It’s been a while since my last post. I did some relaxing, hung out with my kids, but mostly I spent my time writing a long, dense article summarizing my book — an invited article for a journal. I found myself back in the ring, fighting the Disease Model of Addiction… Round 17.
Is this some imaginary nemesis? Am I some demented Batman doing battle with hidden enemies? My dear cousin, Karen, who’s given me advice on all matters of personal deportment, diplomacy, table manners, and proper toilet practices since the age of three (she even instructed me to wipe after peeing, which turned out not to be necessary for boys) …Karen tells me to put down my slingshot. Goliath is more imaginary than real, and I should try to be nice and get along with others.
And then my knowledgeable email buddy, Sally Satel, sends me an issue of the New England Journal of Medicine, published only last month, in which the disease model is centre stage once again. The title of the article is…
Neurobiologic Advances from the Brain Disease Model of Addiction
The second sentence says it all: “In the past two decades, research has increasingly supported the view that addiction is a disease of the brain.” Nothing new there. In a nutshell…
Addiction is a chronic, relapsing brain disease, evidenced by changes in the brain, especially alterations in the striatum (the brain part that underlies goal-seeking) and in the prefrontal cortex (responsible for cognitive control). These regions become partially disconnected with ongoing drug use. (my summary)
The argument hasn’t changed in years. (For a detailed account, read my book.) But the next sentence takes a new tack: “Although the brain disease model of addiction has yielded effective preventive measures, treatment interventions, and public health policies to address substance-use disorders, the underlying concept of substance abuse as a brain disease continues to be questioned…”
Indeed it does, more and more, and the appendix to the article spells out some of the criticisms leveled by writers such as Maia Szalavitz, Carl Hart, Sally Satel, Bruce Alexander, our cantankerous and relentless Stanton Peele, and yours truly. (Gabor Maté and Johann Hari will agree if you ask them.)
As you might expect, the appendix also includes a brief counter-argument posed against each of these criticism. Here I’m going to review just two of these arguments/counterarguments and tell you why I think we should keep the slingshot loaded.
“1. Most people with addiction recover without treatment, which is hard to reconcile
with the concept of addiction as a chronic disease. This reflects the fact that the
severity of addiction varies, which is clinically significant for it will determine the type
and intensity of the intervention. Individuals with a mild to moderate substance use
disorder, which corresponds to the majority of cases, might benefit from a brief
intervention or recover without treatment whereas most individuals with a severe
disorder will require specialized treatment.”
So are they saying that most people with addictions don’t have a disease, and only those with severe addictions do? But you wouldn’t say that people with mild cases of cancer, pneumonia, tuberculosis, malaria, or even diabetes don’t have the disease. You’d say they do have the disease but it’s not too 
bad…yet. So maybe they’re saying that most people with a mild to moderate level of the brain disease of addiction don’t need intensive treatment? That might make sense, except that it doesn’t. This majority of addicts start using more than they should for a few months or even a few years, and then most of them just stop, without treatment. (The statistics on that are indisputable, so it’s good that the disease folks are finally acknowledging it.) But that doesn’t sound like a disease at all. It sounds like a bad habit that most people recognize is unhealthy and learn how to control. Then is there a threshold at which addiction goes from an overlearned habit to a disease? If there were, it would be measurable. But no one has ever succeeded in measuring it. Few would even try.
“3. Gene alleles associated with addiction only weakly predict risk for addiction, which
is hard to reconcile with the importance of genetic vulnerabilities in the Brain Disease
Model of Addiction. This phenomenon is typical of complex medical diseases with high
heritability rates for which risk alleles predict only a very small percentage of variance in
contrast to a much greater influence of environmental factors (i.e., cirrhosis, diabetes,
asthma, cardiovascular disease). This reflects, among other things, that the risk alleles
mediate the response to the environment; in the case of addiction, the exposures to drugs and stressful environments.”
My last post covered the genetics issue in some detail (and I’ll get back to it in a later post). But here’s the crux of the issue. Yes, weak genetic predictors may be typical of many diseases with high heritability. But they’re also typical of a bunch of other stuff…like personality! Personality outcomes 
fall into distinct categories: extrovert, anxious-neurotic, sociable, suspicious, dependent, etc, etc. (Should we add “addict” to the list?) And all of these “types” have weak genetic predictors (though high concordance between, say, identical twins). The reason is because people become the way they become based on what happens to them in life — the environment shapes them while they shape their environment. So the whole “genetics issue” — which has been a holy cow for disease model 
advocates — ends up saying nothing at all about whether addiction is a disease.
I’ll end by saying that holy cows get my goat (that actually means something in American). Next post, I’m going to tell you why I think it’s so hard (though it would be nice, Karen) to actually reconcile the disease and learning models of addiction.
Informed by unparalleled neuroscientific insight and written with his usual flare, Marc Lewis’s The Biology of Desire effectively refutes the medical view of addiction as a brain disease. A bracing and informative corrective to the muddle that now characterizes public and professional discourse on this topic.” —Gabor Maté, M.D., author of In The Realm of Hungry Ghosts: Close Encounters With Addiction
Hey Marc
I was just about to send you some comments on this for the rebuttal! So I will post some things here.
1) Volkow, Koob et al are essentially self-referencing and much of their pieces are now tautological in nature. The amazing thing is that it is not the huge numbers of scientists who “believe” addiction is a disease – it is actually a small group of highly influential people plus the disease misnomer in 12-step programmes that have driven that famous sentence that starts so many articles “Addiction is a chronic disease of the brain (Leshner)…” if we look at the original sources of this, they are few. In the fields of sociology, psychology and anthropology we seldom see addiction being described a disease. The disease model is a popular conception because that is what doctors are taught and because 12-step programs are so ubiquitous.
2) The biggest argument against the disease model, in my opinion, comes from some very strong data: What is it that works in the treatment of “addiction”
We have motivational interventions which run from contingency management to motivational interviewing to brief interventions.
We have social interventions, such as housing, changed relationships, family system modification (CRAFT by example).
We have pharmacologies that are either agonist or partial agonist or aversive (with limited effect) or the antagonists which block affect, but often lead to increases in other drug use.
None of the above indicates any sort of disease process. I could expand on this, but another time!
3) What I am also seeing is a very subtle expansion of Volkow’s position – I am not the only one who has picked up on this! I think that there is some shift taking place, and I believe that eventually a bifurcation point will come. When that happens, know that you were there with a sling aiming at the giant, and the giant will fall with a resounding crash!
Must run!
Really great points, Shaun. Thanks a lot! I had to go back and insert an image of Gulliver and the Lilliputians after I read your comment. David makes a good hero, but it’s all the little voices put together that brings down the giant…and maybe they’re not so little and maybe the giant isn’t so big. Thanks for that insight.
Are there a couple of website links with the data showing that on “addicts” recovering without treatment? I really appreciate your perspective and this blog.
Thanks for asking. Here are some I just pasted from that article I’m completing:
…Yet several large epidemiological studies report that most alcoholics and addicts do recover (e.g., Lopez-Quintero, Hasin, et al., 2011) and most of those do so without treatment of any kind (e.g., Dawson, Grant, Stinson, & Chou, 2006; see http://pubs.niaaa.nih.gov/publications/AA70/AA70.htm, and a comprehensive review and analysis by Heyman, 2013).
And I’ve just embedded a link — go back to the main post — to a great summary and review of the “spontaneous recovery” issue in a blog-post by Maia Szalavitz.
One of the most convincing studies, particularly because of who the author is, is William White’s Recovery/Remission from Substance Use Disorders: An Analysis of Reported Outcomes in 415 Scientific Reports, 1868-2011.
The PDF is here: http://www.naadac.org/assets/1959/whitewl2012_recoveryremission_from_substance_abuse_disorders.pdf
Thanks, Shaun. This is excellent!
a terminal illness, which is what alcoholism is called within 12 Step circles, has no cure, yet as you say many alcoholics, myself included, no longer drink. diabetes or heart disease suddenly don’t stop producing symptoms, least not without some form of treatment. in many cases alcoholics and addicts get well despite what the treatment does to them, which is often to make things worse in convincing a person they are diseased and morally corrupt. None of the disease theory makes sense when talking about behavioural addictions. I am tending more and more to the belief that addiction rather than a problem, disease or issue, is in fact normal in some form or other as a means for humans to provide security for the self whether it be in an extrinsic form such as drug or alcohol use or intrinsic in habitual behaviour which we all (not that I normally speak for all) have even if it is down to the ritual coffee in the morning, going to the gym or being ‘set in our ways’. the war on drugs and the disease model will not die without a fight but the groundswell is beginning and your posts are a welcome part of that
Great points. The normalization of addiction is a tack many are taking these days…and the upshot is that “addiction” in its conventional sense is whatever we define it to be, based on a poor fit between the particular habit and the current cultural surround. I’m glad to be a part of this groundswell!
Hi Marc etc.,
I’m new to this forum, though wanted to post my thoughts about what you thoughtfully shared.
