This article, by Satel and Lilienfeld is appalling. Their arguments for why addiction shouldn’t be called a brain disease ignore important evidence, imputes arguments to those who support the brain disease that they do not make, and make a mockery of the real role of shame in addiction treatment. They should be ashamed of themselves for such careless work.

First, let’s consider some “real” diseases, like atherosclerosis, hypertension or adult onset diabetes. These are brought on by voluntary activities (e.g., overeating, lack of exercise, etc), are affected by the genes we are born with, create changes in the biology of the body (plaques in arteries, insulin resistance), can be treated with medications, and if disease control is to be attained, require changes in behavior.

Addiction has all these characteristics: it is brought on by a voluntary behavior, is affected by our genes, creates biological changes in the brain that outlast drug use, may be treated with medications, but ultimately require changes in behavior for a long-lasting remission. Yet, no one stigmatizes people who come down with atherosclerosis or hypertension, and their medical needs are covered by all insurance policies. They are even covered for second or third heart attacks brought on by their relapses back into the behaviors that made them ill in the first place. When addicts have a relapse during treatment, they are often kicked out of the program (see stigma below).

Paradoxically, while arguing that addiction isn’t a disease, Satel and Lilienfeld recognize the involuntary, brain-based nature of craving, which they admit can be triggered by what are in non-addicts neutral environmental stimuli.

Those, like myself, who favor labeling addiction a brain disease are fatalistic about its outcome. This is Satel and Lilienfld’s invention - a straw man they can easily dispose of. We all favor widely available treatment because we know addiction is treatable. We also understand the importance of personal agency, because, while no one gets addicted without first taking drugs voluntarily, no one successfully escapes from addiction without deciding to and sticking with that difficult task. Addiction is a disease that diminishes a person’s capacity to make free choices. Only those wishing to oversimplify it for the sake of their own agenda would argue that those who think it’s a disease believe it obliterates free will.

Sometimes, medications can make this easier, sometimes, things like sanctions (like drug courts) also help. This has nothing to do with whether a there is an underlying disease. Cognitive/behavioral therapy, which helps people to willfully change their thoughts can be an effective treatment for depression, does that mean depression’s not a brain disease. Does the element of will in the treatment mean depression’s not a brain disease (see stigma, below)?

The author’s description of the role of stigma in addiction diminishes it to a throw away consideration. This is misleading. Stigma does keep people out of treatment, it keeps them from using insurance coverage they might have, and it is responsible for a huge financial toll on society. Stigma is why addiction treatment is not part of mainstream medicine, it’s why coverage for treatment isn’t a mandated part of health insurance coverage and it’s why (almost literally) the North Carolina legislature recently voted for health insurance parity for mental illness, but not addiction. According to the Robert Woods Johnson Foundation, in 1995 the economic costs for alcohol and drug addiction were over $275 Billion. Of that $55 Billion was for medical costs and deaths related to drug use. If we could get more people into treatment, many of those costs could be mitigated. Stigmitizing addicts in the bizarre hope that shame will drive them into treatment only helps to ensure we will continue to bear the personal, family and societal costs of addiction. Arguing that it’s not a brain disease only does the opposite

Isn't your last paragraph the real key to the debate: getting access to insurance coverage? Aren't the mental health practitioners self interested in the debate?

Big mistake: The first sentence in the 6th para should read :Those, like myself, who favor labeling addiction a brain disease are NOT fatalistic about its outcome.

Serves me right for rushing my reply.

The parallels you draw between addiction and "lifestyle" illnesses certainly creates doubt that addiction and illness are always clearly separate things. But it ignores some differences:

• The linkage between the value-seeking behavior and the injurious consequence is much more direct and immediate in addiction than it is in the lifestyle diseases you mention. They typically develop over many years; the onset of addiction, though sometimes gradual, is usually much more short-term and its injurious consequences become more immediately apparent.
• The social dimension differs between lifestyle diseases and addiction. Some of the former have no particular social dimension (e.g., hypertension), others are relatively low-impact (e.g., obesity). Addiction, almost by definition, is a high-impact phenomenon, typically regarded as a problem by others long before the addict himself sees it as such.
• The legal dimension also differs. It's perfectly legal to overeat, be indolent, or subject yourself to stress. Most addictive drugs, however, are controlled substances. Alcohol is legal (though not for minors and those under court order), but in the excessive quantities associated with addiction it is intimately involved with much illegal behavior (e.g., public inebriation, DUI, or domestic violence ).

These differences make it impractical to classify addictions as medical problems in the same sense that even lifestyle diseases are. In both cases, it is desirable for an individual's behavior to change, but in one case society is comfortable with leaving the individual in control of that decision and in the other society is not. Addiction is perceived to impair the individual's decision-making competence, while other lifestyle defects are not. Addicts typically resist changing their behavior for shorter or longer times. That, combined with the more immediate and more significant social impact of their behavior, is why society tends to treat them more coercively than it does lifestyle "offenders."

