Is addiction a disease or a choice? Is it caused by genetics and/or physiology? Is it the substance or behavior that enslaves people or is it a matter of personal characteristics?
Is addiction a disease or a choice? Is it caused by genetics and/or physiology? Is it the substance or behavior that enslaves people or do some people have personal characteristics that cause them to choose addictive behaviors?
Although addiction has been a recognized phenomenon for centuries, there is still no clear consensus on the definition of addiction.
The World Health Organization (WHO) defines addiction as a mental disorder in which a person engages in the repeated use of a substance “despite knowing and experiencing its harmful effects.” WHO goes on to say that the person has uncontrollable urges to use the substance, needs increasing amounts to achieve previous effects and experiences physical withdrawal symptoms upon stopping use. 1
The American Pain Society, The American Academy of Pain Medicine and the American Society of Addiction Medicine have together put forth definitions concerning drug-related addiction. 2
These organizations define addiction as “a primary, chronic, neurobiological disease, withgenetic, psychosocial, and environmental factors influencingits development and manifestations. It is characterized by behaviorsthat include one or more of the following: impaired controlover drug use, compulsive use, continued use despite harm, andcraving.” 2
The three organizations define physical dependence separately from addiction as a “state of adaptation that is manifested by a drug-class specific withdrawal syndrome.” 2
The American Psychiatric Organization collaborated with the World Health Organization to create criteria for the definition of addiction. 3 positive responses to any of the following questions (in part or as a whole) result in a person meeting the criteria for this medical definition of addiction: 3
- Tolerance. Has your use of drugs or alcohol increased over time?
- Withdrawal. When you stop using, have you ever experienced physical or emotional withdrawal? Have you had any of the following symptoms: irritability, anxiety, shakes, sweats, nausea, or vomiting?
- Difficulty controlling your use. Do you sometimes use more or for a longer time than you would like? Do you sometimes drink to get drunk? Do you stop after a few drink usually, or does one drink lead to more drinks?
- Negative consequences. Have you continued to use even though there have been negative consequences to your mood, self-esteem, health, job, or family?
- Neglecting or postponing activities. Have you ever put off or reduced social, recreational, work, or household activities because of your use?
- Spending significant time or emotional energy. Have you spent a significant amount of time obtaining, using, concealing, planning, or recovering from your use? Have you spend a lot of time thinking about using? Have you ever concealed or minimized your use? Have you ever thought of schemes to avoid getting caught?
- Desire to cut down. Have you sometimes thought about cutting down or controlling your use? Have you ever made unsuccessful attempts to cut down or control your use?
Substance abuse is defined separately from addiction by the American Psychiatric Association (APA). People may abuse alcohol or drugs but not be addicted to them. The APA defines substance abuse as: 3
- Continued use despite social or interpersonal problems.
- Repeated use resulting in failure to fulfill obligations at work, school, or home.
- Repeated use resulting in physically hazardous situations.
- Use resulting in legal problems.
According to these definitions, addiction, dependence and substance abuse are separate entities, and for the most part, addiction is considered a physiological disease or disorder.
However, drug and alcohol use aren’t the only things that are considered addictions today. Eating disorders, internet use, gambling, even shopping addictions are on the rise. When excessive use or abuse of necessary activities can be considered addiction—how is the definition of addiction affected?
The majority of these organizations view addiction as a disease, and a rising number of scientists propose that addiction is an individual choice. Others consider addiction a socially-derived ill.
This lack of consensus severely affects the study of addiction. Statistics, classifications, diagnoses and the measurement effective treatments are all compromised. Health care coverage and the individual’s perception of the differences between interest, dedication, attention to detail, craving, obsession, compulsion and addiction are ambiguous.4
Addiction is perceived in a social way. Cigarette smoking isn’t considered aberrant or illicit in some cultures. It is the medical, political and social policies that determine the public’s view of what is deviant from the norm. 4
And the fact that addictive activities like gambling or sex can cause physiological effects with both their use and withdrawal challenges much of the perceptions of a disease-model of addiction. 4
Addiction as Disease
The Addictions and Recovery Organization takes the stance that 50% of addiction is due to genetic predisposition and the other 50% is due to poor coping skills.5 The organization bases this view on family histories, twins studies and changes in neuro-functioning of the brain in addicts.
The problem with this proof is that family environments can influence the development of addiction in twins and others and that mind-body medicine is providing proof that thinking, behavior and nervous system wiring are all very inter-related. That 50% genetic basis can not isolated from environmental effects. Furthermore, we know today that both environment and behavior can influence the expression and evolution of genes.
