Are Addicts Sick, Bad, Both, or Neither?

Jacob Sullum | August 29, 2007

reason contributor Maia Szalavitz had an interesting essay in yesterday's Washington Post contemplating the essence of addiction, drawing on her own experiences as a cocaine and heroin injector as well as research and expert opinion. Her opening frames the issue this way:

Is addiction a disease? A moral weakness? A disorder caused by drug or alcohol use, or a compulsive behavior that can also occur in relation to sex, food and maybe even video games?

Yes, she more or less concludes:

So is addiction disease or learned behavior? Given its complexity, some experts say, what probably matters most is which view best yields compassionate and effective treatment.

This position seems backward to me. If you've already decided that "compassionate and effective treatment" is the appropriate response to addiction, that pretty decisively tilts your perspective toward the disease model. But as Maia notes, even people who claim to champion a disease model seem ambivalent about it: Can you think of any other disease for which the most widely accepted treatment involves asking the patient to surrender himself to a "higher power" and make amends for the wrongs he's done as a result of his illness?

My own view (which I think is similar to Maia's) is that addiction is a learned behavior that, like many other things in life, is influenced by various genetic and environmental factors. Viewing it this way neither requires nor precludes compassion for addicts. As with anyone in trouble, the moral evaluation hinges on the specifics of the individual's situation, including disadvantages that are beyond his control and the extent to which he has hurt other people. Drug addiction should be seen as part of the continuum of human behavior, not as a special case in which all-powerful chemicals take control of people and dictate their actions.

[Thanks to Jeff Schaler for the link.]

Comments

|8.29.07 @ 1:48PM|#

I dunno. I reject the disease model, but I'm in favor of compassion. I can't fathom those who "have no sympathy" for addicts, unless they've never watched someone they love descend the downward spiral. But I think that kind of heartless attitude is more often born of the pain they experience when they lose someone close to them.

Syloson of Samos|8.29.07 @ 1:48PM|#

My own view (which I think is similar to Maia's) is that addiction is a learned behavior that, like many other things in life, is influenced by various genetic and environmental factors.

And what if some people - due to their genetics - are more prone* to said "learned behavior?"

Then again, many libertarians do bring a lot of baggage to this issue via their views on free will and the like.

Anyway, I think that it is pretty clear that addictions are in the main the result of how our reward resposes evolved over time. That makes as much a matter of biology as anything and because it resembles a disease to me.

*Say, well, very, very prone?

saltatory|8.29.07 @ 1:52PM|#

Addiction is an exploitation of basic biology. If that isn't a disease, I don't know what is. Is the big hang-up about responsibility? If it's a disease does that diminish the addict's responsibility?

Marcvs|8.29.07 @ 1:55PM|#

I'm pretty vehemently against the disease model of addiction, but there has been interesting research in the past 10-15 years that lends credence to the idea that habitual use of alcohol does make physical changes to the brain that actually makes it damn near impossible for hardcore alcoholics to "choose" to stop drinking.

That said, one of the biggest problems with addiction in this country is that we have ceded control of the issue to a bunch of religious nuts that think that you need to give your life over to a "higher power" before you can be "cured". Funny, but taking responsibility seems to be exactly what these people need to do.

Syloson of Samos|8.29.07 @ 1:55PM|#

saltatory,

Lung cancer caused by smoking is a disease. Colorectcal cancer caused by eating too much burnt meat is a disease. Now these aren't perfect analogies of course.

Marcvs|8.29.07 @ 1:57PM|#

A good book on the subject:

The Science of Addiction: From Neurobiology to Treatment

Syloson of Samos|8.29.07 @ 1:57PM|#

Marcvs,

Those are seperate issues though. Addiction looks primarily like an aspect of our biology gone haywire. As such, it looks like a disease to me.

|8.29.07 @ 2:01PM|#

That said, one of the biggest problems with addiction in this country is that we have ceded control of the issue to a bunch of religious nuts that think that you need to give your life over to a "higher power" before you can be "cured".

BINGO! The question of "is addiction a disease" is a perfectly fine one for academic/medical debate. The real question is, how do we deal with it. And the elephant in the room, is the rehabilitation industrial complex that has sprung up like a new religion of faith healers preying on the desperate.

|8.29.07 @ 2:03PM|#

Those are seperate issues though. Addiction looks primarily like an aspect of our biology gone haywire. As such, it looks like a disease to me.

When you broaden the definition that much, you could practically say that someone who beats their wife has a disease, as you're essentially qualifying a disease as being a deviation from the norm.

Syloson of Samos|8.29.07 @ 2:08PM|#

MP,

Well, cancer is a deviation from a particular norm, correct?

If we are indeed biological machines then it seems to me that when we malfunction we should have the tools to be put back into proper order.

Of course what "proper order" is, well, is an issue for debate.

|8.29.07 @ 2:08PM|#

Whether drug addiction is a disease or not is beside the point. Labeling it as a disease opens up a Pandora's box of Federal rules, requirements and money for the taxpayers and private enterprise to cover.

