In Defense of the Disease Model of Addiction

Addiction was once dismissed as moral weakness or indulgence. Today, thanks to decades of research, we know that addiction is a chronic brain disease that “compels a person to become singularly obsessed with obtaining and abusing drugs despite their many adverse health and life consequences,” as the National Institute of Drug Abuse explains.

Most major health organizations endorse this definition (the World Health Organization, the American Medical Association and the American Psychiatric Association are just a few) but not everyone is on board — a point emphasized by a recent flurry of books and commentaries challenging the concept.

As an addiction professional, I believe it’s important to keep the conversation going about substance use disorders and how best to treat them. We are far from having a complete understanding, but my firsthand experience with those struggling with alcohol and other drugs puts me firmly in the “disease model” camp, and I worry that turning away from this definition may damage those who need help most.

Although the points raised by those who feel addiction is not a disease vary from person to person, I’d like to share a few of the recently voiced objections, along with my own thoughts. 

“Addiction isn’t a brain disease; it’s a bad habit.”

In Defense of the Disease Model of AddictionThe disease model of addiction explains that drugs of abuse cause sustained and sometimes irreversible structural and functional changes to a variety of brain centers. As this happens, the addict loses the ability to make healthy choices. Critics of the disease concept, however, say the brain is always changing in response to new experiences and this is proof only that addiction is learned — and can be unlearned. It is, they say, simply a bad habit.

We know that only a small percent of those who experiment with drugs become addicted. Those unlucky few appear predisposed to becoming addicts. In fact, research shows that the brains of those who become addicted are often neurologically and genetically different before drug use begins. Environmental influences — such as how a person was raised, the relationships they have and whether they are loved or abused — can also affect the onset and course of the disease. The result can be a dysfunctional brain that becomes unable to stop the process of wanting, no matter the consequences.

Unlearning negative ways of reacting and responding to substances — those “bad habits,” in other words — is a crucial part of the healing process, but expecting people to will themselves into health misses the depth of addiction’s power. That’s why effective addiction treatment so often uses a combination of processes to loosen the disease’s grip, including cognitive behavioral therapy to help redirect thoughts; medications to calm cravings and make relapse less likely; psychotherapies to help rewire neural pathways; and group therapy to provide social support. Each of these acts together to positively influence the disease of addiction much as diet, exercise, lifestyle changes and medication are used to treat other chronic diseases like diabetes, heart disease and hypertension.

“Calling addiction a brain disease is disempowering.”

Viewing addiction as a disease limits the shame and stigma felt by those dealing with it, but critics of the disease concept say it also does something more negative: increases feelings of powerlessness. After all, if it’s a disease, what can be done?

This attitude fails to recognize that a disease diagnosis doesn’t preclude improvement. It’s true that addiction is chronic and progressive, meaning it tends to worsen over time without treatment and lifetime monitoring may be required to keep it in check. But the same can be said of diseases such as cancer, diabetes, hypertension and asthma – and these conditions, like addiction, can be treated with medication and lifestyle changes. It’s not true, then, that disease equals hopelessness. Addicts can find help as well as help themselves.

“Addiction isn’t about disease; it’s about connections.”

Some have theorized that a lack of positive connections is the true cause of addiction. They point to research such as the famous “rat park” study, which showed that rats allowed to engage with other rats in a stimulating and rewarding environment — as opposed to being stuck in a cage — were less likely to turn to substances.

Connections and a healthy environment are indeed crucial, but they are just part of the picture. After all, not everyone who has a lack of positive connections in their life becomes an addict; conversely, positive connections don’t guarantee that addiction won’t take hold. In short, connections are vital in helping lower the risk of developing addiction, but we can’t count on them to preclude it or to heal it. I view it like this: Addiction isn’t about connections instead of disease, but about connections and disease.

“The disease model lets users off the hook for their behavior.”

People choose to take drugs, but they don’t choose to have a disease, so how can the two be equated? It is true that the first use of a substance is a choice, but for the addict, the concept of choice soon evaporates. It’s easy to doubt this. From the outside, the addict can seem like a narcissistic pleasure-seeker who doesn’t care who gets hurt along the way. Saying they have a disease can seem like a way of rationalizing bad behavior.

But consider how many people use drugs or alcohol and never develop a problem. Do they just have extraordinary willpower? No one disputes that addiction runs in families. This alone is a strong indication that something is going on other than a lack of self-control. Rather than excusing behavior, what the disease model really does is help us understand it. Addiction is, when all is said and done, an obliteration of “free will,” explained Nora Volkow, director of the National Institute on Drug Abuse, in an eloquent commentary that explored her grandfather’s suicide in response to his distress over his alcoholism.

One thing is certain: No one sets out to be an addict. With help in the form of medication, support and therapy, however, the addict has a chance of reclaiming his or her willpower. The solution then is not punishment, but treatment that prompts the addict to be a partner in his or her own recovery.

“The disease model is offensive — labeling addicts as ‘diseased.’”

I couldn’t agree more that labeling someone “diseased” is offensive, but that’s because the word has a much different and more negative connotation than its root word “disease.” Just as we wouldn’t call someone with cancer “diseased,” nor should we refer to or think of addicts as diseased. They do, however, have a disease — and recognizing that means a better chance of getting them the help they need.

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