Addiction as a Disease: A Brief History and Science

Addiction as a Disease: A Brief History and Science

Disease of Addiction in Philadelphia and the Main Line

Not everyone agrees that addiction is a disease yet this concept is a helpful rubric with which to understand how addiction works.

It is clear that addiction has devastating consequences in our society. The National Institutes on Drug Abuse and the Substance Abuse and Mental Health Services Administration reported in 2001 that 104 million people stated that they had used an illegal drug at some point in their lifetime.  About half of the United States population has engaged in illegal drug use at some point in their lives.  There has always been debate about whether addiction is a disease, a disorder of the brain,  a moral failing, learned behavior or some combination of these. As a bio-psycho-social illness, addiction practically comprises some elements of each of these realms except that it has very little to do with moral fortitude.  Addiction is generally defined as a mental disease in textbooks and research literature, but this has not always been the case.

Before addiction was defined as a disease, it was thought to have existed in people because of a lack of willpower or because afflicted individuals  were just “bad people” or morally corrupt. This sentiment prevails little today and is referred to as the moral model. However these stereotypes have caused those who were addicted throughout the years much mental anguish, and have done little to help individuals grappling with addiction. Our prison system continues to operate chiefly from a moral model with devastating consequences. Our society tends to lock up addicts which can cost 60,000.00 per year on average when the cost of medication, therapy and treatment for addiction can be as little as ten thousand dollars per year.  As the scientific community has adopted the collective belief that addiction is in fact a mental brain disease, people have started viewing addicts differently. Instead of being bad people, they are just sick people that need help. This has had many positive outcomes.

Though addiction is generally classified as a disease, there are many aspects of it that do not neatly fit in the disease model rubric. For instance, you cannot usually treat a physical disease like diabetes with determination, hard work, therapy, counseling and a support group. Unlike other diseases, the  biological processes tend to be less clear with no obvious infectious agent or biologically degenerative condition that clearly ensues with addiction. It is a lot harder to understand mental diseases when physical diseases are easier to define in terms of their origin, course, manifestation and treatment.

It has been clearly documented that drug and alcohol use permanently changes or rewires the brain and literally opens new neural pathways which were not there before prior to the addictive behavior. To be fair this is probably true for any activity we engage in, food we eat or sensation and perception that we experience. However, once opened or activated these neural pathways will always remain changed to some extent. This can explain to some degree why many addicts may in part always remain addicts affected by the disease and why addicts and alcoholics must always be vigilant in their recovery process for the remainder of their lives.  

The limbic part of the brain is the main section of the brain that is affected when drug use occurs. This area of the brain is integral and central to immediate survival. The long term effects and consequences of drug use have little jurisdiction here and little conscious thought would be devoted to the impact of drugs on the user. As such, when an addict is craving or consuming a drug, no thought is given to lasting implications of the drug use. It is often said that if addicts and alcoholics cared about consequences there would be no addicts and alcoholics. When addicts have their drug of choice, the pleasure center of their brain is activated, dopamine is released in addition to many other neurotransmitters of various types all converging to reinforce the drug using chains of behavior. This is the same pleasure center that is activated when other pleasurable experiences happen, such as falling in love, watching your favorite sports team score a goal, eating a molten chocolate cake…

Many addiction psychologists and other addiction professionals believe that addiction is more of a disorder of certain parts of the brain necessary to make good and healthy decisions. As one becomes addicted to cocaine for example, the ventral tegmentum nucleus accumbens in the midbrain is affected which causes stress-induced hedonic regulation. This in turn creates symptoms including loss of control and craving, and relapse.  In an effort to understand the disease model in addiction and addiction psychology, one should understand how genes, reward, memory, stress, and choice impact each individual. Below is an explanation of these addictive processes.

Genetic Basis to Addiction
The genetic makeup of an individual clearly determines how one responds to alcohol. What causes an individual to be more prone to addiction is their genetic makeup. There are clearly documented genetic differences in how people respond to various drugs of use and abuse.

Reward Pathways of Drug and Alcohol Use
Increased dopamine is correlated with increased pleasure. For that reason, dopamine plays a significant role in reinforcing experiences. It tells the brain the drug is better than expected. When an individual uses a drug, there may be a surge of dopamine in the midbrain, which can result in the shifting of that individual’s pleasure “threshold” in addition to numerous other neurotransmitters being released.

Memory and Addiction
The neurochemical, glutamate is an abundant neurochemical in the brain crucial in memory consolidation. When an addict discovers or engages in an addictive behavior, glutamate plays a role by creating drug signals and triggers. It is the neurochemical in motivation which initiates drug seeking, thus creating addiction or compulsive drug and alcohol use.

Stress Drugs and Alcohol
When under stress the brain is unable to achieve homeostasis. As a result the brain reverts to allostasis, which in turn alters the brain’s ability to process pleasure, which is experienced at the hedonic “set point.” Thus, previous pleasures may become no longer pleasurable. This is also known as anhedonia, or “pleasure deafness.” This may be responsible for extreme cravings for drugs and alcohol or possibly other addictive behaviors.

Choice in Addiction 

Many believe that addicts and alcoholics have no free will and are powerless over their addiction. However that most likely applies after the first drink or drug is consumed.

An addict may incur damage to the orbitofrontal cortex (OFC), the anterior cingulate cortex (ACC), and the prefrontal cortex (PFC). This damage causes a tendency to choose small and immediate rewards over larger but delayed rewards, deficits in social responding due to decreased awareness of social cues, and a failure of executive function such as sensitivity to consequences. This suggests an underlying biological explanation for the “insanity” of addiction. In Alcoholics Anonymous one hears about the insanity of alcoholism where someone could touch a stove and become burned yet moments later they might convince themselves that they can touch the stove again but maybe they won’t get burned this time.  

There are many reasons addicts can become addicts including a combination of biological, environmental, psychological and genetic factors. Addictive personalities and tendencies often run in families. If you have a biological relative who is an addict you are four times more likely than the next guy to have an addiction yourself. The National Institutes on Drug Abuse and the Substance Abuse and Mental Health Services Administration reports that children of alcoholics are 50-60 percent more likely to develop an alcohol use disorder than the general population. They further reported that in 2001 there were 182 million prescriptions written for pain medications suggesting a full fledged prescription epidemic in the united states.

It is unclear whether identifying addiction as a disease stifles or encourages  treatment research and the accessibility of a range of  treatments that are available.  One of the benefits of addiction being classified as a disease is that those on the outside looking in, family members, friends and others who have never suffered from the disease themselves seem to have softened their views over time. People don’t think so horribly and hopelessly of addicts like they used to. Our society seems more understanding of the condition in general, and more helpful towards active addicts and those in recovery. We all know someone who is an addict and we’ve had presidents, role models and friends who have used drugs, become dependent and entered into recovery.  This has in turn, helped other addicts realize that they need help, and encouraged them to seek it more often. To be sure, this has led to better treatment and a higher percentage of success, sobriety and recovery in those that engage in treatment and begin the process of recovery.

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