Compassion and help should be voluntary and private, just like drug use that leads to addiction.

Syloson of Samos|8.29.07 @ 2:09PM|#

MP,

This is of course where materialism (of the philosophical variety) rears its (some would say ugly) head.

Marcvs|8.29.07 @ 2:16PM|#

If "deviation from the norm" is the definition, doesn't that make libertarianism a disease?

|8.29.07 @ 2:18PM|#

I think a good "addiction is a disease" analogy can be found in diabetes. Diabetics have very easy to understand rules to live by for near perfect management of their disease. When they don't follow those rules, they get sicker. Addicts (not recreational users) are aware that drugs are not healthy, they still feel compelled to consume them. Having a compulsion is not the same as acting on it.

If a diabetic has an extra-large piece of pie, is he responsible for getting sicker or is the diabetes?

short fat guy|8.29.07 @ 2:22PM|#

Similar to labeling obesity a disease.

No doubt that profound physiological changes occur in a body exposed to excesses for extended periods of time. These changes can and do result in illness that requires medical treatment.

But should a combination of genetic disposition to addiction and free will to consume things be labeled a disease in and of itself?

I'd vote no, but would also argue forcibly against the notion that addiction merely the result of moral failure.

Episiarch|8.29.07 @ 2:23PM|#

Considering the prevalence of addiction in people with mental health issues (such as bipolarism, depression, etc.) it seems to be heavily linked to brain chemistry involving seratonin, norepinephrine, etc.

This could make it a disease, I suppose. It's so clearly a mishmash of biology, mental state, environment, and other factors that I don't see why they are trying to shoehorn it into one category.

Syloson of Samos|8.29.07 @ 2:24PM|#

Marcvs,

Possibly. :)


Then again, I didn't use that sort of language in my original statements.

SugarFree,

I think the difference is that food eating hasn't had the sort of taboos associated with it that alcohol and drugs have.

|8.29.07 @ 2:25PM|#

Addiction is a disease is basically a free will question. If you believe in the concept of free will, then it's not as the alcoholic could simply stop drinking.

If you don't believe in free will, then it is a disease because the alcoholic can't help but drink.

|8.29.07 @ 2:34PM|#

Disease, deviation, misfunction or "feature", what makes addiction interesting like few other things that fall under the above categories is that it affects the subject's ability to judge whether or not they want to change what's going on. While there are scads of former addicts who insist that they are happy that they are no longer in the throes of addiction, those in the midst of it are, at most, conflicted about the merits of quitting the cycle.

As Sullum has pointed out in "Saying Yes", there are scads of regular users who are self-reportedly functional and happy. How many of them are addicts who will quit after a string of unhappy events and report later that they are much happier on the recovery side of addiction. As Gilbert points out in "Stumbling on Happiness", even they will be crappy judges of whether they will be happier as addicts or as former addicts.

Lee|8.29.07 @ 2:35PM|#

Can you think of any other disease for which the most widely accepted treatment involves asking the patient to surrender himself to a "higher power" and make amends for the wrongs he's done as a result of his illness?

We've all seen the Penn & Teller show on addiction, so we all know the stock answer that AA is a pseudo religion. I can see why this idea would gain traction, but I have a different theory.

An addict will, in general terms, have tried to stop using countless times in the past, sometimes maybe with temporary success. Inevitably, though, they'll end up using again. This there is a learned behavior in the failure -- "I cannot stop using." It removes from the individual the belief that they are strong enough to quit using on their own.

In comes the higher power. The first step requires you to recognize that you are "powerless" over your addiction, and that a higher power (HP) is needed to restore you to sanity. Whether or not God exists is, I think, immaterial to the treatment. What the HP does is remove the burden from the shoulders of the addict. "I've tried and failed more times than I can remember. I don't have the power to quit, but the HP does."

I'm not a religious person in the slightest, but I can see the dynamic here. The addict is essentially fooling himself into believing someone else is doing it, thus in reality giving him the strength to do it himself without realizing it.

I do agree that this course of treatment is not for everyone, and that people can and do quit on their own or through other methods. Addiction is a complicated disease, and I think that we can't look at it as a singular disease with a singular solution.

If believing in a Sky Pixie of some kind is giving you the strength to refrain from drinking or using, then what's the harm? It's a psychological trick with positive benefits.

joe lite|8.29.07 @ 2:39PM|#

You should all be thrilled to cough up 15% or more of your gross income to ensure that the victims of addition have their suffering relieved.

|8.29.07 @ 2:40PM|#

Syloson of Samos,

I agree about the taboos, but I was only trying to address the responsibility side of the disease analogy. What is a more primal compulsion than to eat? Sure, you can satisfy that compulsion with healthy food, but diabetics are often drawn to high-carb / low nutrient density food (due to the body thinking that it is starved of sugar for quick energy because of the insulin release mechanism.)

