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A Disease Defined

Definitions Of “Addiction” And “Disease”

A Disease Defined

Definitions Of “Addiction” And “Disease”


Addiction: A Disease Defined

Source Butler Centre for Research August 1998 https://www.hazelden.org/web/public/document/bcrup_addictiondefined.pdf.

Definitions Of “Addiction” And “Disease”

The question of whether addiction is a disease has been debated for decades. The answer to the question is important to researchers, medical practitioners, treatment providers, and to those who suffer from addiction. Because both concepts–disease and addiction–have not been clearly defined, the debate continues. Disease can be defined using several criteria. Lewis suggests that criteria for disease include the degree to which: the condition has a clear biological basis; is marked by identifiable signs and symptoms; shows a predictable course and outcome; and the condition or its manifestations are not caused by volitional acts. According to Hyman, Lesner, and the DSMIV, addiction is characterised by a person’s marked impairment in their ability to control their alcohol or other drug use. This loss of control, as it is often called, expresses itself as a person’s inability to predict when she or he will discontinue their use, once begun. The condition is characterised as one that is chronic, progressive, and relapsing. The American Medical Association, American Psychiatric Association, and World Health Organisation, have stated that addiction is a disease. A joint 1990 report of the Committee of the American Society of Addiction Medicine and National Council on Alcoholism and Drug Dependence provided a detailed description of alcoholism as a disease. In 1960, a researcher named Jellinek delineated five types of alcoholism and classifies three as diseases. What is the research that has led so many groups to state that addiction is a disease?

What Does The Research Show?

Using Lewis’s four criteria of a disease, let’s examine what the research shows for each. A disease has a biological basis: ample studies demonstrate that alcohol and other drug dependency often has a genetic basis. Some researchers are conducting animal studies on inheritable differences in reactions to mood-altering substances. These differences include tolerance, sedation, susceptibility to seizures, righting reflex, or preference for the substance over water. Other researchers are focusing more on identifying aspects of a person’s temperament or personality that predispose a person to use and dependency. Repeated use of a chemical may produce biological changes. Hyman in his study of neural function, found that brain cells adapt to the introduction of chemicals.

These molecular adaptations may usurp the functioning of critical pathways in the brain that control motivated behaviour. Leshner suggested that the brain has a mechanism that changes at some point during drug use. This molecular “switch” signals a change from use/abuse to addiction.

A disease has identifiable signs and symptoms: The American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-IV) codifies symptoms of dependence, based on evidence in research and expert consensus. Major symptoms include withdrawal symptoms; tolerance; using more of a substance than intended; unsuccessful attempts to control use; a large time investment in obtaining, using, or recovering from the effects of use; and, use despite of internal and external consequences. The disease is identified when several of these symptoms are present.

A disease has a predictable course and outcome: most recently, Schuckit and his colleagues conducted two studies describing a common pathway of alcoholism whose onset is marked by heavy drinking and social consequences, leading to loss of control and intensification of social difficulties, and then later, to serious problems in health, relationships, and employment. The desired outcome is complete abstinence, but short of this, it appears that the natural history of the disease includes periods of abstinence and relapse.

A disease’s condition or manifestations are not caused by volitional acts: a cardinal feature of dependence is one’s inability to control use, once begun. And, for most dependent people, drinking or using becomes a top priority, despite willpower to the contrary. This lack of volition is what differentiates abuse from dependence. Despite the strong evidence that addiction is a disease in terms of etiology, symptoms, course, and outcome, many people view addiction as a moral weakness and treatment as ineffective. But addiction is very comparable to other chronic diseases in terms of treatment compliance and outcome. A team of researchers under the auspices of the Physician Leadership on National Drug Policy (PLNDP) prepared a series of reports comparing addiction with other chronic diseases. The genetic contribution to addiction is comparable to that of other diseases such as hypertension, diabetes, and asthma. In addition, patients’ compliance with a treatment regimen, and need for repeated treatment, is similar across all these diseases.

How To Use This Information?

Implications for treating addiction as a disease affect public attitude and policy, as well as insurance reimbursement. As a disease, addiction can be approached as the important public health issue that it is. Insurance reimbursement for addiction treatment is essential to treat this disease. Like cancer and other diseases, effective treatment is required to interrupt the progression of the illness. Continued research and emphasis on the biomedical aspects of addiction may help restore parity when legislators and third party payers address the issue.

Controversies & Questions

Controversy: Some people object to the idea that addiction is a disease, saying that diseases ‘happen to’ a person but addiction is caused by a person’s decisions and behaviour.

Response: First, diseases fall on a continuum in the significance of behaviour on the etiology and course of the disease. Some diseases are caused mostly by genetic factors or unknown environmental factors. Other diseases, such as many forms of lung cancer, heart disease, diabetes, and hypertension, are highly affected by an individual’s behaviour. Yet we still agree that these are diseases.

Secondly, a large portion of the population drinks alcohol, experiments with illicit drugs, or uses prescribed narcotic medications. Most of these people think, “I’ll watch for problems with my use and quit if I have any.” And indeed, most people never develop problems. But some individuals will develop a problem and cannot simply quit. It is therefore unfair to say that people who develop addiction “brought it on themselves” when their intentions about their use were no different than those of normal users’.

Controversy: Some people object to calling addiction a disease because it seems to absolve a person from responsibility to recover, or excuses them from criminal or irresponsible behaviour while under the influence.

Response: People who have a disease are still responsible for their behaviour and the social consequences of it. Further, once they understand they have a chronic disease, they have a responsibility to follow a treatment course and make necessary lifestyle changes to maintain recovery.

