Why the newest classification of addiction as a “brain disease”, while accurate, may cause more harm than good

One of the major focuses of the addiction and recovery advocacy movement over the course of the last couple of years has been to create a shift in public perception and public discourse that moves addiction away from a stigmatized, demonized, criminalized moral issue into the light of looking at addiction as both a medical issue and a public health issue. The understanding is that those people suffering from substance use disorders are not “bad” or “weak” or “evil” people, who are making a choice to cause chaos and harm in the lives of others and kill themselves through substances, but rather they are sick people, dealing with a hijacked brain and a number of societal, genetic, psychological and environmental factors who are in need of vital life-saving addiction treatment in order to heal, recover and re-enter society as functioning human beings.

Amazingly, one of the biggest supports in the argument against addiction being a “moral failing” or choice, was the classification of addiction and alcoholism as a disease. In 1956, The American Medical Association (AMA) came out publically and declared that alcoholism was an illness. In 1991, the AMA further endorsed the dual classification of alcoholism in the International Classification of Diseases under both psychiatric and medical sections. In 2011, the American Society of Addiction Medicine (ASAM) released their newest definition of addiction after a four year process involving more than 80 experts on the topic. At the time, past president of ASAM Dr. Michael Miller said, “At its core, addiction isn’t just a social problem or a moral problem or a criminal problem. It’s a brain problem whose behaviors manifest in all these other areas. Many behaviors driven by addiction are real problems and sometimes criminal acts. But the disease is about brains, not drugs. It’s about underlying neurology, not outward actions.”

To get a good understanding of what addiction is, here is the latest and most up-to-date definition of “addiction” as defined by the American Society of Addiction Medicine (ASAM): “Addiction is 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.”

From 1956 to the present, the classification of addiction and alcoholism as a disease occurred for a number of reasons, the least of which being that addiction IS a disease since it fits the definition for being a disease and therefore there is no reason to think otherwise. Simplistic, we know, but when the heaps of evidence demonstrate a pretty open and shut case and from what it seems, typically those arguing against addiction as a disease are doing so from the stance of personal opinion, personal experience or preconceived notions. However, there are additional reasons as well. Calling addiction a disease gives addiction and alcoholism the validation and credibility needed in order for it to be taken seriously by society; it strengthens the position that addiction and alcoholism are medical issues that require treatment and therefore insurance companies cannot simply dismiss them or refuse to pay for treatment services, thus strengthening and improving reimbursement for providers and improving quality of treatment services; it lessens long-standing stigma overall in society and in doing so reduces the guilt and shame felt by individuals and families that suffer from addiction; finally, and perhaps most important of all, classifying addiction as a disease sheds the addict from blame for the addiction, takes addiction out of the moral arena, removes fault and judgment and ultimately frames the conversation of addiction into that of a medical, health and/or scientific dialogue rather than a moral one. It is both a powerful and truthful tool.

Most recently, over the last several years, the content of the “addiction is a disease” conversation has shifted into an even more medically-driven discussion and the moved into an even smaller, more specialized point of emphasis. For many years, people would go and call addiction a disease because it fits the definition of a disease. However, it seems that the conversation has moved to fit a narrower, even more specific type of disease. Now, when we hear people talk about addiction or alcoholism as being a disease, more often than not what you are going to hear is this: Addiction is a chronic, progressive, incurable disease of the brain. As a society, we have taken a step further in our classification of addiction and, leaning on medical industry insight and expertise, have defined addiction as more than simply a disease and have begun to recognize addiction as a disease of the brain, thanks to years of studying the addict brain and the impact that substances and addiction and addictive behaviors have had upon the brain of an addict. It is widely agreed upon and now the medical industry has even taken a sort of ownership of addiction as a brain disease. It is a powerful stance in breaking stigma, moving research forward, improving treatment modalities, incorporating evidence-based treatment approaches, improving recovery outcomes and removing barriers so that those that suffer from addiction can get the help they need. It is a powerful stance that has long-reaching implications…and it may be a more dangerous stance than anyone first realized.

Why? How? What could possibly be dangerous about the medical community and society as a whole agreeing on the idea that addiction is a brain disease? The problem lies in the simplistic nature of the idea and then in how we as a society approach treating disease.

