Recently, a friend asked me whether or not I believe that addiction is a disease.
My opinion is that it most certainly is. Uncategorically, it is, in fact, a disease.
This is not mere conjecture, nor is it a hypothesis. It has been established to be a disease based upon its properties, its mechanism of action and its genetic predisposition.
Finally, its need for ongoing treatment and the likelihood of resurgence of symptoms when treatment is halted, further give evidence to its disease model.
The three most glaring characteristics of addiction are the first indicators that it is a disease process, and not mere moral depravity. Addiction has been proven to be: progressive, incurable and fatal, if unarrested. This is no different than the properties of hypertension, cancer or diabetes. Unlike with those diseases, however, we do not understand ALL of the physiologic mechanisms that play a role. There are some, however, that we know to be true scientifically. This brings us to the effects that mind-altering substances have on the brain, and the mechanism of action which has the ability to change the brain irreparably, even after years of abstinence.
It is this understanding of the neurophysiologic pathway of addiction that confirms it as a disease.
When the brains and neurotransmitters of those with addictions have been studied, the following things have been found:
• The ingestion of alcohol, opioids, amphetamines, etc. lead to the release of dopamine, which is associated with pleasurable effects of substance. Initially, these are reinforcing and rewarding;
• Other pleasurable activities (gambling, sex, exercise, etc.) can co-opt the brain in the same fashion;
• The nucleus accumbens, which is a part of the brain’s limbic system, has the greatest dopamine release and effect. It has come to be known as the brain’s “pleasure center”. It is the cradle of where physical dependence and eventually, addiction are born ;
• In certain individuals, chronic engagement in pleasurable activities or use of mind-altering substances leads to a short cut to the brain’s reward center by flooding it with dopamine;
• The hippocampus responds by forming memories of this intense satisfaction and the amygdala creates a conditioned and rapid response to such stimuli;
• It has been found that dopamine also plays a role in learning and memory. When coupled chronically with something that quickly stimulates pleasure, the brain goes from merely liking something to linking it with intense pleasure and becoming dependent upon it, craving it and eventually, becoming addicted to it.
• Chronic use of, or exposure to, whatever the object is leads to alteration in how the brain functions without that substance.
• After some time, due to the complete saturation of dopamine receptors, the brain becomes less able to achieve the same level of satisfaction that it once did. Eventually, the brain adapts so that the sought after substance becomes less and less pleasurable. This is known as tolerance. However, due to the alteration of the brain and its inability to find sufficient pleasure and reward without the substance(s) of choice, it continues to seek what it now needs to function and to feel “normal”. This is seen as an escalation in use of the drug or activity of choice.
• Because the dopamine receptors are saturated, the brain in its efficiency, now produces LESS dopamine, despite the increased ingestion of or exposure to the substance or activity in question.
• The memory and learning of the original pleasurable event(s) persist, and given the decreased sensation of even normal pleasure or comfort, the brain seeks and craves such relief. This is often the start of compulsive and risky behavior to obtain the substance or engage in the activity to bring pleasure or relief, simply to feel “normal”.
• There have been studies done where people in recovery from cocaine addiction for years have been placed in an MRI and shown images of cocaine for a millisecond-so fast that the images don’t register consciously for them. Decades after their last exposure to cocaine, it has been found that the parts of the brain that reflect triggers and craving will still light up in response to that millisecond view of the drug. There clearly has been a permanent alteration in the brain as a result of chronic substance use or behavior.
So, given the long term and sometimes permanent physiologic and physical changes that have occurred, is this any less a disease because it has a component of self will and patient participation? Do we call lung cancer any less of a disease because a person who willfully smoked for years got it? Do we call gonorrhea any less of a disease because the infected person had unprotected sex?
Addiction has even been created in laboratory mice. There is a very famous experiment, conducted at the University of Indiana, which demonstrated the same behavior in alcohol addicted mice, as is seen in alcohol dependent human beings.
In this experiment, large numbers of lab mice were placed in a cage with one bowl of water and one bowl of water laced with vodka. It was found that there was a subset of the mice that repeatedly returned to the bowl of water laced with vodka. These mice drank to excess, preferred the water-vodka cocktail over pure water, and performed tricks to get more alcohol. It came to a point where these particular mice began to ingest the water-vodka combination in lieu of water or even food. They consistently represented 10-15% of the study population… even after breeding. This comes very close to the incidence of people addicted to substances within the human population.
And that brings me to the 3rd level upon which a disease model has been established… genetics.
It has been demonstrated that if a person has 1 parent with an addictive disorder, they have a 40% chance of also becoming an addict/alcoholic. 2 parents confers an 80-85% risk.
