A few months ago, I was having lunch with a most respected client in the treatment space who came right out and said the following: “Addiction, for the most part, is not a disease. It was a labeled a ‘disease’ so that insurance would pay for its ‘treatment’.”
I was shocked.
Here I am, a person advocating for the rights of people to be protected from discrimination for having the “disability” of having the “disease” of addiction/alcoholism, and here I am confronted with a thought leader in the treatment industry telling me that the modern evolution of drug addiction treatment is a joke.
But the more he talked, the more convinced I became.
Not that he was right, but that our 20+ year assumption that “addicts” have a “disorder” was too broad of a brush to paint the landscape with.
For every person who simply cannot have just one drink, there are others who use substances to simply escape their day-to-day reality, and who might otherwise meet the federal ADA definition of being “disabled,” but for which prior generations may have stuck the person into boot camp to get their personality in check.
Tough love, or empathy? Is there a one-sized fits all approach that we can apply to this?
On this point, David Schimke of The Chronicle of Higher Education wrote yesterday, a longstanding argument over whether or not addiction is a disease prevents researchers from identifying effective treatment strategies. The “disease model” remains dominant among medical researchers as well as in the treatment community. But it is not universally embraced, and some researchers think it gets in the way of fresh ideas about how to help people.
Today, as the nation’s opiate epidemic makes headlines and policy makers grapple with the question of whether to legalize marijuana, academics from a variety of disciplines are trying to understand addiction and find successful treatments. Meanwhile, a 2013 survey conducted by the National Institute on Drug Abuse indicated that an estimated 22.7 million Americans needed treatment for problems related to drugs or alcohol. The institute also determined that the “total overall costs of substance abuse in the United States, including productivity and health- and crime-related costs, exceed $600 billion annually.”
But even as new insights emerge from both the physical and social sciences, we are still not spending nearly enough federal research dollars to make a dent.
“We don’t have very good science yet,” says Sheigla Murphy, a medical sociologist and director of the Center for Substance Abuse Studies at the Institute for Scientific Analysis, in San Francisco, “and a lot of that has to do with issues of conceptualization and politics.”
The lack of consensus was palpable at a conference on addiction last October at Gustavus Adolphus College, in St. Peter, Minn. There, 11 panelists from various academic disciplines — including neuroscience, psychology, philosophy, physiology, and sociology — spoke to a crowd of 2,500 students, educators, concerned citizens, and health-care professionals.
Researchers and treatment providers “don’t come together as often as you might think,” said Peg O’Connor, chair of the conference and a philosophy professor at Gustavus Adolphus. But those who came to the two-day event looking for innovative, multidisciplinary solutions to a growing crisis probably went home wanting. Before the first morning session was over, it was clear that the accepted wisdom regarding substance abuse and the brain is still largely a matter of debate.
Rhetorical fireworks went off immediately after the conference’s inaugural presentation, given by the Nobel Prize-winning neuropsychiatrist Eric Kandel. A professor at Columbia University and director of its Kavli Institute for Brain Science, Kandel described his research on memory disorders, mental illness, and addiction, including studies on mice that show nicotine use can lead to cocaine abuse. Marc Lewis, a neuroscientist and professor of developmental psychology at Radboud University, in the Netherlands, kicked off the day’s first round table by challenging Kandel’s implicit contention that addiction is a disease.
Lewis’s argument, outlined in his 2015 book, The Biology of Desire: Why Addiction is Not a Disease, is that dependence on substances and other behavioral patterns are learned via the “neural circuitry of desire,” and do not result in permanent, irreversible changes to the brain.
Kandel countered that neural imaging shows definitively that addiction causes physical changes in the brain, and that because of those changes, a certain percentage of people simply can’t stop their self-destructive behavior. Just because social factors contribute to the condition and can help mitigate its symptoms — as is true with depression and schizophrenia — doesn’t mean addiction isn’t a disease.
When Lewis pushed back, arguing that the brain changes all the time, Kandel became exasperated. “I think we need a course in biology before we go any further, to be honest with you,” he said.
Their quarrel over terminology picked up again during the second panel discussion, with a back-and-forth over whether or not hard, epidemiological evidence should be filtered through more subjective data on individual experience and difference. “Of course [those things] matter, because we tackle different problems,” Kandel snapped. “But ultimately I should be able to replicate your findings and you should be able to replicate my findings, otherwise it’s not science, it’s bullshit.”
The panelists at the conference expressed a range of opinions about the disease model. Though their views did not break down entirely along disciplinary lines, the social scientists tended to be the most wary of the label. On the one hand, nearly everyone ceded, it’s an established fact that addiction alters dopamine receptors in the brain and can affect how the limbic system functions. There’s also compelling research that some drugs, such as naltrexone for opiate abusers, can help curb certain cravings, which suggests that dependence is at root a biological phenomenon.