Who is eating the pie, you or the diabetes? Who is taking the drugs, you or the addiction?

(None of this is to suggest I don't have sympathy for addicts. I just reject the disease model of addiction when it is utilized to abrogate personal responsibility. The ability to infantalize addicts is the ability to infantalize us all.)

|8.29.07 @ 2:46PM|#

Syloson,

The issue of disease should not be one of "deviation from the norm". Rather, it should be one of "not working as it should". And "should" shouldn't have a moral basis, but only a physiological basis that can be objectively defined.

There's rarely something about addiction whereby the body is not working as it should. It is working, almost predictably, in response to inputs. The failure in addiction (if one is to use that term) is a moral failure, not a physiological one.

Robert|8.29.07 @ 2:46PM|#

I don't even think the words "addict" & "addiction" deserve to exist.

|8.29.07 @ 2:50PM|#

Considering the prevalence of addiction in people with mental health issues (such as bipolarism, depression, etc.) it seems to be heavily linked to brain chemistry involving seratonin, norepinephrine, etc.
This could make it a disease, I suppose.

Or, since there's more and more acceptance of psychological problems as symtoms of bacterial or viral infections, this could make addiction just another symptom of previous infection. Personally I think it's just part of the explanation for addictions, most of the rest being that the additive substance or activity didn't exist until recently (in an evolutionary timeframe), so that pleasure/pain responses don't work appropriately.

Similar to labeling obesity a disease.
As above, obesity may be just another symptom of infection(s), but not the disease itself.

Episiarch|8.29.07 @ 2:52PM|#

I just reject the disease model of addiction when it is utilized to abrogate personal responsibility. The ability to infantalize addicts is the ability to infantalize us all.

This is an excellent point, and something to consider in terms of the motivation of some of those who push for the disease model.

|8.29.07 @ 2:57PM|#

An important distinction to bring up here is that between a physical disease and a mental disease, if there is one (que Thomas Sasz).

My experience as a gainfully employed 40 year user of alcohol with no criminal record tells me that alcohol use in and of itself does not always lead to addiction. Hence alcohol alone cannot be the cause of addiction.

Yet my professional experience with heroin users shows me that they, once addicted, have severe physical problems when they try to quit and can almost never do it by simply "desiring" to quit.

As with so much of life, I suspect addiction is the result of a combination of factors, not any single "cause."

This debate, however, is the result of hypocracy at the political level: drugs must be illegal because using them leads to the enslavement of addiction. But if you are actually enslaved, how can you be morally repsonsible (a key component of our puntive justice system).

If the legality of use were not at issue, we would not need to debate disease/moral failure distinctions. We could simply turn to health professionals to devise the most effective means of treating those with the signs of addiction (who may research further the various complex factors that lead SOME folks to addiction).

|8.29.07 @ 3:00PM|#

Episiarch,

I always meant to tell you that I like your handle. I love how Brin turned "Danikenite" into a swearword while building a universe based on his ideas. (Although I always felt the last book of the 2nd trilogy went a bit tits up in the end.)

DannyK|8.29.07 @ 3:05PM|#

Mr. Sullum, you seem to be saying that we shouldn't offer treatment for addiction because it reinforces the disease model.

Empirically, chemical dependency treatment does work. It's been shown to help people recover their health, and some forms of treatment have even been shown to be cost-effective, i.e. it's cheaper to offer the treatment than not to, given the costs associated with ongoing addiction.

So why shouldn't addiction treatment be available at least as much as any other medical treatment for preventable disease, such as lung cancer due to smoking, Type 2 Diabetes due to heavy donut use, or a head injury due to riding a motorcycle without a helmet?

Episiarch|8.29.07 @ 3:12PM|#

SugarFree,

You are only saying that because I agreed with you :-)

Yes, the 2nd trilogy got progressively more involved in his meta-consciousness stuff, the insane (but cool!) D-hyperspace, and other concepts that he seemed to want to get into so much that he let it detract from the overall story.

Still, Brin wrote some great shit.

|8.29.07 @ 3:15PM|#

Episiarch,

Well, yeah, but not totally...

Now let us, as all admirers of Brin, indulge in a silent two-minutes-hate of The Postman movie.

dude|8.29.07 @ 3:19PM|#

Probably the best description I've heard was from a former alcoholic who said "I don't know what it is, but whatever it is, I have it". I other words "there's something wrong with me that makes it seemingly impossible for me to stop once I start". Personally, I think it's a combination of aquired and inherited neurochemical sensitivity to a particular substance whereby the brain, once it's exposed to the substance, chemically demands more exposure to the substance, and make's life hell(physically and emotionally) until that happens. If the addict can resist for a period of time by some means (God, methadone, whatever), the brain adjusts and the "need" for exposure to the chemical subsides.....until the brain is exposed again. I think the term chemical dependance is a good one. So, call it what you want, but I think lending a hand to the chemically sensitive who become dependant is a good thing, but it is most definately the addicts responsibility to accept help, and once helped, stay off of the stuff.

short fat guy|8.29.07 @ 3:21PM|#

There's rarely something about addiction whereby the body is not working as it should. It is working, almost predictably, in response to inputs. The failure in addiction (if one is to use that term) is a moral failure, not a physiological one.

