Sunday May 28th 2017

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Are We Diseased? The Inconsistencies and Implications of the Disease Model of Addiction

“They’re going to tell you that you have a disease.”

I spent the end of my drug using days on a golf course­. I enjoyed golf in my youth and a new acquaintance allowed me to golf at a discount. As any good addict, I started to compulsively play golf and started taking multiple lessons per week.

My golf instructor had just recently left treatment for his own addiction and I would tell him about my own struggles with addiction. When I made the decision to seek residential treatment for my substance use I told my golf instructor and asked him what I should expect in treatment. He didn’t encourage or discourage me; all he said was “they’re going to tell you that you have a disease.”

How the Disease Model Can Be Good For You

A disease? This was not the answer that I was expecting. I knew nothing about drug rehab or what “treatment” was but having a disease was definitely not what I was expecting. Sure enough on the first day of treatment, after paying over $10,000, I was told that I had the disease of addiction. This disease was progressive, meaning that it would only get worse, and the only treatment was total abstinence, that could only be found by attending twelve step meetings for the rest of my life.

Looking back, I’m not sure if I truly believed that I had a disease or not, but I definitely thought that it was possible. I was so desperate that I would have believed anything. In some ways it was a relief to find an explanation to my problem; it took away some of the shame I felt about my behaviors. Learning about the disease concept of addiction, at the least, allowed me to realize that the way I drank was problematic and that drugs affected me differently than the average person.

I have spent the last ten years of my life considering what it means to be an addict and what it means to have the disease of addiction. For the past seven years I have been working in the field of addiction counseling, after receiving an associate’s degree in addiction counseling and becoming a California State certified addictions treatment counselor. Having extended education in the fields of addiction studies, sociology, and social work; having read countless books, and taken hundreds of hours of trainings, I am no closer to understanding what this “disease” is than that day on the golf course with my instructor.

In this article, I will write about the inconsistencies that I see with the disease concept of addiction and the implications of how this affects us who are in recovery, and those who work in the field of addiction counseling.

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What Are We Talking About When We Use The Word “Disease?”

Addiction as a “disease” is almost universally stated as fact, and gospel, when discussing addiction. The assumption that addiction is a disease is so imbedded into clinical work that the definition of the disease concept has been lost. There is no clear definition of the disease of addiction. There is no clear consensus of the meaning, cause, or manifestation of the disease. This confusion is further exacerbated across disciplines and it is assumed that we are all talking about the same thing when using the disease concept.

Our understanding of the disease has changed drastically over time but the term is used interchangeably when referencing the conceptualizations throughout the historical perspective. The disease that was conceptualized in the 1930’s is not the same conceptualization in 2017, but we use the same word as if they are the same concepts. Some treatment modalities teach one disease concept while others teach another.

Inconsistency #1: The Alcoholics Anonymous’ Allergy DOES NOT Exist

The book Alcoholics Anonymous starts off with a letter from a physician who specialized in the treatment of alcoholics in the 1930’s. This doctor theorized that the alcoholic has an allergy to alcohol; that once the alcoholic ingested alcohol, this allergy creates a craving in which the alcoholic losses the ability to control his drinking. The allergy is further complicated by the alcoholic’s obsession for alcohol that drives him to take the first drink that triggers the allergy––therefore creating a never ending cycle of problem drinking.

This idea of physical and mental abnormalities is central to the Alcoholics Anonymous concept of addiction. If this theory is true, then the allergy would only apply to the chemical composition of alcohol; not other drugs. This specificity is overlooked when treatment centers use the doctor’s opinion to apply it to drug addiction. Nevertheless, the majority of treatment centers use the book Alcoholics Anonymous as the foundation of their treatment.

Then, there is the fact that there is no allergy of addiction. There is no proof that the body of an alcoholic is any different than a nonalcoholic. There have been studies where alcoholics have been given alcoholic drinks without their knowledge and there were no symptoms of an allergy of loss of control. Plus, addiction is no longer thought of as a physical allergy but rather a disease of the brain. Contemporary psychologists and 12-Step counselors are both using the term “disease” although they are talking about two completely different disease concepts.

