Likelihood of Success

Ron Coleman’s pretty good blog

Addiction, disease and choice

Posted by Ron Coleman on July 25, 2007

Sally Satel, a psychiatrist, and Scott Lilienfeld, a psychologist, writing in Slate, push back on the politically-correct concept of addiction as a kind of mental boo-boo. Long quote here:

A new bill sponsored by Sen. Joe Biden, D-Del., would change the name of the National Institute on Drug Abuse to the National Institute on Diseases of Addiction and change the name of the National Institute on Alcohol Abuse and Alcoholism to the National Institute on Alcohol Disorders and Health. Called the Recognizing Addiction As a Disease Act of 2007, it explains, “The pejorative term ‘abuse’ used in connection with diseases of addiction has the adverse effect of increasing social stigma and personal shame, both of which are so often barriers to an individual’s decision to seek treatment.” Addiction should be known as a brain disease, the bill proclaims, “because drugs change the brain’s structure and manner in which it functions. These brain changes can be long lasting, and can lead to the harmful behaviors seen in people who abuse drugs.”

As a psychiatrist who treats heroin addicts and a psychologist long interested in the philosophical meaning of disease, we have chafed at the “brain disease” rhetoric since it was first promulgated by NIDA in 1995. Granted, the rationale behind it is well-intentioned. Nevertheless, we believe that the brain disease concept is bad for the public’s mental health literacy.Characterizing addiction as a brain disease misappropriates language more properly used to describe conditions such as multiple sclerosis or schizophrenia—afflictions that are neither brought on by sufferers themselves nor modifiable by their desire to be well. Also, the brain disease rhetoric is fatalistic, implying that users can never fully free themselves of their drug or alcohol problems. Finally, and most important, it threatens to obscure the vast role personal agency plays in perpetuating the cycle of use and relapse to drugs and alcohol.

“Personal agency” is what the rest of us call “personal responsbility.” And believe me, I do not write this as a scold (that was the previous post). I am not an “addict” of anything in particular (surely chocolate does not count!) but I do understand human weakness. For this reason I have always been skeptical of the idea that really, really wanting something so bad “it hurts” is a “disease” any more than the human condition — and the temptation and sin that accompanies it for most people — is a disease.

Even when you’re talking about, say, heroin? According to the widely-published and -quoted Theodore Dalrymple, yes. I believe my first exposure to his writing on this topic was in this Wall Street Journal column:

Heroin doesn’t hook people; rather, people hook heroin. It is quite untrue that withdrawal from heroin or other opiates is a serious business, so serious that it would justify or at least mitigate the commission of crimes such as mugging. Withdrawal effects from opiates are trivial, medically speaking (unlike those from alcohol, barbiturates or even, on occasion, benzodiazepines such as valium), and experiment demonstrates that they are largely, though not entirely, psychological in origin. Lurid descriptions in books and depictions in films exaggerate them à la De Quincey (and also Coleridge, who was a chronic self-dramatizer).

I have witnessed thousands of addicts withdraw; and, notwithstanding the histrionic displays of suffering, provoked by the presence of someone in a position to prescribe substitute opiates, and which cease when that person is no longer present, I have never had any reason to fear for their safety from the effects of withdrawal. It is well known that addicts present themselves differently according to whether they are speaking to doctors or fellow addicts. In front of doctors, they will emphasize their suffering; but among themselves, they will talk about where to get the best and cheapest heroin.

Now from this, thank God, I know nothing. But if you can make headway in the culture with the argument that not even a junkie is a victim of the “disease” of addiction, perhaps next we can dispense of the “disease” of alcoholism. And maybe eventually “personal agency” gets somewhere closer to the driver’s seat. Not because we want to punish, and not because there is no role for “brain juice” in behavior.  Clearly there is.  But because looking away from the truth only makes the problem harder to solve for all concerned.


5 Responses to “Addiction, disease and choice”

  1. Barrette said

    When I read your post all I could think of was the psychiatrist in “The Natural” repeating the phrase:

    Losing is a disease…

  2. Now that’s a toxic formulation right there!

  3. My AA sponsor said, “You choose to stop in a bar. You choose to order a drink. You choose to drink.”

    I didn’t choose having high cholesterol. My father-in-law didn’t choose having cancer.

    The “addiction as disease model” is just another way of avoiding responsibility – something addicts have down in spades.

  4. Gary said

    These are probably one of the same “PROFESSIONALS” who told someone’s AA sponsee in the hospital, after a bad episode, she didn’t really need to go to treatment, if she promised to quit, or slow down. They know it all. She broke her promise!

    There is a thing we call the phenomenom of craving. This is a part of the “disease” the “PROFESSIONALS” can’t figure out.

  5. Sam said

    Another good article which looks at whether or not addiction is a disease:

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