Why Addiction Is Considered a Disease

The fact that modern-day conversations about addiction use the word and idea of disease represents a seismic shift in how the medical and public communities understand the spectrum of substance abuse. But even as our understanding of human psychology and neuroscience expands, what we thought we knew about addiction (as a disease), and how it works, continues to reveal surprises about the science of human behavior and thought.

The Roots of the Moral Model of Addiction

alcohol dependency The disease model of addiction is the conventional approach to talking about substance abuse, but this was not always the case. More than two centuries ago, the work of Benjamin Rush, one of the Founding Fathers of the United States, and a man regarded as “the father of psychiatry,” published one of the first scientific papers on the effects of alcohol on drinkers. His 1784 essay, An Inquiry into the Effects of Ardent Spirits Upon the Human Body and Mind, took the unprecedented stance of arguing that the drunkenness exhibited by people who had consumed too much alcohol was only partly their own responsibility; never before had the case been made that the alcohol itself had any culpability in the inappropriate behavior.[1]

Rush was of the opinion that alcohol’s production and consumption needed to be moderated, and his essay fit very well with the narrative espoused by religious revival groups of the time. There had existed a loose temperance movement in the United States, but what they heard from Benjamin Rush himself – a man who signed the Declaration of Independence, no less – boosted both their determination and their visibility.

In the eyes of these religious groups, drunkenness and substance abuse were most certainly the weaknesses of the individual drinker. Deriving their perspective from Bible verses that equated intoxication with sin, small groups of people began actively campaigning against the production of whiskey and the serving of alcohol on the Sabbath.[2]

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The Prohibition Movement

prohibition movementWhen the dust of the Civil War began to settle, the religious revival began again in earnest. Scarred by the horrific toll of the war, preachers called for Americans to return to a simpler, more Biblical way of life, turning away from the evils of the world that (they felt) led to the war. This second wave of temperance adopted a much harder attitude toward drinking and drunkenness than the pre-Civil War groups did. No longer satisfied with merely regulating their own behavior, groups like the Women’s Christian Temperance Union sought to solicit politicians to their cause. They were aided by hysteria surrounding the impending end of the 19th century, with preachers whipping their flocks into repentance and abstinence by claiming that the end times were approaching.

The moral panic coalesced into the Prohibition movement of the early 20th century, which actively sought to return the country to a time of faithful observance of Christian mores. By this point, the anti-liquor movement had drummed up enough support in its platform of alcohol being the source of society’s ills, and that those who drank – and got drunk – were suffering from moral decay.

By 1920, US Congress ratified the 18th Amendment to the Constitution, which outlawed the production, sale, and public consumption of alcohol.

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Introducing Disease

The temperance movement did not base its opinions about the nature of addiction on any scientific understanding of the concept, but the influence it had on the development of the moral model of addiction lasted for most of the 20th century. The etymology of the word moral comes from an Old French word, meaning “pertaining to character,” and this was how the general temperance movement – even after the failure that was Prohibition – presented substance abuse: that those who drank to excess were morally bankrupt and void, all too willing to surrender to their baser impulses.[3] Such people, goes the model, are not patients in need of medical help, but criminals who have to be removed from society for their own good, and the good of the moral fabric that they have frayed with their vice.

The prevailing view of alcoholics being lazy sinners who lacked the fortitude to say “no” to a drink rang strongly in the ears of Bill Wilson as he put together the foundations of what would become Alcoholics Anonymous.[4] AA was the first established group to use the word disease when talking about alcoholism, introducing not only a radical concept of treatment, but adding that addiction was something that could be treated – like a disease.

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Addiction in the Brain

Unbroken Brain, a book on addiction by Maia Szalavitz, explains how science and psychology have found that people with substance use disorders are literally incapable of not showing the symptoms of their disease: compulsively craving and indulging the drugs and alcohol that led them to this stage of their struggle. As with most people, addicts walk the line between what they want and what it costs to have those things. While the moralistic point of view presents the addict’s needs as pleasure and satisfaction, the disease theory posits the addict’s needs as an escape from a life of anxiety, trauma, and depression – however the psychological void in their lives manifests itself.[5]

There is something wrong with the addict, Szalavitz writes, and between the options of a moralistic view and a disease view, the disease view is the best way to address and treat that problem. She also points to the well-established research that has identified complex biochemical processes under addiction. Addiction has its basis in neurophysiology, she says, which swings the pendulum in favor of the disease model.

