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Unnecessary Debate: Is Addiction a Disease?

Unnecessary Debate:  Is Addiction a Disease?

Imagine two stalwart fans of professional wrestling locked in debate. One holds that the wrestlers are athletes. The other argues that they are not athletes but entertainers, performing in a variety of theater. Both fans are thoughtful and persuasive. Notice that their disagreement is not about the physical attributes of professional wrestlers, or about what they do inside and outside the ring. Their disagreement is about how to name, or classify, the group of people who engage in professional wrestling.

Professional wrestlers are what they are and do what they do.  Naming and classifying, however, are conceptual, and therefore somewhat arbitrary.  This arbitrariness is no revelation.  As Shakespeare’s Juliet said: 

What's in a name? that which we call a rose
By any other name would smell as sweet

But when debates about classification heat up, people often think and act as if the issues are absolute rather than arbitrary, especially if debaters have a personal or professional stake in one point of view.  Or just like to debate.

Diseases are classifications. They designate groups of people with health problems whose problems are not identical but are so similar in their biological mechanisms and responses to treatments that, when individuals are accurately diagnosed with a disease, they can benefit from knowledge of causes and treatments drawn from research on others like them.

Disease categories exist to be useful. They convey medical understanding and guide treatment. They are subject to change over time because, to maintain usefulness, they must evolve along with the practical applications of science and technology.

Whether to classify addiction, including addiction to alcohol, as disease has been controversial for decades. Some participants in this dispute, regardless of the position they uphold, imply that diseases are more than categories. They argue as if diseases somehow exist on their own. But concepts are not tangible things. I cannot sit on the concept of chair, but I can sit on the particular black swivel chair beneath me now.

Current disease categories for addiction are substance-specific (alcohol use disorder, cocaine use disorder, etc.) and may evolve to a single category of addiction that encompasses not only compulsive substance use but also problems such as compulsive eating and compulsive sexual activity. Some experts advocate classifying addiction as a syndrome—an alternative term closely related to disease—because individuals develop addiction by dissimilar routes, comparable to the diverse causal paths that lead others to the syndrome of congestive heart failure.

The particulars of diseases are the people grouped together due to the similarities of their health problems and classified using specific diagnostic names. The group bearing a single diagnosis may be very large, extend over generations, and be divided into clinical subgroups based on practical differences.  An example of a clinical subgroup would be individuals addicted to opioids who are maintained on medical therapy with methadone or bupernorphine.

When those who join the debate on addiction as/as not a disease do not understand the conceptual nature of disease classification, their arguments can be confusing, misleading, and ultimately irrelevant. In their defense, even the question that leads this article—“Is addiction a disease?”—is itself misleading and can contribute to confusion.

Clarity is attainable. If we agree that there are real people who experience harm due to behaviors such as drinking alcohol excessively, injecting heroin, or smoking crack cocaine, yet continue the behavior despite the harm; and if we agree to call their condition “addiction,” we can then pose relevant questions. “Do science and technology contribute to the understanding and treatment of addiction? If so, is it useful to classify addiction as disease? And if so, is it always useful to classify addiction as disease?”

Sciences such as epidemiology, genetics, and neurobiology provide a great deal of information about the causes and mechanisms of addiction, and that knowledge is useful in prevention, patient education, and developing treatments. Psychology and pharmacology, among other disciplines, equip healthcare professionals with interventions that frequently help those with addiction.

Add to these points that classifying addiction as disease decreases stigma for some, gives healthcare personnel and other resources such as health insurance reason to address addiction, and excuses affected individuals from work or school so they can obtain help. The resulting case for classifying addiction as disease is persuasive. Standard compendia of disease categories have included addiction for years.

Addiction can be classified as disease, is classified as disease, and many individuals who are either affected by addiction or treat addiction perceive this as useful. But, is classifying addiction as disease ever harmful? Are there other useful points of view? Does someone have to be wrong?

One reason our debates about addiction as/as not disease are so heated, is that the assertion “addiction is a disease” is closely associated with Alcoholics Anonymous (AA) and other Twelve-Step Programs, with parties on both sides of the debate prone to regarding diseases as tangible things rather than categories. AA has strong advocates and strong adversaries, with adversaries objecting to some or all of Twelve-Step Programs’ tenets, customs, and central role in some treatment centers. In the past it was not uncommon for advocates to fuel debate by declaring the Twelve-Steps the best, or perhaps only, path to recovery. The new normal, or at least emerging normal, is diversity in treatment and recovery, with emphasis on what works for the individual. Current debates are sometimes fueled by a trend to declare medication for addiction as the best, or perhaps only, path to recovery.

Classifying addiction as disease has potential drawbacks. For example, it may foster resignation and inhibit individuals from taking responsibility for the changes in lifestyle, relationships, and priorities that may be necessary for recovery. Clinicians and patients who view addiction as disease may consider only conventional treatment modalities and overlook useful additions such as mindfulness and self-compassion.

Historically, the view of addiction as a moral weakness was clearly harmful.  It increased shame and resistance to change among those affected and deprived them of social support, which most individuals with addiction need in order to recover. On the other hand, there are newer, persuasive, and potentially useful views that validate the inertia and pain of individuals with active addiction, take neuroscience into account, and classify addiction, for example, as a disorder of learning or as a regrettable, and ideally transient, consequence of people/brains seeking pleasure and relief.

Classification is not always necessary or desirable. Some individuals mature out of apparent addiction without formal treatment. They likely have interpersonal supports and make lifestyle changes, but do not consult healthcare providers or attend support groups. Becoming a person who does not drink or use drugs is sufficient for them. Putting a name on that could induce stigma and make their transition more difficult.

Let’s return to the wrestling fans. Is their debate useful? Perhaps, if they both get a kick out of debating. But if they long to share their appreciation of professional wrestling with others, their polarized stances limit each of them to celebrating wrestling with like-minded fans. If they stop viewing their positions as mutually exclusive, however, and communicate about what they each enjoy about wrestling, they might enrich one another’s experience and discover even more opportunities for sharing.

People with addiction, people at risk for addiction, and our communities in general will be better served when all concerned, which is everyone, stop unifying around concepts and more consistently unify around people. We are useful when we provide respect and acceptance, recognize and support individual responsibility, decrease access to addictive substances, decrease permissive attitudes toward misuse of them, and facilitate individualized treatment for those who need it.

The NCADD Addiction Medicine Update provides NCADD Affiliates and the public with authoritative information and commentary on specific medical and scientific topics pertaining to addiction and recovery.

Original author: Geoff
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NCAD Addiction Medicine Update

The NCADD Medical-Scientific Committee is made up of physicians, psychologists and others to provide advice and guidance to the NCADD Board of Directors, staff and National Network of Affiliates on activities related to medicine, health and addiction to alcohol and drugs. The Committee develops NCADD position papers, advisories, and other public statements for approval by the Board which reflect the latest medical and scientific understanding of the disease of alcoholism and drug dependence.