Drug addiction has received extraordinary attention over recent years to the point where politicians have become interested in the problem. This is a sure sign that a real problem will be the subject of a lot of muddle headed thinking. For the past three decades or so addiction has been held to be a disease. During that time I have repeatedly argued that the disease model was inapposite for the problem and resulted in management that was wrongly directed. A PowerPoint presentation of a talk I gave 16 years ago arguing against the classification of addiction as a disease is at the end of this article. I think its arguments still hold.
The current Opioid Crisis seems to be primarily blamed on physicians promiscuously prescribing opioids which in turn leads to addiction which in its turn leads to the illegal purchase of heroin and similar drugs – the worst being fentanyl. Data are hard to find, but I suspect that the majority of opioid addicts obtained their first dose of their drug not legally from a physician, but illegally on the street or from someone else’s medical chest . Opium derivatives have a place in medical practice for the relief of severe pain and rarely cause addiction in patients not predisposed to it. See below.
On October 17 last, PBS presented America Addicted as part of its Nova series. It gave the conventional depiction of drug addiction (and other so called addictions) as a disease. The following day the New England Journal of Medicine published Brain Changes in Addiction as Learning, Not Disease which challenged the disease model of addiction.
The PBS program which is likely to reach far more people than the paper in the NEJM which is behind a paywall. The lay press to my knowledge has not reported on the paper. Watching the show one would not get a hint that its central premise is controversial. All the “experts” interviewed have their livelihoods dependent on addiction being a disease. The brain imaging studies shown prove nothing and have been criticized years ago. All of the “scientific” studies shown in America Addicted lack adequate controls. There are many people active in the addicition field who do not think it a disease. PBS was either unaware of their existence or chose to ignore them. Stanton Peele has made a career of arguing against the disease model depicted with so much color by the program.
A few preliminaries. The biological basis for human behavior is mostly a mystery, unlike that of the kidney or heart, and is so complex that we may never fully comprehend it. Using the disease model to depict harmful behaviors steams from a desire on the part of a sizable portion of both the lay and professional population to medicalize these behaviors. Thus, gun violence and overeating become medical problems in and of themselves rather than the cause of medical problems. The genesis of this view is, at least in part, reflected by the World Health Organization’s definition of health: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” (Constitution of the World Health Organization). Using this definition there has never been, nor will there ever be, a healthy person to the extinction of the species.
So what is a disease? Here’s my definition: A disease has an exclusive pathogenesis; diabetes mellitus is always due to an absolute or relative deficiency of insulin. It has the potential for harm. It is never voluntary, though voluntary acts may cause disease. The voluntary act itself is not the disease All acts are voluntary until proven otherwise.
Humans should held to be responsible for their acts. Mental illness absolves the patient of responsibility for his acts. Mental disease differs from all other illnesses because of volition. Accordingly we should be spare in our designation of unwanted and harmful behaviors as disease. These behaviors are at an intersection of philosophy, sociology, medicine, economics, psychology, and yes medicine. Treating addiction as another disease crosses the border of the ridiculous and results in a vast oversimplification that is detrimental to those whose behaviors are harmful.
A failure to appreciate the complexity of the human condition and ignorance or disregard of what great thinkers in other disciplines have to say about society, liberty, and free will places the physician who would ignore this vast body of knowledge, and put bad behavior in a medical cubby hole, in the same position of a man blind from birth tasked with describing a rainbow.
The influence of scientific patterns of thought on our general outlook has become extremely pervasive; and the overwhelming majority is today uncritically in thrall to more or less crude forms of scientism (Roger Hausheer, Introduction to Isaiah Berlin, The Proper Study of Mankind, 1997).
Suppose I am an alcoholic, a slave to the bottle. Would I not wish to renounce part of my liberty that enslaves me to the bottle. (W)hat are we to do with the majority of mankind who are unable to master their sinful passions? Here, says Berlin, the real horror of a purely rational view of life unfolds. For if it can be shown that there is only one correct view of life, people who fail to follow it must be forced to do so (Noel Annan, Foreword to Isaiah Berlin, The Proper Study of Mankind, 1997).
Liberty and responsibility are inseparable…. It (responsibility) often evokes the outright hostility of men who have been taught that it is nothing but circumstances over which they have no control that has determined their position in life or even their actions (Friedrich Hayek, The Constitution of Liberty, 1960).
[Parenthetically, Hayek’s influence on a legion of subjects is still expanding. Hayek’s first class at the University of Chicago was a faculty seminar on the philosophy of science attended by many of the University’s most notable scientists of the time, including Enrico Fermi, Sewall Wright and Leó Szilárd. During his time at Chicago, Hayek worked on the philosophy of science, economics, political philosophy and the history of ideas.]
It is doubtful that democracy could survive in a society organized on the principle of therapy rather than judgement, error rather than sin. If men are free and equal, they must be judged rather than hospitalized (FD Wormuth The Origins of Modern Constitutionalism, 1949).
The word addiction is so loosely used that a definition is necessary. A bad or unwanted habit is not an addicition. My strict pharmacological definition holds that a substance is addicting if it posses all four of the following – habituation, dependence, tolerance, and withdrawal. Thus it is nonsense to talk about food, or sex, or gambling addiction irrespective of how harmful these conditions may be. By this definition opioids, barbiturates, and alcohol are addicting. Cocaine, amphetamines, are tobacco not as these three are not associated with true withdrawal syndromes.
Our attitudes towards addiction are exactly what you would expect from simultaneously loosing thousands of lawyers and psychiatrists on the same problem. Alcoholism as a disease is no more than 200 years old, though it has been used for thousands of years (Levine, J Stud Alcohol 39:143, 1978).