Fritz,

This is a very thoughtful response to my post, far more thoughtful (unless you consider artful twisting of logic artful) than the article that caused me to write in the first place. I must, however, disagree with you. Let me start at the top.

It's not clear to my why the linkage between any particular behavior and injurious consequence should be a criterion for judging whether the outcome is a disease or not. The key criterion should, I believe, be the injurious outcome. There is now ample and ever accumulating evidence that addiction changes the brain in ways that outlast the drug use that induced the changes. I really can't see how this is any different than an arterial plauqe caused by too much fatty food.

Similarly, the speed with which the injurious consequences occur should not be a criterion. Infections develop in days. Addictitons can often take years or even decades to manifest themselves. Again, it's the outcome that matters.

And then there's the legal dimension. Tobacco is, by many measures (e.g, the percentage of people who try vs. the percentage who become addicted is highest for tobacco) the most addictive drug. It is legal only for adults, but widely available to teens. It does not cause the kinds of social dislocations or antisocial behavior that alcohol and other drugs do. Yet, it undeniably causes addiction. Worse, it kills far more people (more than 400,000 per year) than all the other drugs put together (~110,000 for alcohol and 20,000 for illegal drugs).

Until very recently, all mental illnesses were stigmatized, and parity for mental health treatment is still not universal, although recognizing it as a brain disease has been changing this. Addiction was, and still is, the most stigmatized affliction of all (perhaps AIDS was in first place for a while, but arguing this point is absurd).

By calling it a sin, or a moral failing, or anything like that, we remove from ourselves (society) the responsiblity of doing anything about this. As I pointed out in my first post, the costs of this, to individuals, to families, and to society are enormous. We need a paradigm shift, and this begins by recognizing that addiction has all the hallmarks and characteistics of many other conditions we recognize as diseases. Maybe it's just semantics, but the real and symbolic value of changing how we think about addiction couldn't possibly be underestimated.

Just ask the family of an addict who can't afford effective treatment.

I don't wish to repeat excessively what I said in another post. However, to summarize, in spite of the interesting points you have made there is a strong reason to deal with drug abuse and addiction as a disease: the public health approach is far more effective (overall, and on a per-dollar basis) at reducing the costs and harms borne by society as a result of drug abuse and addiction than the criminal justice approach. Defining drug abuse as a disease rather than as a crime is a step in the right direction, and may help shift scarce resources into a more productive utilization system in the long run.

In some of the diseases you mentioned. If I have atherosclerosis, I cannot reverse it by changing my eating habits today. The addict can stop his "disease" by being chemical free...today, tomorrow and for the rest of his life. Some of the other diseases take their toll on the old, not the young and (presumably) productive.

I can't say it better, I can only add, that as a former alcoholic/addict, it is definitely not just another "Bad Habit". Of all the appaling things I read, that hit me the most. I did not work my butt off for recovery because I had a Bad Habit. Biting my fingernails is a 'bad habit', interrupting people while they are speaking is a 'bad habit'...alcoholism is a disease. A treatable one, yes, one that takes self determination and accountability, yes, but so is heart disease. You are responsible for heart attacks when you don't exercise, when you CHOOSE to eat poorly, when you sit on your toosh and watch TV..I need not go on. My point is that I agree with this response and while personal accountability and responsibility are a huge part of recovery, it is just that, recovery from a disease. The authors mentioned identifying 'triggers' that made an addict want to use, well guess what, SHAME was one of my triggers and even today feeling shameful will sometimes make me want to run and escape, not motivate me to seek help. The difference is today I have tools to use and support to lean on when these urges take me. Geez, while I respect your education and experience, have either of you ever been addicted to alcohol or drugs? Because reading your article made me feel as if you don't know the addict at all. While I realize we all have our own opinions and beliefs on what works and what doesn't, I have not met anyone in my program who does not think it is a disease. And guess what, we are still in recovery and not hiding behind the label of disease. If you truly understand addicts, you would not believe that simply recognizing it as a brain disease would provide them with an umbrella under which they can justify their problem. An addict will recover when and only when they are ready and when they and only they want it. Not because they are shameful or forced into it by a judge or family member. Same goes for the heart patient who has multiple heart attacks and surgeries because they are not ready to give up the junk food, or the diabetic who eats sugar and carbs because they are not ready to give them up. A disease is a disease but many of them do take personal accountability and responsibily for effective treatment. It took my father one heart attack to "do the right thing", another friend's father is on his 3rd and while both diabetic and heart diseased, he is still eathing chips, not exercising and eating cookies for breakfast with coffee. Now tell me how this behavior is any different than an alcoholic or drug addict who chooses to continue using? Its all about education, treatment, and personal responsibility...but with all, you have to be ready and determined. Shame will not drive you to recover, it might just drive you to death.