It seems to me that there’s quite a bit of binary thinking and attempting to label/classify issues of addiction. I don’t adhere to the disease model, though I believe there is enough evidence to show some changes in the brain often ensue. I’m not sure what that makes addiction? An illness? A condition?
It also seems to me that sometimes, a great deal of time and energy is spent on debating what addiction really is. While I know that has and can have major implications in terms of treatment, I can’t help but wonder if such debates can detract from addressing certain aspects of something that maybe just can’t be fully pinned down.
From what I’ve read, there’s also a lot of variation in the brains and behaviours of addicts and former addicts. There isn’t a one size fits all approach, despite the many attempts to find one, in different ways and at different times.
Having just read something about how AA only works for about one third of addicts, It would be interesting to know more about the implications of adhering to such different schools of thought…
Regardless, thanks for sharing this interesting info,
Marin
Hi Martin,
Thank you for the very thoughtful comment. There are many of us in the addiction research field that don’t a lot of weight into this binary debate – which is a great way to phrase it, by the way. I wrote a rather ranty op-ed about this a little while back:
https://therealedition.com/addiction-choice-or-disease-lets-just-move-on/
You’re right to point out the variability, and understanding the heterogeneity among people with substance-use disorders is key to better treatment.
This binary debate basically exists in the media and some minds of the choice advocates. When you talk to addiction scientists, you understand that they get the nuance of addiction: that there is biology, there is environment, there is choice. All these influence addiction. There is ‘not either-or’; there is ‘both-and’.
Take care,
Paul
*edit: There is no ‘either-or’; there is ‘both-and’.
Hi Martin, and welcome. The reason I engage in this “binary” debate is because I think it does matter, not only for scientific reasons but because the implications for treatment vary widely between the disease and “learning” models. As you say, there are many gradations and qualities of addictions, or of the people struggling with them. That implies that we need to help people move on with their own development, not cure them. The disease model points to helping people return to some standard of normality. And to many of us, that seem the wrong approach.
Also, yes, the brain changes with addiction. But that’s the worst possible argument for the disease model. The brain changes with all intensive learning experiences!
Hi Marc,
As always, love your post. But as I get further into research on treatment of addiction, I find myself frustrated by this debate. I don’t believe that addiction is a disease, but I do see how people who are not as well informed as you and most of your followers are simply can not comprehend how serious addiction is unless they think of it as a disease. The learning model to a normal person sounds like another version of the “What’s wrong with you, you can stop at any time,” idea that puts shame and blame on the addicted person. Addiction is more serious than a bad habit, and something different is going on. If I don’t consume alcohol, I have an incredibly successful, well-ordered life. I don’t keep bad habits, have a great lifestyle, and basically succeed at everything I try. If I consume alcohol, I end up with blackouts and in the hospital. Something is going on that is more serious than the idea of a bad habit in most people’s minds. I know you know that, but the average person doesn’t.
And therein lies the problem. Unfortunately, policy isn’t determined by people as well educated as you and our colleagues. It’s largely determined by politicians trying to appease voters and insurance companies trying to minimize costs. I’m dong my thesis research now on the experiences of gay, lesbian, bisexual and transgender people who went to rehab. In my interviews with them, what is evident is the power of shame to harm, and the power of acceptance and love to heal. In my mind, whatever brings more acceptance and love is best. When family members who have rejected an addicted person learn that that person is suffering from a disease, not just being a jerk, they find it easier to accept that person back into the family. This matters more to me than whether or not the disease model is biologically true (which I think it obviously is not.)
When I go on anti-AA and anti-disease model sites, I see a lot of addict-blaming. This makes me sad, because I’ve found such wonderful community here, and your books and the community you’ve created have been very important in my own recovery. Moving away from the disease model seems to mean, for some people, just one more way to talk about how addicted people should just “get over it,” or “man up, take responsibility.” If it were that easy… well, you and I are pretty smart. Wouldn’t we have just done that before our lives fell apart?
I don’t believe in the disease model, but I believe in love, care, and healing. I don’t believe in addict-shaming and addict-blaming. I don’t believe there is a one size fits all. There are a lot of differences between those who have underlying mental illness and those who do not, for just one example.
The 12-steppers don’t actually believe addiction is a disease – they believe it’s a result of “character defects” and that they were alcoholics before they started to drink. I can barely sit through a meeting listening to that insanity. If addiction were just about having some maladaptive thoughts and behviors, everyone would be an addict.
Meanwhile, I’m looking at PhD programs and interested in focusing on funding of addiction treatments and evaluation/regulation. She who controls the funding stream controls the debate. And wouldn’t you rather that be me? 🙂 🙂 🙂
Also, I just got certified as a SMART Recovery facilitator! First SMART meeting in Philadephia starts on Sunday, March 6!
Thank you for all your work. You have helped me, personally, more than you’ll ever know.
Much love and respect,
April
Congrats on becoming a Smart Recovery facilitator. Ive been one for 8 years
And I sure hear your argument alot . But the choice model is just as flawed or worse than the disease model . No reason though to accept one bad model to replace another bad one in my opinion.
I agree a new model has to have more compelling language than bad habit and learning a new one. But thats an easier task than getting others to accept it
But thats the monumental task ahead if we have the right stuff to do it .
April, what an incredibly thoughtful and articulate comment. I was about to remove it from this comment section and ask for your permission to post it as a stand-alone post, but I see it’s already got several responses, so it’s become part of a thread and I better not mess with it. And your last sentence is very moving to me.
I don’t want to write a long response, because others obviously have lots to say. But here’s a thought:
Yes, shame and stigma are almost always harmful. Yes, the “man up” retort is misguided and destructive. But your main point is this: “[people] can not comprehend how serious addiction is unless they think of it as a disease…” I think that’s often true but it doesn’t have to be true, and we can keep working on it until it’s not true at all.
When we realize how serious racism is, knowing certainly that it’s not a disease, or bullying, which never gets called a disease, or spousal or child abuse, which are not diseases either…when we realize just how serious, embedded, pernicious, and ubiquitous these phenomena can be, where do we go for an explanation? We go outward and inward. We look at the “perpetrator” as part of a larger social/cultural system, we start to examine the social forces that created this awful behaviour pattern, we contextualize, we take a developmental perspective, we look more deeply at both the person’s individual history and his/her social surround. And that’s when we start to make progress.
I’m not into a semantic debate for its own sake, and I’ve thought a lot about whether my rebuttal of the disease model can be a force for progressive thinking and better care rather than a war of words. I think it can. And the work of Maia Szalavitz, Bruce Alexander, and all the others encourages me to keep up my barrage.
And yes, I’d love it if you were in control of the funding.
Hi April,
While I do not agree with you on the ‘addiction is not a disease’ point, I do agree that the stigma of addiction is largely perpetuated by a society that doesn’t understand the neurobiology of addiction. I do wonder what Dr. Lewis hopes to bring to this discussion that others (e.g., Gene Heyman, Carl Hart) haven’t already stated. I think it’s his unique perspective as being a person with addiction (not an ‘addict’, Marc – come on, you know that term also perpetuates stigma).
I am an addiction scientist, and I hope to bring these two very extreme and exaggerated points together. On one end, you have Dr. Lewis (Addiction is not a disease) and the other you have Dr. Nora Volkow (Addiction is a disease of free will). What you don’t hear, April, is that addiction scientists understand the nuance of addiction. It’s not just a disease, it’s a complex disorder involving environment, genetics, conditioning, etc. Marc knows this. Nora knows this. When you talk to addiction scientists, you understand that most scientists get the nuance. The reality is that a percentage of people using drugs have an actual medical disorder (just talk to people who used to smoke and how often they think about smoking still) with neurobiology that drives choices. Sure, we all have agency, but some more than others.
Also, Bruce Alexander (as well as Serge Ahmed) find that, yes, most animals choose not to use drugs when faced with other alternative rewards, but there is still a percentage (~15-20%) that uses drugs over the alternatives. So, even if most people spontaneously remiss, there is still a significant portion of people (and animals) that have a gd medical disorder.
Pursue a PhD, April, and good luck. Soon, you’ll be a part of the discussion and help shape the way we talk about addiction and move it passed this binary debate. If you have questions about programs or want some advice, feel free to DM me here: https://twitter.com/PaulRegierPhD
Cheers,
Paul
If “most scientists get the nuance” and you’re an addiction scientist, I wonder why you don’t get the nuance that April is already part of the discussion.
Thanks for the comment, Marc. Yeah, I agree. I guess I felt I didn’t really have much of a voice on these matters until getting into research – which just a few years ago. But hopefully that’s changing with the way we communicate these days. And, I think it helps to have discussions with the people involved in research. I didn’t understand that most scientists had this nuanced opinion until I started talking to them.
Paul, Part of what makes this blog so fulfilling to me and why many readers keep coming back is that we acknowledge and listen to each other’s voices. Many people who’ve been through addiction or are still struggling feel that they lost their voice long ago…if they ever had one. So what I do and what we do for each other is to encourage, listen, share, and connect, regardless of our professional status or lack thereof. In one sense, you only have to have lived through addiction to be an expert and be aware of nuances.
