A version of this post was originally published in 2016 and is part of an ongoing review of past posts about the conceptual boundaries of addiction and its relationship to the disease model and recovery.
I’ve had a lot requests to respond to this recent piece in the NY Times.
A Personal Narrative or Universal Model?
The piece is really interesting and engaging description of the author’s personal experience. I get the impression that she’s frustrated that most people would say that her experience with heroin means she has the disease of opioid addiction. She does not believe she has a disease and doesn’t want to be shoehorned into that model. So, she’s offering an alternative framework to explain her experience.
She believes her drug problems were a result of disordered learning, self-medication, and something akin to a love relationship with the relief that heroin provided.
I can imagine it’d be frustrating to be shoehorned into a model that doesn’t fit one’s experience. The problem is that she constructs a model of understanding addiction from her personal experience—an experience that seems fairly atypical—and then presents it as a model for understanding addiction in general.
Addiction as a Category
It’s important to point out that I don’t believe the author uses the same definition of addiction I do. I limit the term addiction to people with chronic and high severity substance use problems characterized by impaired control—most people with drug problems do not have addiction.
In a previous post, I took a long look the categorization of substance use problems. In that post, I made the case for addiction as a different kind of problem from less severe substance use problems rather than a more severe version of the same problem.
Dependence was far from perfect. This is not an argument for a return to the abuse/dependence model. (Though I will argue that we should return to conceptualizing as addiction as a different kind of problem from low to moderate SUDs, rather than a different severity.)
Let’s start by stating that addiction/alcoholism is the chronic form of the problem is primary and characterized by functional impairment, craving and loss of control over their use of the substance.
Problems with the categories of abuse and dependence include:
- Dependence has often been thought of as interchangeable with addiction/alcoholism, but this is not the case.
- Dependence criteria captured people who are not do not have the chronic form of the problem. We know that relatively large numbers of young adults will meet criteria for alcohol dependence but that something like 60% of them will mature out as they hit milestones like graduating from college, starting a career or starting a family.
- Dependence criteria captured people who are not experiencing loss of control of their use of the substance.
- The word dependence leads to overemphasis on physical dependence which, in the case of a pain patient, may not indicate a problem at all.
- The word abuse is morally laden.
- For me, there are serious questions about whether abuse should be considered a disorder at all.
Several of these problems are related to doing a poor job in distinguishing which kind of user the patient or subject is.
The abuse/dependence model fell short in distinguishing between kinds of users. Rather than taking a step forward in distinguishing between the kinds of users, the continuum approach implies that there is only one kind with different levels of severity.
In that post, I also pointed out that framing addiction as a more severe version of the same problem would undermine the disease model.
The continuum approach becomes especially troubling when you think about the idea of giving people with low severity SUDs and people with the disease of addiction the same diagnosis, only with different severity ratings.
There’s little doubt that large numbers of young people on college campuses meet diagnostic criteria for an alcohol use disorder under the DSM 5. I doubt anyone would argue that all of these young people have a disease process? Even a mild one?
This seems likely to undermine the acceptance of addiction as a disease. Not just by the public, but also by insurers and policy makers.
So, it’s not surprising that she’s using the broader definition of addiction when questioning the disease model.
Addiction as a Learning Disorder
I don’t at all disagree that addiction involves disordered learning.
However, I would disagree that addiction is only (or primarily) disordered learning. Addiction is disordered learning AND much more.
The idea that learning plays a role in addiction is not new. The American Society of Addiction Medicine definition of addiction includes the following. (Keep in mind that references to memory speak to learning.)
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Addiction affects neurotransmission and interactions within reward structures of the brain, including the nucleus accumbens, anterior cingulate cortex, basal forebrain and amygdala, such that motivational hierarchies are altered and addictive behaviors, which may or may not include alcohol and other drug use, supplant healthy, self-care related behaviors. Addiction also affects neurotransmission and interactions between cortical and hippocampal circuits and brain reward structures, such that the memory of previous exposures to rewards (such as food, sex, alcohol and other drugs) leads to a biological and behavioral response to external cues, in turn triggering craving and/or engagement in addictive behaviors.
