A few weeks ago I participated in an hour-long talk show, via Skype. It's called The Agenda with Steve Paiken, and a lot of Canadians watch it. I was a bit nervous that night. Behind me the camera picked up vague shapes in a dark, messy living room—watching it afterward, I thought I looked like a resident in some unlit chamber of hell, compared to the bright faces in the studio in Toronto. But the real problem was that one of the three other guests was an MD, a psychiatrist, named Peter Selby—a guy who does both research and clinical work at a psychiatric/addiction institute in Toronto, called the Centre for Addiction and Mental Health. And he, like many of his colleagues, really sees addiction as a disease.

But I don't. So we argued about it. It was all quite civilized, but we weren't seeing eye to eye. And yet he had some good points.

Politics and pontification aside, am I really so sure that addiction is NOT a disease? This is a topic that I've gotten into before, but not in much depth. I know how to talk the talk. I'm used to arguing cleverly that the "disease concept" of addiction is really just a metaphor, and a sloppy one at that. It can be useful. It helps us refrain from beating ourselves up if we think we've got a disease. But maybe it robs us of the sense that we can overcome it through our courage and our creativity—something you can hardly do with a real disease.

I have some good sound bites... like: if addiction is a disease, then you must contract it at some point, and then you have it, and then you get treatment, and if the treatment works, then you're cured. And if it doesn't, you have the disease until you die. I can talk like that, and I can conclude that those are NOT the characteristic features of addiction. But now I'm not so sure, and I wonder if I'm the one being too superficial to give this matter the attention it deserves.

Because Selby was right about one thing: "disease" is not such a simple black-and-white concept. Take Type 2 diabetes. You don't catch it or otherwise contract it. Rather, it grows—it's really a developmental disorder that comes about when people make bad choices about what they eat. Or live in unhealthy environments. And it's not something you try to cure, it's something you try to treat. The same could be said for quite a few "medical" diseases. Like high blood pressure? Like colitis or irritable bowel syndrome? Like carpal tunnel syndrome? When I'm on an anti-disease rant, I often fall back on the argument that brains change with development, they change with experience, they're supposed to change: learning changes the brain, addiction is a kind of learning, it's highly accelerated, it's very focused, but it's still a process of learning. So I'm thinking, diabetes, colitis... do they change the structure of your body too?

Well, of course they do.

And yet your body isn't supposed to change in those ways. Aha! I think I've clinched the argument. Except that I have this intrusive thought: brain changes that come about with addiction are NOT so natural after all. Sure, the brain is designed for its mutability. It's supposed to be able to change with learning. But it's not supposed to change so much that you can't secrete dopamine in the ventral striatum without focusing on your drug or drink or sexual obsession or food obsession of choice. That's a pretty screwed up brain, even if it got that way through a "natural" "developmental" process. So... is the outcome of addiction really distinguishable from what we call a disease?

I have a few more thoughts about this, but first I'd like to hear your comments. And having said that, I suggest we all leave our politics at the door. Because the 12-step versus do-it-yourself versus the self-medication approach versus the "choice" position—all those territorial disputes take our attention away from the fundamental issue, the thing we really need to focus on. Which is: what is addiction? What is it really?

(Please also visit my home blog, and tune in to a fascinating dialogue among addicts, ex-addicts, scientists, and therapists.)

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