Thank you Marc! I like the racism analogy. We will keep working on it! And thank you for pointing out that I am already in the debate. 🙂 That’s one of the things I love about your work and this community: I feel like my ideas are valued and I was just as much a member of the community at 30 days sober as I am now. Not tests of time or doing steps, just honest discussion.
Meanwhile, where should I get my PhD? I’m looking at U of Michigan, where the chair of Health Management and Policy does work on addiction/mental health treatment funding and regulation. Right up my alley. I also have fantasies of moving to Toronto, my favorite city. 🙂 Thoughts?
April
Hi April. I think you should just email me about choices re graduate school. I’ll try to give you some suggestions and help in any other way I can. You can use the CONTACT form…far right on the menu bar.
Hi April…
Just want to thank you for your comments, very refreshing Indeed!~ I’ve been working in the field of addiction for over twenty-years and have never gotten caught up in semantics with respect to “disease-model of addiction or otherwise. Basically, for me, what causes a problem is a problem and if it’s to do with drinking then maybe you have a drinking problem.
For many folks they can “self-regulate”, maybe hit their bottom, which by the way is different for everyone, family problems, work problems, health problems, financial difficulty etc…, I never met a person in my life whose desire or wish was to become addicted it develops as a result of repeated use. There may be many reasons why a person decides to use or behave in ways that create problems and devise a narrative as to why they smoke, drink, gamble etc.
The thing is, I had thought an awful long time of quitting drinking, drugging/smoking, before I actually decided to change. Despite the consequences, I used for may years, and in fact due to the consequences they had become my new reasons for using. For my drinking I did attend treatment followed by years of involvement with the A.A. Program. For me, it was a new “Family Of Affiliation ” one that I could relate to thus sharing a common bond. However, though it has been years since I have attended an A.A. meeting it was a place where I was able to get “re-rooted” into my own life.
My definition of the disease-model is determined by the lack of “Ease” in a persons’ life thus creating a “Dis”-Ease”. What is important is that a person or family can find a way to heal and grow together!~
Agreed! I was so fortunate that I had a ton of support from my family and had saved up enough money that I was able to take some time off from the rat race to focus on self-care while getting past Post Acute Withdrawal. I never realized how serious PAWS was until I got past about six months and realized how much clearer my thinking had become. Minimizing stress was key, and I was in a position of privilege to be able to do that. It breaks my heart to see how much harder it is for poor people and people of color to try to recover. The society wants me to get better, yet it seems to want to lock up people of color and write them off. In my career I want to change that. Gotta aim for something!
This is an important point, Rachel. The whole war on drugs began when race issues and drug use issues became intertwined in the 1920-30s with Harry Anslinger as drug czar. Based on prison statistic, we haven’t made a great deal of progress since then.
Hi Marc…
The “War” on anything is doomed to fail, in war there really are no winners. Repeatedly I noted that “Change” is an inside job and until and/or unless we can appreciate that we are “All” susceptible, at some degree, to harmful involvement or chronic addiction in todays society. Once upon a time they put people, suffering from addiction, most notably alcoholic’s, into “Insane Asylums'”, currently we put them in jails or prisons. In my own personal view, “using”, is only the symptom rather or not it is a “learned behavior” or otherwise. In many regards, it is a byproduct of the society in which we live. The root of many social problems exists within our collective conscious doomed to be repeated. Modification, using the same mindset, doesn’t deal with the root problem which we are all a part.
It is about time that we treat people as people regardless of race, status or any other background. We really need one another in order to bring about change within. One heart, one mind at a time!~
Many commentators these days would certainly agree, chief among them being Johann Hari (Chasing the Scream) and Bruce Alexander (The Globalization of Addiction).
Great discussion & I’d like to share some details about my son that touch on these comments. I will say that I believe that a person can be born with a high risk for addiction if there is addiction that has been passed down in past generations. My son began showing signs of addiction at a very young age to certain foods such as pasta, milk, eggs, ketchup. I believe much of what he seemed to crave was the sugar in some of the foods. He is now 20, hasn’t finished highschool, can’t seem to hold down a job, & is addicted to marijuana. My son’s dad is an alcoholic (quit drinking without treatment 2 years ago), his father was an alcoholic & his fathers father was an alcoholic as well. My mother’s father & brother were also alcoholics. About 5 years ago we had our son at a counselling session. I was asked what my concerns were with our son. I said that I felt he had a problem with self-efficacy, self-esteem & that he couldn’t seem to know who he was or where he was going in life. He quit sports. He spends very little time talking with us & we think it’s because he feels shame about himself that he can’t be motivated to do something with his life. He has insomnia & this has been a real problem for the last 5 yrs or so. He always said that the weed helped with his bad anxiety & insomnia. But it all became worse & he ended up on Xanax that he got from a friend which got out of control very quickly & by taking too many pills he ended up in the hospital for a week. Drs weren’t clear if it might’ve been a suicide attempt but for cautionary measures, they kept him against his will. He was seen by a psychiatrist & at the end of the week, they diagnosed him with Borderline Personality Disorder. He was order by the dr to attend group & personal therapy but he’s never done either. He says that he wants to get his GED & start college as a mature student. He has a textbook for studying but I have only seen him studying once. I mentioned that he needs to apply to some colleges & apply for OSAP. He’s not doing either. His older sister, who is married with a few kids says we should kick him out. She doesn’t believe in labeling & worries that this BPD label is only making him feel more flawed about himself. I cannot make him leave as I do feel he has too much going in inside himself & I wonder if, with more time, that he may be able to get on some sort of track towards some goals for himself. So I believe my soon does have an addicted, diseased brain & I feel it is because he was born with a high risk for addiction & then became addicted & now his brain is diseased. Thank you Marc for creating these topics for discussion. Jennifer
Jennifer
Id like to add a few words of care and comfort for you. Your story is heart-rendering and all so common . Ive heard countless like it,
The genetics here is tough- its likely some sort of predisposition comes from families but just how it works is not known
For example I have two kids- both their parents ( Im one) and all four of their grandparents have had serious alcohol addiction . Neither of them do.
More important maybe is your son is only 20– the brain is still maturing – especially the parts that exert ” control” … and this in your son might still be coming online . So please dont give up hope. Most kids will age out of their addictions given further time , support, and love .
Thank you William for that reply which does offer hope. I’ve tried to tell my daughter that I can’t kick him out because I’m trying to help him in a compassionate way. I told her that I feel he needs more time to mature so you mentioning this helps me feel better for how I’m handling him. He really resents when we try to encourage him to look for work or to go to College. This tells me that he’s not ready. We have him doing chores around the house for a weekly allowance. He mentions quite often that he wants to be out on his own & I believe that he will make goals for himself eventually. Thank you again William.
Okay, give him time, but don’t give him too much time. If he resents you for trying to help him grow up, then, sure, shame is part of what he feels. But he has also become too dependent — on you — and that is the surest way to nurture resentment. As long as you see him as someone with a diseased brain, you continue to excuse attitudes and behaviours that are totally inappropriate. I don’t think that’s doing him very much good.
Yes, respect his journey, but make sure he takes responsibility for his choices. Otherwise, you may be reinforcing his sense of being inadequate and his shame at treating you in a way that he knows isn’t fair.
Thank you Marc for your reply. How on earth can someone gauge for sure how much time someone needs to mature. His Dad & I question him about looking for work and/going to school. It seems to make him feel too much pressure. We still need to do this as he needs to know we have expectations that we want him to fulfill. I don’t think we should stop talking to him but I do think that he needs to take steps towards something & this is the point I think where he falters. I try to talk to him about having a plan & then working towards fulfilling some goals or even just one goal to start. He is too dependent on us & that’s where I do agree with his older sister. He’s not happy with how things are & I think that’s a very good sign. Anyway I’m very happy that you’ve given us some advice & I guess the plan on our end as his parent’s is to make sure he has a plan & work to fulfill goals. Thank you again Marc.
Exactly so. I’d imagine that anyone or anything living in one’s house has expectations to fulfill, and that would include house-guests and even pets. Since the world does not provide a free ride, parents should try to avoid creating a fake environment, like a Disneyland, where that reality magically disappears. Even little kids grow up healthier and happier when they feel they are pulling their weight.
When the NEJM publishes something like this it adds alot of oomph. But what would we expect from a zealot like N.Volkow who in my opinion is the worst kind of scientist- one with a closed mind – the first author of this paper.
The problem here is not the lack of supportive science some of which is decent– its with the method. One can easily ” prove” an hypothesis but thats not the way to do good science. You set out to disprove it or as we say ” falsify ” it. And that is easily done as Marc shows in his book and is easy to find most anywhere you look. So these ” experts” start with a bias– which they call hypothesis – show supportive data and say ” see I told you so” .. and sign up for what is mostly costly and largely ineffective treatment ( at least in the US )
Of course they dont pay attention.. they already know they are right !!!