It is somewhat ironic that the authors chose Sen. Biden's Recognizing Addiction as a Disease Act (S.1011, in the House as HR 1348) as the entree into their deeply misguided analysis.

While this bill is winding its way through the legislative process, both chambers are also considering what would probably be the most significant legislation for the addiction treatment and recovery community in 15 years--legislation requiring that all insurance plans covering over 50 employees must cover addiction and mental health treatment at the same level that they cover standard medical/surgical benefits. These bills (S.558 and HR 1424, which is preferred over the Senate language by most of the addiction treatment community) would be an enormous step forward not just in reducing stigma, but in actually getting people the medical care they need.

Almost 80% of substance use funding comes from the public sector, even though about the same percentage of people suffering from addiction are employed. A "parity" law would help move addiction into the the mainstream medical system.

If this issue is important to you, I encourage you to e-mail your Representative and ask him or her to cosponsor HR 1424 or thank them for their support it if they've cosponsored it already. A list of cosponsors can be found here.

I have to agree with the pro-disease conclusions. And allow me to add some additional support to this argument. There has recently been an increased interest in seeing the connection between addictions and the varying levels of depression, including schizophrenia and borderline personality disorder. It may seem obvious that in a pool of addicts one could easily conclude that many or even a majority of these people are suffering from depression. But, that depression can range from minor depression to the other side of the spectrum into bipolar depression. There is a problem then in trying to decifer whether or not the addictive behavior preceeded the depression or became a symptom of the depression. When one gets into the bipolar, schizophrenic, borderline side of things - there are often impulse control issues. And in no way am I saying that all of the people who suffer from these afflictions are addicts, just that among addicts there is a new attitude that there may be bigger issues at hand than "simple addiction" - not that addiction is simple either. Simply, addiction may be a flag for undiagnosed depressive/psychological issues that if treated properly may eliminate themselves. It's possible that many of these people who might otherwise be diagnosed with a treatable disease and then eliminate their addiction (aka - self medicate) with treatment continue to be addicts in spite of themselves or any desire to stop because of much, much bigger chemical issues. It's also possible that many of these people who become bipolar, borderline, schizophenic, etc become that because the addiction "flips the switch" for that disorder that they very likely inherited genetically to begin with.

Some of these inherited disease is just a game of roulet - you often get it whether or not you take all measures to avoid it - it's just a matter of when and how severely.

Addiction is very particular in example, and the range of explanations put it out for debate. Anything that alters ordinary mental functionality is by far a disorder. Addiction is something sought with no greater motivations, but occupation does not keep some working class folks from finding it in their own lives, to open tensions or restraints. Addiction has many faces, and the addicts out there probably cover a surprising range, from types to the first time they did a drug. If they are left out of treatment, then they are left out of being compatable with a society that disgraces them, and puts them in a position to bend or rebel.

I want to reply but it's difficult to find the time until this evening. Check back tonight or tomorrow.

eom

I'll be honest: I think that past a certain point (and I'm not sure where that point lies, exactly), addiction BECOMES a brain disease. The consumption of psychoactive substances (including addictive substances) does remodel the brain and has the potential to permanently alter the brain's chemistry. That's what I think when I'm responding rationally.

On another level, I just want all addicts GONE, punished, scorned and shunned. I unwittingly married a drug addict. He hid his addiction extremely well. We remained married and together for over 5 years. It wasn't until I found out that he'd been fired from his job because he failed a drug test (and I found that out from a friend whose husband worked with mine) that all of the strange, crazy stuff over the past few years made sense. So I left. But he put me through 4-plus years of hell because of his addiction, and I want to lash out at any addict.

I'm also irate because I spent about 16 years battling my own mental illness, intermittently trying to get treatment, but denied (until January of this year) because I didn't have substance abuse issues or an arrest record. The substance abusers and petty criminals got higher priority than I did because I "only" had mental health issues. When I hear people fresh out of rehab talking about their experiences, I feel only resentment because they could get treatment while I couldn't. I FEEL that their woes are self-inflicted, whereas I fell ill through no fault of my own.

However, I'm fairly good at shoving my emotional responses aside. I know that prudent policy is to treat addiction where possible, and to provide services to intractable addicts. Morality shouldn't come into it: cost, and cost-effectiveness should. It's cheaper to house and monitor homeless alcoholics than it is to pay for the inevitable ambulance ride(s) to the emergency room. It's safer for the alcoholic, and it's safer for those around him or her. It's folly to expect everyone to do what they *should* do, and far better to be ready to deal with the consequences of those who won't.

Natural illness should take priority before conditioned illness. It is terrible to hear it doesn't work that way. Of course, when someone almost kills themselves over it, the unfortunate outcome is to treat the addicted first. Personal problems and the system, never seem to work out adequately, it is pretty much seeing who can get screwed over without the evidence.