The neurobiology of addiction encompasses more than the neurochemistry of reward.1 The frontal cortex of the brain and underlying white matter connections between the frontal cortex and circuits of reward, motivation and memory are fundamental in the manifestations of altered impulse control, altered judgment, and the dysfunctional pursuit of rewards (which is often experienced by the affected person as a desire to “be normal”) seen in addiction–despite cumulative adverse consequences experienced from engagement in substance use and other addictive behaviors. The frontal lobes are important in inhibiting impulsivity and in assisting individuals to appropriately delay gratification. When persons with addiction manifest problems in deferring gratification, there is a neurological locus of these problems in the frontal cortex. Frontal lobe morphology, connectivity and functioning are still in the process of maturation during adolescence and young adulthood, and early exposure to substance use is another significant factor in the development of addiction. Many neuroscientists believe that developmental morphology is the basis that makes early-life exposure to substances such an important factor.
. . .
In addiction there is a significant impairment in executive functioning, which manifests in problems with perception, learning, impulse control, compulsivity, and judgment. People with addiction often manifest a lower readiness to change their dysfunctional behaviors despite mounting concerns expressed by significant others in their lives; and display an apparent lack of appreciation of the magnitude of cumulative problems and complications. The still developing frontal lobes of adolescents may both compound these deficits in executive functioning and predispose youngsters to engage in “high risk” behaviors, including engaging in alcohol or other drug use. The profound drive or craving to use substances or engage in apparently rewarding behaviors, which is seen in many patients with addiction, underscores the compulsive or avolitional aspect of this disease. This is the connection with “powerlessness” over addiction and “unmanageability” of life, as is described in Step 1 of 12 Steps programs.
Is addiction a disorder of learning? Yes. But, it’s also a disorder of genetics, motivation, reward and stress.
Dirk Hanson has written eloquently on the convergence of thinking of addiction as a learning disorder and muddying the distinctions between problem use and addiction.
For harm reductionists, addiction is sometimes viewed as a learning disorder. This semantic construction seems to hold out the possibility of learning to drink or use drugs moderately after using them addictively. The fact that some non-alcoholics drink too much and ought to cut back, just as some recreational drug users need to ease up, is certainly a public health issue—but one that is distinct in almost every way from the issue of biochemical addiction. By concentrating on the fuzziest part of the spectrum, where problem drinking merges into alcoholism, we’ve introduced fuzzy thinking with regard to at least some of the existing addiction research base. And that doesn’t help anybody find common ground.
Addiction as Love and Self-medication
Addiction as an unhealthy form of attachment or love is also not a new idea. Stanton Peele, a gadfly and long time critic of the disease model wrote the following:
An addiction may involve any attachment or sensation that grows to such proportions that it damages a person’s life. Addictions, no matter to what, follow certain common patterns. We first made clear in Love and Addiction [published in 1975] that addiction— the single-minded grasping of a magic-seeming object or involvement; the loss of control, perspective, and priorities—is not limited to drug and alcohol addictions. When a person becomes addicted, it is not to a chemical but to an experience. Anything that a person finds sufficiently consuming and that seems to remedy deficiencies in the person’s life can serve as an addiction. The addictive potential of a substance or other involvement lies primarily in the meaning it has for a person.
Theories of addiction as a form of self-medication have been about for decades. These theories frame addiction as secondary to another problem which may be social, psychological, environmental or physical in nature.
However, addiction is widely accepted as a primary disease among professional societies.
Further, addiction’s (I’m referring to severe and chronic substance use problems.) onset, course and response to treatment is often affected by social, environmental, psychological and physical problems, but it generally does not fade away when those problems are addressed.
Multiple Mechanisms
The more we learn about addiction, the more we find that there are multiple mechanisms involved. In a 2011 post, I wrote the following (keep in mind that this is abstract speculation rather than a concrete theory):
Or, maybe there are several neurological mechanisms (reward pathway, memory circuits, risk evaluation, self-regulation, stress responses, etc.) and some people may have 2, others may have 6. Some factors may be associated with a more chronic form, others may be associated with a more severe loss of control and overall severity may be associated with the number of factors the person has. (Some might be primary to addiction, others secondary.)
There are probably a lot more than 6 but, for the sake of argument, let’s stick with 6. So, is it possible that the author had 1, or 2 or 3 of these mechanisms (ones involving memory, attachment and learning) while most people with addiction (chronic and severe) suffer from 5 or 6?
Could this provide a way to view her model as true for her (and some others) and the disease model as true for most people with addiction? I think it might. And, maybe it could also shed some light on a portion of that segment of young, heavy users who mature out.
It’s not that she’s wrong. It’s just that she’s zooming in on one part of a larger story to the exclusion of the rest of what we know.