Is Addiction A Disease?

This was originally published on my blog, www.psychaddiction.com.

The disease model of substance use has enveloped the scholarly discussion of how best to treat addiction. The model posits that addiction is a physical ailment that causes the afflicted individual to be incapable of doing anything but pursuing their drug of choice. This has done substantial work in the eyes of the public in terms of destigmatizing addiction, but forces medical terminology and treatment onto a distinctly psychological problem. Not unlike considering depression to be nothing more than a chemical imbalance in the brain that only needs a regimen of Zoloft to recover, the disease model fails to capture the entirety of addiction and treat it in its entirety.

Addiction Is The Brain’s Reward Pathways Functioning Normally

In his book?The Biology of Desire, Dr. Marc Lewis makes a compelling argument that addiction is not the result of a diseased brain, but of a brain doing precisely what it is intended to do. We know that drugs of abuse have significant effects on the dopamine reward pathway – the network of neuronal structures that provide the biological basis for feelings like “that was good, come back here, do this again.” This pathway is activated for all manner of activities: eating good food, having great sex, playing sports, watching engaging television, or enjoying time with your friends. What makes drugs different from these activities is that they trigger this brain region significantly more than most other activities we find rewarding.

Over time, repeated use of recreational drugs changes the structural makeup of these pathways. As psychologist Donald Hebb once said, “Cells that fire together, wire together.” Drugs cause a large spike in dopamine upon use, followed by a crash that encourages re-administration. Using recreational drugs for a long enough period makes neuronal highways out of footpaths, reinforcing the pathways that indicate drugs are an excellent source of reward and should be returned to often.

Moving Past Disease Labels

But are these changes enough to declare the brain of someone addicted to drugs as a diseased brain? Having structural changes in brain networks sounds like serious business, but?structural brain change happens to all of us, every day. Any and every activity results in neuronal firing, creating stronger pathways for repeated behaviors and letting unused pathways get pruned away. It’s why you’ll always remember how to ride a bike even after years of it sitting in your garage, how you’ll remember to swim even if you haven’t dived into the water in years, and why activities get easier and more intuitive the more time you spend practicing them. An addicted brain isn’t diseased – rather, it’s a brain that’s learned that drugs are an excellent short-term solution to a host of problems.

Here’s something you might read in any given article referencing alcoholism:

Alcoholism is a chronic, relapsing brain disease that hijacks the brain’s dopamine system and leads to overactive liver metabolism. Left untreated, an alcoholic brain will repeatedly seek out alcohol instead of maintaining healthy social relationships and engaging in productive activities.

Let’s try rewriting it with a different activity, and see if we still follow the logic of the disease model applied to a different subject:

CrossFit is a chronic, relapsing brain disease that hijacks the brain’s dopamine systems and leads to overactive fat metabolism. Left untreated, an exercised brain will repeatedly seek out physical activity instead of maintaining healthy social relationships and engaging in productive activities.

Jokes about the cultishness of CrossFit aside, it’s easy to see that we wouldn’t consider somebody enthusiastic about fitness as having a diseased brain.

But wait, addiction is incredibly harmful, and you just compared it to something overtly healthy. Surely, the consequences of drug addiction are what make it a disease.??

Addiction can have severe, debilitating consequences; in many cases leading to true medical diseases. Alcoholism can lead to cirrhosis of the liver, for example – significant liver damage that leaves the liver unable to process the toxins in the body effectively. Opioids and stimulants can both lead to cardiac disease, where the heart no longer functions properly. Smoking any substance causes damage to the lungs and can lead to diseases like pneumonia.

This brings us to the definition of disease:?

Disease:?an illness that affects a person, animal, or plant?:?a condition that prevents the body or mind from working normally.

Merriam-Webster

The essential characteristic of disease is the prevention of normal function. It’s my argument that an addicted brain is functioning exactly as intended.

Addictive Forces In The Modern Era

Our brains have developed over thousands of years to seek out rewarding stimuli and engage in them repeatedly. In a pre-civilized world, this meant foraging for food, huddling together for warmth, and seeking sex in the pursuit of reproduction. We evolved in scarcity, and these drives helped reinforce behaviors that led our species to survive and thrive.

In evolutionary terms, the world of abundance we live in today is brand new. Food is readily available, cheap, packed with sugar and calories, and delicious. Social media gives us the semblance of connection with the flashing light appeal of a slot machine. Goods and services can be delivered to your home the next day with the click of a button. But true to its evolutionary roots, the human brain takes all this stimulus and demands?more.

Drugs of abuse activate this reward pathway stronger than anything else. And just as our eating habits have changed to deliver more salt, calories, and sugar, so too have our drugs evolved. Our ancient ancestors may have chewed coca leaves or drank poppy tea – but today, we have a veritable cornucopia of highly potent narcotics designed and manufactured to have the most stimulating effects. The invention of technologies like the hypodermic needle notwithstanding, our ability to take drugs like fentanyl or methamphetamine make even a trivial amount of substance highly potent and makes it increasingly likely that we become addicted.

