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The disease/non-disease debate obscures the reality

August 22, 2016
by Roland Reeves, MD
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Growing up with a deficiency of vitamin D can lead to growth deficiency and malformed bones, a disease called rickets. The fact that this disease would be avoided by a healthy diet does not make it less of a disease. Growing up with an addicted mother, leading to a deficient endorphin release and its resulting dopamine deficit, often leads to a disease called addiction. Whether it is derived from vitamin D or a biologically required attachment, a deficiency of a biological substrate leads to a disease state. Our body's physiologic and behavioral attempts at achieving allostasis, normalcy, can lead to other symptoms and syndromes. These are usually called diseases.

I see with increasing frequency books, blogs and partisans saying in bold print or loud voices that “addiction is not a disease!” Passion dramatizes these declarations with a fervor seen in political debates. These pronouncements of the non-disease status of addiction seek to “set the record straight.” They imply that those who call addiction a disease are bringing great harm to those with addiction. Those supporting non-disease status explain that choice, not helplessness, is present, suggesting that if there is a personal choice it is not a disease. Addiction as a disease would confer catatonic automation to addiction, which they say is clearly not present. This idea just deflects personal responsibility and research dollars, they suggest.

On the other hand, many people who are just as passionate in support of the disease model have become biological reductionists, seeking the next pharmacologic cure. (Personally, I can't wait for that one pill that will give meaning to life. I wonder what two of them will do?) As with most issues that stake out ends of a spectrum, the truth includes both sides.

The disease vs. non-disease argument misses the point. It is like the global warming debate, where the respective sides have chosen facts supporting their side while delusional about the rest. A debate is a good thing. It facilitates learning, as long as it remains a debate and not an argument between two close-minded poles. Zealous polarity diverts attention from the real issues of preventing, diagnosing and treating addiction. “Non-disease” implies a treatment philosophy and actions along a certain pathway, just as “disease” does. These respective paths are both incomplete, though, and neither best serves recovery distinct from the other.

Addiction easily meets all criteria of a medical dictionary definition of disease:

1. An interruption, cessation, or disorder of a body, system, or organ structure or function. See also: syndrome. Synonym(s): illness, morbus, sickness.

2. A morbid entity ordinarily characterized by two or more of the following criteria: recognized etiological agent(s), identifiable group of signs and symptoms, or consistent anatomic alterations. Also, generally not caused by a physical injury. Genetic or environmental factors may bestow susceptibility.

Concerning the first definition, there is a definite change in structure and function of the brain, including altered receptor expression, altered neurotransmitter levels, increased cortisol (stress), diminished prefrontal cortex integration, and many other objective findings.

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As long as the goal is long term abstinence and quality of life what difference does it make.?
I believe that AA refers to an allergy. SMART does not take a position. They both support abstinence.

I do not believe that anyone with a modicum of knowledge of the issue of addiction would argue that a person is closer to true health as we are designed to be if abstinent from addictive substances. The problem is the argument between "either/or" concerning abstinence. Just as the disease is found expressed along a spectrum, so should treatment and recovery. If there is a diabetic that has had an amputation or is on dialysis because of mismanagement of their glucose, and they continue to eat ice cream after dinner, I have seen that patient discharged in frustration with a frustrated provider pining "I can't help them if they won't do what I ask them to do!" Perhaps the provider could manage as best as possible with that specific patient, continuing to show compassion. On the other hand, they should never stop gently nudging the patient toward better glucose control. This may never be reached, but they are better than they were. In my own practice and I must guard against allowing my own values and hopes for a patient end our relationship. My struggle is not allowing this relationship become an enabling one when destructive behaviors are present. I struggle with the solution many times, but I want to err on the side of compassion. So it should be with addiction treatment. Some will become abstinent and have an amazing life as they were intended. Some simply will not be able to achieve that, but they are better off than they were. It could be a deadly mistake to discharge that person as a patient because the best they can do is not good enough for me.
Roland Reeves, MD

Make no mistake. I am a strong advocate for abstinence in my practice and treatment center. Anything less is a compromise and less successful. My struggle is how to reconcile my definition of success (AA, abstinence, amazing life on a spiritual basis) and the different reality some patients continue to present to me. I will never stop advocating the former. I am reluctantly learning how to manage the latter. Without judgement I hope. Compromise in any situation only works if you accept progress toward your goal along with reality, and an intent to keep working.
Roland Reeves, MD

I was a little loose with my initial reply. I firmly believe that we treat a chronic, progressive, and possibly terminal disease. Abstinence is the goal of everything we do.
I'm a believer that addiction is a disease that needs lifespan recovery management. If harm reduction can refer to a person who has been in remission for several years, whose disease became active for a brief period of time, followed a return to remission, I can live with that. I don't even think that person needs another white chip. The person never left recovery.
I don't believe that person needs to endure the shame of starting all over again or the connotation of "relapse."
Too much of what we do is either/or. Michael Weiner, Ph.D., MCAP

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Roland Reeves MD

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Roland Reeves MD

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Dr. Roland Reeves, MD, is the Medical Director of Destin...