Over the weekend, I was talking to a physician who didn’t believe that addiction was a disease. It is a frustrating fact of our profession that we need to have this debate over and over again despite the long historical recognition of addiction being a disease. In the United States, Dr. Benjamin Rush, a signer of the Declaration of Independence, was the first to identify the symptoms of alcohol addiction in his publication An Inquiry into the Effects of Ardent Spirits on the Human Body and Mind in 1784 and the American Medical Association recognized alcoholism as an illness in 1956, and addiction as a disease in 1987. In other countries the path to acceptance of addiction as a disease may have been earlier and faster or later and slower, but still most everywhere it is accepted as fact in the medical profession.
What makes something a disease? This is a difficult question and something that is worth asking our students to contemplate. There is no obvious answer. Some things that were once categorized as a disease are now considered part of the normal spectrum of human behavior. In many countries, homosexuality would fall into this category. Other things that were once considered part of the normal range of human experience, for example ADHD or senile dementia, are now categorized as a disease. So there is a social aspect when it comes to how we define what is or is not a disease, particularly when we look at behavioral conditions.
When Alan Leschner’s Science article on Addiction as a Brain Disease was published in 1987, it helped us redefine the nature of the disease and to clarify that compulsive drug seeking regardless of consequence and the craving for a drug in its absence was the distinguishing symptom of the brain disease of addiction. He described the changes in the mesolimbic system of the brain as the indicator and that addiction is a chronic, relapsing condition and ought to be treated as a chronic rather than an acute condition. There is a biological difference in the brains of people with addiction compared to people without it. One area of current research is to understand whether there are identifiable differences in the brain of people who develop addiction compared to those who do not. This is one question of the U.S. National Institute of Health’s Brain Initiative: https://www.braininitiative.nih.gov/.
When we make the argument that addiction is a disease, it is the changes in the function of the mesolimbic system of the brain that we focus on – the biological differences. It will be interesting to know whether they exist before a person begins using a drug or whether they are a result of drug use or, more likely, the effect of various environmental factors have on different people’s brains and their response to various drugs. But will this knowledge finally settle the debate for everyone?
I think there is a moral dilemma at the heart of the debate where it still exists. The moral or perhaps philosophical dilemma revolves around choice and personal responsibility. In the United States, we highly value the concept of individualism and free will. If you are a student of philosophy, you will understand that the debate between determinism and whether or to what extent we have free will is one of the core debates in the study of philosophy. This issue of free will and its requirement of self-control are usually at the heart of any argument I hear against addiction as a disease. They will say “He chose to drink. He chose to use the drug.” “They keep making bad choices over and over.”
I suspect most of our students have not read philosophy these days. But it might be useful to have this perspective when we are debating with people who don’t understand or believe that addiction is a disease rather than an extreme form of the same bad behavior that many people have at times when the drink too much and just a lack of self-control.
We are not alone in this debate. A 2012 study in Finland, there was wide variation in what types of “states” were considered disease states and therefore worthy of payment for treatment by the publically funded medical system. With no clear definition of what constitutes a disease state, with the variation in need for and response to treatment, with our ongoing philosophical debate on the nature of choice and capacity for self-control, this may be an ongoing discussion for some time. One thing our students will need to be able to do when they go into practice is to be able to discuss the disease concept and why addiction is a disease with patients, family members and people in affected communities. A necessary skill is to effectively address these issues starting from the perspective of the patient or family member that absolutely believes that stopping use is simply a question of will.
And it might serve us all to remember that while we might think that a disease is a biological phenomenon, there are really biological, social, and philosophical/moral aspects to defining a condition or state of being as a disease. Many of the people with whom we and our students interact will arrive at a different conclusion given the same facts about the state we call the disease of addiction.
Some sources I used as I considered this blog post and that are open and may be useful to you if you choose to have a debate or discussion with your students:
Scully, J. L. (2004). What is a disease?: Disease, disability and their definitions. EMBO reports, 5(7), 650-653. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1299105/
Leshner, A. I. (1997). Addiction is a brain disease, and it matters. Science, 278(5335), 45-47.
Hume on Free Will. Stanford Dictionary of Philosophy https://plato.stanford.edu/entries/hume-freewill/
Tikkinen, K. A., Leinonen, J. S., Guyatt, G. H., Ebrahim, S., & Järvinen, T. L. (2012). What is a disease? Perspectives of the public, health professionals and legislators. BMJ open, 2(6), e001632. https://bmjopen.bmj.com/content/bmjopen/2/6/e001632.full.pdf