MP, are you arguing that dependence does not exist? That withdrawal symptoms are fictional?

Or are you aruging that that everyone is morally culpable for simply taking the first "taste" of any potentially addictive substance?

Syloson of Samos|8.29.07 @ 3:24PM|#

MP,

|8.29.07 @ 3:25PM|#

We treat everyone like an addict.Get caught with a little pot or drink 2 beers and get stopped and your a problem user.The treatment,jail and fines.The true abusers will never come forward because of the legal ramifacations and the casual users are lumped into the group and told to pray and donate to MADD.90 percent of people that have used drugs or alcohol have no addiction problem at all.

Juanita|8.29.07 @ 3:28PM|#

It is a moral failing and is thus sinful. The best treatment is some good 'ole fashioned SEVERE PUNISHMENT!!!

If it is a disease, then why do we treat it with prison? Therefore it is obviously not a disease but a sinful behaviour deserving of prison.

Syloson of Samos|8.29.07 @ 3:28PM|#

MP,

The issue of disease should not be one of "deviation from the norm". Rather, it should be one of "not working as it should".

I'm not quite sure how these are all that different.

There's rarely something about addiction whereby the body is not working as it should.

That is simply wrong on its face. I can easily analogize the haywire nature of cell production associated with certain cancers to the haywire nature of the reward response mechanism associated with various types of addiction.

Juanita|8.29.07 @ 3:31PM|#

90 percent of people that have used drugs or alcohol have no addiction problem at all.

Correct, with respect to alcohol, because it can be used safely, but not true with respect to drugs, because drugs cannot be used safely under any circumstances. That is why they are illegal. Because they are illegal, if using them is so important that you are willing to break the law, then you have a problem and are addicted.

|8.29.07 @ 3:33PM|#

I'm an air addict. It's gotten to where I can't go more than a few seconds without it.

|8.29.07 @ 3:35PM|#

Why do you think dealers often offer the first taste for free?

Juanita,

You forgot to add "Period. End of sentence." If you have a trademark phrase like you do you gotta stick with it.

|8.29.07 @ 3:46PM|#

Or are you aruging that that everyone is morally culpable for simply taking the first "taste" of any potentially addictive substance?

Neither. I was expanding on the concept of a deviation from the norm, which is essentially a failure of the body to perform as it should. I was then rejecting the notion that anyone dealing with an addiction was existing in a failed state.

That's not meant to disavow the existence of physiological dependencies. But those dependencies, when they occur, are simply the body's adaption to inputs. They are only harmful in a social context, not a physiological context. The only reason a person who has a dependence on, say heroin, needs to stop taking heroin is because of social pressures, not impending physical doom.

Just because you change your body based on inputs does not make those changes a disease. The disease should have both a discrete physiological component, and the component should only be considered to be "damage" if it causes a failed state. Again though, failure is still relative to something. Should it be relative to the ideal physiological human? Should it be relative to the socially functional human? Both answers are probably no, because the "ideal" human doesn't exist and the social human is a moral judgment. So then it becomes very gray. I don't see a dependency as being a failed state because the body has adapted to the inputs in a manner that isn't physiologically destructive to itself.

Just as I don't see obesity as being a disease.

|8.29.07 @ 3:54PM|#

I can easily analogize the haywire nature of cell production associated with certain cancers to the haywire nature of the reward response mechanism associated with various types of addiction.

Isn't the "haywire" nature of the reward/response mechanism sociological and not physiological? Just because your body has developed a desire doesn't make that desire haywire. The desire, in and of itself, does not mean that something has become defective. Simply that it has adjusted based on inputs. However, those adjustments are only socially destructive, not physically destructive.

If you classify any deviation from the norm as a disease, then why isn't a person with a stronger heart from running regularly afflicted with exercise disease? Or a person who has adapted to high altitude afflicted with oxygen disease? The body is built to adapt to inputs.

Syloson of Samos|8.29.07 @ 3:56PM|#

MP,

Isn't the "haywire" nature of the reward/response mechanism sociological and not physiological?

No, it appears to be part of our biology - that is the reward mechanism. If it starts malfunctioning (keep in mind that I didn't adopt the term "norm") then that seems to look like a disease to me.

Syloson of Samos|8.29.07 @ 3:59PM|#

Anyway, as with many definitions there is room for debate. I however have run out of time for debate (today). :)

|8.29.07 @ 4:02PM|#

No, it appears to be part of our biology - that is the reward mechanism. If it starts malfunctioning (keep in mind that I didn't adopt the term "norm") then that seems to look like a disease to me.

