Years back, I set out to critique the disease model of addiction only to find that there was no consistent model – that is, there was no thorough explanation of what the whole thing is and how exactly it works to make substance use an involuntary behavior. That no-one had a coherent (whether true or false) explanation for the disease claim became painfully clear to me as I was analyzing an interview of Alan Leshner (Nora Volkow’s predecessor at the NIDA), point by point, where he drifted among various common myths, fallacious arguments, and propaganda techniques used to support the disease model. Another thing struck me that day, during the moments of his interview that centered on the brain disease explanations, I realized that this whole thing was about learning. FYI, the brain disease argument basically boils down to this in most presentations:
- repeated drug use changes the brain
- therefore addiction is a brain disease
As Leshner was discussing these devastating brain changes, the interviewer, Bill Moyers (a dedicated diseaser himself, given that he sent his own son to several rehabs, culminating in an eventual executive position working for Hazelden) astutely asked:
Doesn’t every experience change our brain? When you learn that the Normans invaded England in 1066, your brain changes because somehow, you don’t forget that. It’s stored somewhere, something’s different to code that.
Leshner weaseled his way out of letting it appear that this fact cut down the disease view, but I never forgot it. It molded my signature argument against the brain disease model which essentially boils down to this:
- Diseases involve physiological malfunctions
- the brain changes that supposedly prove addiction is a disease are simply evidence of wholly normal physiological functioning
- therefore, addiction is not a disease.
There are plenty of other arguments I can make. I can argue against any point out there, but I think that this is the point that no one seems to recognize – the point that hides in plain sight, and with which every claim that involves “brain changes” should be filtered through. If brain changes are evidence of a disease and of us having no control over our behavior, then everything is a disease, and none of use have any control over our behavior – that’s how normal “brain changes” are. As I don’t recall anyone else of stature making this direct specific criticism of the modern presentation of the brain disease model of addiction, I was happy to read a recent blog by neuroscientist Marc Lewis, where he expressed the same basic point:
pretty much all the major theories agree that dopamine metabolism is seriously altered by addiction, and that’s why it counts as a disease. The brain is part of the body, after all….
Then why don’t I buy it? Mainly because every experience that has some emotional content changes the NAC and its uptake of dopamine. Yet we wouldn’t want to call the excitement you get when you’re on your way to visit Paris, or your favourite aunt, a disease. Each rewarding experience builds its own network of synapses in and around the NAC, and that network sends a signal to the midbrain: I’m anticipating x, so send up some dopamine, right now! That’s true of Paris, Aunt Mary, and heroin. In fact, during and after each of those experiences, that network of synapses gets strengthened: so the “specialization” of dopamine uptake is further increased. London just doesn’t do it for you anymore. It’s got to be Paris. Pot, sex, music…they don’t turn you on that much; but coke sure does. Physical changes in the brain are its only way to learn, to remember, and to develop. But we wouldn’t want to call learning a disease.
Now I don’t think I necessarily agree with everything Lewis has to say, and in fact he may have a different vision of addiction that I find horrifically flawed, I really don’t know as I haven’t read him much, but I’m glad we seem to agree on this point (here’s a link to his blog if you’re interested).
While I’m at it, another writer, Derek Meyer, summed up the same point perfectly in the comments of another post:
there is nothing abnormal about the biological adaptation of the brain to drug use; it’s nothing more than the brain’s process of learning. The presence of a neurobiological correlate to a particular behavior does not mean one is powerless to control that behavior – unless you believe that free will is an illusion and humans are essentially robots, predestined to act out the dictates of their brain’s wayward neurochemistry. There is nothing abnormal about the pathology underlying “addiction” – the process is conceptually identical to any other form of learning.
This issue matters greatly, because the wrong answer will send you down a frustrating fruitless path that never comes close to increasing quality of life for anyone.
The 12 steppers say addiction is a spiritual disease, and once an addict always an addict. They don’t claim it is a physical disease. Do the treatment centers say it is a physical disease?
Addiction is a habit, not a disease. I’d like to read more about habits, what makes some people choose certain habits over others, how they stay stuck in habits, how they change them.
Two things have always troubled me about the claim that addiction is a disease:
1. Not only is there is no physical factor that can be used to counter the claim – or accusation – that a person is suffering from an addiction, but that very fact is used to prove to those who resist the accusation that they *are* addicted because they are showing a classic symptom of addiction, i.e., denial of the accusation that one is addicted. (Can you say “Catch-22”?)
