Anti-addiction-as-disease believers?

I was invited to screen the documentary "The Greater Good" (how's that for a self-aggrandizing title?) as a part of the New York Film Festival. The film was anti-vaccination propaganda -- a movement which I have disparaged, sometimes politely, sometimes not.  Of course, the film's creators and supporters reject the idea that they're anti-vaccination, which they realize sounds crazy. Instead, they claim to be starting a "discussion."

But let me leap to the last question from the audience, which comprised anti-vaccination supporters and fellow filmmakers (it was shown at NYU, no less!).  Following a number of questions by people obviously in the anti-vaccination camp, a woman in the rear asked, "Why did you only show cases of people you claim have been harmed by vaccines, but no cases of people whose families were harmed by NOT being vaccinated?"

Why indeed? This one-sidedness undercut any claims of objectivity the filmmakers might wish to make. One of the couple who made the film gave a long explanation about how they found such people but couldn't include them in the movie.  This was the only comment about the film from the filmmakers -- the rest of the "discussion" was controlled by an anti-vaccination activist from the film. I felt like I was at a Hara Krishna prayer meeting (did I mention that this was held at NYU?).

Of course, the impact is overwhelming from seeing families devastated by losing a child, autism, and -- in the most detailed case -- a high school girl who developed severe immune-system and neurological diseases as a result, she and her mother believed, of receiving Gardasil.  The Mayo Clinic Web site says about being vaccinated against sexually transmitted infection human papillomavirus (HPV): "Widespread HPV immunization, however, could reduce the impact of cervical cancer worldwide." Hmmm, they couldn't film the horrors experienced by one person with cervical cancer who wasn't vaccinated?  Gardasil incurs, in addition to the wrath of anti-vaccinators, that of the abstain-from-sex crowd. Indeed, the poor girl depicted said she should never have taken the vaccine because she had already resolved to remain a virgin until she married.*

But all of that is not what this post is about.  This post is about how, as I sat in the audience, I imagined that someone -- many people -- might say, "Stanton, you support the anti-disease theory of addiction, which is exactly the same thing as opposing vaccinations." Indeed, they have been proposing anti-addiction vaccines for years now!

I recall an experience I had once at a conference on addiction organized by the New York Psychological Association.  A researcher from the University of Pennsylvania medical school approached me to tell me how visionary my book, Love and Addiction, had been in anticipating decades earlier the movement among addiction researchers to see addiction as occurring with involvements other than with drugs.  Surprised, I asked if I could come to speak to his group, which was led by Charles O'Brien and Thomas McClellan - neither of whom I have ever met.  This psychologist said, "I wouldn't want to embarrass either you or my program—you are completely out of touch with modern developments."

These worthies view me like I view the anti-vaccinationists!

So let me take on two ways in which this can be said to be true, in the form of a comment on a post of mine by Ian.  Ian first notes all the organizations aligned in support of the disease theory of addiction—just as every major public health body supports vaccination.  He then goes on to cite brain imaging research—sort of—to prove addiction is a disease.  In the second case, as we shall see, the addiction-as-disease people and the anti-vaccination nuts are in the same camp!

I.  Organizations Backing the Disease Theory

Ian says:

Here are other organizations that recognize addition as a disease:

AMA, ABA, APA, WHO, Americans with disabilities, NIDA, SAMHSA, IRETA

I have no personal experience with addiction but I have been a tx provider for over 20 years. Most of my collegues agree with the disease concept, but still others do not. Those who don't provide excellent care to their clientele anyways. Furthermore, with the strides made in brain imagery (PET), measurable changes are now available to provide evidence addition as disease (sic).

Ian is actually somewhat wishy-washy on anti-disease theory people as nuts, since he notes that redoubtable professionals he works with hold anti-disease views.  But his post is essentially, "the disease theory is science -- discount it at your peril."

Here is my response to Ian:

When you write "APA," that might refer to either the American Psychological Association or the American Psychiatric Association -- two quite important organizations in regards to thinking about alcoholism, don't you agree?

When I Google "American Psychological Association alcoholism disease" (and this blog IS Psychology Today) I arrive here: "Understanding Alcohol Use Disorders and Their Treatment." That doesn't sound very diseasey, does it? The page doesn't use the word "disease."

By the way, George Vaillant claimed the American Psychological Association said alcoholism was a disease in his book, "The Natural History of Alcoholism," which I reviewed for the Sunday NY Times Book Review here. I notified the APA, and they objected, forcing George to retract his statement, which really pissed him off.

