Addiction Masterclass: Is Addiction Really a Disease?

For a very long time, addiction or alcoholism was viewed as a moral failing. Here was an activity people were partaking in willingly. It was a choice they were making to seek these pleasure seeking activities. And therefore, it's a moral, a behavioral issue and not one of physical and mental. For a very long time, addiction was viewed as a moral failing. Meaning this was an activity people chose to take. Pardon? They were making an active choice to do activities that were pleasure seeking. Right.

That were maybe viewed as sinful. However, this idea of addiction actually being a disease of mind and body is not all that new. We could date it back at the very least to the founding of America. One of the founding fathers, Doctor Benjamin Rush, had this opinion that alcoholism was, in fact, a disease. But if we're going to get into this debate whether addiction is a disease, first we have to agree on what a disease is and essentially define it. Now, it's not actually a very specific or really hard criteria to meet.

Essentially, a disease is a defect in an organ that causes symptoms. That is it. So a lot of things by that criteria would meet the qualifications for a a disease. But does addiction, does alcoholism, do behavioral addictions meet that criteria? Now, it's not all that clear, so let's break down some of the arguments for it and against it. In a documentary called Pleasure Unwoven, doctor Kevin McAuley examined a question that plagued him as a physician and newly recovered alcoholic. And that's whether addiction is truly, scientifically a disease.

And what doctor McAuley pointed out is that, in his mind, the best argument for addiction not being a disease is that it is one of the only diseases you can choose not to have. Meaning you don't have to take a drink. No one is forcing you to take a drink. Unlike other things like cancer, you can't choose not to have it or have symptoms or something like diabetes. So he gives us example of imagine someone who is struggling with an alcohol addiction. They're at a bar. Someone comes to the bar, puts a drink on the table, and says, here you go.

However, if you take this drink, I will shoot you right here, right now. Now, that individual would probably choose not to drink, therefore, well, doesn't that mean they always have a choice? Now, I recommend you watch this documentary, and I'm kind of spoiling most of it for you, but there's a lot of good information in there. He says that it is, in fact, a disease, because even though there is this element of choice, the individual at that bar craving that drink cannot help having that severe craving that even though that guy may have a gun to his head, he may be sitting there contemplating, well, is this guy serious?

Should I just take it anyways? Right? The problem, the malfunction in the brain, is within that reward system that you become so compelled to take that drink or use that drug, despite all evidence saying that this is horrible for your life and that it may actually kill you. You can even date some of these ideas back to the founding of a program like Alcoholics Anonymous that based some of their understanding of alcoholism on a prominent doctor whose medical opinion, after working with thousands of alcoholics in an asylum setting, said that what he noticed about severe alcoholics is that they had a craving that was beyond their control.

That's what separated these severe alcoholics from ones that were maybe just problem drinkers or someone who doesn't have an issue with alcohol whatsoever. He called this the phenomenon of craving. Now, again, this idea that addiction is a disease was hard fought and won by medical professionals and by advocates. Basically, what they're saying is this needs to be taken seriously as a medical condition, that this is not a moral failing, that we don't just castigate these individuals based on the fact that it's their choice.

However, there are some prominent voices that push back on this idea, the pendulum starting to swing the other way. However, they're not doing it from a place of saying, well, no, it is a choice. It is a moral failing, but they're trying to frame it more. Like alcoholism, drug addiction is a tool to solve a problem that maybe it's not a disease, it's just a rational response for, let's say, individuals who are experiencing childhood trauma or PTSD, that maybe this isn't best to look at it from an addiction standpoint, but more of an adaptive coping mechanism.

Now, these ideas are promoted by some very serious and respected people, like Doctor Gabor mate, who studied the intersection between trauma, PTSD and addiction, and the connection that really binds those two things. Now, the question is, well, what do I think? Is it really a disease? Is it just a maladaptive coping response? Could it be both? Well, as I've been sharing throughout this series, I believe that people find their way to addiction in many different pathways, whether it is genetic or whether it is trauma based.

So does it really make sense to have this overarching umbrella for what an addiction is? And again, there's a fine line between what is addiction and what is an addiction. It's all on a spectrum. So I don't think it always makes sense to want to just label it one thing or another. Not everything is black and white. Things usually lie within the gray. For example, substance dependence or a more severe use disorder looks very much like a disease. It creates a ton of symptoms that are ongoing. I find that when people have more of a dependence or a severe use disorder, it looks very much like a disease.

There is a defect in the organ, in the brain, in the reward system, that is creating a ton of consequences. Those consequences are ongoing. They seem to be out of control of the individual who is suffering from them. The disease is chronically relapsing. It's also progressive. The disease tends to get worse over time if it is not treated. This very much looks like a disease on every front. And that's why I think it makes sense that a lot of addiction is viewed as a disease. Now, when it comes to people who arrive at my office who are maybe in the more abuse stages, more problem drinking, mild use disorder, it looks very different because many of us, at some point in time, even if we're not addicts or alcoholics, we may have had a phase where we're drinking a little too much that we were having consequences.

It's not always difficult to meet the criteria for a use disorder. If we went through a problematic stage in college or after a breakup, it's likely our use may have had consequences that were ongoing for more than a month and more than two symptoms. Therefore, I could say, well, you have a use disorder, even though it's mild. Addiction is a disease. Therefore, you have a chronically relapsing disease. To me, that doesn't make all that much sense. Now, is it really important that we differentiate these types of abuse and dependence in different ways?

An addiction shows up? Well, I think it does. The reason it's important we have a basic understanding of these categories is in the end, we need to make a certain recommendation. As a clinician, if someone's coming to my office, I need to have a general idea what pattern they are struggling with when it comes to their addiction. Is it more abuse? Is it more long term dependence? Because I need to make a recommendation for what treatments are most appropriate. And for someone who's struggling with abuse, saying, hey, you should go to inpatient treatment and go to Alcoholics Anonymous, the rest of your life, may actually be counterproductive.

So it's not just all one disease, however, individuals who are more severe, I may make that recommendation for. It makes more sense if it's a chronically relapsing progressive illness, to take more precaution to make sure that treatment is matching the severity of the issue that they're going through.