2.Why is it that this one disease that is impossible to detect on a physical level requires treatment that centers around accepting belief in God (Notice that 6 of the 12 steps mention God, but not one says, “I will quit drinking/using”)
Related to #2, most people who know they have a disease don’t get sentenced by courts to medical care. Most sick people seek treatment, and those who don’t, either because they feel the side effects are worse than the untreated disease, or because medications available aren’t very effective, are allowed to decline treatment. Even after initiating treatment, patients can withdraw from treatment voluntarily, without facing judicial consequences.
Why is it the only “disease” that courts see fit to oversee treatment for is the very “disease” that there is no evidence to prove it’s a disease?
Also, if “addiction” merely caused the craving & persistent use of drugs (alcohol), would courts, society or loved ones really be so worked up about it? Or is it because Americans have been trained to believe that “addiction” is the cause of criminal, work-sky, fraudulent & selfish behaviors that impact the community that there’s such a call to stamp out drugs? (And, looking at history, it is very noticeable that all the categories of crime & selfishness attributed to “addiction” predate every drug except maybe alcohol, and even today, many crimes are committed by people who are not under the influence at the time of the offense, or even by people who don’t use any drugs/alcohol at all. I always get a kick out of relatives of criminals saying on TV “at least so-and-so didn’t use drugs” – as if drug use is worse than whatever crime is being discussed on the TV show)
Addiction is not a disease for me. I’m a healthy woman and I have been addicted to substances that I thought I needed just to live, that I couldn’t imagine my life without. Past tense. I think most people who say they have a disease are just confused, and many in the programs have depression, bi-polar and/or mommy/daddy issues that make them feel broken, so they are confused about the cause of their despair. They blame is on addiction, but really they just need mental help.
I would love some thoughts on an abstinence question. What is the harm/value of having some wine now and then? Drinking alcohol is certainly not necessary to life, but neither are the following and we don’t chastise people for engaging in them: eating cookies, having an orgasm, getting your nails done, watching TV, or drinking coffee. In other words, is abstinence a worthwhile goal, and why?
If you look at how they do things in Europe, where abstinence isn’t the goal when treating someone who drinks too much, instead, they encourage reducing drinking, there is probably no harm in having some wine now & then. Considering that the older people are, the more moderate their consumption is, a responsible adult who is getting older is probably not going to go back to the patterns of drinking they engaged in during their frat party days…
Considering the fact that every human society -ever- has had some form of alcoholic beverages, and that before the discovery of infectious germs & modern public sanitation, water was not safe to drink & the only beverages that wouldn’t include the risk of rapidly fatal GI diseases contained alcohol, the idea that some people would have some sort of in-born (i.e., genetic) response to alcohol that would cause people to become wildly antisocial, it would seem to me that such a variant would be deleted from the gene pool in a short amount of time.
Instead, we see that the definition of “”alcoholism” & “addiction” are not only defining the problem downward (when I was growing up, the popular belief was that alcoholism & addiction took long periods of high consumption to occur. There were no teens going to AA. Also, “addiction” is now not just about consuming lots of drugs for a long time & behaving badly at work, towards loved ones & maybe committing crimes outside of drug purchases/sales, but now “addiction” is being applied to activities that don’t even involve ingesting anything – people who cheat on lovers (“sex addiction”), gamblers – I’ve seen psychologists on TV claiming hoarders are addicted to acquiring stuff and FBI profilers on TV claiming that serial killers are addicted to murder.
Addiction is just that: addiction. It is not a disease or a choice but a disorder which can be extremely dangerous. People will die seeking the altered state. They will loose jobs, friends, parents, children, marriages, freedom and mucho dinero yet still ‘chase the high’. It is an engrained habit learned the normal way, neurobiologically. Some people change when life circumstances change for them. They get married, have children, get a new job, get promoted, get sick, have a religious conversion – the list goes on and on. Some people change when they make a choice to change. They go to therapy, join AA, substitute a more benign addiction – the list goes on and on. Some people make a decision to change and fail over and over. The neurobiology is strong. The reactive brain is powerful. We live most of our lives reacting. The mind isn’t asked what to do until the reactive brain has processed the imput and made decisions about what to do. It usually only asks if it hasn’t seen the situation before. Marc Lewis describes this in his blog http://memoirsofanaddictedbrain.us2.list-manage.com/track/click?u=f73df3c6066483aed9ac91a84&id=5c0efdeb21&e=887206837c
Evolution makes it so. Without providence we are left with choice as the only way out. Hopefully, when we choose we will find a method that works. Some can will it but most need help. Unfortunately, most of the available help tells us to seek a miracle while insisting the problem is a disease.