The Washington Post explains that people who have substance use disorders have brains that make it difficult to resist the pull of addictive drugs and alcohol. Two decades’ worth of research has discovered a number of chemical and physical changes that take place in the brain, and its functioning, that render an addict effectively helpless to their compulsions.[6]

drugs and the brain

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Inside the Brain

The human brain naturally produces dopamine, a neurotransmitter, whenever a person performs an action that is associated with survival or breeding. Such actions, like eating and having sex, also give humans a sense of pleasure, a kind of evolutionary side effect to encourage us to keep doing things that keep us alive and keep the species going.

Healthy activities and indulgences will trigger this response, but so do unhealthy activities, and to a much greater and far more powerful degree. Someone snorting cocaine or injecting heroin into their veins will experience a flood of dopamine that is simply incomparable to anything else. The brain is forced to pump out greater amounts of dopamine than it should, even as it tries to regulate the neurotransmitter’s production. Over time (ranging from a single use to days or weeks, depending on dozens of factors), drugs or alcohol become the only way for the person to get that same rush of dopamine, that same rush of pleasure, that same sense that the only way to survive is by taking more cocaine, more heroin, or more alcohol.

Someone who has entered this stage of addiction will not be satisfied with incremental doses, but is compelled to actively seek out larger doses. Nothing will ever replicate the sensation of the first time, but the brain becomes so warped and hooked on the drugs that the chase continues.

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Changing the Brain

addiction roots

This understanding of neuroscience has opened the door to further insights into how addiction, as a disease, works. It explains why people who have recovered from their addictions can still struggle with temptation or relapse: not because they are inherently bad people, but because the parts of the brain that are responsible for dopamine production have been primed to associate anything resembling past drug use with pleasure. Therapy and treatment can correct that balance, but never entirely. This is why a recovering alcoholic cannot go to a bar – not because of a character defect, but because the smells, sights, sounds, and environment of a bar (or other location where alcohol is easily available) will unwittingly trigger a dopamine response and the motivation to seek out more pleasure sources.

To that point, Pacific Standard writes that “addiction […] is not about willpower.”[7] The magazine quotes the results of a study published in the American Journal of Psychiatry, which found that the abuse of drugs and alcohol causes changes to the brain’s functioning that lead to a person developing one, or more, of the four roots of addiction:

  • Tolerance: more and more amounts of the substance required to feel the same effect
  • Dependence: an inability to function without the drug
  • Dysphoria: excessive negative emotions, which can lead to relapse
  • Sensitization: greater responsiveness to a drug, which is what makes people more likely to relapse if they have gone for a period of time without using

The researchers in the study – one of whom is Dr. Nora Volkow, now the director of the National Institute on Drug Abuse – write that because “all [addictive] substances work in a similar way on the reward system,” the idea of treating addiction as an issue of morals – that one user has better or lesser willpower than another – cannot stand.[8]

Other scientific advances have also illustrated why what we know now about addiction, compared to what we used to know, gives credibility to the disease theory. For example, as recently as 2013, Nature Communications reported on a study that found a gene that both regulates alcohol consumption and can induce a person to drink excessively when it (the gene) does not function properly.[9] It overstates the case to the point of inaccuracy to say that “genes cause addiction,” but the National Institute on Drug Abuse reports that genes account for 40-60 percent of the chance that a person may be susceptible to developing a substance use disorder.[10]

Given those odds, the argument about substance abuse being an issue of morals or character becomes much weaker.

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Making Addiction Personal

The paradigm has shifted to the point that even political conversations eschew the moral model of addiction. NPR compares the different tones with how the candidates for the 2016 United States presidential election shared stories about their loved ones battling with the “disease,” and their predecessors from the 1980s and 1990s who adopted a significantly harder tone.[11] Vox called the focus on the more forgiving approach to drug addiction “one of the unexpected benefits of the 2016 elections,” as Carly Fiona and Donald Trump both told stories of losing family members to addiction.[12]

Governor Chris Christie of New Jersey, for example, explicitly said, “This is a disease. This is not a moral failing,” at a town hall event in February 2016. In August 1986, on the other hand, President Ronald Reagan promised that his administration would “refuse to let drug users blame their behavior on others.”

