People often hold strongly to vastly differing ideas and opinions about addiction. Many people see heroin addicts as despicable, depraved criminals, without conscience or morals. Yet, addiction doctors insist addiction is a disease. These viewpoints are difficult to reconcile. What is the truth?
To understand why addiction is a disease, let’s compare alcoholism, the archetypal addiction, to diabetes, which is undeniably a disease. Superficially different, these two conditions are actually fundamentally very similar.
Risks of developing either alcoholism or diabetes are strongly affected by genetics. Both conditions depend on the environment – diabetes rates are 50% higher in Mississippi than in Colorado; Las Vegas has higher alcoholism rates than Salt Lake City in Utah, a state with strong alcohol laws. Lifestyles are important – sedentary and fast-food lifestyles promote diabetes; lifestyles involving frequent alcohol intake facilitate the development of alcoholism. Diabetes affects kidneys, blood vessels, and nerves; alcoholism affects the liver, pancreas, and nerves. Most importantly, both conditions affect the ability to control consumption – diabetics have trouble controlling food and sugar intake; alcoholics cannot control alcohol consumption. If diabetes is a disease, then so is addiction.
Some proclaim addiction to be a choice, not a disease. Actually, lifestyle choices are major contributors to many diseases, including diabetes, heart disease, and many cancers. Other potentially lethal choices include distracted driving, neglecting medical attention or advice, refusing seatbelts, etc. Patients’ complicity in their illnesses have no bearing on their conditions being diseases or not, or on the need for treatment. Furthermore, addiction specifically damages the brain’s decision-making neurocircuitry. Addiction causes poor choices rather than the reverse. Blaming addiction on choice is like blaming the cart for pushing the horse.
If addiction is a disease, then we should treat addicts the same way we treat diabetics. The goal in treating diabetics is not to cure diabetes but to limit its harm: treatment helps prevent heart attacks, strokes, blindness, kidney failure, nerve damage, arterial blockages, etc. Similarly, addiction treatment is not aimed at “curing” addiction but at controlling damage: Treatment decreases mortality, criminal activity, and transmission of Hepatitis. Treated addicts often return to productive lives.
Medicines used in opioid addiction have proven effective at controlling the damage from addiction. Understandably, many people bristle at the idea of treating opioid addiction with opioid medications, such as buprenorphine or methadone – it feels like we are merely feeding the addiction. The easiest explanation for this strategy is to compare it to the apparent paradox of fighting fire with fire. Forest fires are contained by deliberately burning a narrow strip of land ahead of the advancing fire, depleting the fuel needed to spread. Using buprenorphine or methadone is like fighting fire with fire!
Anxious to be “cured,” people often stop treatment prematurely. Normal sugar readings do not mean we can stop insulin. Similarly, we cannot stop addiction medications because street drugs stopped showing up on urine tests – this is the first step to sobriety, not the final step. Staying on medications can be crucial for addicts and diabetics alike.
Do addiction treatments actually work? Absolutely! I had no interest in treating heroin addicts earlier in my medical career. Yet, once I started, I witnessed such remarkable transformations that addiction medicine quickly became among the most rewarding things I have ever done in medicine. That’s why I became an addiction doctor.
I want to help change how the public understands addiction. How people feel about heroin addicts matters a great deal. It affects how people with this disease are treated in emergency departments, in courts, and in their families. I often draw a parallel between 21st century heroin addicts and lepers of Jesus’ day. Both groups were marginalized (outcast), considered “unclean,” shunned, and feared. Yet, Jesus showed them compassion and even healed some lepers. As people afflicted by a terrible disease, addicts deserve our compassion, not our scorn. They need treatment, not punishment.