In my opinion, Alcoholics Anonymous has fallen victim to its own success. A.A. was never meant to be held to clinical standards of treatment. The professional community has turned A.A. into something that it is not, and then judges it for its failings, or unjustly praises it for unwarranted success. I am not critical of A.A., as I often sound in my writing, rather I see A.A. as something so special that should not be ruined my comparing it to, or viewed as, clinical treatment.

Inconsistency #2: Jellinek’s Curve DOES NOT Theorize Disease Progression

E.M. Jellinek is often credited for formulating the disease concept of alcoholism. His famous book The Disease Concept of Alcoholism is cited in countless academic articles about the disease of addiction. He is the target of both proponents and opponents of the disease concept; referring to him as both a hack and a genius. Treatment centers use his chart of progressive alcoholism, known as the Jellinek curve, as proof that addiction is a progressive illness that only gets worse over time.

As a student of addiction I wanted to learn about Jellinek’s disease concept, so I did something radical––I read his book. What I found was confusing!Nowhere in his book, The Disease Concept of Alcoholism, does he obviously state that alcoholism is a disease. Talk about judging a book by its cover.

What Jellinek does is discuss that there are different types of alcoholics. Of the four alcoholics that he identifies only the two most severe types could a disease theory be applied, and even then he only states that these alcoholics have a condition that is similar to a disease. Even with these four types of alcoholics, each more severe than the last, he theorizes no progression between the types; meaning that type one does not necessarily progress into type two and so on. The famous Jellinek curve is only in reference to the fourth and most severe alcoholic.

I would suggest to both advocates and opponents of the disease concept to actually read Jellinek’s book before making an example of him.

Inconsistency #3: Not All Clients Need to Abstain

Jellinek was a genius, and ahead of his time, not for creating a disease but rather thinking about it critically. Jellinek calls for students of alcoholism to think about addiction on a spectrum of severity. He even cautions his readers to not automatically believe in A.A.’s concept of alcoholism and not be so quick to label and stereotype all problem drinkers as the same.

In addiction treatment there is a tendency to label all clients as having the same disease; therefore needing the same treatment, which is abstinence. If Jellinek’s theory is true, then type one alcoholics are living in a world that only caters to type four alcoholics. When a type one enters treatment and tries to plead his case for being different, he is automatically labeled as “in denial” or noncompliant to treatment.

Inconsistency #4: Arousal Theory and Self-Medication Indicate Inadequate Mental Health Diagnosis and Treatment, NOT a “Disease”

The idea that drug users are using drugs as a way to self-medicate a neurological malfunction of the brain is often viewed as separate from the disease theory. In the arousal theory, drug users are using substances to make up for the lack of production of crucial neurotransmitters that the brain is lacking for whatever reason in that individual. Someone who has a mental illness who uses drugs to manage their symptoms would fall into this category.

I don’t understand the need to differentiate between the arousal and disease theory. If someone has mental illness that causes them to use drugs, is that not still a disease? Many people that I talk to in recovery are able to stop using, or moderate, drugs once they address their mental illness through medication or therapy. For these individuals it doesn’t matter to them whether or not they have a separate disease of addiction. What matters to them is that since they managed their underline mental disorder they are able to manage their lives and drug use. Since a large portion of people who enter treatment have a separate mental diagnosis, it seems to mean that addiction is not a disease on its own but rather a symptom of inadequate mental health treatment.

Inconsistency # 5: Drug Use Itself Causes the Disease

Addiction as a secondary disease is a popular conceptualization for disease. People acquire the disease of addiction over time through the consumption of drugs the same way that a diabetic acquires their disease through an overconsumption of sugar. As people use drugs they reinforce brain pathways that make it difficult to stop using drugs; they have changed their brains which could be interpreted as a disease. Although they have lost the ability to control their drug use, at some point they could of.

I see this as the most effective theory of explaining the disease because it focuses on the addicted person’s current usage. This concept is expertly explained in HBO’s series on addiction. However this paradigm of the disease is not the same as others when the term disease is used. Whether this person has a disease or not, is of little importance to the substance user who is seeking treatment. It doesn’t make any difference to the substance user whether they choose to call their condition a disease, or some other word, to describe the changes that have occurred in their brain.

