Are Addicts Sick, Bad, Both, or Neither?
Jacob Sullum | August 29, 2007, 1:39pm
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.]
Lee | August 29, 2007, 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.
JW | August 29, 2007, 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.
Paul | August 29, 2007, 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)
Neu Mejican | August 30, 2007, 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.
Neu Mejican | August 30, 2007, 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.