Yes, but how is it malfunctioning? The body has found something it likes and says "Hey, I want more of that!". How is that a malfunction?

Again, I'm not denying that physiological changes can occur as a result of substance input. I'm debating the point that those changes are a defect. If you're at the point where you want to change back, then fine. And maybe it will be hard.

But it's hard to lose 20 lbs. too. And not simply because you might not like to exercise. Because also your body may have adapted to the weight. It wants to keep it. You've undergone a physiological change. But you aren't diseased.

|8.29.07 @ 4:06PM|#

Doting on it for a few minutes leads me to this very lay conclusion: a disease is something that you cannot choose to get or not get, not counting physical injuries due to accidents. You can, of course, take steps to avoid infection of common viruses, like washing your hands regularly or avoiding parts of the world where certain diseases are known to be common, but whether or not you become infected with a disease really isn't up to you.

There are exceptions of course, HIV being the most obvious one. Here, you can avoid the behavior that opens you up to the most common vectors. Hemophiliacs and recipients of donated blood in a medical procedure mitigate this risk avoidance in some cases, but by and large, by avoiding the high risk behaviors, you lower your risk of infection considerably.

But, HIV is a close example of addiction in this sense. By avoiding the substance or behavior that you know, or should know, that will lead to an addiction under a particular set of circumstances, you can avoid the addiction.

Most of us can handle social drinking. Others, obviously, not. All of us have cravings of some kind, but we can resist them in most instances should we choose to do so. Is addiction different, in that personal choice is not involved at some point(s) in the process?

From where I sit, addiction is no more of a disease than is a car accident. What happens as a result of the accident can lead to disease (infection, etc.) or other "deviations from the norm," but it is not a disease per se. It's only a vector for harm, as is addiction.

Fluffy|8.29.07 @ 4:24PM|#

This argument tends to stay consistent over a long series of threads.

I'm still sticking with my current position, which is that the concept of addiction has been overblown, and the manner in which it has been overblown is exposed by the overreaching of the advocates of the addiction model. It has lately become fashionable to express every addiction flavor-of-the-month in terms of addiction to cocaine or heroin, and experimental evidence is routinely now produced to prove that cigarettes are just as addictive as cocaine, or that gambling or video games are just as addictive as heroin. All this has done is convince me that cocaine and heroin mustn't really be all that "addictive", at the end of the day, in the way I was led to believe they were. Because anyone with any willpower can quit smoking, and anyone with half a brain can walk around from the blackjack table, and anyone with a life can put the Wii down and walk outside. I was always led to believe that heroin was this terrifying substance that would enslave anyone based on the irresistible physical need it created. But if it's just like fucking video poker, I guess that was always BS.

poco|8.29.07 @ 4:28PM|#

a sinful behaviour deserving of prison

Juanita is a Canuck! (or Brit? antipodean?)

|8.29.07 @ 4:42PM|#

I never understood why this issue creates such controversy. The 'cure' for alcohlism is simply to put down the fucking bottle. Its not easy, but it is that simple. Once you have cancer, AIDS, diabetes, whatever, you can't just choose not to one day in the same way you can choose not to exhibit a certain behavior that same day.

NeonCat|8.29.07 @ 5:01PM|#

To quote the great Mitch Hedburg, "Alcoholism is the only disease you can get yelled at for having. 'Mitch! You're an alcoholic!' 'Mitch, you have lupus!'"

|8.29.07 @ 5:13PM|#

I find it interesting that these H&R threads on addiction take such an anti-scientific direction.

The definitions of disease and addiction are well enough established to include addictions under the term "disease." A misunderstanding the term "disease," that confuses it with etiology, leads to false semantic distinctions, it seems. The disease is the result of a cause, not the cause itself.

MP:

The physiological changes that occur as the result of "inputs" are not a disease until they cause a problem. That problem may be physical (alcohol is very bad for your body), social (drunks lose jobs, friends, etc...), or psychological (depression, etc...). When the physiological changes result in a pattern of behavior that persists despite the negative consequences, then those changes are not neutral, they are a source of dis-ease. In the case of psychological addiction, the person wants to stop, but fails. This causes dis-ease. In the case of physiological addiction, the person wants to stop but doing so will result in severe physiological hardship (in the case of alcohol this includes the potential for death). They have a disease.

libertreee|8.29.07 @ 5:25PM|#

I find it interesting that these H&R threads on addiction take such an anti- junk scientific direction. Neu Mejican.

Fixed it.

The Democratic Republican|8.29.07 @ 5:27PM|#

People are tending to focus on the disease v. behavior part of the story. The real danger, from a policy view, is the "compassion" part.

Oklahoma State University, for example, announced yesterday that it was becoming a "tobacco-free campus" (both smoking and smokeless). They have left punitive options, such as suspension and ticketing, on the table.

However, even worse than this are the statements from administration about how we should show "compassion" for those who "want to quit smoking" -- all written in a tone that makes it seem that anyone who DOESN'T want to quit smoking must be either a deviant or truly diseased.

