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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    5 Responses to In Defense of the Disease Model of Addiction

    1. Avatar
      Silver Damsen July 30, 2015 at 11:34 am #

      What strikes me the most about Sack’s article is that he never addresses the fact that the “disease” model was created by the self-help group of Alcoholics Anonymous. So that many of the criticism of the “disease” model he tackles in this article are incomplete unless they are placed within the entire 12 Step program model. For example, the first step of AA is “We admitted we were powerless over alcohol and that our lives had become unmanageable.” Thus, when Sack argues that the “disease” doesn’t necessarily have to include a concept of “powerlessness” his argument is incomplete.

      If he were to strive for a more complete answer he would have to begin by making his stand on the effectives of Alcoholics Anonymous more clear, and the fact that the idea of being personally “powerless,” so that one should turn all of one’s major and even minor decisions over to an AA sponsor, is the core of the AA program and, thus, all that he says is not actually applicable to the issues at hand.

      Lance Dodes and Ann Fletcher are well-known and respected professionals on the topic of addiction, and their various critique of the “disease” model are always in the natural context of 12 Step program. As Dodes does an effective job proving in The Sober Truth, and his recent short works, AA has about a 5% success rate. Dode explains that the “disease” model is one reason for this huge failure.

      What I find especially tragic is that the 5% of those that do well in AA are very, very vocal (despite it being supposedly an anonymous program) and shout to heavens of the benefits that AA membership has bestowed upon them. Even more tragically, various addiction specialists also seem convinced that AA is the best way, even though its success is so very low and more and more people are coming forward with stories of the severe sexual and emotional abuse that is rampant in 12 Step culture.

      I suppose then what I find most troubling about this article is that it is trying to deceive its readers. Sack takes AA culture and AA’s low success rate out of the discussion so that he can attempt to disprove the arguments against AA’s dangerous ineffectiveness. In other words, one must pretend that AA is something other than it is for it to seem safe and effective, yet many, many people have been willing in the past to participate in this misrepresentation. Thus, an analysis of Sack’s content and form works to show why AA is a cultural institution and yet at the same time is a horrific failure from even the disease model concept. Any physician that boasts of a 5% success rate for his patients is a huge, huge failure. Voodoo, prayer, and doing absolutely nothing would seem to have about a 5% success rate. However, if Sack wants to present an even semi-lucid Pro AA and Pro “disease” model argument, he must ignore AA and its ideology entirely, which is probably the most telling indictment of why the “disease” model of 12 Step Program must be abandoned for a saner and more effective one.

    2. Avatar
      Carlos July 30, 2015 at 2:20 pm #

      My position is that addiction may minic a disease and God knows I know how had it is to give up. I mean i like my drugs. It got efficacy. I that sence it does whaf I want it to do. It take away physical pain that a thousand years of psychotherapy will never make a scratch. The proble is thaf the Jnited States government has hated us for so long that they bave done everything but kill us… Appologist, the government has managed to kill a good number of us. In the most hedious genocidal fashion. They have driven a number of us into proverty with all the preemployment urine test. And have tried to arrest as many of us as posible even though there is no victime for the crime of possew, … by driving users into proverty has added thec condition that those who have become dependent has gone to crime as a way to get their fix.

      The problem is that the same studies done for alcoholism and drugs has been replicated with homosexual. YET FOR HOMOSEXUAL it is a issue of way of life, but for addicts it is a disease. There is something politicaly hypocritical. We have a non funtioning brain while for homosexuals everything is hooky dory…I remember not too lo g ago when homosexuality was also a disored, until some homosexual psychiatrist lobbied the APA to take off their psychiatric categorization. We can forget that the APA 396 dignosis in the DSM system is neither valid nor relaiable. Talk a out really fucked up. The DSM system has about science about the same chance of me going to Pluto within the next half hour. It is bogus and frodulant.

