The Disease Model of Addiction: A Polemic

I'm going to take this opportunity to express an opinion that, while not inappropriate, really can't be expressed in a professional context.

See, the most popular approach to conceptualizing addiction is the disease model. And I start off by saying that I respect this concept. It is a good thing.

Why? Because it lends the proper perspective to it all. It's a viewfinder through which one can properly see the scope of what lies before them.

If a family system is no longer able to function, the fact that they rail against the "disease" that's doing this to them is useful. They understand it, and it doesn't presuppose that addiction is wholly a moral failure. It nods to the biology at work.

It's the model supposedly embraced by AA, a widely-respected organization. Substance Abuse Counseling (Lewis, Dana, & Blevins) writes, "The disease model was first conceptualized by Jellinek (1960)."

But the "Doctor's Opinion" portion of the preface to the first edition of the AA "Big Book," published in 1939, states:

It did not satisfy us to be told that we could not control our drinking just because we were maladjusted to life, that we were in full flight from reality, or were outright mental defectives. These things were true to some extent, in fact, to a considerable extent with some of us. But we are sure that our bodies were sickened as well. In our belief, any picture of the alcoholic which leaves out this physical factor is incomplete."

It seems that AA, by soliciting the opinion of medical experts who espoused a disease model, chose to abandon the facets of addiction that they had originally accepted. They appeared to be pushing for a disease model decades prior to Jellinek.

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Some of the tenets of the disease model:

*Alcohol- and drug-dependent people have physical cravings that can be irresistible.

*They lose control over drinking and drug use.

*The condition is progressive and irreversible.

"Many adherents of the disease concept view all slips as relapses, and a client's slip is thought to obviate prior success." (Lewis, et al). That is, a person who has been sober for a period of time has to "start over" if he or she ever drinks or uses again. The prior clean time has, in accordance with the model's "all or nothing" assumptions, been in vain.

The disease model also does not account for the phenomenon of spontaneous recovery. Sometimes addicts quit successfully, with no particular intervention or medical assistance. I would venture to say that there is little in a progressive disease that is analogous to this behavior.

And sometimes addiction does not progress like a disease. Substance use/abuse occurs on a continuum, with non-problematic users at one far end and problematic, physically dependent users at the other. Many people who abuse alcohol do not worsen to the point of their demise.

(Nor do they improve to the point of complete sobriety)

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I am a proponent of the biopsychosocial model. Let's break this down:

BIO, as in biological, refers to elements of addiction found in the disease model. It can be a deep physical need. Withdrawal from alcohol, for example, is potentially lethal, as it can cause grand mal seizures.

There is a genetic component. A child with an addict parent has a 50% chance of becoming an addict herself.

[Question: How would you, as a parent, react if a genetic test could tell you that the child you have conceived carries an addictive gene?]

The need for drugs or alcohol can become hard-wired into the brain. We all share some basic brain parts with other, simpler creatures. Our primitive or "lizard" brain structures are the ones that control basic things like regulation of heartbeat and respiration, fight or flight (and other) instincts, all that. So if a person has spent years dealing with anger, which is considered to be an offshoot of the basic emotion fear, by drinking, the need for this chemical becomes imperative. Those old brain areas, which typically would be flooded with endogenous (neuro)chemicals during such times of stress, become trained to expect the foreign chemical as well.

The brain is essentially screaming for alcohol.

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PSYCHO is psychological. There is no magic here. This is when the substance is used as a response to some emotional stimulus. Use is a coping mechanism. The person who dealt with anger by drinking was initially drinking for psychological reasons. Only by pounding the brain with this chemical repeatedly does the biological need develop.

Typically, the brain will have some means for responding to anxiety or fear or other emotions. The unpleasant nature of the response, such as tremors, is sometimes coped with through substance use. How many of our heroes of old war films dealt with a troubled conscience with marijuana or bourbon?

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SOCIAL is the point at which others' behaviors can affect what happens to the addict.

If someone has cancer that is in remission, their health is not jeopardized by socializing with someone who has active cancer. The same cannot be said to be true for addicts. An addict in recovery can relapse simply as a result of socializing with people who use.

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For years, addicts were thought to be morally deficient people who could be saved if they would simply acknowledge and change their sinful ways. Well, in reality no matter what they acknowledge, addicts can't just stop. That is addiction--the inability to stop, no matter what. Addicts know every consequence of their addiction: lost jobs, screwed-up relationships, squandered money, betrayed relatives, and so on. But they can't help their behavior. Dr. Drew Pinsky, Cracked.

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In substance abuse treatment centers, patients are currently given dual diagnoses. The idea is that addiction does not occur in a vacuum; it is comorbid with emotional disorders. The patient is perhaps disagnosed with opioid dependence and depression, for example.

There are over 100 pages devoted to substance abuse disorders in the Diagnostic and Statistical Manual IV. Surely in the coming years and decades we will look back on even this time as somehow missing the mark regarding addiction. I do believe, however, that whatever we uncover in our quest, we will be better served if we can find some way to more accurately conceptualize addiction.