There has been a campaign to educate people that addiction is a disease and not a choice. The hope has been that this will help dispel some of the stigma associated with addiction. However, as an addiction specialist, I find that few people, even physicians, either believe or fully understand what being a disease means.
The American Society of Addiction Medicine (ASAM) very carefully and deliberately defines addiction as a disease. However, alcohol addiction and opioid addiction are not the official diagnostic terms. The Diagnostic and Statistical Manual of Mental Disorder, 5thEdition (DSM V), often referred to as the “Bible of Psychiatry” classifies these conditions as alcohol use disorders and opioid use disorders. Similarly, the most current 10thRevision of the International Classification of Diseases (ICD-10) put together by the Word Health Organization (WHO) lists addiction problems under “Mental and Behavioral Disorders due to Psychoactive Substance Use”. In other words, addictions are classified as “disorders” rather than “diseases”.
What is the difference between a disease and a disorder? The distinction is not always a clear one and the two terms are often used interchangeably. “Disorder” generally refers to abnormalities in function. For example, hypothyroidism is a disorder of low thyroid function while the actual disease might be Hashimoto’s thyroiditis, surgical thyroidectomy or iodine deficiency. Diseases are discrete medical abnormalities while disorders can occur along a spectrum from normal to abnormal. Thus, sadness and anxiety are part of normal human experience but they might meet criteria for disorder if symptoms become too severe or last too long. Thus, many people use alcohol without ever developing an alcohol use disorder.
If all this feels confusing, it is. Alongside ASAM, which draws its members from the ranks of non-psychiatrists, there is another competing organization, the American Academy of Addiction Psychiatry (AAAP) that sees addiction as a branch of psychiatry. It is difficult to separate addiction from psychiatry. However, thinking of addiction as a mental disorder does not achieve the desired objective of reducing stigma because mental illnesses are also shrouded in stigma.
In order to break away from psychiatry, addiction must be considered a chronic medical disease. This is actually not a new or different perspective on addiction but the same position embraced by ASAM as well as ISAM (the International Association of Addiction Medicine), and CSAM (Canadian Association of Addiction Medicine). All these organizations compare addiction to chronic medical diseases like diabetes. However, the campaign proclaiming addiction to be a disease does not explicitly is state that it is NOT a mental disorder. The terminology is confusing and the break from psychiatric disorders is not complete. Adding to the confusion, ASAM’s press release announcing their new definition of addiction as a disease still used the term “brain disorder”. Very unhelpful.
I seek to promote the idea that addiction is a typical chronic medical disease, with the emphasis on “medical”. Specifically, addiction should be thought of as a brain disease, just like Alzheimer’s dementia or Parkinson’s disease. Alzheimer’s and Parkinson’s are not considered psychiatric diseases but medical diseases, usually treated by neurologists rather than psychiatrists. The stance that addiction is a medical disease does not negate all links with psychiatry because addiction is also frequently associated with co-existing psychiatric conditions, such as depression or anxiety. Of course, addictions can also be associated with co-existing medical conditions such as Hepatitis C. Furthermore, many medical conditions can also be associated with co-existing psychiatric problems. For instance, heart disease has been linked to anxiety and depression as well.