So, this is typical of most government "compassion": compassion backed by a monopoly on force.

libertreee|8.29.07 @ 5:33PM|#

If we are indeed biological machines then it seems to me that when we malfunction we should have the tools to be put back into proper order. -S of S.

I suppose he has left but I am struck by how meaningless his phrases actually are. He seems to be substituting antithetical definitions or analogies for scientific wisdom. WTF is a "biological machine" anyway? Does he mean that we are simply programed to respond to stimuli in an automatic way, but this programming is somehow imprinted in a biological entity, which by definition includes the antithetical concept of spontaneous order and adaption to environment? If so he is simply throwing out oxymorons of a slightly higher order than George Carlins' "jumbo shrimp"...

libertreee|8.29.07 @ 5:35PM|#

Democratic Republican--I see you are NOT a "compassionate conservative". Good.

BTW, why not Republican Democrat?

libertreee|8.29.07 @ 5:52PM|#

Such supposedly scientific discoveries immediately require whole new levels of supposition and hypothesis in order to account for data on actual drug use. The researchers who acknowledge reality and note that most drug users, even regular users, do not become addicted are immediately required to hypothesize inbred biological differences in the neurological mechanisms that predispose some people to addictive drug use -- although their own data show no such differences related to addictive drug use. That people recover from addiction and resume non-addictive use of the same drugs forces hypothesizing about complex neurological-situation interactions on which the researchers likewise have no data. That susceptibility to addiction and failure to achieve stable remission are related to systematic social differences could result in racist theories -- i.e., inner city addicts fail to escape addiction (to heroin, crack, cigarettes, and alcohol) as readily as middle class people because they are biologically predisposed to addiction.

I think Dr Peele puts a good ending on this thread...

|8.29.07 @ 5:55PM|#

I was gonna go home early and finish my work from home. Now I crave a beer - a six pack in all honesty. Do I have a problem? Or is it only a problem if I drink the beer and don't get my work done?

|8.29.07 @ 6:18PM|#

Neu Mejican,

You're simply stating a broad definition of disease that covers anything one could classify as a problem. That definition is neither helpful nor self-evidently correct.

Paul|8.29.07 @ 7:17PM|#

Late to the party, but I reject the disease model out of hand, but why does that preclude treating addicts who are looking for help with compassion?


Neu Mejican:

A disease that can be entirely cured with counsiling therapy? I'm with MP, you're taking such a broad swipe that any "behavior" can be labeled a disease.

Paul|8.29.07 @ 7:17PM|#

*counseling... durn typos sorry.

Paul|8.29.07 @ 7:36PM|#

Well, cancer is a deviation from a particular norm, correct?

If we are indeed biological machines then it seems to me that when we malfunction we should have the tools to be put back into proper order.

Of course what "proper order" is, well, is an issue for debate.

S of S. Mmyeah. Kind of. Acting like a dip-shit could be defined as outside the "proper order".

My wife who worked with clinically insane people used to ask "When is it the disease, and when are they just acting like an asshole?"

A long running joke between her and her colleagues was "Is there an entry in the DSMIV for 'asshole'"?

|8.29.07 @ 8:25PM|#

I've certainly read some interesting stuff by Theodore Dalrymple on this. It certainly becomes easier to think about what should be done with addicts when you can heap scorn on them and hold them accountable for their own wretched choices. I feel the same about the fatties, too. Obviously, some people are much more strongly drawn to a junkie lifestyle than others, so it's a little unfair to hold them to the same standards, but hey, life's unfair.

|8.29.07 @ 9:08PM|#

I'm with MP, you're taking such a broad swipe that any "behavior" can be labeled a disease.

No, actually, I am not. I am saying that a disease is a multidimensional construct that involves harm to the individual. If it is a physiological disease, that harm will be physiological. If it is mental, that harm will be mental. It is hard to construe most behaviors as harmful to the degree that they get labeled as a disease.

MP
You're simply stating a broad definition of disease that covers anything one could classify as a problem. That definition is neither helpful nor self-evidently correct.

How is it helpful to try and split hairs between different genre's of suffering?

|8.29.07 @ 9:17PM|#

Like it or not, disease is a broad category...

Here's a defintion...

http://cancerweb.ncl.ac.uk/cgi-bin/omd?query=disease&action=Search+OMD

Here's a short list of diseases...

http://www.mic.ki.se/Diseases/Alphalist.html

I don't believe I have overstated the broad application of the word in describing human suffering.

|8.29.07 @ 9:36PM|#

I agree with NM, I'm not sure why disease has to have a physiological aspect (and btw there certainly are physiological aspects to most addictions, so perhaps the idea is a physiological cause).
If I remember my Jellinek the disease concept was supposed to recognize that addiction, like "physiological" diseases, has a recognized pattern of progression and is treatable.

|8.29.07 @ 9:40PM|#

How is it helpful to try and split hairs between different genre's of suffering?

