There has been a campaign educating the public that addiction is a disease. But why is this message important? It seems improbable that any addict remains unaware that treatment options exist. Pronouncements that addiction is a disease are often followed by advertisements for some form of treatment. Has the message that addiction is a disease become no more than a senseless commercial slogan for industry, like Coca-Cola is Happiness?
The message has indeed been commercialized, cheapened and rendered nearly meaningless. Yet, I will argue here that understanding addiction to be a disease is essential because proper comprehension has potential to profoundly alter our worldview of addiction. The resulting shift in understanding should produce major changes in how we manage addiction and how we treat addicts. Currently, there is no shared common worldview of addiction – addiction is variously understood through mutually inconsistent models as a sign of societal depravity, personal moral weakness, criminal activity, psychiatric illness, brain disease, or any hybrid of the above.
Although addiction is now recognized by most physicians as a disease, mainstream addiction treatments retain attitudes held over from a time before addiction medicine emerged as a medical field. The legacy of non-medical approaches to addiction can be seen in the wide range of available treatment options. Responses to addiction include faith-based, medication-assisted, psychotherapy-based, abstinence only programs, legally enforced options, long-term residential programs, 12-step programs, etc. Furthermore, options listed above are not exclusive; approaches may be combined in any number of ways. For example, court-mandated programs might allow some medications to be used but not others, 12-step programs may or may not be faith-based, etc. Some countries dispense with treatment altogether, treating addiction purely as a criminal affair, locking up drug addicts not for the sake of the addict but to protect society.
If this feels chaotic, it is. No other field of medicine is nearly so disorganized with such a dizzying array of disparate philosophies, guided variously by any combination of ideology, prejudices, personal experiences, anecdotal accounts and importantly, profit motives. Some treatment programs decry use of any medication, others allow naltrexone but not “opioid-replacements” such as methadone or buprenorphine, and some embrace even unproven medications. Yet other programs only use medications to “detox” patients, getting them off street drugs but do not endorse long-term maintenance therapy. Not only is there a wide range of philosophies but many perspectives are held very strongly, often despite a lack of empirical support or even against the preponderance of scientific evidence. Given the plethora of different messages, imagine the confusion and cacophony that must confront addicted patients – what kind of therapy should they pursue? No wonder Columbia University’s National Center on Addiction and Substance Abuse compared today’s treatment of addiction to general medicine in the early 1900s.
The root cause for this chaos – addiction does not yet enjoy the standing of a bona fide disease. Physicians specializing in addiction medicine are nearly unanimous in the stance that addiction is a chronic brain disease. However, many other interested parties persist in treating addiction as either a moral problem or only as a quasi-disease. By quasi-disease, I mean they recognize elements in addiction that respond to medical care but other elements that relate to character weaknesses (e.g. selfishness, lack of will power), criminal mentality, social depravity, etc. The way forward I propose is to insist addiction be recognized as typical medical disease, with all that designation entails.
In another essay, I point out that diabetes and alcoholism are remarkably similar, differing only in the substrate. Both conditions are influenced by genetics, environment and lifestyle, and each is characterized by loss of control over consumption – food or sugar for diabetics; alcohol for alcoholics. However, we do not generally promote drug-free approaches for diabetes, send diabetics for “rehab”, or rely on faith-based interventions. Lifestyle modifications are equally important in managing diabetes as for addiction, but we do not refer to pharmacotherapy of diabetes as “medication-assisted therapy” (MAT), which is exactly the term used by the CDC, US Department of Health and Human Services, and other governmental agencies. Why do we not simply refer to MAT as pharmacotherapy? “Medication-assisted” implies medications should occupy a subordinate role – betraying the quasi-disease status applied to addiction.
The status of addiction as a “second-class” disease is also visible in the very core language of addiction. One of the most common terms used in addiction treatment is “Recovery”, used even by governmental agencies such as the Substance Abuse and Mental Health Services Administration (SAMHSA) as well as the American Society of Addiction Medicine (ASAM). However, I would point out that we do not use “recover”, “recovery” or “recovering”, to characterize the treatment of other diseases, such as diabetes. Recovery implies the problem has resolved – why would we need to continue administering antibiotics once someone “recovers” from pneumonia? Use of the term “recovery” in addiction traces at least as far back as the Big Book of Alcoholics Anonymous (AA), which was an overtly religious organization at the time. Alcoholism is seen as a fall from grace, and “recovery” is nearly synonymous with “redemption”. Someone in recovery might once again fall from grace (relapse) with fault accruing to the drinker. Recovery is a process for the patient (“I am in recovery”), rather than a trajectory for the disease (“my disease is getting better”). In contrast, if addiction were a chronic brain disease, the term “recovery” would be inappropriate. Chronic diseases under control are in “remission”. Someone treated for breast cancer with no sign of residual disease is not characterized as being in “recovery” but in “remission”, sometimes treated with tamoxifen for an additional 5 or even 10 years. If cancer does return, we do not blame the patient.
Remission versus recovery is NOT merely semantic – the difference is subtle but pernicious. I have encountered many patients taken off pharmacotherapy after a year or so of being “clean” (another word I do not like) because both the patients and their doctors believed in “recovery”, only to relapse. The resulting guilt, shame and self-loathing can be intense. However, the relapse likely related to coming off medication prematurely without scheduled follow-up to ensure early detection and intervention of relapse. Patients with cancer in remission are followed regularly for years and so should addicts in remission.
The way to truly defeat the stigma of addiction is for addiction to emerge from the mists of its current quasi-disease status, to be recognized as a bona fide medical disease.