The Hazelden Experience

Patients in treatment at Hazelden are taught that addiction is a disease–a treatable disease. It is a disease that not only has physical origins and implications but emotional, spiritual, and behavioural aspects as well. The Hazelden treatment approach helps patients understand what is known about the disease and then to leave the “why” of it behind to move on to take concrete problem-solving steps. In this way, patients are encouraged to let go of shame and frustration they have about their inability to control their past drug use and accept responsibility now for recovery. Hazelden’s approach integrates principles from behavioural models, which is a common trend in the field.


The Disease Concept Of Addiction Revisited

“The disease concept of addiction revisited” by Richard S. Sandor, MD http://www.addictionpro.com/article/disease-concept-addiction-revisited

In The Face Of Recent Questioning, The Disease Model Holds Up To Rigorous Analysis

Despite the fact that The Disease Concept of Alcoholism by E.M. Jellinek was published 50 years ago, and although the idea that addiction is a disease is now widely accepted, it remains poorly understood. The latest contribution to the confusion is a book published last June called Addiction: A Disorder of Choice by Gene M. Heyman of Harvard University. It’s an ironic recapitulation of history—20 years earlier, Herbert Fingarette of the University of California advanced essentially the same argument in his book Heavy Drinking: The Myth of Alcoholism as a Disease. Both men based their conclusions on epidemiology studies and surveys. Fingarette, a philosopher, argued solely from his reading of the scientific literature. Heyman, an academic psychologist, based his conclusions on epidemiology surveys and laboratory research on the psychology of choice. It seems that neither writer spent much time in the clinical trenches, actually listening to alcoholics and drug addicts describe their lives.

It Seems A Fitting Moment To Re-Examine The Disease Concept Of Alcoholism And Other Addictions.

To start, scientific data can no more “prove” that addiction is a disease than it can “prove” that the sky is blue. Either we all agree that the colour of the sky is sufficiently like everything else we call “blue,” or we agree to call it something else. In the same way, asserting that addiction is a disease cannot be proven by scientific data. A disease concept is really a theory of addiction—a way of showing that addiction is like all the other things we generally accept as diseases.

Although it may sound strange, when we say that alcoholism or drug addiction is a disease, we are not talking about the behaviour of drinking or using. Behaviour might signify the presence of a disease, but behaviour itself cannot be a disease. A disease isn’t something you do (voluntarily or otherwise); it’s something you have. The common sense inherent in our language reflects this same idea. We don’t speak of someone “high blood pressure-ing” or “pneumonia-ing.” We say a person has high blood pressure or has pneumonia. This is true for all diseases. The behaviour we call a “seizure,” for example, might indicate an infection, a haemorrhage or a tumour in the brain. The seizure is the sign of a disease, not the disease itself.

If the behaviour of drinking or using drugs is only the sign of addiction, then it is no surprise that measuring drinking or using behaviour brings no uniform picture of the disorder. In virtually all illnesses, especially early in their course, signs and symptoms are remarkably variable. Just as fevers may be high or low, pain severe or mild, alcoholic drinking or addictive drug use may be heavy or light, intermittent or continuous, boisterous or quiet—all depending on biological, social and psychological factors influencing the individual with the disorder.

So if by calling addiction a disease we mean that sometimes drinking or using is a sign of something else, a result of something a person has, then we need to be clear about what that something is. Without a simple conception of what an addiction is (on par, for example, with what an infection is), we have no strong argument for the disease concept of addiction.

The Experience Of ‘Powerlessness’

Part of the difficulty in establishing the disease concept of addiction is that the essence of the condition is known to us primarily through the reported experience of the person who has it. Although advances in brain imaging have begun to show us the disordered biochemistry underlying addiction, diagnosis is still based mostly on what patients tell us about their experience. As a result, the data are largely subjective and can be quantified “objectively” only indirectly. That’s why it is so important to listen carefully to the stories of alcoholics and addicts themselves—to hear what they say about what’s going on inside them. When we do that, we learn that they describe their experience as “powerlessness.”

But the idea of powerlessness is paradoxical. After all, many alcoholics and addicts do quit drinking and using for good. What happened to powerlessness, then? Choosing, “one day at a time,” not to drink or use sounds like having power, not like having lost it.

More than 100 years ago, in describing his own struggles with tobacco, Mark Twain gave us the solution to this puzzle when he said: “To cease smoking is the easiest thing I ever did. I ought to know because I’ve done it a thousand times.” Twain put his finger directly on the essential experience of addiction—when it is fully developed, it is an all-or-nothing experience. Although addictive behaviour is remarkably varied, in the end virtually all addicts discover that abstinence is the only reliable foundation for recovery. “Quitting,” it turns out, is hard, but it isn’t the major problem. The bigger problem, brilliantly expressed in AA, is “staying quit—not starting again.

Like many other illnesses, addictions progress. The beginning is marked by the struggle for control (“never before 5 pm,” “only on weekends,” and so on). But as time goes on, control becomes increasingly difficult to achieve. Eventually, it is attained only by quitting. Indeed, episodes of quitting and relapsing are almost an unmistakable indication of the diagnosis of addiction (as opposed to mere abuse or misuse). At this stage, if people begin again, they spend increasing amounts of time and effort trying to maintain “control,” but in the end it is lost. This is what AA’s founders described as having become “powerless” over alcohol—not just for a particular episode of drinking, but repeatedly and inevitably for all drinking. In the end, all addicts discover that there is just no such thing as one.