The American Psychiatric Association makes its views about mental disorders known primarily through DSM -- which is the diagnostic manual used worldwide. I was an advisor on DSM-IV's substance use disorders section -- it doesn't say alcoholism and addiction are diseases. In fact -- DSM-IV doesn't use the terms "alcoholism" and "addiction," but rather the term substance dependence. Here's what Wikipedia says about alcohol dependence: "Alcohol dependence, as described in the DSM-IV, is a psychiatric diagnosis (a substance related disorder DSM-IV) describing an entity in which an individual uses alcohol despite significant areas of dysfunction, evidence of physical dependence, and/or related hardship."

Doesn't sound so diseasey either, does it? So, when you decide on the nature of alcoholism by listing organizations, it's quite a bit more complicated than your list might make it seem, wouldn't you agree, Ian?

Now, DSM-V plans to resume use of the term "addiction," which Nora Volkow and Charles O'Brien had a lot to do with -- as I describe here for Psychology Today. They are great believers in addiction as a brain disease, so it will be interesting to see whether DSM-V decides addiction is a disease (by the way, DSM-V labels gambling as addictive).

Ian, don't you find it intriguing that, at this late date (after all, AA began in 1935, more than 75 yeas ago), there are still all these uncertainties around the addiction-as-disease concept (and even use of the terms "alcoholism" and "addiction")? Somehow, despite your neat list, there seem to be continuing complications in resolving the matter.

Why do you think that is?

I might have added in my response the National Institute on Alcohol Abuse and Alcoholism, which at its Web site announced in 2010: ALCOHOLISM ISN'T WHAT IT USED TO BE, picking up from ideas I have been expressing for decades, including in Psychology Today.

The realization dawned gradually as researchers analyzed data from NIAAA’s 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). In most persons affected, alcohol dependence (commonly known as alcoholism) looks less like Nicolas Cage in Leaving Las Vegas than it does your party-hardy college roommate or that hard-driving colleague in the next cubicle.

II.  The Science of Diseases

The documentary did have the good grace to interview Dr. Paul Offit, of the University of Pennsylvania, author of Deadly Choices: How the Anti-Vaccine Movement Threatens Us All. (Offit and the woman in the audience at NYU both have guts!) Offit confidently asserts that the scientific data show the anti-vaccinationists to be living in fantasy land -- that all epidemiological studies show that children who received thimerosal (the mercury vaccine medium originally identified as the culprit in autism) have no higher rate of autism than those receiving thimerosal-free vaccines.

In this odd circumstance, the anti-scientists claim that Offit and others are looking at the wrong science -- they should, anti-vaccinators maintain, examine the results of laboratory studies showing that mercury and other heavy metals found in vaccines are toxic.  Of course, when the goal is to explain autism, the issue isn't whether various chemicals are bad for you -- the object is to show that these substances cause the problem the anti-vaccinators claim they do.  When they can't, they change the grounds on which the argument occurs -- indeed, they change the definition of science.

Science is an intensely pragmatic, reality-oriented affair.  If research can't be related to the reality we confront, then -- it is useless.  It isn't science.  Which returns us to Ian's comment: "Furthermore, with the strides made in brain imagery (PET), measurable changes are now available to provide evidence addition as disease [should read: 'addiction is a disease')."  What does this mean?  It means the NIDA and Nora Volkow and related researchers examine PET scans of brains of cocaine users and addicts.  And does Ian believe they have found what addiction looks like in the brain—perhaps Ian thinks people in the United States are diagnosed by brain scans?

They're not.  A lot of people take cocaine, few become addicted.  A lot of people gamble, few become addicted.  A lot of people eat and have sex, few become addictedAnd we know nothing, nor have we shown any differences in the brains of addicts from non-addicts to explain this. Nor, when the majority of people quit addictions, as the NIAAA has belatedly (long after me) discovered they do, is something specific observed in the brain to account for this self-cure. So, you see, the anti-vaccinationists, regarded as anti-scientific, make exactly the same claim that the pro-disease-theory-of-addiction people do: disregard epidemiological evidence like that which the NIAAA cites to show that most alcoholics and addicts don't behave like they have a disease, in favor of scientific-seeming studies that -- do what? Ian, you neglected to say what brain images show that proves addicts suffer from a disease. 

It's unfair to lay this on Ian, of course.  He's just reading science magazines, the NY Times, Time Magazine, et al. We need to ask Nora Volkow and Charles O'Brien the question: "How do brain images prove those addicted to cocaine, alcohol, food, gambling, sex have diseases?"

They don't.


*The Mayo Clinic reports this about cases like this girl's:

Serious side effects — including a severe allergic response (anaphylaxis), and neurological conditions, such as paralysis, weakness and brain swelling — have been reported in a small number of women. The FDA continues to monitor all such reports. To date, however, almost all reports of such adverse side effects appear to have occurred by chance around the time of immunization. They don't appear to have been caused by the vaccine itself.

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