Dr. John Halpern believes in the disease model of addiction. He uses cigarette smoking as an example. Although the dangers of smoking are well known today and has been nearly criminalized in public perception; many people are unable to stop smoking. It is not a choice, he says. 6
Halpern also points to twin and family history research as evidence of the biological basis of addiction. 6
He points out that homeostatic changes occur with drug use that sensitizes a person in ways that make them susceptible to relapse, that neurotransmitter receptors and gene expression are decidedly affected by substance abuse and so the substances themselves are the root cause of addiction as a disease. 6
Halpern believes that the view of addiction as choice is faulty because users do not have control: if they did, he believes that they would stop once they recognized the cost/benefit ratio of addiction in their lives. 6
In fact, what most self-help groups recognize is that people are able to stop once they come to re-value social relationships and other factors above the use of the drug. 3
What we may view as devastating—the loss of employment, home, marriages, children, self-respect etc.—may, for a long time, still hold a lower place on an addict’s measure of value and priority. It takes a change in individual perception of the positive and negative effects of the substance use and/or activity in order for the cost/benefit ratio to align with publicly perceived values.
Halpern does recognize the value of support groups in helping to change an addict’s perception of cost/value, but he stresses the medical model of addiction and adds that many addictions may have self-medicating components that can be alleviated with proper pharmaceuticals. He even muses that someday, a vaccine will be discovered that provides immunity from cocaine addiction! 6
Halpern believes that viewing addiction as a disease can help temper social stigma, reduce persecution of the individual, shift responsibility for addiction from the individual’s shoulders and to society’s, increasing acquisition of treatments for the disorder. 6
Dr. Howard Shaffer doesn’t hold with the disease model of addiction. He points out that neuroadaptation and addiction are two very different things. 4
Neuroadaptation refers to physiological changes resulting from addiction. The transforming of neurotransmitter activity in increasing tolerance, relapse risk etc., are physical manifestations of addiction to substances.
He points out that post-operative patients can become physically dependent upon pain-killers but don’t display addictive behaviors. He stresses that addiction includes behavior patterns that are not solely the result of neuroadaptation and points out that evidence is building that finds addictive behaviors (not just the physical properties of substances) such as gambling can contribute to physiological changes. 4
Shaffer also points out that many people who are genetically prone to addiction do not develop the disorder, that use of a drug doesn’t always result in addiction and that personal characteristics aren’t a consistent predictor of addiction either.4
Shaffer believes that the more we learn about the biology of addiction, the more evident it becomes how much social and cultural influences affect its development. 4
Addiction as Choice
Author of Addiction Is a Choice, Dr.Jeffrey Schaler, bases his view on two major points: the first is that “many activities that are not themselves diseases can cause diseases” and secondly, “foolish, self-destructive activity is not necessarily a disease.” 7
Schaler speaks of drug use when he asks: If a person uses drugs, does this act cause a disease? He believes that it is instead a behavior and so—a choice. 7
Schaler points out that addiction does not necessarily include lack of control. The alcoholic does not drink him or herself to death in one sitting. Instead, they choose and plan for a period of recovery between binges. This, Schaler believes, is evidence that the alcoholic exercises some control over his behavior and chooses his or her rate of consumption (wisely or not.) He also points out that research show that an alcoholic can control his or her behavior in response to incentives. 7
Schaler also believes that the increasing evidence of relationship between mind and body has been misconstrued by conventional medicine. Instead of looking at the emergent properties of a single and holistic system, there is a tendency to view mental and personality processes as being caused by physiological processes. 7
Grief, Schaler says, is a trauma that can occur along with corresponding physical attributes but that doesn’t mean that the event alone causes the physical symptoms. In the same way, substance use can cause physiological changes that in turn are correlated with different mental states but, chemical rewards themselves do not have the ability to compel people’s behavior. It is the person’s choice and will that determines whether or not they ingest a drug or eat a fattening food. 7
The widespread use of self-help groups such as Alcoholics Anonymous provides more evidence to discredit the disease model of addiction, Schaler says. These groups have a strong religious component, which illustrates the ethical nature of the treatment and the problem. 7
Self-help groups may be more effective than psychotherapy, Schaler believes, because most therapy is based on the disease model, prompting patients to accept that the addiction is physiological and therefore beyond much of his or her conscious control. This abnegation of responsibility undermines therapy meant to help an addict change their values or behaviors. 7
Addiction as a Social Ill
Although genetics and a substance’s characteristics can play a part in the development of addiction, other common causes are thought to be: 8
- Self-medicating for anxiety and depression
- Environmental influences and learned habits
- Lack of religious affiliation
- Lack of coping skills
- Physical or sexual abuse
- Low self-esteem
- Accessibility and familiarity
In 1983, The National Academy of Sciences recognized the following common personality traits in various addictions: 9
- “Impulsive behavior, difficulty in delaying gratification, an antisocial personality and a disposition toward sensation seeking.
- A high value on nonconformity combined with a weak commitment to the goals for achievement valued by the society.
- A sense of social alienation and a general tolerance for deviance.
- A sense of heightened stress. This may help explain why adolescence and other stressful transition periods are often associated with the most severe drug and alcohol problems.”