I also like this conceptualization because it allows room for critically thinking about what makes people use substances to the point where they irreversibly change their brain. We can then consider outside influences such as poverty, mental illness, oppression, racism, and trauma without negating the most useful components of the disease theory.

Inconsistency # 5: Addiction as a Primary Disease Allows No Room for Variation

The American Society of Addiction Medicine (ASAM) believes that addiction is a primary disease: meaning that the disease of addiction is not caused by any outside factors and it is a disorder that you are born with. The primary disease theory is closely related to the theory of genetic predisposition, which states that addiction is genetic and therefore inherited. ASAM has gone as far as stating that all addictions are the same disease; that the disease is manifested in the different behaviors that are addicting. This theory is rooted in the idea that addicts are born with the inability to stop engaging in activities that release dopamine in the brain such as drugs, sex, gambling; basically anything that feels good.

This idea is intriguing and deserves serious consideration especially the link to dopamine and addiction. Having a brain that is unable to regulate dopamine is a prime example of where the medical establishment would be most useful in treating addiction. However, this idea perpetuates the large scale labeling that we are seeing in treatment. You are either an addict or you’re not; with no room for variation.

Harm reduction, which is so effective with many substance users, has no room in this framework. It doesn’t allow for the fact that some substance users are able to stop using one harmful substance while continuing to use less harmful substances. Whether all addictions are the same disease or not, it’s not realistic for a substance user to abstain from all behaviors that release dopamine.

Inconsistency # 7: The Anthropomorphized Disease Does Not Want Us Dead

Not only is the disease concept of addiction become medicalized but somewhere along the line it has taken on a life all its own. “The disease,” as it’s referred to in the treatment field, has its own personality and lives somewhere within the person who is afflicted. A common saying in twelve step meetings is “the disease of addiction in the only disease that tells you that you don’t have a disease.” In fact, this is the only disease that “tells you” anything. Another common thing is to attributing the symptoms of the disease to “your addict,” as in the addict who lives in your head is telling you to do things that will compromise your recovery.

Personally, I don’t like to think that I have an alternate personality that is always trying to kill me and I don’t talk to my clients this way. I understand the reasoning behind this but talking like this is borderline delusional. This thought process has similar connotations to Christian fundamentalism, which so many people find offensive, where all bad decisions are blamed on the devil’s handiwork. It reminds me of those cartoons where Bugs Bunny has an angel on one shoulder and the devil on the other. We need to move away from this childish conception of addiction if we are to be taken seriously in the professional community, and by our clients.
Inconsistency #8: Most People Choose to Stop or Moderate On Their Own

In Gene Hayman’s book, Addiction: A Disorder of Choice, shows that most people who used drugs and met the criteria for substance use dependence, according to the DSM IV, stop using drugs on their own by their early thirties without any type of treatment. This is irrefutable evidence that questions the progressive theory of addiction as a disease. If addiction is a progressive disease then those who meet the diagnosable criteria for addiction should never be able to stop or moderate substance use.

Inconsistency #9: People Can Choose Rationally

Further, Dr. Carl Hart is a neuroscientist who is doing some amazing work that is contradicting the disease concept of addiction. He conducted experiments with crack cocaine users that questions the ideology that drugs and drug addicts are unable to control their drug use. He gave crack addicts a hit of crack cocaine and then offered them another hit or $5. What he found was that half of the crack addicts chose the $5 over the next hit of cocaine. This completely goes against everything that the disease concept teaches. At least half of the addicts were able to make rational decisions even when actively using cocaine. Even if those participants used their $5 to buy crack at a later time, it still shows a level of delayed gratification that was thought to be impossible.

What Heyman and Hart Tell us about Treatment

With the current model of addiction treatment these studies have little practical implications because most people who seek treatment are those who cannot stop or moderate on their own. What it does tell us, is that professionals who work in the field of addiction treatment are only seeing those with the most severe addiction; which is only a small percentage of those people who use substances. It makes sense that we believe that addiction is a progressive disease because those are almost 100% of the cases that we see.

