves that people can overcome an addiction – and also without treatment. But aside from this study, there is a great deal of evidence that the majority of people who, at some point in their life, would fulfill the criteria for a Substance Use Disorder (SUD), actually quit on their own and do so without treatment. Overcoming addiction is actually the rule not the exception.

So why is this fact not more widely known? Clearly from a purely cynical point of view the treatment industry – especially the rehab industry – is a multi-billion dollar financial machine. It is financially lucrative to tell people that they can’t get better without treatment – or that they need an intensive residential stay that is on average around 30,000 US a month.

On a less cynical note, a great deal of the research available is conducted with people who are already in the treatment system, the ones at the far end of the addiction spectrum who are very likely to be struggling with mental illness as well as addiction. This would cause results to be skewed as they are not representative of the whole population of people who would fit the criteria for an SUD.

There is a gene for addiction

There is no gene or set of genes that directly cause addiction. Yes, addictive behaviour will be influenced to some extent by our genetic make up as is a lot of the behaviour we exhibit. But addiction is not directly inherited from an addicted parent. Whether or not someone develops addiction is due to a whole range of biological, and environmental factors.

The gene theory of addiction has become popular because it adds credibility to the brain disease theory and also because of the key role that dopamine plays in addiction. Dopamine, the neurotransmitter responsible for our feelings of pleasure and motivation, is released by the majority of substances. There is a gene that is responsible for the production of dopamine in the brain, which if affected, can cause people to produce less dopamine than the average person.

Brain disease theorists claim that addicts become dependent on the dopamine from drugs because their dopamine system is not functioning as it should. But this theory is far too simple to explain the complex interactions between genes and the environment. There are also genes that affect levels of anxiety, impulsivity and stress – all known risk factors for substance abuse.

We now know that whether or not a gene is ‘expressed’ i.e. whether it will have an effect is dependent on a range of factors such as nutrition, stress, trauma, and our attachment to care givers when we are children. It is extremely difficult to point to the exact reason a gene might be expressed. You may have a vulnerability to addiction for a variety of reasons, some genetic, but to say that addiction is genetic is just not accurate.

Addiction is a disease because it changes the structure of the brain.

The National Institute on Drug Abuse (NIDA), is by far the most influential body in the ‘addiction as a disease’ camp. The major evidence that NIDA uses to give credibility to the disease theory is that the brain is changed by addiction and is therefore diseased. They tend to compare it to diabetes – which changes the pancreas or heart disease, which destroys the heart.

But the brain cannot be compared to other organs. The brain is neuroplastic – the heart and pancreas are not. It has the capacity to change constantly in response to our internal and external environment. While cancer clearly destroys the cells of an organ, addiction does not necessarily destroy the brain. A recent book by neuro-scientist, Marc Lewis – himself a former addict – describes how addiction does change neural pathways but it doesn’t destroy the cells – and this is a key difference.  

There are some drugs that have a neuro-toxic effect on the brain, but this is the action of the specific drug, not from the process of addiction. Addiction, he states, is a actually a learned behaviour, and the changes that take place within the brain are not very different from the changes that take place when learning how to drive or learning how to play an instrument. This is not to say that changing the patterns of addiction is easy, it isn’t.

As addiction develops, certain structures in the brain responsible for over-riding impulsivity and pausing before making unhelpful decisions, become less effective. But there is now research to show that after quitting, the parts of the brain that are not working well during active addiction, actually start to function more effectively and efficiently in recovery, sometimes more so than a never-addicted person.

So, in effect, the brain CAN heal from addiction and can actually work better than before.

So if there is so much evidence contradicting the disease theory – why is it still the most prominent theory used to explain addiction? And why does it matter? 

The benefits of ‘diseasing’ addiction

For years, addiction was pretty much stigmatised by the medical community and very little, if any of a government’s budget was allocated to research or treating addiction. When it was finally recognised by the medical field as a ‘disease’, this prompted a change in policy and large amounts of funding was allocated for treatment and research. Suddenly, treatment became more widely available through insurance providers and people struggling with addiction faced less stigma. Bob Shuster, the head of NIDA from  1986 to 1991, did not believe that addiction was a disease but he was “happy for it to be conceptualized that way for pragmatic reasons… for selling it to Congress”

Another prominent figure, the  first white house adviser on drugs, psychiatrist Jerome Jaffe, saw the adoption of the brain-disease model as a useful way to “convince congress to raise the budgets ” but also that it represents a “Faustian bargain –  the price that one pays is that you don’t see all the other factors that interact (in addiction)”  

So the disease theory has done a lot to raise the profile of addiction treatment, de-stigmatize it, provide credibility for professionals in the field and enable more people to access treatment. So why is it such a bad thing?

As Jaffe pointed out, it is a set-back for science. Focusing exclusively on the brain and searching for a medical cure will just stunt the growth of the addiction treatment field and prevent the development of effective treatment methods that could help millions of people, whom the twelve steps are failing. Recent research shows that at best, only around 8 % of people who use AA 12 steps as a treatment method  actually successfully quit.

This is not really surprising when you look at some of the practices that go on in a large proportion of 12 step treatment centres. The majority of centres will discharge anyone found to be using substances. But surely if addiction is a chronic ‘relapsing’ disease, returning to active use would be expected? So why are people being thrown out of treatment because their ‘disease’ came back? We don’t throw people out of hospital because their heart disease took a turn for the worst.

Also, around 80 % of rehabs in the states don’t dispense medication – the 12 step philosophy tends to view any kind of substitution drug use as ‘relapsing’. But if addiction is a medical disease – surely treating it with medication is the answer? They do allow nicotine though – despite the fact that tobacco is the leading preventable cause of disease, disability and death in the United States. 

 

But does it matter what we call it?

Yes it does, calling it a primary disease takes the focus away from someone understanding what is maintaining their addiction and what might be playing into relapses. It prevents people from exploring the deeper meaning behind their addiction and trying out different methods to overcome it. There is a huge amount of evidence that indicates addiction is a symptom of other issues not just a problem in itself. 

Belief that addiction is a disease can also be damaging in itself – one study found that, of the six factors that predicted relapse – the two main ones were lack of coping skills and belief in the disease concept of alcoholism.

Addiction is best viewed as a multifaceted condition that involves many factors. Yes, it involves powerful biological forces but it also involves psychological, emotional and social factors as well. It needs to be viewed from the individual sufferer’s point of view. How does addiction make sense to them? What does the substance help them to manage or cope with? What are their fears about quitting? What coping skills do they need to develop?  How can motivation to quit be enhanced? What support do they have in their life? How does their substance use allow them to make social connections that without it, would be difficult?

Effective treatment needs to target the underlying causes and lack of coping skills combined with education about what is happening in the brain. Advances in neuroscience are now allowing us to develop strategies that can help re-wire the affected parts of the brain and regain functions that have been lost due to lack of use or abuse.

People need to understand the role that substances are playing in their lives. They need be given a choice of different kinds of treatment, not told there is only one way and if it doesn’t work it’s their fault. If the twelve steps and AA are helpful for them then great! if not, offer other options.

People need to be empowered and motivated by the idea that they do have control over their condition, that it will take work and effort but it is possible – as the millions of people who give up drugs and alcohol prove. Being told that you have a damaged brain, that can never be cured, that there is only one form of treatment and if it doesn’t work it’s because YOU failed – is inaccurate at best and potentially fatal at worst. People need to understand that quitting is the norm not the exception and that it is entirely within their power to achieve.