An Illness in the Family

Christie’s insight into the nature of addiction may stem from his mother being a lifelong smoker and losing a friend to addiction. He drew a sharp contrast between how his mother’s smoking addiction was handled and how the general public talks about addicts. If the substance of choice is heroin or cocaine, Christie said, the consensus is that, “They decided it,” and “They’re getting what they deserved.” No one, however, said that about his mother. Speaking about his friend, Christie argued that substance abuse “can happen to anyone,” even someone who, like his friend, had a “great career and family.” The solution, he said, was to offer treatment, not jail time.[13]

Similarly, Governor Jeb Bush of Florida, whose daughter Noelle has had highly publicized battles with prescription and recreational drug abuse, called for the stigmas and barriers around addiction to be removed, so that people with substance abuse disorders do not have to feel ashamed or humiliated to seek treatment for their “illness.”[14]

Ironically, in 1989, President George H.W. Bush – Jeb’s father – delivered a speech from the Oval Office where he said the country needed “more prisons, more jails, more courts [and] more prosecutors.”

But a lot has changed since the last decade of the 20th century. An improved perception of substance abuse, and the people who suffer from it, has led to more state and local governments adopting policies toward addicts that treat those people as victims, not criminals.

For example, the police chief of Gloucester, Massachusetts, directed his officers to walk with heroin users to the nearest treatment center, instead of arresting them, even if they had heroin on them when the officer arrived.[15] A program in Seattle empowers officers to go with people picked up for minor drug offenses to meet with social workers, as opposed to sending them to jail.[16]

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Public Opinion

However, old habits take a long time to die. With so much of the narrative from the 20th century being about how drug addicts and alcoholics were flawed people who deserved harsh treatment and criminal penalties, some elements of that message still persist today. As recently as 2014, research from the Johns Hopkins Bloomberg School of Public Health found that the general public still holds very negative views of people who suffer from addiction issues and believes that such patients should not be granted insurance, housing and employment policies to assist in rehabilitation. On the other hand, the same people who feel that way hold more positive impressions of those who have other mental illnesses.[17]

The findings, which were published in the Psychiatric Services journal, suggest that society has not yet accepted that addiction is a treatable medical condition in the same way that other health problems are. An associate professor at the Department of Health Policy and Management at Johns Hopkins reiterates that drug addiction, like mental illness, is a treatable health condition; but due to misunderstandings of human psychology and the way drugs work, people still tend to think that alcoholism and drug addiction are signs of moral and character failings. There is no concept of people with substance abuse problems actively struggling against their compulsions, only that they are weak-willed people who are beholden to their craven impulses[18]

One reason for that, she says, is that most drug use remains illegal, so people who fall victim to addiction – regardless of the complex overlap between psychology, family history, and environment – are regarded as criminals.

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New Problems and Old Perspectives

Another reason is that the public is primarily exposed to outdated images of addicts: usually poor, homeless people who are more often than not from an ethnic minority group, living in destitute areas. The reality, say researchers, is that more and more drug abusers are affluent white Americans living in suburbs, who become addicted to their prescription medication, and then make the transition to harder, more dangerous drugs that work in similar ways.

This situation describes the state of the opioid epidemic that is infecting communities and neighborhoods across America, how this has changed the demographics of drug abuse, and how this is – very slowly – changing the tone of the conversation about addiction. The New York Times reports that the zero-tolerance and tough-on-crime message sent by the War on Drugs, championed by the administrations of Ronald Reagan and George H.W. Bush, fit the worldview of addiction being confined to “poor, predominantly black urban areas.”[19] But then pharmaceutical companies began marketing and selling prescription painkillers by the millions, introducing a new generation of people to opioids. The Journal of the American Medical Association writes of ”the changing face of heroin use” across America, where almost 90 percent of the people who tried heroin for the first time in the first decades of the 2000s were white.[20]

With addiction issues striking much closer to home than they used to, larger numbers of people are calling for a more sympathetic approach to dealing with the problem. The director of the White House Office National Drug Control Policy says that with a new demographic being affected by substance abuse issues, families of the victims – who tend to be wealthier, better connected, and have more resources available to them – “have been so instrumental in changing the conversation.”

heroin use in white people

Now that heroin is “ravaging largely white communities,” the feelings toward the people who steal prescription tablets, and then overdose on heroin, have become much more forgiving.