It's about an abdication of responsibility.

And for Pete's sake, two can play the battle of the dictionaries.

My definition ate your definition for breakfast.

Paul|8.29.07 @ 10:21PM|#

Neu,

Not sure how hard you had to look for the etymogical root of the word to support your argument. Sure, fine, Olde English definition "dis ease". We get it. However...

The simple medical definition of disease:

Disease: Illness or sickness often characterized by typical patient problems (symptoms) and physical findings (signs).

http://www.medterms.com/script/main/art.asp?articlekey=3011

Is there wiggle room? Sure. But note 'physical findings'. Can you find something physically different in a drug addict than a non-addict? A physical finding that is not caused BY alcoholism/drug addiction but one the cause OF alcoholism/drug addiction? Do people drink because of a genetic mutation, or affectation of a bodily organ? Is there a test that one can be given that will show the patient will develop alcoholism, re HIV positive -> AIDS onset?

If it is a physiological disease, that harm will be physiological. If it is mental, that harm will be mental.

I'm not so sure. We recognize schizophrenia as a disease. The harm is mental. Also social harm can come from it. Inability to hold a job, maintain a social network etc.

What's the effect of an alcoholic's disease if he doesn't have access to alcohol? And no, I'm not talking about a full-blown alcoholic who was forced to go cold turkey-- we know that death is unique to alcohol DT's. But what about heroin? Or... cigarettes? You're addicted to cigarettes. You have a disease. The cure was to take away the cigarettes? Is that the cure to having the disease of need to smoke?

The notion that addiction is a disease forces us into a strange circular logic that I'm not even sure I can yet articulate. We can test for cystic fibrosis-- whether you're showing symptoms or not, we know if you have the disease. How do we know you're an alcoholic or a heroin addict if there isn't any alcohol or heroin to be had? Will you ever display symptoms? Say, if in some fantasy world, one were never able to aquire the substance to which your...what... addiction disease desires, do we consider your disease to be in permanent remission?

I agree that the language with which humans have used to describe "disease" could be applied to a broader scope than I may be willing to accept. But that's an issue of language, not an issue of human physiology. Can I "catch" addiction? Is it handed down from my parents? What twin studies have been done on addiction? In fact, it was twin studies that showed that schizophrenia was not entirely genetic. That it might actually be "caught". (Scary, I know)

Paul|8.29.07 @ 10:41PM|#

I did a little thinking after posting above, and I think I can break this down a little better.

Two people, sitting in a room. One has cystic fibrosis, the other has... oh, alcoholism.

The person with the disease of cystic fibrosis displays symptoms of lungs filling up with water. She's basically sitting in a dry room and slowly drowning.

The person with the disease of alcoholism displays the symptoms of holding a 12oz can of Mickey's in his hand.

The cystic fibrosis patient's future is obvious: drowning unless she's treated or cured.

The alcoholism patient's future is a little muddier. They might die of liver disease. But the liver disease can be avoided if I take away his 12oz can of Mickey's. He may never develop liver disease, but his life could go into the toilet due to the social ramifications of constant drinking. Or, like some people, he may never suffer any ill effects at all, and live to be a ripe old age with the reputation that he liked to party.

But if I took his can of Mickey's away-- according to the logic that alcoholism is a disease-- I've not cured him, I've simply disallowed him to suffer his symptoms. He still has the disease, but yet he'll suffer no ill physiological effect beyond withdrawal symptoms. But withdrawal symptoms are symptoms cause by the removal of his symptom: the 12oz can of Mickey's. Confused yet? I sure am.

huxley|8.29.07 @ 11:04PM|#

Do you think Senator Larry Craig has a disease
and if so what is it?

Sex addiction,risky behavior seeking I'm sure they are all in the DSM under "science-y" names.

Or is his public pole-smoking behavior that forgotten scientifically established disease homosexuality (Science until 1971!).

The same goes for your addictions ( we aren't counting actual physical dependency in that broad definition, I mean the convulsions and death kind of dependency).

Your science is nothing but fad, fashion, and folly.

I Got Happy Disease|8.29.07 @ 11:45PM|#

You can get Mickey's in 12-ounce cans now?

I know who my next date to the movies is.

Syloson of Samos|8.30.07 @ 12:19AM|#

MP,

It's about an abdication of responsibility.

Not really.

There are after all many things one has to do in order to combat cancer just as there are a number of things one must do in order to combat addiction. If one fails to do these things there are consequences associated with such (typically).

Robert|8.30.07 @ 1:33AM|#

"In the case of physiological addiction, the person wants to stop but doing so will result in severe physiological hardship (in the case of alcohol this includes the potential for death). They have a disease."

That doesn't look like a disease, it looks like disease prevention. The person keeps drinking to keep from dying. The cessation of the disease produces disease?

Paul|8.30.07 @ 2:03AM|#

You can get Mickey's in 12-ounce cans now?

