*I can’t believe I actually have to write this but* Is addiction a disease?

Yes. Now we can all stop reading. Thanks very much, please read again.

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OK fine I will go into more detail, but seriously? Why is this even a question?

The definition of a disease according to Wikipedia: “A disease is a particular abnormal condition that negatively affects the structure or function of part or all of an organism, and that is not due to any external injury” well yep, I’d say that covers addiction wouldn’t you? Wikipedia goes on “In humans, disease is often used more broadly to refer to any condition that causes pain, dysfunction, distress, social problems, or death to the person afflicted, or similar problems for those in contact with the person”, wow it’s almost as if the person who wrote this broader definition did so with addiction in mind!

Still doubtful? OK what does the National Institute of Health say? “Recent scientific advances have revolutionised our understanding of addiction as a chronic, relapsing disease and not a moral failure”. That really gets to the crux of it, don’t you think? Because what people are really saying, when they say that addiction is not a disease, is that it is a choice, a moral failing. They see it as the individual’s choice to pick up a drug or a drink, that they could stop at any time if they wanted to. OK so let’s unpack that a little. Is addiction really a choice? Luckily, my research speaks directly to this question.

It is well established, and without dispute, that addiction is accompanied by particular chances in the brain. Some of these I have talked about on this blog already: the alteration in phasic dopaminergic firing from responding to the drug itself to the stimuli that predict it, and the long-term plastic changes in glutamatergic receptors in the nucleus accumbens to name but two examples. There are many more.

However, it is also true that all learning and memory changes the brain, and some have used this as their reasoning to say that addiction is not a disease after all. In particular, that other ‘neuroscientist in recovery’ Marc Lewis is a strong proponent of the idea that addiction is a memory disorder that is formed by repeated experience. I don’t dispute this, but I would argue that it does not mean that it is not a disease.

*Sciencey bit*

In addition to the changes I have already described on this blog, there are alterations in the striatal “action-selection” centres of the brain during addiction. To be specific, there are two parts of our dorsal striatum that control action selection the middle ‘caudate’ and the more lateral ‘putamen’. When we are in control of our actions, or our actions are voluntary and conscious, there’s a lot of evidence from animal studies, neuroimaging studies in humans, and more, that it is the caudate that regulates action selection.

Huntingtons

On the other hand, when actions are repeated over and over, in the presence of the same stimuli, they no longer become consciously controlled, but are instead involuntary, automatic, and habitual. At this point action control is transferred to the putamen.

*End science bit*

There are a number of consequences of this switch in control from what we call ‘goal-directed’ to ‘habitual’ processes. One of the main ones is that actions will be elicited in the presence of particular stimuli much faster than they would if they were voluntary, and under normal circumstances this is efficient. For example, right now I am touch-typing this blog post without any thought as to where the letter ‘A’ actually is, and if I start to try and think about where the letters are, it slows me down. This habit is adaptive.

However, in the case of addiction, habits can be maladaptive. This is because another consequence of action selection becoming habitual is the fact that, once habitual, the ‘goal’ or the ‘outcome’ of the action itself becomes somewhat irrelevant to whether the action will be produced or not. So when you hear someone say that they went to X place and ended up drinking/drugging, without even really knowing why or how they ended up there, chances are that it was a simple reflex, a habitual response elicited in the presence of particular stimuli without any thought for the consequences. This often happens outside of addiction too: when we automatically take a wrong turn because we are so used to turning left at a particular intersection, for example. At these moments, it is our putamen and not our caudate that is in control.

There is lots and lots of evidence that, in addiction, goal-directed control is impaired. What this means is that addicts have less voluntary control over their actions, and are more reliant on habits. When those habits are tuned towards drinking and taking drugs, well you can imagine the consequences: more drinking/drug-taking. So no, sorry, addiction is not a choice. Absolutely not.

The other thing I’d like to point out, is there are plenty of brain disorders that involve an interaction between a genetic predisposition to a particular disorder and environmental circumstances, that no-one would question the nature of whether they are legitimately a ‘disease’ or ‘disorder’. Individuals with a genetic predisposition to schizophrenia, for example, who smoke a lot of weed in adolescence, might end up schizophrenic. If either of those components had been missing: the predisposition OR the smoking weed, the individual might not develop schizophrenia. Does that mean schizophrenia is not a disease? Of course not! To take a different disease: there is evidence that individuals who do not look after their health generally, do not exercise, and do not perform cognitively demanding tasks are at more risk of Alzheimer’s. So again, there is often an interaction between a genetic predisposition and environment for an individual to end up with Alzheimer’s. Do we then say it’s not a disease because there’s often (although not always) an environmental component? Of course not.

The truth is, addiction is just like these disorders in the sense that individuals who have a genetic predisposition to addiction who are exposed to alcohol or drugs will often become addicts. Again, if either of these elements are missing: the exposure or the predisposition, an individual will not become addicted. Indeed, most people who drink alcohol do not have a genetic predisposition, and therefore do not become problem drinkers. Yet they still make the same choices addicts do initially: to have a couple of drinks. No-one sets out to become an addict. Therefore, to characterise addiction as a disorder of low will-power is simply ludicrous.

To those who prefer not call addiction a disease because they find it empowering and believe that it gives them a choice not to drink in recovery, that’s fine by me. Do whatever you need to do for your recovery. But I choose to exercise a lot, partly because I know it is neuroprotective against Alzheimer’s -that’s my choice, but it doesn’t mean Alzheimer’s is not a disease.

Having said all of that however, whether you call addiction a disease or not, the really, really important thing to remember is that addiction is not a moral failing, it is not a choice, and most importantly of all: you can make choices every day that will help you recover.

5 thoughts on “*I can’t believe I actually have to write this but* Is addiction a disease?

  1. Have you read Marc Lewis? Its not helpful to call it a disease. Hes kinda given up the whole issue as far as what we call it in the US anymore because at the end of the day treatment is s l o w l y changing for the better. I think your articles help people recognize that their are varying ways to get better-and that’s awesome! That aside: Harm reduction-developmental disorder- Clearly the way to go-although i wish we could all agree addiction is obviously more complicated than any one model at this point!

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    1. Yes I have read his books, listened to podcasts with him. I don’t disagree with a lot of what he says, but we disagree on this issue. I specifically respond to his ideas in the blog post. Just to be clear: his opinions are outside of those of most scientists, and that’s fine! He’s allowed to have his opinion, as I’m allowed to have mine. But I disagree with his basic premise: just because learning and memory change the brain, as does addiction, does not mean it is not a disease, and I explore this in the post above. Obviously ideas are very polarised on this issue. Just because it’s a disease does not mean we don’t have a choice about how to overcome it. If you have cancer you can choose to have surgery but it’s still a disease. If you have the disease of addiction you can choose to stop drinking/drugging/whatever. It’s not easy, your conscious, goal-directed desires (caudate) will be forced to try and inhibit very strong, very ingrained habits (putamen) and urges (OFC) and so on, but it can be done. Honestly, call it a disease, don’t call it a disease, it’s really up to you. What is important is a) that it is not an addict’s fault nor is it a moral failing, and b) That it can be overcome (but it may take more than sheer willpower).

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  2. Huh. OK. That’s where we are and that’s where we will stay. Addiction-The only disease where can you pay people not to use? i.e. contingency management. I guess in the same capacity you don’t get it-I just don’t get it. I feel grateful that I don’t. Continuing to call it a disease just keeps so many folks from getting help because of that label. But-Hey- as long as some us know what it is. That’s so great.

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