A Reading of The Urge: Our History of Addiction, Part III
People have debated whether addiction is a disease for as long as I know and have never settled the matter for me, so that I cannot say for certain whether it is or isn’t. It depends on what you mean by disease. The word is inherently slippery, according to Carl Erik Fisher in his book, The Urge: Our History of Addiction.
Fisher is an addiction psychiatrist, bioethicist, and assistant professor of clinical psychiatry at Columbia University. The book presents the history of the concept of addiction and our consequent response to it, paired with his own history of alcoholism and recovery.
People who claim addiction is a disease say it is not a moral failing, a choice, or a character flaw. It all comes down to brain chemistry. The brain is wired to reward you when you do something pleasurable. Exercising, eating, and other behaviors that are directly linked to our survival trigger the release of a neurotransmitter called dopamine. Large surges of dopamine teach the brain to seek the addictive object at the expense of other, healthier goals and activities. The reason some people get addicted, and others don’t, has to do with genetics, exposure to trauma, or substance use at an early age. They go on to say harsh consequences, shame, and punishment are not effective ways to heal a person’s addiction.
It’s hard to argue with any of that, but the question is, how far do you take it?
At one level, disease means medical treatment could be among the many approaches you can take to a problem. At another level, it means medicine is the single best approach because the problem is rooted in biology. Some people take the disease concept so far as to say that addiction is only about brain chemistry and the only ones who can speak to it and help with it are medically trained professionals. I say that when you take it that far, you are addicted to the medical model, in the original sense of the word. Addiction, as it was originally used, meant a strong attachment to an idea or a behavior.
There are many risks to taking the disease concept too seriously and reductively. For one, it overlooks the contributions many people who are not medical can make towards healing. It means all of us talk therapists, clergy, recreation people, shamans, probation officers, yoga teachers, worried parents, lawmakers, and AA sponsors need to shut up when the doctors are talking. It means medicine owns addiction.
We also need to examine what you mean by disease, for there are many mistaken or outdated beliefs of what a disease is. Disease is often meant to imply that people with the disease are different from those who don’t have it. It also implies that it is a property of an individual, not of his family or society at large. Disease is something that happens to you, you often have little choice in the matter. Proponents sometimes claim that the medical model alleviates sigma and encourage suffers to seek help.
None of that is true, according to Fisher. The more we learn about all diseases, the less simple they look. We used to be able to think of diseases as discrete categories with a clear line between sick and well. Now we know they are functional, complex, interacting systems. With addiction, there is much grey area between sick and well. Addiction can more properly be thought of as a spectrum disorder. We all have our addictions and many of them have nothing to do with biology.
I don’t know how anyone can claim that when you call something a disease, it alleviates stigma. We used to call homosexuality a disease and there was plenty of stigma then. I also know that calling something a disease does not encourage people to seek help. It only encourages them, when they do seek help, they would need to see a doctor. When you place something like alcoholism in a binary disease model, as opposed to a spectrum, you make it harder for people to recognize their own drinking is harmful. They start thinking, if they’re not on skid row, they’re not an alcoholic.
My biggest objection to calling addiction a disease is that sufferers will figure that recovery is not their responsibility, or that it’s impossible. One study showed that addicts who believe in the disease model are more likely to relapse because they don’t see the point of struggling against it.
Is addiction a disease? It depends on what you mean by disease and how far you intend to take it.
Other posts in this series
Part I: The Spectrum of Addiction
Part II: The Origin of Addiction
Next in the Series: Zero Tolerance or Harm Reduction?