      But the biggest problem of addition as a disease is that after over one hundred years of talking about it and all the auestionable science this article is trying to convince us of there is trully NO CONCLUSIVE EVIDENCE, the data at best suggest a posible disease. There are too many personal biases and wishful thinking to justify thirty or more years of careers as such expertise that doesn’t exisr. I agree with Dra Volkow
      When we do not understand the medical condition well. Doctors blame the outcome on the patient.

      After over one hundred years of talking about the disease modal you should have had an objective non biase test to prove the existance of the disease and the intensity or how bad this disease is.

      Am not that confusef, you don’t have to convince me your evidence is at best quesionable.

    3. Avatar
      Mike August 11, 2015 at 2:23 am #

      I notice the doctor acknowledges his own struggle with substances, however I get the sense he’s not quite without a bias blind spot regarding his attachment to an axiom which has worked for him.

      I say this because he is objective and impressive in his other articles, in this one, he goes from straw men to red herrings to ad hominem arguments and appeals to authority, kind of all over the place attacks on the presumed effects and some suprisingly over-baked reliance on epigenetic factors without any real discussion on what disease, exactly, addiction is? What is the proposed pathology, and is the abuse of a substance(s) the best common factor in the group of people who attend treatment centres and call themselves addicts?

      Is stimulant addiction related to running addiction more than opiate addiction to hystrionic personality disorder? 50% of “addicts” are concurrently diagnosed, but are they really, or is alcohol just a easy to take sedative for people with anxiety disorders, or meth for those with ADHD, boredom, major depression, etc.

      I think he he got it right in the first paragraph: “addiction” is not a disease but a mental health spectrum disorder. All sorts of factors come in to play in severe substance abuse, I agree, but these are largely external environmental factors. Poverty is not medical disease. Abusive parents, abandonment, bullying, trauma, epigenetics, etc. Most importantly, we don’t cure or treat things by callling them diseases, we describe them first if something is there medically to describe, and an objective way of diagnosing it physically in the brain.

      I take Concerta following stopping methamphetamine use, and although I have ADHD I never needed such a high dose before abusing meth. However, I got into meth after a doctor had me on too high of a dose of Concerta for 4 years, then stopped it suddenly. My judgement was way off and impulsivity, etc.resulted in my trying meth. My bet is that there now is permanent AfosB related damage, my neuroscience is pretty basic but I’m now in a bit of a feedback loop where medical management will be required for life to keep my reward system in range. A similar case may or may be made for GABAergic substances, but not the same case, really. For now, addiction as a tern could be kind of like the old axis II personality disorders, and specific pathologies due to substance abuse could be like axis I.

      In any case, the splitting of choice into only yes or no and the labelling problems are not properly the issues we should worry about in simply describing something medically. The shame and problems with 12 Step programs have to do with the fact that they are simply nonsense therapies, which don’t work statistically. Group therapy and the other benefits are separable anyways. There is no statistically valid basis to recommend AA to an alcoholic. Period.

      My point of view is that the feedback loop on the reward system with increasing genetic damage to the recptors is a medical disease, but I’m not sure they have described the mechanism yet such that we can say its predictable and describable

    4. Avatar
      um September 26, 2015 at 3:14 pm #

      wouldn’t it make more sense to refer to it as a mental disorder than a disease? the fact that addicts rarely refer to addiction as a mental disorder and constantly throw around the disease label instead should be proof that they’re basically just using the word disease as a way to erase stigma. mental disorders carry just as much stigma, so of course they won’t throw out that possibility as easily as calling it a disease.

    5. Avatar
      Greg November 13, 2016 at 12:34 am #

      The disease model of addiction is based on fairly recent findings in brain science about how certain repeated substances or behaviors impair the reward function of the brain. The actual definition of the disease model of addiction is lengthy and complex. Dr. Sack isn’t explaining the brain science behind the disease model or discussing its definition. He’s addressing some of the most common objections to the disease model, and he does this very well. HIs discussion of the claim that the disease model is disempowering is especially convincing and insightful, as is his discussion of attachments. This article is actually hopeful and encouraging, because Dr. Sack is saying that seeing addiction as a disease doesn’t make recovery any less likely.

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