Whats needed here is not only the case against the disease model but a better one that fits the whole picture better. And Marc- in his last book- describes one.. a learning model which needs further development and explication in future work .
Yes, the best antidote to inadequate models it to propose better models. In fact it’s really the only way. Disconfirmation usually boils down to a battle between two models, and the question is simply, which one does a better job of explaining the data?
See Galileo!
Alan (expletive) Leshner, Volkow’s predecessor, was bought and paid, essentially hired to produce the “hi-jacked” brain nonsense, to support the drug war blah blah blah. They built the prisons and helped no one. Same shit different day. Learned? Yeah, what isn’t. Why is still the question. Nothing figured out here.
The reason I think for keeping the sling shot handy is that no one benefits by being stigmatized with a fatalistic label (chronic). The diseases model does nothing to help one move on or stay in balance or get back on balance when one gets off balance. Life is all about balancing disorder and when we are taught or treated how to cope with disorder we are all in better place as far as staying and regaining that balance.
Hi Marc,
I read your first book and just finished reading your second. I learned a lot.
Could you comment on two aspects of addiction that weren’t addressed in either of them?
First, as I understand it, the disease model says that the way tolerance worsens over time is the central mechanism of the addictive process. Your books don’t say much about tolerance. How does deepening tolerance over time fit into your analysis?
Second, unlike the people you profile in The Biology of Desire, there is a small minority of addicts who fall off the cliff into addiction right from the start. In the dozen or so people I went through rehab with, three told the same story. They each had parents and grandparents who were alcoholics. When they had their first drinks as teenagers, they said they’d found the “magic solution” to all their problems. Figuring more must be better, they drank to extreme excess and suffered terrible consequences – blackouts, car crashes, arrests and terrible hangovers. But their reaction was opposite to that of most people who, after their first really bad hangovers, swear they’ll never do that again. Instead, my rehab mates all said essentially the same thing: “I couldn’t wait to do it again,” despite the awful consequences. And they did, becoming compulsive drinkers from the beginning, with continuing disastrous consequences. And I’ve heard this consistent story from many others since I got out of rehab nearly 20 years ago, though they are a distinct minority.
How does their experience fit into addiction being a learned habit rather than a disease?
Thanks
I think this minority really exists, the ones who just can’t help themselves. So far, no answer for that. I’ve known a couple, long gone friends. Maybe THEIR problem WAS medical. I suffered from moderate depression and it was a hellish seemingly intractable condition. Medication fixed it completely with no heavy emotional lifting. Maybe the right medications could serve to un-paralyze the hopeless addict’s will.
Just a guess.
Thank you for your reply, but it doesn’t explain why Marc doesn’t discuss tolerance in his books (the indexes don’t even contain the word). As my original post says, advocates of the medical model say the way tolerance deepens over time is the central mechanism of the addictive process. So shouldn’t those who argue the medical model is wrong address how the medical model gets it wrong when it comes to tolerance? There’s probably a good reason Marc doesn’t address the issue, but he hasn’t so far.
Hi Steve, I don’t address tolerance because it’s beside the point. We grow tolerant of many substances, including various psychiatric drugs that nobody would ever want to take voluntarily. Tolerance is simply an effect of continuing to take the same substance repeatedly. It is loosely correlated with withdrawal symptoms, and some people assume that withdrawal is the hallmark of addiction. But even that is wrong. Cocaine, meth, marijuana and alcohol (except in high doses) don’t produce withdrawal symptoms. Opiates do. That’s not the deciding feature.
Now that behavioural addiction are acknowledged to be “true” addictions, showing the same sequence of brain changes you find with drugs and booze, it becomes clear that tolerance and withdrawal are aspects of substance “dependency”…but that addiction is a psychological process.
Even the most prominent spokespersons for the disease model (Volkow, etc) write about the similarities in brain change between, say, binge eating disorder and drug addiction. So neither tolerance nor withdrawal could possibly be the indices of addiction. And there’s gambling, and porn and sex addiction….and they all look pretty much the same in the brain.
That said, tolerance and withdrawal symptoms create a second layer of suffering for those addicted to opiates, and an additional obstacle to those who are trying to quit. So…it’s important to consider for people with those specific addictions.
Hi Steve
Tolerance is a natural adaptive process. This happens with many things and activities. It can also serve to reinforce learning. The bodies quest for homeostasis is not the sole domain of addiction, although drugs can catalyze the process.
I certainly agree that there are some people like those you describe. However, there can be many reasons for this – think of people who “fall in love at first sight” – these processes are very similar. Familial history is often a factor, but essentially the “learning” could have been happening up until that moment. The “learning and seeking” is happening and then VOILA – SOLUTION!
Having said that to simply dismiss the biology would be simplistic. As Jeffrey has stated below, people with depression can find alcohol incredibly attractive as it is a great (short-term) mood stabiliser. Sometimes the correct medications can prevent the “instant attraction” as can a multitude of other factors.
Thank you for your reply. I may have misunderstood Marc’s books, but as I understand them, he says habit formation results from repetition over time, which strengthens synaptic connections and embeds the habit. That makes sense to me. But the people who take drugs obsessively from their very first use don’t fit that pattern – they have the habit with a single use rather than through repetition. My question is: what is the neuroscientific explanation for a habit that’s full-blown from a single occurrence rather than a repeated series of occurrences?
I think that, as Shaun is also saying, that simply isn’t the case. The problem is “learned” over time…and that leads to what seems a solution when something new is presented.
Yet these situations appear in the literature far more frequently than they do in real life. Because they are so dramatic.. They make a good story.
People fall hopelessly in love immediately…don’t they? Maybe..but only rarely. People suddenly decide that music is their pathway to heaven..but usually that takes a few tries. So it is with drugs. Nobody develops a habit in one trial, but a brand new kind of experience can be life changing to someone who is hungry for change.
Hey, Shaun, Steve
Sean–You took the words right you of my…brain? 🙂
I really feel like I was one of those people who wanted it from the get-go. Maybe it was driven and controlled by my “predisposition” (genetics, depression, desire to self-medicate and control my own mood) and by opportunity. The moment I did “it” I felt focused and all the self-loathing and destructive negative self-talk fell to the wayside and I was allowed to “be” and “act” without expectation. I was exerting control I hadn’t known was possible. The first time I did “it” I had no idea that I could feel different, that fear, depression, anxiety and worrying over every little thing I did wasn’t the only way I was supposed to feel. If I hadn’t had the structure in my life, and had unlimited access and opportunity to use, I probably wouldn’t have been able to stop myself. The drive for emotional as well as physical homeostasis was that strong.
I felt that way when I first tried booze, and then weed. But what I got addicted to was opiates…and that took a few months. Again, we have to consider what’s going on psychologically. For me, and maybe for Matt, just the realization that one can change one’s mood (which has generally been awful) by ingesting a substance is a pivotal experience.
Hey Marc.
This forum is a great resource to those who use it. Your books are being pretty widely read and are doing some good. Please don’t get too discouraged! You are having an effect, but you don’t have the mighty bureaucratic leverage of Volkow. At least she’s smart and offering something better than the old Presbyterian blame game.
I agree that addiction is not a disease. This begs the question: Well, what is it? So far, no pat answer. The disease model provides a simple explanation many well intentioned people (think they) understand. People have to be willing to do some brain work to engage that and the few who are capable mostly have their focus elsewhere.
Keep on keepin’ on.
If addiction or behavioral dependence or whatever you want to call it isn’t a disease, then it sure looks like the symptom of one. I dealt with chronic-acute neuropathic pain for over 10 years primarily through the use of strong opioid medications, eventually potentiated by alcohol. It allowed me to stay functional and keep working— until it didn’t. I palliated pain and depression both chronic and situational, through the use of drugs and alcohol until that didn’t work— until the symptom began to look more like the disease. In the end, I struggled for years to reassert more viable coping mechanisms until they replaced my negative addictive behaviors. I had been self-medicating, applying salves and medicaments to alleviate my own suffering. And just as a doctor that treats himself has a fool for a patient, I was a person treating myself– and had a fool for a doctor.
The social milieu this debate inhabits is rife with inexplicable inhumanity and misunderstanding. In this context, I would assert that the racism Marc mentions is very much like a disease, and at the root of its etiology is ignorance– very much like addiction. I facilitate or co-coordinate 12 meetings a week across a variety of contexts (detoxes, psychiatric units, open meetings) from homeless populations to the well-to-do. In all of them I ask questions like “How many people think this is a disease?” and “How many people have a mental health issue associated with your addiction like depression, anxiety, bipolar, PTSD?” In all of them, the overwhelming majority of people answer yes to both questions.
My question at this point is, does it matter what we call it? For the street level person with addiction, if it’s a disease, we have to stop. If it’s not a disease, we have to stop. If it’s genetic, a medical issue, a mental health issue, a personality disorder, a maladaptive behavioral response to life stressors…whatever host of simulacra we attach to it, we need to stop to get at the root of all this…otherwise all this argument is just a distraction. And in meetings, it can be a distraction from fixing the problem.