Thank you so much for your post. I found the reading intriguing, esp. this post on choice:
http://www.memoirsofanaddictedbrain.com/connect/addiction-resulting-from-choice/
I agree that choice becomes more difficult as the brain receptors are changed, as habits and memories are formed, by repeated drug use. But what the writer does not answer is why someone chooses the repeated drug use in the first place, because there is choice in falling into that pit of addiction in the first place!
In the first few times of using a substance, you know the negative side effects, so you have to ask yourself what benefits you get that make those side effects worthwhile? Why does someone choose to take a substance that keeps them up all night, that makes them skip school or work to keep doing more, that requires lots of alcohol to come down, that requires living with fear of arrest just for possessing it? Why does someone choose to take a drug that makes them nod off, be constipated, unable to climax, share needles? These side effects are apparent from the very beginning.
First excuse my poor spelling. It should be empirical and pigeons. I’m lost without spell check. I don’t believe it is a choice. The neurobiolgy makes it a reaction. We do it without thinking. Alcohol may be different because we don’t believe we will lose control and become addicted. We’ve been taught how to ‘hold our liquor’. Maybe we drink too much but there’s nothing wrong with that. Through ignorance or ambivilence we go too far and we’re addicted. Now we have to deal with withdrawal if we try to quit or cut down. At this point we know we’re in trouble and we decide to seek help. The help usually available is comical if you examine it critically. AA meetings which don’t allow ‘crosstalk’. It’s rather difficult to discuss something without feedback. Asking God to restore us to sanity. Group therapies where the patients do all the talking. Confrontational counselors whose only qualifications are being ex-addicts or maybe they have a Masters in Social Work which I assume anyone with an IQ above 85 can earn. Psyciatrists who tell you everything Nora Volkow says is golden (actual quote). I could go on but I won’t.
I don’t believe anyone chooses to become addicted. They get introduced to the drug or drink, they like it and before they know it they begin to seek it frequently and then obsessively… They function just fine until they’re deep into it. Sometimes it may take years to become a problem. Some people never have a problem. They can drink or use moderately and never become addicted. This is certainly true with alcohol and I imagine some may do a few lines now and then or puff on a pipe and never become addicted. So while certainly use is a choice but addiction isn’t.
Holt, I don’t see my journey into addiction as innocently as you do, as in “I just fell into it because I liked it”. So here are my questions to you based on your comment “They get introduced to the drug or drink, they like it and before they know it they begin to seek it frequently and obsessively”.
Why do they like it, rather than going about the everyday business of life with school, work, relationships? Why do they spend money on that rather than investing in the stock market, saving for a house, or buying gardening supplies? Why do they spend time in the pursuit of that, rather than in reading, working, gardening, playing music, surfing, volunteering?
I do agree that once into it, it is extremely hard to stop. It takes an intervention or courage or a desire for something better. My 2 cents.
Your question asking why people like drugs, why they choose to engage in doing drugs instead of investing in the stock market, has a very complex and wildly differing reason for each individual that engages in drug use. The reason that each individual person engages in drug use is different and unique to that person. How could you expect someone to answer your vague question when the answer is extremly complex and esspecially different for everyone.
Dear Kelly: I was commenting on my experience with alcohol. I’m sure others were more aware of the dangers when they crossed the line into addiction but I know many who did not believe they would become addicted until it was too late. Looking back it is hard to believe I didn’t understand the addictive nature of alcohol until I was in very deep. The National Study on Alcoholism found about 35% of former alcoholics were in remission but the mean time spent abusing alcohol was maybe 12 years. This means that 65% abuse alcohol for more than twelve years. Along the way, scientists have estimated the death rates of alcoholics as 2 to 3 times that of the general population.
The scientists tell us drugs of abuse stimulate neurotransmitters in the brain which are associated with reward, survival, euphoria, hypnotic effect, analgesia, calmness, alertness… the list goes on depending on the drug in question. Our brain has evolved to value these effects and seek them because the same neurotransmitters and brain regions are involved with basic instincts like sex, food, drink and social interaction. For many, but not all, we value them above investing, gardening, school work and (very sadly) relationships. People have been faced with death and still are not able to resolve their addiction. But, there are no absolutes and many do recover.
I am interested in the exploring the paths to recovery. I would like to ask any and all who have recovered to tell us how they did it. For me the key was when I discovered that addiction was learned habitual behavior. With that truth I could plan and think my way past the problem.
Holt, I agree with you that “through ignorance or ambivalence we go too far”. I think drug education is just a disgrace. Scare tactics turn out to be lies, so I just discarded everything they said. We should teach kids to beware of what habits they form. I don’t see what I did with the pills as any worse than what many do by escaping their lives in computers, work, or romance novels. And in the end, I have a terrific marriage while my other friends are bored with their husbands. Except my finances still suck.