Some researchers note that addictions are a product of social, psychological and physiological components. 10
Personality is not simply a result of genetics but social and cultural influences, so focusing on common characteristics of addicts can be a limiting view too. The high rate of addiction among physicians, for example, could be due to availability, stress and personality. 10
Dr. Robert Millman describes the “non-addict” personality as “those who have strong families, often with religious backgrounds and who have good social relations.” 10
The recent book, The Globalisation of Addiction, by Dr.Bruce Alexander poses a social theory of addiction. 11
He thinks of addiction as “overwhelming involvement” with any substance or activity. He does not believe addictions, compulsions and obsessions are distinct or distinguishable from each other. 11
Alexander does not think of addiction as a medical condition or disease and points out that this view and its treatments have proved widely unsuccessful in curing or preventing addiction. 11
He believes that addictions exist on a continuum of harm and that they are a recurrent and rising social phenomenon in western countries and all large civilizations throughout history. 11
This phenomenon helps us to think of addiction, says Alexander, as not a matter of “enslavement” to pernicious substances and not a matter of disease, but as a philosophical issue pervasive throughout the history of the human condition. 11
Addiction, he says, is an individual and social response to dislocation, the opposite of psychosocial integration.
In the chapter, Poverty of Spirit, Alexander explains that psychosocial integration is “a profound interdependence between individual and society that normally grows and develops throughout each person’s lifespan [and is] experienced as a sense of identity because stable social relationships provide people with a set of duties and privileges that define who they are in their own minds.” 11
This social bonding is what makes life bearable and is the key to humanity flourishing in creativity and cooperation. Addiction, stresses Alexander is the adaptation response to this psychological and social separation, or what we commonly think of as alienation and disconnection. 11
Our current culture, Alexander says, is a powerful catalyst for every kind of dislocation and so…all kinds of addiction. 11
He quotes Karl Marx in his effort to capture the upheaval and change that a rising tide of capitalism brings:
“Constant revolutionizing of production, uninterrupted disturbance of all social conditions, everlasting uncertainty and agitation distinguish the bourgeois epoch from all earlier ones. All fixed, fast frozen relations, with their train of ancient and venerable prejudices and opinions, are swept away, all new-formed ones become antiquated before they can ossify. All that is solid melts into air, all that is holy is profaned.” 11
The crumbling and morphing of economic, familial, political, religious and social institutions is behind the rising rates of addiction. A perspective such as this helps us to view addiction in a holistic way that offers pathways to recovery for both individuals and society at large.
Bruce Alexander works with Vancouver addicts. He insists that they need community, belonging, usefulness and positive group identities in order to abstain from their addictions,11 just as all global citizens do.
1)WHO Staff (2001). Drug Addiction. World Health Organization [online]. Retrieved from http://www.emro.who.int/mnh/whd/PublicInformation-Part3.htm
2)Fainsinger, Robin L., Thai, Vincent, Frank, Gary and Fergusson, Jean (2006, November). What’s in a Word? Addiction Versus Dependence in DSM-V. American Journal of Psychiatry [online]. Retrieved from http://ajp.psychiatryonline.org/cgi/content/full/163/11/2014-a
3) Addiction and Recovery Staff (2009, December 10). The Definition of Addiction. Addictions and Recovery Organization [online]. Retrieved from http://www.addictionsandrecovery.org/definition-of-addiction.htm
4) Shaffer, Howard J. (2009, March 31). What is Addiction?: A Perspective. Cambridge Health Alliance [online]. Retrieved from http://www.divisiononaddictions.org/html/whatisaddiction.htm
5) Addiction and Recovery Staff (2009, December 10). The Genetics of Addiction. Addictions and Recovery Organization [online]. Retrieved from http://www.addictionsandrecovery.org/is-addiction-a-disease.htm
6) Halpern, John M. (2002, October 1). Addiction Is a Disease. Psychiatric Times [online]. Retrieved from http://www.psychiatrictimes.com/display/article/10168/48281
7) Schaler, Jeffrey A. (2002, October 1). Addiction is Choice. Psychiatric Times [online]19:10. Retrieved from http://www.psychiatrictimes.com/display/article/10168/47476?verify=0
8) Brainz Staff (2009). 10 Common Causes of Addiction. Brainz [online]. Retrieved from http://brainz.org/10-common-causes-addiction/
9) Nelson, Bryce (1983, January 18). THE ADDICTIVE PERSONALITY: COMMON TRAITS ARE FOUND. N ew York Times [online]. Retrieved from http://www.nytimes.com/1983/01/18/science/the-addictive-personality-common-traits-are-found.html
10) Nelson, Bryce (1983, January 18). THE ADDICTIVE PERSONALITY: COMMON TRAITS ARE FOUND
11) Levine, Harry G. (2009, June 23). Review of “The Globalisation Of Addiction: A Study In Poverty Of The Spirit” by Bruce K. Alexander. Harm Reduction Journal [online]. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2717062/