Addiction: Neither choice, nor disease.

I spend a lot of time thinking about addiction. Probably an inordinate amount of time, really.

Part of that is due to my role as manager of a wilderness based addictions treatment program for youth with Enviros. Partly it’s due to my diabetes diagnosis a few years back, and the swift realization that comes when you understand that sugar and cocaine aren’t all that different, neurologically speaking.

I thought I’d treat you to a somewhat long(ish) post on my thoughts about what addiction is, and isn’t.

So what, exactly, is an addiction?

The American Society of Addiction Medicine defines it as;

A primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.

Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.

Let’s break that definition down a little bit.

Reflected in an individual pathologically pursuing reward and/or relief. What is pathological? “Behaviour being such to a degree that is extreme, excessive, or markedly abnormal”. Huh. Suddenly checking my smartphone 10x an hour, cruising Twitter late at night, binge-eating almonds while writing blog posts…are these extreme? Excessive? Abnormal? And who gets to decide what’s normal and abnormal? One of the problems that instantly arises when using the word pathological (essentially, abnormal), is that we then need to establish what “normal” is. And that’s a problem in a society that thrives on addiction, from the afore-noted smartphone and twitter checking to excess consumption in all of its various forms.

Let’s dig a little deeper, shall we?

Characterized by inability to consistently abstain, impairment in behavioural control, craving, diminished recognition of significant problems with one’s behaviours and interpersonal relationships, and a dysfunctional emotional response. Yes. All of these things are symptoms of addiction. Craving. Diminished recognition of significant problems (health, financial, social, relational). Impairment in behavioural control, the inability to abstain. Kind of sounds like the typical Friday night dip into the ol’ tub of ice cream, no? It’s all good and then BAM…diabetes. Or 30lbs of extra weight around the middle. Or any number of significant problems.

One of the biggest issues that I see with how we currently conceptualize addiction in society is that there are two school’s of thought. Choice, and disease. Both of which are kind of true, but not really.

Proponents of the choice model of addiction would see addicts as simply being morally inferior, unable to “just say no” and make a better choice. Because someone wakes up one day and decides to go live in the gutter and score some heroin. Makes sense. Here’s the thing; addicts don’t wake up and “choose” to smoke some crack, like you and I might choose what to eat for breakfast. Addiction is a disease of brain reward, motivation, memory and related circuitry. In other words, it’s a problem with our executive function centres in the brain (the places that make decisions).

Of course, the choice model fits very nicely into the (largely conservative, right of center) philosophy and narrative of individualism, free will and personal agency. Not that any of those ideals are inherently flawed (and I’ll try and avoid this become a pseudo-political rant), but when applied to addiction, well, these ideas completely ignore ALL of the related science on the matter, as well as the experiences of addicts and professionals everywhere.

The choice model of addiction locates all of the responsibility and blame within the addict themselves, absolving society of addressing the systemic and underlying causes of addiction. And it certainly doesn’t explain why certain populations are at much higher risk of addiction. You would expect that an equal number of people across the social strata would “choose” to use substances, when the reality is that some communities are hit much harder than others, and some people are much more susceptible than others.

Let’s look at the disease model. I’ll admit to finding more in common with this definition, but I still find it lacking in some key areas.

First, addiction is incredibly complex. If it wasn’t, we would have solved it decades ago. One of the challenging parts for me with the disease model, is that it removes the addict from being in control. Wait, didn’t I just bash the choice model? How can the addict have control when addiction isn’t a choice? Considering addiction a disease, in the same realm of cancer or arthritis, puts the addict on a different cycle of dependence…the health care system. Doctors. Psychologists. Therapists. Experts with the answer. And maybe a pill or two to help along the way. It does a good job of externalizing the problem for the addict…but it doesn’t provide a hell of a lot of hope, does it? You have a disease. A really complicated disease. A disease that we aren’t very close to figuring out.

Other factors that can contribute to the appearance of addiction, leading to its characteristic bio-psycho-socio-spiritual manifestations, include (according to ASAM, 2011):

  1. The presence of an underlying biological deficit in the function of reward circuits, such that drugs and behaviors which enhance reward function are preferred and sought as reinforcers;
  2. The repeated engagement in drug use or other addictive behaviors, causing neuroadaptation in motivational circuitry leading to impaired control over further drug use or engagement in addictive behaviors;
  3. Cognitive and affective distortions, which impair perceptions and compromise the ability to deal with feelings, resulting in significant self-deception;
  4. Disruption of healthy social supports and problems in interpersonal relationships which impact the development or impact of resiliencies;
  5. Exposure to trauma or stressors that overwhelm an individual’s coping abilities;
  6. Distortion in meaning, purpose and values that guide attitudes, thinking and behavior;
  7. Distortions in a person’s connection with self, with others and with the transcendent (referred to as God by many, the Higher Power by 12-steps groups, or higher consciousness by others); and
  8. The presence of co-occurring psychiatric disorders in persons who engage in substance use or other addictive behaviors.

You don’t often hear other diseases that have factors including the “ability to deal with feelings” and “distortions in a person’s connection with self, with others and with the transcendent”. Got a tumour? Cut it out or blast it with radiation. Got addiction? Build your emotional literacy and connect with a higher power?! That doesn’t sound like a disease to me, at least in my somewhat mainstream understanding of disease.

This is turning into a long post. Why don’t we break it up with a TED talk? Watch Johann Hari as he explains why everything you think you know about addiction is wrong.

Suddenly, neither choice nor disease seem like adequate descriptions of addiction.

What if, instead of viewing addiction as a problem, we started to view it as a symptom?

And let’s go even further. All of us, all of the time, are consciously and unconsciously meeting our needs. From biological to psychological, social to spiritual (quick aside, check out this book…the most important one you’ll ever read, which does a great job of explaining a needs-based approach to just about everything). What if addiction is simply an attempt to meet an unmet need? 

Suddenly the list of “other factors” that influence the development of addiction make a lot of sense. Been traumatized and have poor emotional regulation as a result? Suddenly smoking some weed or having a drink makes a lot of sense. The problem with both the choice and disease models of addiction is that they stop short. They presuppose that the addiction is actually the problem that needs to be tackled, instead of viewing it as the symptom of something deeper that it is.

If we’re really serious about addiction, we’ll stop the practice of both scapegoating addicts through the “choice” lens and trying to explain it away as a “disease”.

As Johann says in his talk…the opposite of addiction is not sobriety, it’s connection.


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