Sorry. A little cranky today.
WOW Matt
” And just as a doctor that treats himself has a fool for a patient, I was a person treating myself– and had a fool for a doctor.”
Gotta love that one– I went both ways , LOL
That was very good Matt.
Hey Matt –
I am with you in believing that the question of disease/not disease is not the most important issue in addressing addiction. Marc, as a neuro-scientist has a professional interestst in the question. My professional background is in history and technology. My only direct experience with addiction is tobacco,which is not that big a problem until it kills you. But I have friends who struggle every day, with varying success with drugs and alcohol.
I have a very close relationship with a blackout alcoholic. She struggled for years, never managed to quit for long. I spent a lot of sleepless nights worrying about her. She couldn’t stick with 12 step. Then on her hundredth attempt to quit, she did. When I have dinner with her in restaurants, she drinks moderately. In the last 3 years she has fallen back into compulsive drinking twice but only for a week or two. As I said she dtrinks socially. The usual 12 step explanation for such stories is that this person wasn’t “really an alcoholic’, but that is a circular argument.
I don’t buy it. If twelve step works for someone, I would never try and talk them out of it. The question for me is: How does something as transparently behavioral as ingesting an intoxicant qualify as an incurable disease? I have an incurable disease, progressive primary MS. I didn’t do anything to “get” it. Nothing I can do will cure it. I don’t of anyone who has been cured or recovered from this. Is addiction, which commonly goes into spontaneous remission, in the same category? I can’t see it.
This is not to say that that addiction doesn’t kill, or that everyone can quit. I know 3 people who lived and then died that way. I have no explanation.
I wish you success in your meetings. Al Anon tought me lot, but I don’t need it anymore. Hope the crankiness leaves you be directly, I go there a lot myself.
Regards – JS
Dear Jeffery,
Here is a section on Spontaneous Remission as seen from the DILECTION Model of Addiction, which is a new model to be proposed later in 2016. (feel free to comment if you relate to this:-)
SPONTANEOUS REMISSION:
It is commonly understood that solid and long-term friendships, marriages, and partnerships can linger for life. The want and desire forever remaining.
Plays, stories, films and books are filled with unrequited love, where long-term friendships, marriages, partnerships come to a physical end, yet the desire and want to return, remain for life.
It is also commonly understood that solid and long-term friendships, marriages, and partnerships have ended, sometimes abruptly, and with no lingering wants or desires to return.
Human history, stories, films and books are filled examples of this.
Sudden, or Spontaneous Remission describes when persons addictive feelings, thoughts and behavior instantly change and they are no longer craving or interested in the addiction. This can occur at any level of addiction, and time is no longer an element.
In the physical medical field, the factors or mechanisms responsible for Spontaneous Remission are currently obscure or unknown.
But this is readily known in human relations, and the DILECTION model for Addiction can account for this.
It is common knowledge that long-term and intense friendships, loyalties etc, can instantly change, due to realizations that may occur.
Specific and actual accounts of these instant changes are part of human history, and are key scenes in numerous plays, films and books throughout time.
In the DILECTION Model, the life-long lingering desire, and also the spontaneous loss of Addiction dependency, fits this same pattern.
Carlton,
where can I find more on this – are there any publications (being lazy).
Certainly the comparison with a relationship resonates with me. Marc and I have discussed this at length. And you are right, sometimes relationships (and addiction) can resolve over-night. Intense religious conversion interests me because I have seen many drug users stop instantly (or almost instantly). Sometimes relationships just fizzle out, and sometimes there is the one that keeps cropping up, often at inconvenient times!
Interesting topic.
Shaun,
I have a series of drafts for the Dilection Model, and am corresponding with a neuroscientist at Mt. Sinai, here in NYC about the language, wording and even research, hoping for an official presentation sometime..hopefully this year?
I would be delighted and honored to post sections here on UNDERSTANDING ADDICTION. Thoughts, feedback and comments would be welcome 🙂
Hi Carlton, I know nothing about your model because you haven’t told us anything about it. Of course I’m always skeptical of new models — someone reinventing the wheel out there? — but that’s how we’re trained to think.
But I do like your post about spontaneous remission, and it’s useful to show how it applies to a host of celebrated human dramas…not just addiction.
I’d go a bit further in parsing the possibilities. The behaviour (or relationship) can end with or without the spark being extinguished. I’ve lost at love enough times to know that. Luckily, athough the wish might remain indefinitely, it doesn’t have to. Often the spark dies out gradually, for lack of fanning the flames. Luckily the brain really is very plastic and learns from not doing as it does from doing. It’s critical for us addicts to know that you can lose the desire with time. You don’t have to wait for that golden moment. Sometimes it’s best to just stop the behaviour and wait to see what happens next.
Hi Mark,
Since the professional medical, science and addiction is not my field, This new model needs work and needs to be presented in the academic language, so it is not misconstrued and is clear and concise in its description and language.
The model is based on Hindsight, and what I found from a number of coincidences, it was not a “goal” or quest.
It is a model that a lot of the people that recovered on there own will recognize once its put in words. Personally, I utilized several recovery groups and approaches over the decade of trying to re-gain my own freedom from the state of addiction, but I think, I am many people using recovery groups will recognize and relate to this new model.
I work in the visual arts, so this is something I am doing on my own time, and its not something that comes easily at all!
I think its important to make available though, because as a person who experienced the feelingly of utter despondency and hopelessness, I think, in Hindsight, a model like this , would have been a very valuable thing to realize existed while experiencing the often-times life threatening nature of feeling imprisoned by an addiction, (in my case it was alcohol).
Also, it may help re-evaluate ways to help people that want help with their addiction
problems.
Since this website is not a specific recovery type-website, you can read that there are others that are open to new and additional “takes” on addiction by the replies. Perhaps I could post “the Dilection Model” for addiction on this site when its ready for launch.. it would be great to get thoughts and feedback for readers of this UNDERSTANDING ADDICTION blog!
Di`lec´tion n. 1. Love; choice.
Hi Marc,
Its actually a discovery, not an invention.
Rather like Copernicus watching and observing the already existing heliocentric solar system, and then writing about it.
The writing of the Dilection Model is the difficult thing, and I am not a writer.
Scientific tests and research may confirm it at some point.
A key thing is that it accounts of all the other models and beliefs about Addiction, yet offers a universal understanding and sympathy for those that experience a dependance on something that is clearly counterproductive and destructive to themselves.
Marc,
Here is a draft, or brief summery of the DILECTION Model that I have sent to a number of people in the Recovery Field.
Any comments or questions are welcome.
Best,
Carlton
Currently, Addiction and Recovery are defined as opposites. The most popular and deterministic model is that Addiction is a disease and that Recovery is the maintaining constant resistance to the disease.
The DILECTION Model is radically different.
The DILECTION Model of Addiction considers Love to be the initial origin of Addiction. Therefore, the absence, or loss of Love (for the addiction) describes Recovery.
Addiction and Recovery are thus re-framed and presented as two ends of a spectrum; just as “Being in Love” and “Being out of love” are part of the same spectrum.
This is not a deterministic model, but a stochastic model that allows for the complexities that occur in a natural world and in an individual’s life.
It allows for the various beliefs and models of addiction and recovery (including the Disease model).
It also allows for the re-framing and re-thinking of control, abstinence, sobriety, triggers, strength, commitment, choice, relapse, slips, biologic/environmental factors, treatment programs, support groups, self-empowerment, and many other aspects of the Addiction/Recovery spectrum.
Most importantly, the DILECTION Model allows the discovery and exploration of new and effective ways to help people who experience addiction.
D. Carlton Bright© 2016
…the last paragraph had been recently revised to read:
“Most importantly, this new model allows people to relate, comprehend and understand in a realistic way, what they are experiencing.
It also allows for the discovery and exploration of new and effective ways to help people who experience addiction.”
Here is an example of re-framing the role of relapses when this model is considered;
During a persons recovery process, Relapses as a whole, could be seen as a series of many incremental realizations that may lead to a change of heart, or a “loss of love” for the addiction, which is in a sense, is recovery.
Hi Marc,
Here is a recent Draft on the topic:
The Dilection Model and Recovery.
Because falling in and out of love “occurs” rather than being something “you do”, a Recovery Program based on this model would be different from current Recovery programs.
A persons own history of falling in and out of love could play a key role in their own Recovery.
A new recovery program could encourage people to explore and examine their own experiences with falling in and out of love, and consider these past experiences to valuable elements of self-reference in their effort to get over an addiction.
Also, since the change of feelings and the realizations that are experienced when falling out of love can only be conveyed in hindsight, the recovery program could feature a Reference Library consisting of an ever-accumulating number of people’s accounts of important or life-changing realizations that led to the falling out of love with an addiction.
This could help initiate and motivate people to explore and re-examine their own history.
It could also serve as evidence that falling out of love,(or recovering) is possible, and does occur, (this can seem unimaginable when addicted).
This Reference library could also be indicative of the Programs effectiveness, and naturally attract other people that are struggling with an addiction.