These statistics were reflected in the offspring of addicted/alcoholic rats out of Purdue University. Assessment of breeding and alcoholism within the rats’ offspring were performed. In fact, the study demonstrated that, in laboratory rats, there are at least 930 genes associated with excessive drinking.
While we can consider and debate the effect of environment upon the addicted individual, or even consider the question of ethics, morality and religion, we cannot attribute any of those factors to why the rats became addicted. Their addictions could only have been due to sheer primitive instinct and/or pathophysiologic adaptation.
Unfortunately, when people insist that addiction is not a disease, but all about sheer will power and being “strong”, they are likely to drive the alcoholic or addict, who understands nothing about their disease, farther and farther away. It is important that that person understand that addiction or alcoholism, in and of themselves, are not moral failings. Understanding and accepting this better allows the suffering addict/alcoholic to ask for help.
That is not to say that they may not have done things during their active disease that were corrupt or immoral. Those things will need to be recognized, analyzed and accounted for in order for recovery to be possible. But, that comes later in the recovery process.
First, the individual MUST GET HELP.
What is help? What does help look like when treating a disease such as addiction?
Our conditioning to think of medical treatment as simply including medications, procedures and surgeries will impede us from understanding that treatment also encompasses behavioral modification and changes in lifestyle. Again, I point you to some of the elements used to treat hypertension and diabetes. Many times, significant improvement occurs when behavior is modified. When diets are changed and a regimen of exercise implemented, many treatment goals will have been realized.
Addiction is no different. Treatment can, and sometimes does, consist of use of pharmaceutical agents. However, long term success almost always requires a behavior-based approach, which involves more than just abstention.
On a level seemingly unrelated to physiology and genetics, we know that the idea, understanding and application of certain spiritual principles play a big role in recovery for many, and is the crux of almost all 12-step programs.
Because self-will does play a role in human addictive behaviors, it is believed that the root of that must also be explored. It is not enough to say, “I have the disease of addiction. It may have been a genetic inheritance and I cannot do anything about it.”
No. While the addict or alcoholic may not be responsible for their disease, they ARE responsible for their recovery. Just as the diabetic is responsible for checking their blood sugar, eating an appropriate diet and taking any prescribed medications, the person seeking recovery must also remain in treatment and be compliant with the tenets of that.
For most 12 step programs, that means attending meetings on a regular basis, getting and working with a sponsor, doing step-work, being of service to other addicts, alcoholics, sexaholics, gamblers, etc within their fellowship, developing and nurturing a relationship with a god of their understanding.
This also means a deep exploration of one’s self in order to become self-aware… aware of beliefs, philosophies, experiences, impulses and drives that have likely been at play in the individual’s life for the entirety of their life… even before substances became an issue.
Which of these attitudes and behaviors have been helpful and which have been harmful? Which were responses and patterns of behavior that would have led to pain for the individual and made the seeking of pleasure and/or relief more likely? What can the individual change about his/her responses to their environment and those things that they cannot change? What other things are they doing that are self-destructive or harmful to others? Is there insecurity, self-centeredness, dishonesty, defiance, fear, etc., that lead to unnecessary pain in the person’s life that they seek to self-medicate?
It is believed that a big part of the solution and new design for living involves: acceptance that this person cannot control the use or engagement with the substance or activity with which they are addicted and must abstain from it; reliance upon something greater than themselves; a faith in that being, that, no matter what, as long as they do the next right thing, that entity will take care of them; a commitment to changing behaviors that have caused pain and difficulty for themselves and others in the past; the ability to ask for help when needed; the willingness to follow the will of that entity or deity in which they have started to place their belief and faith.
12-step programs often guide those with addictions to that self-awareness as well as that reliance upon a god of their own personal understanding. When the individual learns to live the principles of the Serenity Prayer (acceptance, faith in God, courage and a petition for God’s help), life becomes less burdensome and scary. Serenity is possible, even in the face of adversity. It is no longer necessary to seek comfort in material things.
When the individual learns to be honest with others about what is really happening in their hearts and in their lives, they can get help and an honest reflection of themselves. They learn to trust and they start to learn intimacy. This means that self-will is no longer as much of an issue. Peace becomes possible and the pain that once demanded relief through the use of drugs, alcohol, food, sex, gambling, etc. is no longer as great. But even if it is, they have found healthier ways to address it.
As with any disease, however, recovery and wellness require vigilance and work through a prescribed treatment plan. Without those things, relapse is possible in any number of ways, as is death.
I do believe that addiction is a disease. In fact, I know that it is. It has the potential to destroy an individual physically, emotionally and spiritually. But, when recognized and treated appropriately, recovery is possible.