2022’s #3 post: Is it misleading to call addiction a disease?

January 4, 2023
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The New York Times published a guest essay this weekend challenging the disease model of addiction.

I’ve read several similar pieces over the years and frequently have the same experience. I agree with most of the writer’s points, but disagree with his conclusions.

Let’s walk through it.

Annual U.S. overdose deaths recently topped 100,000, a record for a single year, and that milestone demonstrates the tragic insufficiency of our current “addiction as disease” paradigm.

Is Addiction Really a Disease? by Carl Erik Fisher

The drug death rate is very troubling and discouraging. If we were to add deaths associated with tobacco and alcohol, it’s much worse.

This strikes me as evidence for the insufficiency of our interventions to prevent and treat addiction, and/or the insufficiency of our systems to deliver those interventions. It does not strike me as evidence that it is not a disease. If COVID, type 2 diabetes, or asthma are associated with a large death toll, is that evidence that they are not diseases?

Thinking of addiction as a disease might simply imply that medicine can help, but disease language also oversimplifies the story and leads to the view that medical science is the single best framework for understanding addiction. Addiction becomes an individual problem, reduced to the level of biology alone. This narrows the view of a complex problem that requires community support and healing.

Is Addiction Really a Disease? by Carl Erik Fisher

This portion starts to illuminate the disagreement between me and the writer.

He’s concerned that too many people believe biology and medicine are the only frames we need. Further, he’s troubled that this might lead to interventions that target only individuals and omit social interventions.

I share those concerns.

However, I don’t see this as reason to doubt the disease model.

I believe asthma is a disease and environmental interventions are important. In the case of asthma, climate change might be a reasonable target for intervention. I believe type 2 diabetes is a disease and community-level interventions are critical. COVID is a disease and individually targeted interventions are clearly an insufficient response. I also believe depression is a disease and interventions targeting social support will be essential for many patients.

I also believe that behavioral interventions are essential for responding to all of these diseases and many others.

My experiences and those of my patients seem more in line with how 16th- and 17th-century writers described addiction: a disordered choice, decisions gone awry.

Is Addiction Really a Disease? by Carl Erik Fisher

If we view addiction as a brain disease, I don’t see how disordered choice is incompatible. Choice occurs in the brain. One could argue that other diseases involving the brain (depression, bipolar, schizophrenia, OCD, etc.) also result in disordered choice.

[Benjamin Rush] was famous for describing habitual drunkenness as a chronic and relapsing disease. However, Rush argued medicine could help only in part; he recognized that social and economic policies were central to the problem.

Is Addiction Really a Disease? by Carl Erik Fisher

This is a better understanding. It might be worth asking how to restore and protect that broader understanding.

The author points to a history of using the disease model (or beliefs associated with the disease model) in ways that are racist. All of this history is true and important, but it doesn’t really say anything about whether addiction is a disease. COVID was racialized, particularly early in the pandemic, but this is not grounds for reclassification of COVID.

The author continues addressing social justice issues in responses to the drug problem and raises another important consideration:

Not all drug problems are problems of addiction, and drug problems are strongly influenced by health inequities and injustice, like a lack of access to meaningful work, unstable housing and outright oppression. The disease notion, however, obscures those facts and narrows our view to counterproductive criminal responses, like harsh prohibitionist crackdowns.

Is Addiction Really a Disease? by Carl Erik Fisher

I see how a narrow medical/biological framing of disease can obscure the roles of inequities, injustices, and oppression. I also see how blindness to those factors could lead to criminalization. However, a disease model, at worst, cuts both ways. A deterministic view may contribute to prohibition and criminalization, but a model that locates addiction, not in the drug, but in the interaction between the brains of certain users and the drug, might push in the other direction.

The important point he raises here is that “not all drug problems are problems of addiction”. To be sure, addiction constitutes a relatively small fraction of all drug problems. It would be both incorrect and harmful to classify non-addiction drug problems as a disease. This is a critical point that, to me, reinforces the need to clarify the boundaries of addiction and distinguish it from other drug problems that are not a disease.

In contrast, today, descriptions of “brain disease” imply that people have no capacity for choice or self-control. This strategy is meant to evoke compassion, but it can backfire.

Is Addiction Really a Disease? by Carl Erik Fisher

No thoughtful expert would suggest that people with addiction have no capacity for choice or self-control. However, the author previously stated that a “disordered choice” model resonated with his experience, which fits well with the impaired control described in definitions of addiction that frame it as a disease.

The public responses that the chronic brain disease model evokes are complicated. (It may evoke less blame but more pessimism.) It seems to me that basing its designation on public reactions is the tail wagging the dog, and that unstable, conflicting messages probably contribute to pessimism and stigma. If that’s true, the best strategy is to just describe it accurately and focus on other targets for stigma reduction.

The author closes with reflections on the incompleteness of the disease model.

I am in full agreement that a narrow medical/biological disease model is incomplete, inadequate, and will lead us in the wrong direction with respect to prevention, treatment, and policy. The author is a physician and have a lot of respect for a professional that seems to be saying that his discipline can only hope to be a part of the solution to the problem.

However, I don’t believe the problem here is that “disease” is the wrong category for addiction. The problem is that too many people think of disease in narrow medical/biological terms. This was addressed in the landmark 2000 article, Drug Dependence, a Chronic Medical Illness, which argued that drug dependence is comparable to type 2 diabetes mellitus, hypertension, and asthma when considering the roles of genetic heritability, personal choice, and environmental factors, as well the etiology and course of all of these disorders. Chronic diseases are generally complex in their etiology and in what’s required to effectively treat and manage them. The kinds of complexity present in addiction are more the norm for chronic diseases rather than the exception.

Recent years have seen increased interest in social determinants of health (SDOH), which serve the purpose of filling in the rest of the picture in terms of etiology and treatments/interventions.

Surprisingly, even genetic counseling offers insight into social and environmental factors that influence the onset and course of heritable illnesses.

So… is it misleading to call addiction a disease? Only if your understanding of disease is too narrow to allow for the complexity of chronic diseases and social determinants of health.

I think the solution is that we get better at talking about diseases and their complexity, rather than reclassify addiction because it’s too complex.

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