D. Carlton Bright- 2016
Any thoughts or suggestions would certainly welcome.
Hi Shuan,
Interesting..because originally It was called the “Relationship” model but it did not stop there.
Over time, it evolved into this new model with much larger arc, which can now account for the beliefs that a large percentage of people have, that addiction a disease.
And yet it also accounts for people that no longer seem to rely on recovery programs, and people who did not seek out or, get involved with a recovery approach.. which, studies say, is a big number of people.
Hi Carlton
This great stuff! The term “spontaneous remission” I find problematic because it sounds instantaneous (to me), and it’s not. We have to discover that we’re recovered, just as we have to recognize we have a problem for treatment to work. One day we realize our habit hasn’t crossed our mind in days, but that’s because something else has taken its place, has filled the hole. And dilection is key in this. We don’t re-engage in life without choosing loving kindness for ourselves and others. It’s what makes us human.
Hi Matt,
I am trying out the term: “Change of Heart” instead of “Spontaneous Remission” with the Dilection Model, because a change of heart can happen over time, yet also be realized instantly, even after decades of addiction.
And to add to your point, sometimes a person can feel that a relationship in over in an instant, even a long-term one, but it can take time to change from the daily life patterns, etc.
Also, the term is easily relate-able, yet it is not absolute either.
It is only the individual who knows when heart-felt feelings change.
Hopefully, research on this may occur with the connection at Mt. Sinai I mentioned earlier.
BTW-
Although the term; “Spontaneous Remission” is a Disease/Medical term, is considered right or wrong,
because it may fit with an individuals belief-system.
Nor are a persons individual beliefs about Addiction and Recovery considered right or wrong.
The various Models for Addiction are seen from a larger framework and are not perceived as right or wrong, correct or incorrect.
This new model is still in the early development stage, but would love to get some practical feedback and thoughts about it.
“It is only the individual who knows when heart-felt feelings change.” So true, and something that so often gets lost in the shuffle of everyone telling us what we should be doing, even ourselves and our own self-criticism, self-loathing… Everyone except our own heart, our own true nature.
It sounds like such a promising tac…Good luck with this and let us all know how it’s going!!
Matt,
Interestingly, I think the first understanding and acceptance of this will be from the Public-at-Large.
Addiction will no longer be seen strictly as a disease per se, yet will still be understood as a very serious thing, even a life-threatening-disease-like thing.
Oddly , I think some of the pop-music lyrics and song titles throughout the decades will underscore this new Public understanding.
The stigma may finally shift away from fear and puzzlement, to sympathy and understanding for the addicted.
Carlton, please send me the material when available. I avoid the terms “recovery” and “remission” and tend to use the phrases “resolve” or “develop through” Substance Use issues.
Hi Shaun,
I will have to check with the person I am working with about what, when, and how to share what is being worked on, and if its a go, how can we touch base?
Hey, Jeffrey…Thanks so much for this!
It’s true people look at smoking as a different category of addictive behavior, even though nicotine is one of the most addictive substances to humans. But the negative consequences– cancer and heart disease– are so far off in the distance. The immediacy of the danger isn’t there. “Now appeal” has carte blanche to run riot.
It’s not that 12-Step is voodoo, or unscientific, or bad. It works for millions of highly rational people. So do all the other methods. What doesn’t work are dogmatic, arbitrary, prescriptive perspectives. All these different programs are populated by humans– humans who are suffering. Consequently, there will be some percentage of zealots, nazis, and nutjobs, gumming up the works with ignorance. What works is to be open: open to suggestions, to accepting there is a problem, to accepting help, to accepting there is no ONE way. There is the way that is going to work for the individual. It’s a process of self-discovery that is enriched when we begin to share what we’ve learned, not lord it over others like some kind of procrustean baseball bat.
Another vacuous trusim in all of this is that it takes as long as it takes. It does take as long as it takes. The second try, the third program, the 45th detox. Your friend is a good example. It took her time to find her equilibrium, but she found it with support. For many of us who use the way we use, it might be possible to moderate. But for me it would take up way too much space in my head and my life that I want for other things– as much if not more space than the addiction did. Abstinence is just easier, and I’m hard enough on myself as it is.
Smoking is a behavior; cancer is a disease. If addiction were a disease, it’d be the only one I know of that goes away just by not engaging in the behavior. Causes are not conditions.
Thanks for your support, and I’ll get over my crankiness. This time of year wreaks havoc with my Seasonal Affective Disorder. Yesterday, marked the 10 year anniversary of my nearly successful suicide attempt due to substance exacerbated major depressive disorder. The most important thing my recovery has taught me is that this is no longer, nor ever was an option.
“He who represents himself has a fool for a client” is attributed to Abraham Lincoln.
I disagree that it necessarily translates to self diagnosing and treating physicians except in the arena of prescription abuse.
I agree however that self medicating individuals are problematic especially given the multifactorial essence of addiction and the element of denial often obscures exactly what it is that is being medicated.
I believe that though there is pathology in an actively addicted brain, no way is “thye disease of addiction” a stand alone entity,, more likely a manifestation of a demonstrable perhaps undiagnosed comorbidity.
It matters greatly in the direction that institutional efforts to address it are focused and more importantly how the addict views oneself an integrates available resources toward their recovery.
Hi Ron. Is it “comorbidity” really? I know that’s what it’s called, but I prefer Matt’s version: ” If addiction were a disease, it’d be the only one I know of that goes away just by not engaging in the behavior.” So if addiction is really only a behaviour, and let’s say depression is “the disease” (although personally I don’t see it that way), then there’s no “co”. All you have is a condition, e.g., depression, and a behaviour that tries to deal with it.
Thanks, Jeff. Much appreciated.
Great discussion, as always. Like many here, I don’t necessarily see addiction as a disease, but I teeter on the fence occasionally, and here’s why:
I see substance addiction, particularly to opiates, as much akin to a disease like type II diabetes. Both have genetic, environmental and behavioral components that, over time, interact to create the “disease.” In both cases, the behaviors impact bodily systems to the point that the body stops producing something it needs to function optimally: insulin in the case of diabetes, dopamine (or whatever brain chemical) in the case of addiction.
Some (many?) type II diabetics can reverse their disease with behavioral changes alone (i.e., weight loss, improved diet, increased physical activity, quit smoking, etc.), without the need for medication or insulin. Others are either unwilling or unable to reverse it with lifestyle changes alone and require medication (and/or insulin in more advanced cases) to manage symptoms (coupled with some moderate lifestyle changes). The same can be true for opiate addiction. Some can reverse it by changing behavior (stopping use, learning new coping skills, etc.), while others thrive with medication (methadone or Suboxone) in addition to those behavioral changes. Finally, in both cases, some never recover or learn to manage symptoms and die or become severely disabled.
I realize this isn’t a perfect analogy and it doesn’t mean that addiction is a chronic brain disease (which I find too reductionist a description), but it does help me understand how some people can conclude that the biological changes brought about by addiction creates a disease state. And that helps to keep me from getting pissed off in discussions with people who buy into the disease model (which is most people that i encounter in online support groups).
Nice summary, very much in line with my thinking.
I’ve known many diabetics in rehab who also game the system. They adjust their insulin pumps or dosing in order to binge on sweets (or alcohol). Is manipulating a situation to get what you want a disease?
Gina, this is a very good argument and rationale for accepting the disease nomenclature — and I know that you’re taking a middle ground, so I’m not coming out swinging. The main problem, I think, is that it still is a metaphor.
Genetic, environmental, and behavioural components don’t say much, because those can be found with any developmental outcome. Changes in dopamine availability? — okay, maybe. But the main problem is that we don’t want to say that opiate addiction is a disease but gambling and sex addiction are overlearned behavioural habits with destructive consequences. They have too much in common to be put in separate categories.
So…should we define something as a disease if there are serious biological changes? I just find that such shaky ground when it comes to the brain. Hungry people and Type A businessmen are also flooded with dopamine in relation to food and money respectively. I once studied this. When rats are deprived of food, their acetylcholine system (another neurotransmitter) is overtaken with dopamine. That’s why they get desperate. And sex and love ride on dopamine waves that recede to backwaters when the love object isn’t around. So biological changes are natural, normal outcomes of shifts in reward seeking and reward availability.
Or….hell, maybe I am zealot.
Marc,
I have read your works and actually took the time to read the NEJM article. First, it is a Review Article and not a this is fact article. It is a Volkow Review. When I read it the second time I found this….
Addiction results in aberrant, impulsive, and compulsive behaviors and conditioned responses that involve stress reactivity with profound disruptions in decision-making ability and emotional balance with disruption in voluntary behavioral control. Relapse is related to Pavlovian learning, motivation and behavior are key components. The overall process causes changes in behavior and affects the executive processes.