Alcoholism as a disease which only affects a small group of biologically predestined individuals is less than 70 years old (Peele J Psychoactive Drugs 20:375, 1988).
Alcohol and opiate use were much more common in the 19th century than now. Both were criminalized in the 20th century and then medicalized “Addiction is now defined as an illness because doctors have categorized it thus” (Berridge & Edwards, Opium and the People, Yale Univ Press, 1987, p 130).
Cocaine and opium were commonly used in 19th century patent medicines. Godfrey’s Cordial, which contained opium, was given to quiet Victorian babies.
Of all men addicted to heroin in Vietnam, only 12 % relapsed to addiction after their return. Of those addicted in the first year back, half were treated and half were not, 47% of those treated had a second relapse. 17% of those not treated had a second relapse. (Robbins, et al, Yearbook of Substance Abuse, 2:213, 1980). Half of those addicted to heroin in Vietnam used it after returning to the US. Only one-eighth became readdicted. Heroin use led to addiction no more often than did amphetamine or marijuana use (Robbins, et al).
The PBS program showed animals engaging in behaviors which stimulated the “pleasure Center” of the brain. It did not mention studies that showed that animals in spacious cages shared with other rats vastly prefer water to narcotic solution even after having drunk the solution exclusively for weeks. Animals that consume drugs and alcohol excessively when under extremely ncomfortable conditions cease when normal lab conditions are restored (Falk, Pharmacol Biochem Behav 19:385, 1983).
Most animals cannot be made into addicts. In response to drugs regularly reported to addict humans, animals generally avoid such drugs when given a choice (Dole, Sci Am:138, June 1983).
The concept of addiction as disease has been used to explain almost every human failing and thus to absolve miscreants of responsibility for their bad acts. When Hall of Fame baseball player Wade Boggs was caught in an illicit sexual relationship, he confessed to sex addiction. His former mistress said, “I guess what I thought was love was just a disease.”
Compulsive drug-seeking behavior is often attributed to the seductive reinforcing of certain insidious drug molecules. Rather behavioral variables are as important as pharmacological ones in the development of compulsive drug-seeking behavior (Charles Schuster, Director, National Institute on Drug Abuse).
Numerous changes in the brain have been described in animals taking drugs of abuse. The link between these changes and behavior is totally absent. Connecting these changes to behavior is apt to be impossible. Similar changes would doubtless be observed following memorization of a poem, if a mouse could memorize a poem The relevance of these animal models is tenuous or non-existent.
The human cerebral cortex contains 100 billion neurons. There are 1014 synapses in the brain. The possible interactions among all the human genes and their transcribed proteins exceed the number of particles in the universe. Human behavior as a purely biological problem is impossibly complex.
“Simply having the list of all genes, and shortly thereafter the list of all proteins for behavioral trait “X” will not be enough for us to achieve understanding of the biological substrates of these traits/disorders…. Complex traits cannot be assessed one gene (or one gene product) at a time. Rather, knowledge of how multiple genes interact, and how their effects depend on the complex environment in which they are expressed will be needed to make progress to the next level of understanding.” (Crabbe, Lancet 357:534, 2001). I think this view way too optimistic.
“If genes truly controlled behavior, our justice system and its guiding principle of equal protection would not be the only casualties. How would our concept of equal opportunity survive? What about the idea of merit? Scientists will find many behavioral factors in the genes. There is one extremely common genetic factor that confers at least a ten-fold increase in the propensity to exhibit criminally violent behavior. The Y chromosome. The case of the Y chromosome is an almost absurd extreme. In the vast majority of cases, genetic factors exert a much smaller influence on patterns of behavior and capability. Looking for genes that encode our unique behaviors and the other products of our minds is like analyzing the strings of a violin or the keys of a piano in hopes of finding the Emperor Concerto.” (Collins et al, The New Republic, June 25, 2001, p 27).
Sending people to jail solely for possession of unapproved drugs will be looked upon with horror in the future Drug abuse is no more a medical problem than bad driving. Those who have declared drug addiction a disease will not readily undeclare it a disease Their faith and their financial interest will not allow it. Illicit drugs are illegal because they’re dangerous. They’re dangerous because they’re illegal. Taking drugs is not a disease, though it can cause disease – toxicity. Similarly, not wearing your seatbelt is not a disease though it can cause disease – trauma.
Many people can be taught to be better drivers. It doesn’t take a doctor to do it. Many people can be persuaded to discontinue the use of harmful drugs. There’s no reason that the persuaders be medical professionals. The vast majority of illicit drug users will stop spontaneously.
The Mayo Clinic, in its usually sensible, way says, “A number of additional factors — genetic, psychological and environmental — play a role in addiction, which can happen quickly or after many years of opioid use.” They cite the following risk factors:
This list contains a lot of problems many of which are beyond the domain of medicine. Addiction is a complex phenomenon which includes a component of volition. Those who engage in this behavior need help, but they cannot escape their own responsibility for initiating and continuing the behavior that that puts their lives in jeopardy. The NEJM paper cited at the start of this piece offers a stimulus for us to reexamine this problem using a wider spectrum of disciplines and with an mind uncluttered by pseudoscience. Doing so may point us in the right direction with the realization that the journey’s end is very distant. As for the present we’ll cope as best we can as our appreciation of the causes of harmful behavior increases.
An army of neurobiologists and addiction specialists will not repeal Free Will. “Sir, We know our will is free, and there’s an end on’t.”( Samuel Johnson from Boswell’s Life)