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A Crime Problem or a Health Problem?

NPR frames the debate: Is prescription painkiller abuse a crime problem or a health problem? While the abuse of opioid-based medications is spreading like wildfire, there are still those who believe that it is a matter of criminal justice and not medicine. Sixty-four percent of new stories on the topic made mention of law enforcement, either in the context of arresting people for illegally buying prescription medication or arresting the doctors who illegally provided the medication. Only 3 percent of news coverage dealt with broadening treatment options.

This came as a surprise to an assistant professor at Johns Hopkins, who expressed her belief that, by now, the public would be more open to the idea of considering addiction a disease of people who need help and not something done by bad people who need to be punished. The public is “prone to [thinking] of drug abuse of any kind as a moral failing,” even when the drugs in question are not notorious substances like cocaine or heroin, but the kind of drugs that are easily found in medicine cabinets and gym bags across the country. Such an attitude, says the assistant professor, “is pretty persistent and hard to overcome.”[21]

Her surprise is understandable, given that as far back as 2000, the Western Journal of Medicine mentioned that the American Psychological Association declared that addiction is not a moral shortcoming, but a disease that can be treated, as early as the 1970s.[22]

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Emerging Perspectives

Yet a third reason for the continuing confusion may come from the treatment community itself. Frontiers in Psychology argues that even while acknowledging the disease model of addiction, “we can conceptualize addiction as a choice,” a methodology that gives both the disease theory and the morality theory equal credibility. How to deal with the problem of substance abuse does not have to be a choice between disease or morals, but one that considers addiction’s neurochemical roots as well as individual psychological characteristics.[23]

Similarly, Maia Szalavitz argues in Unbroken Brain that to call addiction “a disease [of the brain],” on the same level as Alzheimer’s, is too far-reaching of a perspective. Similarly, to totally frame addiction as a medical issue presents an apples-and-oranges comparison with other medical cases, like cancer. Unlike tuberculosis, addiction has no infection agent; unlike diabetes, addiction has no pathological biological process; and unlike Alzheimer’s, addiction is not biologically degenerative.

The crux of the matter is that addiction touches so many elements of human existence that trying to force a connection to a physical system ignores some of the other, uncomfortable realities of what drugs and alcohol can do to a person. If addiction really is to be considered a disease, Szalavitz writes, then it has to be thought of as “a disease of the whole person,” because the very nature of addiction is based on actions and desires, emotions and relationships.

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Asking the Question Again

substance abuse disease Psychology Today offers the same caution: that to slap a “disease” label on addiction is to ignore the full scope of what substance abuse is and what it does to a person. Rephrasing addiction as the compulsive symptom of a behavioral disorder (in a comparable way that excessive washing of hands is the compulsive symptom of obsessive-compulsive disorder) strips the moral model of addiction of validity but also ensures that the square peg of addiction is not forced to fit into the round hole of (other) diseases.[24]

As recently as May 2016, a psychiatry lecturer at Yale University wrote in The Conversation that addiction is not a disease of the brain (although the brain is undeniably involved); addiction, she wrote, “is a problem of the person.” The difference is a critical one, because taking the choices made by a substance user into consideration is a key element of treatment; assuming that they are completely helpless and without culpability robs them of the empowerment that is a benchmark of successful rehabilitation.[25]

The New York Post sums that point up very bluntly: “Addiction is not a disease,” blares a 2015 headline, “and we’re treating addicts incorrectly.” Profiling The Biology of Desire, a book by Dr. Marc Lewis (a former addict and now a professor of developmental psychology), the Post explains that by giving addiction a new model – part-disease, part-morality, part-unique – will allow addicts to take a greater degree of responsibility and control over their own health. Such a method acknowledges the client’s own role in the addiction while not disregarding the biological aspects of what addiction does to a person.[26]

As a psychologist who wrote a book entitled Addiction is a Choice told ABC News, people have more control over their behavior than they think they do. A new model of addiction might be the key to helping patients exercise that control.[27]

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Citations

[1] “Temperance and Prohibition Era Propaganda: A Study in Rhetoric.” (2004) Brown University Library Center for Digital Scholarship. Accessed August 3, 2016.