The conclusion was interesting..”If early voluntary drug use goes undetected and unchecked, the resulting changes in the brain can ultimately erode a person’s ability to control the impulse to take addictive drugs.” and for the most part all of this sounds like, looks like Operant Conditioning or put another way Addictive Behavior, is habit as you say and is conditioned. No question drugs affect the brain and all of the changes affect behavior. I got bored with reading the references finding Pet Scans, animal studies and no concrete Pathology and Histologic studies to demonstrate……here is the part of the brain that is diseased and represents the diagnosis of this disease. All I found on reading was what happens in the brain during the addictive process that is translated into Behavior.
As was pointed out all of the modalities with exception of medical intervention, ie Naltrexone, etc are behavioral. It is fact, on reading Sinclair’s method that addiction is referred to as Learned Behavior and Operant Conditioning is mentioned as well.
Someone asked about recovering without treatment. If you go to this link and click on books and videos you will scroll down and see the book that follows. Someone else mentioned the notion of Spontaneous Recovery sounding instantaneous. This notion is explained in this book and is tantamount to Spontaneous remission of Cancer. All it means is remission or resolution without intervention. It is common knowledge that about 25 % of Cancer will spontaneously resolve regardless of what you do. This was discovered in the Vietnam and other groups and is discussed at length in this book.
Promoting self-change from addictive behaviors: Practical implications for policy, prevention, and treatment
by Harold Klingemann and Linda Carter Sobell
http://www.nova.edu/gsc/
When looking at Natural Self Change or Spontaneous recovery 3 things are clear. When folks do this they make a cognitive decision to stop for whatever reason, formulate a cognitive plan and then assess their goals. This is explained by the Sobell’s in their writings. They have a good read, a clinicians manual for Guided Self Change.
Someone mentioned that most animals won’t choose to use drugs, fact is Tobacco is a poison and insecticide and animals in the wild won’t eat and of course won’t smoke this stuff.
Who cares what you call it disease or not? Folks should understand to not believe in the disease model and to promote it at any level should be taken into consideration because by promoting the disease model unfortunately means that folks are labeled as having this disease forever and a day. The disease model will cause people to be marked by this tag and more likely than not will end up in 12 step facilitation that renders the person to believe that they are their behavior. Studies have shown that believing in the disease model and lack of coping skills lead to and increased incidence of relapse.
Equating addiction to Diabetes appears to make sense until you realize that type II diabetes is resolved, cured, kaput…done away with by diet and Juvenile Diabetics use less insulin as well. I find it odd that and Endocrine and Cardiovascular diseases are equated to addiction. Why not compare it to other known brain diseases like Alzheimer and Dementia. The reason is probably because when you do that you realize that the proof for the Disease model is dependent on scans and animal studies and not histologic studies identifying the problem in the brain.
What people need to understand is that there is no prevention for this disease based on the Disease Model. People aren’t getting genetically screened, no vaccine is on the horizon, no attempt to identify a means of prevention. As far as I am concerned when you look at smoking, stopping the commercials for tobacco, putting labels on the pack of cigarettes, promoting OTC ways of stopping smoking and telling people that they can stop without being put in Rehab has made a difference in this Behavior. The Disease model has done nothing except promote 12 step facilitation because that is what it means when someone accepts this notion. Does it make a difference, well in SMART you are not your behavior and you are taught self sufficiency and it’s associated program CRAFT leans heavily on Operant Conditioning. So does it make a difference? Yes, particularly when you know that 12 step facilitation fails more than it succeeds as demonstrated by Hester.
Thanks for this very thorough review and commentary. The link to the Sobells’ practice is valuable, as are your comments on spontaneous recovery and your discussion of commonalities and discrepancies viz addiction vs. medical diseases.
Your point about the absence of histological analysis is particularly interesting to me. As far as I know, changes in dopamine metabolism are detected by PET studies and observations of general changes in activation levels depend entirely on fMRI…both are, as you imply, way too general to support the specifics of a disease model. And I know at least one study that clearly shows that belief in the disease model actually predicts relapse. I can’t put my finger on it at the moment — I know that Peele refers to it somewhere. Any references to that association would be appreciated.
But I guess the main point is that all treatment modalities are behavioural, not pharmaceutical, with the exception of a few drugs that help opiate addicts and alcoholics to reduce cravings in one way or another.
Thanks for this contribution.
Hello Mark,
I think the environment and diet has more to do with addiction than the genes. A stressed out brain, or a brain having autoimmune damage in the reward system is more prone to addictions. I know of a case of hypophysitis, which is very prone to addictions. I assume the hypophysitis is the cause of addictions (the addictions also worsen the hypophysitis, in a positive feed-back). The person reports having relapses triggered by psychological stress, egg white (food sensitivity?), milk, high glycemic index food, strong natural light during the day or artificial light during the night, etc.
There are 3 therapies little mentioned in mainstream media: circadian therapy, REST therapy and diet, which combined can treat addiction much better than each alone. These therapies lower stress, increase the resources of the brain to cope with stress, and lower autoimmunity as well.
Here you can find a summary of a new therapy, the combination of the mentioned 3 therapies, proposed for addicts, in case you are interested:
https://tranzicionshqiperi.wordpress.com/2016/01/07/new-therapy-for-substance-use-disorders/.
Since autoimmunity may be involved with addictions, lowering exposure to chemicals should also help. I am new to your blog, I will give it a read.
HI Rita, and thanks for introducing these factors into our discussion. Stress reduction is probably the most potent remedy for a great number of problems, from addiction, to mood disorders, to medical conditions, to rashes, to relationship break-ups. The problem is that stress is built in to our lives…and addiction appears to offer relief in the moment, though of course it gives us more to be stressed about over the long term.
…at peak,nicotine consumption was 30% of the population,,,
….nicotine is a dopamine re-uptake inhibitor….
….which means that only people with ‘low’ dopamine levels would
get any effect…
….why would ANYONE subject themselves to the unpleasant ness
of smoking…..unless they were getting a HUGE payoff that most people
weren’t….i.e. having their mood elevated to ‘normal’ levels.
….why would there be less variation in alleles affecting levels of
neurotransmitters than there are affecting height or eye colour……
…we know almost nothing – but enough – about how epigenetics
allows environment to express gene expression and personality
development – ref Michael Meaney, resiience in rat pups as a
consequence of maternal grooming; or aborted development
of binocular vision in kittens if they’re ‘blindfolded’ in the relevant
developmental cycle. Stopping drinking doesn’t make one cured;
it just accedes to physiological incapacity to ‘digest’ alcohol.
Is lactose intolerance either ‘a disase’ or ‘curable” ?
We are all diseased all of the time. We all have cancer yet it gets rampant enough in only some of us to the point where we are diagnosed with it..
We all have habits yet only some of us have habits that control our lives and become all consuming and become diagnosed with it.
Are we ever cancer free. No.
Are we ever habit free. No.
Point is we never were in the first place. Addiction is a perfectly normal process gone awry. Does it cause dis ease. Yes. Is it Chronic yes and no why because its normal.
It can be used for what ever the person chooses (consciously or not). If the addict identifies with it as a victim and chooses to feel diseased then they can spend the rest of their lives as an addict with their devil waiting around every corner.
If the addict chooses to live free and empowered: they can, by merely changing their belief in what their addiction really, is use that old trigger that does weaken over time as a driver to enjoy a better life. Eventually the triggers drive new pursuits, new end points, new goals.. So both are “addicts” with the same pathways working.
One with dis ease… The other with ease….
Believing one is an addict for life is simply replacing one addiction with another.
Kind of like the person with Cancer that does the surgery, the chemo, drops, the stress, unhealthy eating, smoking, starts exercising, takes up mindfulness and lives in remission for the rest of their lives to die of dementia in their old age.. (my grandma)
As opposed to the Cancer patient who gets the chemo, the surgery, and keeps living like they did and dies of cancer three years later. Why…. What is the difference.
Sure these may not be the absolutes my point is they both have cancer. they always did. Just like the addicts always had the neurology that gives them the gift of Habit.
Bottom line for me is that, it is what ever the person wants it to be. Choose your illusion. The science is all flawed because it attempts to monitor with a mass approach. This is an individual disease that may be stimulated by mass insanity but it is still individual.
I understand that the Cancer comparison is not easy to swallow. I used it because it was used in the blog. But it is also a “disease” that is not well understood and has many cases of spontaneous remission.. HOW?
The answers lie outside the box.
Debating from a level of black and white, makes Cancer a death sentence and addiction hopeless.
Get outside the box… Can it not be both??? Disease but not Chronic????
Billy, I find your argument hard to follow. There is a lot of overgeneralization in what you say, and I don’t think that the cancer analogy is completely valid.
BUT your main point, that addicts choose whether or not to view themselves as diseased, seems correct. How we label this thing is a choice, though there is often pressure from family, friends, and various authorities driving us to one choice or the other. And then we define ourselves, our lives, our hopes and needs, according to that choice.
Mark
Thanks for the reply. Unexpected. In reading my post I can see how I am hard to follow.
If we remove the cancer analogies. Focus on addiction. My point or question in simple wording is.
That if we choose to see addiction as a cure less disease do we not make it one just by that choice. P
Interesting, Bill. Maybe prostate cancer is a better analogy. All men eventually get it, so it’s “natural”…and relatively few die from it. Yet it is indeed incurable. So I guess we can choose whether or not to view it as a disease.