The disagreement over terms is rooted in the 1930s and 40s, when AA came of age and provided a life raft for chronic alcoholics, many of whom had been doomed to suffer crippling isolation, institutionalization, and early death. By positing that alcoholics are powerless against their affliction, suffering from an “allergy of the body and obsession of the mind,” the authors of AA’s Big Book, first published in 1939, helped reduce the stigma of addiction. And since no reliable medical protocol was available to provide long-term relief, the group’s charter members encouraged fellow alcoholics to abstain completely, create a fellowship, and help each other work through 12 steps, which promised a cleansing spiritual experience.
The program was far from perfect, but it did provide relief for many of those silently suffering and saved jobs, families, and lives. In the 75 years since, the 12 steps, in one form or another, have endured as a go-to for treating not just alcoholism but also narcotics dependence, compulsive gambling, and sex addiction. Seven out of 10 drug-treatment facilities rely on the model. And chances are good that if a general practitioner encounters a patient with substance-abuse issues that don’t require inpatient treatment, he’ll recommend a 12-step meeting.
One of the earliest and most compelling critics of AA is Stanton Peele, a psychologist and writer who has been challenging its disease-based model since the mid-70s, when the organization was still an emerging cultural force. Peele argues that AA’s methodology, steeped in spiritual rhetoric, is unscientific, predicated on the notion that only by acknowledging their “powerlessness” over alcohol and accepting a “higher power” can an addict find salvation. He’s also quick to point out, along with other critics of the 12-step model, that traditional treatment programs, which generally rely on it, have a depressingly low success rate.
Peele believes that instead of adapting the disempowering language of disease (which he says is itself stigmatizing), addicts should embrace their failings and pursue mindfulness techniques, not to find a cure but to ease anxiety and consider how their history, environmental influences, and personal relationships inform their habits, good and bad.
Michael V. Pantalon, a senior research scientist at the Yale School of Medicine and co-founder of the Center for Progressive Recovery, is agnostic regarding the use of the word “disease.” He does agree, though, that a one-size-fits-all approach to addiction is not necessary or effective, and points out that a number of scientifically proven approaches already exist that can be applied separately or in some combination, including cognitive behavioral therapy, motivational enhancement therapy, and medications. His frustration is that not enough people on the front lines of treatment are offering these alternatives to the AA approach.
One reason the “disease model” remains dominant is that the National Institutes of Health — as well as the American Medical Association and the American Society of Addiction Medicine — believe that the use of the term is scientifically accurate and still helps eliminate stigma. Nora Volkow, director of the National Institute on Drug Abuse (which is part of NIH), frequently evangelizes about the subject, drawing evidence from brain scans. Those show, she has argued on The Huffington Post, “physical changes in areas of the brain that are critical to judgment, decision making, learning and memory, and behavior control.”
William Cope Moyers, vice president of public affairs and community relations at the Hazelden Betty Ford Foundation (which uses the 12-step model) and author of Broken: My Story of Addiction and Redemption, (Penguin, 2006) says he has begun avoiding the term “disease” in his work “because it’s a term that either a lot of people can’t understand or disagree with.” But in the early 2000s, he says, he used to use the term “all the time.” “When I was lobbying for parity in Congress, for example, I always used ‘disease’ because I thought that was the most effective term to describe how an insurance company discriminated against people with addiction,” Moyers explains.
That institutional bias is, in large part, what upsets many social scientists. They’re concerned that precious federal funds are too often pushed toward studies and programming steeped in status-quo assumptions, instead of challenging longstanding treatment paradigms and biases. “The definition of addiction as a disease, endorsed by the medical and scientific communities and most Western governments, may be the most powerful tool for the rehab industry,” Lewis argues in The Biology of Desire.
All of which makes it ironic that in the coming years, a comprehensive $300-million study funded by the NIH, and championed by Nora Volkow, may offer the best hope for eventually resolving the disease debate, one way or the other.
A significant barrier to broader consensus regarding the disease model is a lack of definitive data. Research on chemical dependence is often very narrow in scope and relies on small, unrepresentative samples. The best evidence that addiction is a disease is based on brain imaging of chronic addicts either while they’re using or shortly after. What’s not known is whether or not there are ways to accurately predict if a person with addictive tendencies is about to cross the line from a bad habit to a disease. “Is there a biomarker that tells you that you have a disease? No. Is there a definitive set of circumstances? No,” says Hugh Garavan, a professor of psychiatry at the University of Vermont. “There’s no biological test for it. We don’t have a single medical test.”