This extends outside of psychoactive drugs as well. It’s no coincidence that behavioral addictions are coming to be widely recognized as having the same effects on the brain as recreational drugs. Pick up any book on addiction, and you’ll surely read about how the author struggles with some behavioral problem that they associate with addiction. Gabor Maté talks about his compulsion to buy classical music albums in?The Realm of Hungry Ghosts, Ann Lembke shares her struggles with overindulging in romance novels in?Dopamine Nation, and everyone everywhere has to fight their obsession with constantly checking their smartphone. Addiction is precisely the correct terminology to address these problems – because they’re compulsive behaviors that persist even though they cause us harm. But they certainly shouldn’t be called a brain disease.

Addiction Is Functional Adaptation

Somebody seeking out drugs repeatedly is a normal, if harmful, response to substance use. The reward network isn’t being damaged, rather it is changing to adapt to new circumstances. Some of the most pronounced consequences of addiction are a loss of interest in other activities – they simply aren’t as rewarding as they used to be. This is because the brain, after being washed in excessive amounts of dopamine, adjusts to its new environment to reach homeostasis in the presence of drugs. In the midst of addiction, or after quitting, the comparatively low levels of dopamine from other activities just don’t have the same effective reward as they do on other people. The reward pathway then begins to adjust back in the other direction and given enough time (and effort on the part of the afflicted) everyday activities begin to feel rewarding again.

This accounts for why somebody recovering from substance use often finds excess in other areas of their lives, or ‘trades one addiction for another.’ Lacking the dopamine wash from drugs of abuse, people newly recovered will often become workaholics, find an interest in extreme sports, or suddenly find themselves working out in the gym 5 days a week when they’d shown no interest beforehand. These behaviors are triggering the same dopamine reward pathways that drugs did, but they’re entirely normal and socially acceptable patterns of behavior.

Another large discrepancy in the disease model is the fact that over 77% of people who struggle with substance use disorders achieve spontaneous remission with no medical or clinical intervention whatsoever (Sobell et al., 1996). Additionally, many people can return to moderate drug or alcohol use, as I’ve discussed in a?previous post. Other diseases that affect the function of an organ, such as diabetes, have such ridiculously low rates of remission without treatment as to make the comparison laughable.?

The Harms of the Disease Model

Lastly, believing addiction is a disease can actually be harmful. Endorsement of the disease model of alcoholism before entering treatment is a significant predictor of relapse (Miller et al., 1996). Why might this be? One possibility is that people who struggle the most with addiction are more likely to accept the reality of their situation. A more plausible reason would be that believing addiction is a disease?causes you to lose agency over your substance use. Having a disease is something out of your control – and if you’ve got the disease of addiction, what’s the point of trying to quit?

Relabeling Addiction

So, if addiction isn’t a disease, what is it? A bad habit. A maladaptive coping mechanism that quickly loses its utility in dealing with our problems. We may as well just go back to calling it addiction. A changeable disorder that can get better with compassionate treatment and understanding. Addiction doesn’t have to be permanent, and the adage of “once an addict, always an addict” simply isn’t true. Our brains are constantly developing, even well into our later years – learning new things, adopting new patterns, and honing the skills that we’ve developed over the years.

This isn’t a call for our culture to return to the belief that addiction is a moral failing. Addiction can be incredibly difficult to break free from after sustained substance use and can happen to any of us. We still need compassion for people who suffer, to provide treatment rather than incarceration for non-violent offenders, and ultimately to stop the criminalization of recreational drug use. At the same time, addicts should be held responsible for their actions – there’s no free pass for unethical behavior just because you were under the influence. Personal accountability is a pivotal component of rehabilitation, and you shouldn’t get a pass for playing the disease card.

Moving past the disease model is a way of empowering people with substance use disorders to take back control of their own life. It’s also a better way of describing the effects of addiction scientifically, and an important step in pushing research in the right direction. The disease model has served its purpose well – but it’s high time we move past it.

References

Heather, N., Best, D., Kawalek, A., Field, M., Lewis, M., Rotgers, F., Wiers, R. W., & Heim, D. (2018). Challenging the brain disease model of addiction: European launch of the addiction theory network.?Addiction Research & Theory,?26(4), 249–255.?https://doi.org/10.1080/16066359.2017.1399659

Lembke, A. (2021).?Dopamine nation: Finding balance in the age of indulgence. Dutton.

Lewis, M. (2017). Addiction and the Brain: Development, Not Disease.?Neuroethics,?10(1), 7–18.?https://doi.org/10.1007/s12152-016-9293-4

Lewis, M. D. (2015).?The biology of desire: Why addiction is not a disease?(First edition). PublicAffairs.

Maté, G. (2009).?In the realm of hungry ghosts: Close encounters with addiction. Knopf Canada.?https://rbdigital.oneclickdigital.com

Miller, W. R., Westerberg, V. S., Harris, R. J., & Tonigan, J. S. (1996). What predicts relapse? Prospective testing of antecedent models.?Addiction,?91(12s1), 155–172.?https://doi.org/10.1046/j.1360-0443.91.12s1.7.x

Satel, S., & Lilienfeld, S. (2014). Addiction and the Brain-Disease Fallacy.?Frontiers in Psychiatry,?4, 141.?https://doi.org/10.3389/fpsyt.2013.00141

Sobell, L. C., Cunningham, J. A., & Sobell, M. B. (1996). Recovery from alcohol problems with and without treatment: Prevalence in two population surveys.?American Journal of Public Health,?86(7), 966–972.