The problem is that the labeling of addiction as a brain disease is truthful in that addiction is a disease of the brain, but problematic because unlike many other brain diseases (Parkinson’s, dementia, Huntington’s) or disorders (depression, anxiety), addiction is so much more complex than JUST a brain disease. When picturing addiction, we here at MARC like to think about and to picture addiction and addiction treatment like a wheel. One major issue but many spokes. Yes, addiction being a brain disease and characterized by altered brain structure and function, is part of the overall addiction issue, but it is simply one spoke of a wheel with anywhere from 6 to 8 or more spokes. Additionally, treatment for addiction cannot simply be directly treating the brain the way we would treat other brain diseases or disorders: Only looking to treat the brain disease and treat it with medication over time. In order to treat such complex illness like addiction, providers and treatment professionals need to address the whole picture, looking at every aspect of the patient’s life and then treating all those facets in a comprehensive, multi-faceted approach that addresses every spoke on the wheel.

There is no doubt that addiction is a brain disease. However, addiction is much more than just that alone. Addiction is a complex illness with numerous risk factors, biological factors, environmental issues, psychological issues, family of origin issues and family history and influenced by a large number of internal and external issues. Additional pieces of the addiction puzzle are underlying emotional issues, family history of substance abuse or mental illness, trauma factors, personality issues, stressors, and finally impact of social settings, cultural and societal norms, financial resources, family dynamics and the like. The bottom line is, when it comes to addiction, we may be dealing with the most complex of all human ailments and illnesses and we cannot reduce it down or simplify it to a single issue and therefore the solution to treating and overcoming addiction will require a complex, comprehensive approach.

This brings us to one of the more dangerous comparisons often made between addiction and similar ailments or illnesses. Time and time again, the medical community discusses addiction as a brain disease and compares its treatment to the treatment of other diseases and illnesses. This often comes in the form of medication and medication alone. The idea that by simply popping a pill, addiction can be treated. For anyone that has seen, experienced or treated addiction, this clearly is untrue. However, based on popular comparisons often used in the conversation, such as the comparison is made between addiction and depression, the idea that the brain disease of addiction can be treated in that way seems to be gaining momentum within society. It is said, if a person has clinical depression, they need to take their anti-depressants each day to regulate their brain chemistry and thus treat their depression. The same is true of opioid addiction and medications like Suboxone or methadone. Many medical professionals equate someone suffering from addiction like someone dealing with clinical depression, and in order to regulate their body and brain they simply need to take a daily medication. It’s too simplistic a view and does not account for the multitude of issues mentioned above. This issue really takes hold when discussing the new nationwide initiative to increase the number of Suboxone patients an individual doctor can treat be raised from 100 to 250. First, if anyone has an understanding of time management, it seems almost impossible that any doctor could alone be “treating” 250 people that suffer from such a complex illness as addiction at any one time. 100 seems like a stretch, until we understand that this “treatment” really only requires a 15 minute med management session where a doctor refills a prescription, sometimes no more than once a month. No counseling or drug testing is required of the patient. It simply is “take this pill and call me in the morning.”

The bottom line is that addiction is a disease and it is a disease of the brain. However, the bottom line is also that the impact of addiction on the brain is only one piece of a much larger, more complex puzzle. Unlike diabetes, addiction is not simply managing a patient’s sugar. Unlike depression, addiction is not simply taking anti-depressants (although, that being said, neither should depression be treated solely with a pill.) Addiction is a complex illness that touches all aspects of an individuals’ life, both internal and external, and whose seeds could have been planted generations before that individual was even alive. Saying “addiction is a brain disease”, while going a great way to distance the addict or alcoholic from blame and removing the stigma associated with addiction, can also unfortunately act as a cop out in terms of the level of intensity both a treatment provider AND the patient need to go in treatment in order to overcome addiction, ultimately heal and recover. Instead, it allows for a level of dismissive apathy or instead can allow a patient to seek the path of least resistance with the least amount of discomfort. Instead, what needs to be understood is that this complex disease is going to take comprehensive treatment that focuses on ten or twelve or fourteen spokes of a wheel in order to heal. Addiction IS a brain disease and evidence demonstrates that a patient needs time for their brain to heal and recover, just as addiction is so much more than JUST a brain disease and a patient also needs time to address the many facets and factors and core issues and underlying causes and conditions that have created and shaped and fueled their addiction in order for them as a human being to ultimately heal and recover.

If you or someone you know is in need of help because of drug and/or alcohol abuse or addiction, please give us a call. Maryland Addiction Recovery Center offers the most comprehensive dual diagnosis addiction treatment in the Baltimore, Maryland, Washington, DC and Virginia area. If we aren’t the best fit for you or your loved one, we will take the necessary time to work with you to find a treatment center or provider that better fits your needs. Please call us at (888) 491-8447 or email our team at info@marylandaddictionrecovery.com. For more information on all of our drug addiction and alcohol addiction services and recovery resources, please visit our web site at www.marylandaddictionrecovery.com.

MRI representing Addiction as a Brain Disease

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