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The disease concept of addiction revisited

June 15, 2010
by Richard S. Sandor, MD
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In the face of recent questioning, the disease model holds up to rigorous analysis

Despite the fact that The Disease Concept of Alcoholism by E.M. Jellinek was published 50 years ago, and although the idea that addiction is a disease is now widely accepted, it remains poorly understood. The latest contribution to the confusion is a book published last June called Addiction: A Disorder of Choice by Gene M. Heyman of Harvard University. It’s an ironic recapitulation of history—20 years earlier, Herbert Fingarette of the University of California advanced essentially the same argument in his book Heavy Drinking: The Myth of Alcoholism as a Disease. Both men based their conclusions on epidemiologic studies and surveys. Fingarette, a philosopher, argued solely from his reading of the scientific literature. Heyman, an academic psychologist, based his conclusions on epidemiologic surveys and laboratory research on the psychology of choice. It seems that neither writer spent much time in the clinical trenches, actually listening to alcoholics and drug addicts describe their lives.

It seems a fitting moment to re-examine the disease concept of alcoholism and other addictions.

To start, scientific data can no more “prove” that addiction is a disease than it can “prove” that the sky is blue. Either we all agree that the color of the sky is sufficiently like everything else we call “blue,” or we agree to call it something else. In the same way, asserting that addiction is a disease cannot be proven by scientific data. A disease concept is really a theory of addiction—a way of showing that addiction is like all the other things we generally accept as diseases.

Although it may sound strange, when we say that alcoholism or drug addiction is a disease, we are not talking about the behavior of drinking or using. Behavior might signify the presence of a disease, but behavior itself cannot be a disease. A disease isn’t something you do (voluntarily or otherwise); it’s something you have. The common sense inherent in our language reflects this same idea. We don’t speak of someone “high blood pressure-ing” or “pneumonia-ing.” We say a person has high blood pressure or has pneumonia. This is true for all diseases. The behavior we call a “seizure,” for example, might indicate an infection, a hemorrhage or a tumor in the brain. The seizure is the sign of a disease, not the disease itself.

If the behavior of drinking or using drugs is only the sign of addiction, then it is no surprise that measuring drinking or using behavior brings no uniform picture of the disorder. In virtually all illnesses, especially early in their course, signs and symptoms are remarkably variable. Just as fevers may be high or low, pain severe or mild, alcoholic drinking or addictive drug use may be heavy or light, intermittent or continuous, boisterous or quiet—all depending on biological, social and psychological factors influencing the individual with the disorder.

So if by calling addiction a disease we mean that sometimes drinking or using is a sign of something else, a result of something a person has, then we need to be clear about what that something is. Without a simple conception of what an addiction is (on par, for example, with what an infection is), we have no strong argument for the disease concept of addiction.

The experience of ‘powerlessness’
Part of the difficulty in establishing the disease concept of addiction is that the essence of the condition is known to us primarily through the reported experience of the person who has it. Although advances in brain imaging have begun to show us the disordered biochemistry underlying addiction, diagnosis is still based mostly on what patients tell us about their experience. As a result, the data are largely subjective and can be quantified “objectively” only indirectly. That’s why it is so important to listen carefully to the stories of alcoholics and addicts themselves—to hear what they say about what’s going on inside them. When we do that, we learn that they describe their experience as “powerlessness.”

But the idea of powerlessness is paradoxical. After all, many alcoholics and addicts do quit drinking and using for good. What happened to powerlessness, then? Choosing, “one day at a time,” not to drink or use sounds like having power, not like having lost it.

More than 100 years ago, in describing his own struggles with tobacco, Mark Twain gave us the solution to this puzzle when he said: “To cease smoking is the easiest thing I ever did. I ought to know because I’ve done it a thousand times.” Twain put his finger directly on the essential experience of addiction—when it is fully developed, it is an all-or-nothing experience. Although addictive behavior is remarkably varied, in the end virtually all addicts discover that abstinence is the only reliable foundation for recovery. “Quitting,” it turns out, is hard, but it isn’t the major problem. The bigger problem, brilliantly expressed in AA, is “staying quit—not starting again.

Like many other illnesses, addictions progress. The beginning is marked by the struggle for control (“never before 5 p.m.,” “only on weekends,” and so on). But as time goes on, control becomes increasingly difficult to achieve. Eventually, it is attained only by quitting. Indeed, episodes of quitting and relapsing are almost an unmistakable indication of the diagnosis of addiction (as opposed to mere abuse or misuse). At this stage, if people begin again, they spend increasing amounts of time and effort trying to maintain “control,” but in the end it is lost. This is what AA’s founders described as having become “powerless” over alcohol—not just for a particular episode of drinking, but repeatedly and inevitably for all drinking. In the end, all addicts discover that there is just no such thing as one.