Bill, Marc,
Here is another way to look at this, outside the box:
The DILECTION model considers Love, rather that a Disease, to be the origin of Addiction.
There is a change of perspective if you plug this into Marc’s Prostate Cancer analogy:
“All people fall in love at some point, so its “natural”, and relatively few die from it.
Yet love is indeed incurable, so I guess we can choose whether or not to view it as Love.”
And to add:
Although Love is incurable, people have fallen in, and out, of love, throughout time.
For instance, everlasting love in some relationships is common, but for a large percentage of relationships, a person may not remain in love throughout life.
Now here are the same two scenarios with ”addiction” substituted for Love;
“ It is commonly known that people struggle with a life-long addiction, yet it is also known that a large percentage of people do not remain addicted throughout life.”
And here is this idea if you swap “disease” for “love” in Bill’s general description:
A person may choose to comprehend their addiction in a way similar to loving relationships, good or bad, they have had, or are having, in life.
This is very brief, but I am working on an article for publication describing the DILECTION model in depth, and would honored to post a working draft here on The UNDERSTANDING ADDICTION blog for comments/ discussion if interested.
Interesting if one were to look at heritability through a micro/ macro lens. Is heritability not the habit of generations,(macro) expressed in the in the process of the individual(micro). Basically bringing it all back to Human choice.
Is not Heritability based on the historic choices of man/ancestor? Be it conscious or unconscious. My point being that once the unconscious is pulled into the conscious can we not feed our DNA, and in the Macro and Micro in a sense change humanity and self by our mere choices.
So much disease is pointed at being inherited, and like you say is likely far more complex once one enters into the nuances of debate.
But in the most macro and micro discussions is it not choice. For no matter how “diseased” I am, who is it that allows the final diagnosis. No matter what the vessel of dis-ease…. I may not be able to escape the choices of my ancestors, or my self to this point. But is there not an obligation with that awareness to make wise choices? And from there begin to untangle the the spiral of this addiction called life.
Carlton
To me Addiction has always been about one thing, and dependant on one thing.
Love or the lack there of.
This phenomenon is typical of complex medical diseases with high
heritability rates for which risk alleles predict only a very small percentage of variance in
contrast to a much greater influence of environmental factors (i.e., cirrhosis, diabetes,
asthma, cardiovascular disease).
I fully agree. See the last paragraph of my post.
Marc,
I am in an interesting position. I am currently in a specialized docket dealing specifically with opiate addiction. Their position is obviously “You have a disease, to which there is no cure. The only, and mandatory, ailment to keep your disease in remission is 12 step meetings, medication, and counseling.” While I have found the counseling incredible, I am not on board with the disease model at all. And my inability to keep my mouth shut has left me in a situation requiring me to present an argument to the disease model to the specialized docket staff (judge, attorneys, prosecutors, and all legal staff). I was wondering if you might spare some time to allow me to pick your brain on the matter, so to speak. I feel that I am doing something relatively unprecedented. That being audibly not accepting the easy answer to my past behaviors as an uncontrollable disease. And despite court mandates choose not to participate in spiritual semi cultish programs that further enforce my having and incurable disease. If you have some time, would love to hear some thoughts, and can provide further detailed insight on the circumstances.
I’m currently working on my CSAC after dropping out of my PsyD program when I developed intracranial hypertension requiring brain surgery. I’m really having a problem in this program b/c I’m the only one who doesn’t buy the disease model & im inadvertently making enemies fast as a result. I was even told I’ll have a hard time getting a job!
First, I hate the terms “addict” & “addiction.” Besides being loaded w/ stigma they do very little to describe what is going on. It seems, to me, that it’s first beneficial to make the distinction b/w dependence & abuse. Somebody who becomes dependent from a Dr & then seeks opiates to keep w/d at bay after suddenly being dropped by their physician does NOT have the same thing going on as someone who began abusing illicit substances as a coping mechanism. A baby born narcotic dependent is not the same as someone who began experimenting at 10yrs old & eventually found themselves narcotic dependent years later. Yet, the current disease model, from what I can see, would call all of the above “addiction” caused by a disease! The “addiction disease” & all of the above are afflicted.
I just don’t see that it’s that black & white & it certainly can’t all be a disease. From what I’ve seen in over 15yrs of being involved in 12step programs off/on & from my own personal experience of opiate dependence after brain surgery w/ subsequent illicit use to stave off w/D’s, the disease model has no biological basis! It’s main function is to eliminate stigma (which is not working b/c nobody wants to be around a person so brain damaged they can’t control themselves), & the fundamental issues driving abuse & dependence can be so wildly dissimilar that abuse & dependence should really be their own separate issues. There can be abuse w/out dependence, dependence w/out abuse, & both abuse w/ dependence. I just can’t understand how these two very different disorders are rolled into one thing called addiction & disease or in the current DSM, “substance use d/o’s.” From what I’ve seen & experienced, abuse & dependence should be distinct & clarified. We talk about “addiction” as if it’s all one animal & sometimes abuse & deoendence have nothing in common in terms of behavior w/ the only common thread being that a substance is involved. Onbiously they can overlap but i think that is mostly just presumed when discussing “addiction.” I say that’s a false assumption from the start thst shoild be addressed before any meanjngful conversation can be had about anything. They are entirely different behavioral & physiological processes.
It’s abundantly clear that the combination of bio-psycho-social factors contribute to these dysfunctions & also to recovering from (yes, I think one recovers) these dysfunctions! I can’t even count how many times I’ve heard an abuser in remission helplessly proclaim, “I have a disease. I’m helpless over drugs/alcohol.” That’s the opposite of what we should be teaching people! No wonder recovery rates are so poor from 12step models. I feel like the goal in treatment should be to hear someone in a meeting say, “yes, I really exercised poor judgment & made some bad decisions in my life. I take responsibility, admit it & im committed to making better decisions in the future.” I feel then, THEN we will finally be on the right track to a meaningful, sustained road to recovery. When ppl stop making their identity their “disease,” “I’m Jon & I’m an alcoholic,” & are taught that, “no!” “You’re Jon & you suffered from a complex interaction of bio-psycho-social factors,” then we’ll be going in the right direction of change.
Please! I’m truly the black sheep of my program. I’m considering quitting b/c of my views… I’m an educated, independent, critical thinker & this is what I’ve come to when presented w/ all of the evidence on both sides that I can find… please tell me if I’m wrong. I certainly won’t find a discussion like this where I’m at in my own recovery program or educational program. I’m feeling VERY alone out here. If my reasoning is faulty, please!! Say s/th & explain to me in terms of science why it’s faulty. Im just so tired of hearing that it’s their way (instructors), or the highway. Thx!!
My friend recently told me that they are struggling with a pornography addiction and would like to find some help to recover from it. Your information that addictions are a disease that are caused by physical changes in the pleasure-seeking and behavioral centers of the brain is fascinating. With this knowledge, I think I will start helping them look into addiction therapy services because they won’t be able to recover on their own.
I never understood why 12 steppers will go to their graves, swearing it’s a disease, other than one of the main conditions seen in addicts, that is a major roadblock in ones ability to recover, is denial. Which, unbeknownst to the recovered addict, has stuck with them, all throughout their recovery.
Maybe this is the very reason as to the high number of relapses. For the addict, as well as all addiction organizations are treating it as something it is not. You wouldn’t treat depression with chemo.
I always understood it as a chemical imbalance, in the brain. people who’s system didn’t create enough dopamine, are susceptible to addiction, for chemical ingesting would release dopamine,, til the brain felt it no longer had to produce it, so when the chemical was no longer administered, there was no dopamine being produced, causing severe depression. Thus the great number of relapses and inability for the addict to quit.
That to me says it’s a disorder, because a disease is either terminal, or needs medicine, or surgery to recover from it. You can’t strong will and determinate cancer away, but you can, through strong will and determination, along with repetitive exercises and therapy, overcome, let say, a speech disorder.
I always viewed it as an emotional disorder. why you ask? Simple. The majority of addicts developed their addiction in middle and high school, by being offered a substance by their friends. Wanting to fit in and be accepted, when they are at the most vulnerable and insecure time in their lives that they lack self esteem and confidence. They, 9 times out of 10, end up saying yes,, for fear of being judged and ridiculed, thus being treated as a nerd and outcast.
Thus making it an emotional disorder, which can easily be treated, by building the addicts ego and self esteem, with acknowledgement, praise, encouragement, love, small tasks, with which the addict can easily accomplish resulting in reward and gradually increasing tasks, to allow trust to be regained.
if one does relapse, degrading and/or verbally abusing is extremely detrimental to the addicts recovery.
There is nothing negative you can tell or call an addict they haven’t already told or see themselves as.
The best approach is to inform them they are still loved and someone still has faith in them, will not judge and will continue to support them in their recovery.
There is no disease, that I know of, that is created by peer pressure and can be cured with love, understanding and patience.