This piece and image was in The Guardian in June and was tackling the issue of addiction and why it’s wrong to call it a disease. Written by Mark Lewis PhD who is a developmental neuroscientist known for dynamic systems approaches to understanding the development of emotions and personality. He is currently a professor at the Radboud University in Nijmegen in the Netherlands.
Is addiction a disease? Most people think so. The idea has become entrenched in our news media, our treatment facilities, our courts and in the hearts and minds of addicts themselves. It’s a potent concept: if you’re an alcoholic or a drug addict, then you’re ill. And you’re going to remain ill. According to Nora Volkow, head of the National Institute on Drug Abuse, “addiction is a chronic, relapsing brain disease,” and that definition has been adopted by medical researchers and policy makers everywhere.
Two huge benefits of the disease concept are frequently touted by Volkow and others. First, addicts need treatment, and if we don’t define addiction as a disease, they won’t get the help they require. Second, addicts don’t deserve to be scorned or denigrated: they have a disease, and we don’t put people down for being sick.
Recently, the supremacy of the disease model was highlighted by an article in the New England Journal of Medicine. Volkow and colleagues proclaimed that “research has increasingly supported the view that addiction is a disease of the brain”. But they also inserted a caveat: “Although the brain disease model of addiction has yielded effective preventive measures, treatment interventions, and public health policies to address substance-use disorders, the underlying concept of substance abuse as a brain disease continues to be questioned … ” Those words triggered an allergic reaction in me. Effective? Could anyone deem society’s response to addiction effective? As you might guess, I’m one of the questioners.
There is good reason to ask whether addiction actually is a disease. If it is, then we might expect it to have a specific cause or set of causes, an agreed-on repertoire of treatment strategies, and a likely time course. We might wonder how the disease of addiction could be overcome as a result of willpower, changing perspectives, changing environments, mindfulness or emotional growth. There is evidence that each of these factors can be crucial in beating addiction, yet none of them is likely to work on cancer, pneumonia, diabetes or malaria.
Neuroscience is a young discipline, and the distinction between brain development and brain pathology remains muddy (think ADHD, autism, depression) – ideal terrain for drawing arbitrary lines in the sand. For example, the brain changes observed in long-term substance abusers are nearly identical to those seen in people struggling with obesity, porn aficionados, gamblers, internet “addicts”, compulsive shoppers and simply those involved in intense romantic relationships. They involve overactivation of a part of the brain that directs goal pursuit (the striatum) in response to cues predicting their preferred rewards, and long-term desensitization in response to rewards more generally.
Along with an assortment of other psychologists and neuroscientists, I’ve been challenging the disease model for years. One result has been a volley of counter-attacks: how dare I pull the rug out from under the feet of addicts who rely on the disease label to get help and avoid stigmatization? So, I’m going to put the scientific debate aside for now and challenge the idea that calling addiction a disease is beneficial for addicts. On the contrary, I think it increases their burden.
Do people have to have a disease in order to get help?
People in today’s world face a vast array of problems, including violence in all its forms (for example, child and spousal abuse, bullying), unemployment, poverty, obesity, social isolation, unplanned pregnancy, and plain old unhappiness. But we don’t need to call these problems diseases in order to tackle them. Instead of medical interventions, we implement inventive, humanistic, often community-based measures, including education, social and psychological support, financial aid, access to special programs, specialized personnel, and other public resources. Nor must we call these problems diseases to justify funding for prevention and intervention. For example, anti-racism policies and bullying prevention initiatives embody extensive, often expensive means for confronting pervasive social ills. The equation help = medical care only makes sense for medical diseases.
It’s true that health care systems in the US and Europe provide various services for people struggling with addiction. However, patient advocates, judges, clinical researchers, and those seeking help almost unanimously point out the inadequacy of these services. In the US system, such inadequacies seem directly tied to the profit motive. The majority of patients relapse, not once but repeatedly, following residential programs that typically run between $10,000 and $100,000 per month. (State-run facilities are notorious for long waiting lists, inadequate resources, and a shocking absence of supervision.)
Volkow and others argue that discarding the disease label would cut addicts off from the services presently available to them. However, not only are those services generally inadequate and financially ruinous. They also embody a profound logical flaw – the idea that the current healthcare landscape should determine our definition of addiction. Shouldn’t it be the other way around?
What about reducing stigma?
If we don’t call addiction a disease, don’t we risk going back to the bad old days of denigrating addicts as self-indulgent, spineless pariahs? Not necessarily. Despite the anger and confusion many feel when confronted with the ravages of addiction, we’ve gotten better at recognizing that life circumstances can dictate personal suffering and tragedy. Many of our favorite public figures have crossed the line into addiction, from Elton John to Philip Seymour Hoffman to Robin Williams to Prince. Social norms seem to be advancing (rather than regressing to Victorian settings) as personal struggles are made public in the internet age. We are also starting to recognize addiction as a consequence of social ills rather than individual flaws. Yet the disease label locates the problem of addiction in the individual. It’s hard to see how that counteracts stigma.
Why do we even imagine that a medical diagnosis makes addicts feel better? Being diagnosed with a chronic brain disease is hardly something to celebrate. Pointing to a disease doesn’t necessarily diminish stigma, as exemplified by attitudes toward Aids patients. Even the designation of “mental illness” provokes stigmatization. Apparently, emotional associations color people’s judgments far more than rational reflections on health v illness.
I have heard from hundreds of addicts who recoil at the notion that they have a life-long disease. Especially addicts who are determined – and successful – in galvanizing their willpower and rejigging their habits, their personal goals, and their capacity for self-control. Once they recover, as most addicts eventually do, it becomes confusing and debilitating to be told they are chronically ill. Recovered addicts want to feel that they have developed beyond their addiction and become better people as a result. Many would prefer respect for that achievement over the pity bequeathed by the disease definition.
Where do we go from here?
A remarkable solidarity has emerged between some addicts and the authorities responsible for treating them (as sometimes occurs between doctors and their patients, regardless of treatment quality, and more generally between those who have power and those who lack it). These are the addicts who insist that they have a disease and any attempts to dislodge that definition are hurting them. Other addicts and, importantly, former addicts, see their problems in an entirely different light. For them, the disease label is a damaging sentence and an additional cross to bear.
I don’t expect this debate to be resolved any time soon. But until it is, I urge anyone who has struggled with addiction or who loves or cares for someone who has to keep an open mind. Calling addiction a disease has had its benefits (like the discovery of new drugs that help a subset of addicts, often temporarily). And the disease label continues to simplify our conceptualization of an extremely messy issue, making it appear easier to understand and resolve. But the net value of the disease definition needs to be questioned. It may be time to move on.
I really liked this piece and the bolded sentence encapsulates my view. What do you think?