[2] “The Bible Says Drunkenness Is A Sin (Galatians 5:21). But Is Occasional Social Drinking Okay For Christians?” (December 2010). Christianity Today. Accessed August 3, 2016.

[3] “Moral (adj).” (n.d.) Online Etymology Dictionary. Accessed August 3, 2016.

[4]Alcoholism Through a Doctor’s Eyes.” (February 2014). New York Times. Accessed August 3, 2016.

[5] “‘Unbroken Brain’ Offers New Insights On Addiction.” (April 2016). NPR. Accessed August 4, 2016.

[6] “Brain Changes In An Addict Make It Hard To Resist Heroin And Similar Drugs.” (February 2014). Washington Post. Accessed August 4, 2016.

[7] “Five Studies: New Approaches in Treating Addiction as a Disease.” (September 2015). Pacific Standard. Accessed August 4, 2016.

[8] “The Neural Basis of Addiction: A Pathology of Motivation and Choice.” (August 2005). American Journal of Psychiatry. Accessed August 4, 2016.

[9]Gene Mutation for Excessive Alcohol Drinking Found.” (November 2013). Science Daily. Accessed August 5, 2016.

[10]Addiction Science: From Molecules to Managed care.” (July 2008). National Institute of Drug Abuse. Accessed August 5, 2016.

[11] “WATCH: Republicans — Then And Now — Talking About Drug Addiction.” (February 2016). NPR. Accessed August 5, 2016.

[12] “Why It’s Important Donald Trump And Other Candidates Discuss Addiction In Their Families.” (February 2016). Vox. Accessed August 5, 2016.

[13] “Chris Christie’s Emotional Speech About Drug Addiction Is Going Viral.” (November 2015). Business Insider. Accessed August 5, 2016.

[14] “Jeb Bush Drops Guard to Share Family Account of Addiction.” (January 2016). The New York Times. Accessed August 5, 2016.

[15]A Massachusetts Police Chief Refuses to Arrest Heroin Addicts.” (May 2013). Vox. Accessed August 5, 2016.

[16]How Seattle Is Upending Everything We Think About How Cops Do Their Job.” (July 2015). Washington Post. Accessed August 5, 2016.

[17] “Study: Public Feels More Negative Toward People With Drug Addiction Than Those With Mental Illness.” (October 2014). Johns Hopkins Bloomberg School of Public Health. Accessed August 5, 2016.

[18] “Stigma, Discrimination, Treatment Effectiveness, And Policy: Public Views About Drug Addiction And Mental Illness.” (October 2014). Psychiatric Services. Accessed August 5, 2016.

[19] “In Heroin Crisis, White Families Seek Gentler War on Drugs.” (October 2015). New York Times. Accessed August 5, 2016.

[20] “The Changing Face Of Heroin Use In The United States: A Retrospective Analysis Of The Past 50 Years.” (July 2014). JAMA Psychiatry. Accessed August 5, 2016.

[21] “Is Prescription Opioid Abuse A Crime Problem Or A Health Problem?” (December 2015). NPR. Accessed August 5, 2016.

[22]Addiction is a Treatable Disease, Not a Moral Failing.” (January 2000). Western Journal of Medicine. Accessed August 5, 2016.

[23] “Alternative Models of Addiction.” (2015). Frontiers in Psychology. Accessed August 5, 2016.

[24] “Is Addiction Really a Disease?” (December 2011). Psychology Today. Accessed August 5, 2016.

[25] “Is Addiction a Brain Disease?” (May 2016). US News & World Report. Accessed August 5, 2016.

[26] “Addiction Is Not A Disease — And We’re Treating Addicts Incorrectly.” (July 2015). New York Post. Accessed August 5, 2016.

[27]“Is Addiction Just a Matter of Choice?” (n.d.) ABC News. Accessed August 6, 2016.