I know who my next date to the movies is.

Apologies, Happy, I'm not afflicted with that disease. I wouldn't know.

That doesn't look like a disease, it looks like disease prevention. The person keeps drinking to keep from dying. The cessation of the disease produces disease?

Robert, see my post above.

|8.30.07 @ 11:20AM|#

Paul,

From the definition to "disease" you posted, the important word is "often."

It is equivalent to the definition I posted.

As for the rest of your rambling, there are far too many inapt comparisons to respond to...

Luckily, most of your points have been addressed above. Re-read S of S in particular.

I also think this abstract sums things up nicely...

Addiction, a condition of compulsive behaviour? Neuroimaging and neuropsychological evidence of inhibitory dysregulation.

Addiction. 99(12):1491-1502, December 2004.
Lubman, Dan I. 1,2; Yucel, Murat 1,2,3; Pantelis, Christos 2

Abstract:
Aims: Addiction has been conceptualized as a shift from controlled experimentation to uncontrolled, compulsive patterns of use. Current neurobiological models of addiction emphasize changes within the brain's reward system, such that drugs of abuse 'hijack' this system and bias behaviour towards further drug use. While this model explains the involuntary nature of craving and the motivational drive to continue drug use, it does not explain fully why some addicted individuals are unable to control their drug use when faced with potentially disastrous consequences. In this review, we argue that such maladaptive and uncontrolled behaviour is underpinned by a failure of the brain's inhibitory control mechanisms.

Design: Relevant neuroimaging, neuropsychological and clinical studies are reviewed, along with data from our own research.

Findings: The current literature suggests that in addition to the brain's reward system, two frontal cortical regions (anterior cingulate and orbitofrontal cortices), critical in inhibitory control over reward-related behaviour, are dysfunctional in addicted individuals. These same regions have been implicated in other compulsive conditions characterized by deficits in inhibitory control over maladaptive behaviours, such as obsessive-compulsive disorder.

Conclusions: We propose that in chronically addicted individuals, maladaptive behaviours and high relapse rates may be better conceptualized as being 'compulsive' in nature as a result of dysfunction within inhibitory brain circuitry, particularly during symptomatic states. This model may help to explain why some addicts lose control over their drug use, and engage in repetitive self-destructive patterns of drug-seeking and drug-taking that takes place at the expense of other important activities. This model may also have clinical utility, as it allows for the adoption of treatments effective in other disorders of inhibitory dysregulation.

|8.30.07 @ 11:27AM|#

Robert,

Re: disease prevention.

Stopping cold turkey might kill them, but they could step down intake and avoid that consequence. If they were not addicted, this would be an easy choice to make. It is the inability to change behavior in the face of a desire to do so that characterizes addiction.

To all that reject the disease model of additction...Do you also question the use of the term "disease" for Tourette syndrome?

|8.30.07 @ 11:36AM|#

Paul,

Regarding twin studies...are you serious.
There are thousands of twin studies in addiction research.

Here is a sample abstract
The Washington University Twin Study of alcoholism
Carol A. Prescott 1 *, Constance B. Caldwell 2, Gregory Carey 3, George P. Vogler 4, Susan L. Trumbetta 5, Irving I. Gottesman 6

Abstract
Genetic contributions to the liability to develop alcoholism in males of Northern and Western European ancestry are well-established. However, questions remain concerning the role of genetic variation in the etiology of alcoholism among non-white populations, among women, and the possibility of etiological heterogeneity in subtypes of alcoholism. The answers to these questions are needed to help define phenotypes for molecular genetic studies searching for QTLs for alcoholism. Twins from 295 pairs were consecutively ascertained at inpatient and outpatient psychiatric and alcohol treatment facilities in St. Louis, MO in 1981-1986. Probands and willing cotwins were evaluated by structured psychiatric interviews, psychometric assessment, and lifetime treatment records. One hundred fifty-four probands met criteria for alcohol abuse/dependence (AAD), including twins from 45 MZ, 50 same-sex DZ, and 59 opposite-sex pairs. Twin-pair resemblance was evaluated for AAD and alcohol dependence (AD), as well as for subsets defined by gender, patterns of comorbidity, ethnic background, and clinical features. Among males, heritability of AAD and AD was substantial, with little evidence for common environmental contributions to family resemblance. Pair resemblance among females was also substantial, but similar for MZ and DZ pairs, yielding near-zero heritability estimates. However, based on these sample sizes, the sex differences were not statistically significant. The results confirm prior studies of strong genetic influences on alcoholism in males, but suggest lower genetic influence in females. Power to test other sources of heterogeneity was limited, but the results suggest no evidence for higher heritability for male early onset alcoholism or for alcoholism with comorbid antisocial personality.

Robert|8.30.07 @ 9:12PM|#

"Addiction has been conceptualized as a shift from controlled experimentation to uncontrolled, compulsive patterns of use"

A control set to "high" is still a control.