Substance users who are not in the grips of a severe, seemingly progressive, condition make up a silent majority of individuals. These are people who cannot find services, or sympathetic clinicians, to address their needs in a non biased way. If addiction is on a spectrum, then those at the lower end of the spectrum cannot seek help without being forced to admit to having a disease that they know they do not have. These less severe cases do not seek services because they know that they will not be adequately cared for or taken seriously. If the spectrum of severity is recognized by clinicians then we can begin to help that silent majority that is also silently suffering.

Another Way to Look at Addiction: The DSM

The Diagnostic Statistical Manual is the standard diagnosing tool for clinicians to diagnose mental disorders, including substance use disorders. Each substance has its own set of criteria but each substance basically has the same criteria with the names replaced for the specific substance. Most substances have eleven criteria and depending on how many criteria a person meets within a year period, they are diagnosed with a substance use disorder of mild, moderate, or severe.

This tool reflects how I believe that substance use should be viewed––on a spectrum of severity. The DSM does not reflect a progressive disease but rather a current evaluation of a person’s relationship with substances. They have acknowledged that not all substance users are the same and don’t have the same disorder. Amount of use, abstinence, and relapse are not considered; only the social, mental, and physical symptoms that they are currently experiencing. This leaves room for a substance user to change their diagnosis across time depending on their current relationship with the substance. So according to the DSM, addiction is not necessarily a disease but rather an accumulation of consequences from drugs that are not necessarily permanent.

Medical Model: What Does This Mean For Counselors?

Since addiction is seen as a disease, then a medical model can be applied to the treatment of the disorder. This is not a bad thing since it has opened the door for insurance companies to cover expensive treatment, medications for addiction, and also made federal and state funding more available for addiction treatment. There have been great advancements in medications that have aided in the treatment of withdrawal and long-term abstinence. These medical advancements have helped countless people seeking help for substance use.

There is a trade-off, however, for medicalizing addiction. We are saying that there is only one type of person qualified to treat addiction––doctors. Ironically the same disease concept that addiction counselors are advocating will be the same concept that will, one day, make them obsolete.

Disease or Degenerate: All or Nothing

As with all civil rights movements (and drug use is certainly a civil rights issue), it was necessary to aim high and over shoot the mark when advocating for a new concept for addiction. Those who fought for the rights of substance users did a great job in advocating for a new view on addiction. Society has done a complete one eighty on the perception of addiction in the last 100 years. The pendulum has swung far to the other side from seeing substance users as weak unmoral people, but it is time to pause and consider the implications of our new vantage point. The disease concept has served its purpose of de-stigmatizing substance users but it’s time to dial back our model to a more realistic position on the spectrum.

We have more than just the two options of seeing the addicted person as either victim or degenerate. Just because we are considering that addiction is not a disease doesn’t mean that we can’t be sympathetic to the plight of the addicted person, or that their substance use isn’t a symptom of elements that are out of their control.

Where Do We Go From Here?

Since the definition of the disease concept is so convoluted, I suggest throwing out the term completely. What we are dealing with are people who have a relationship with substances. This relationship is no different than any other relationship with a person, environment, or behavior.

It’s a complicated issue that needs to be addressed on a macro level. We need to all get on the same page with our terminology, or at the very least acknowledge that we don’t have all the answers. This is an exciting time for the field of addiction treatment and we need to keep our eyes forward and not allow ourselves to rely on old ideas, or think we know everything about this condition that may, or may not be, a disease.

Reference Sources: Alcoholics Anonymous.
ASAM. American Society of Addiction Medicine.
Dr Carl Hart. Dr.Carl Hart––Where Drug Myths Die.
Gene M Heyman, PhD. Addiction: A Disorder of Choice.
HBO Addiction: The Science of Relapse. 2016
Psychology Today. Addiction as Self Medication. 2012.
Raging Alcoholic. EM Jellinek on Alcoholism.
The Clean Slate Addiction Site.: Addiction as an Allergy––Loss of Control. 

 

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About Scott Novotny

Scott Novotny, CATC III is a Social Work graduate student with a BA in Sociology. He is a Certified Addictions Treatment Counselor in the San Francisco Bay Area. Before graduate school, he spent seven years working at a treatment center. The center included a social model detoxification unit for alcohol and street drugs and sober living apartments.

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