Is Addiction a Disease?
Addiction is a condition that has long baffled physicians and philosophers, to say nothing of those struggling with it and those around them. What to make of a set of behaviors that in fact induces changes in brain structure and function, provides short-term relief of distress only to create long-term problems of living and self-management, and is difficult to stop even when there is a strong desire to do so?
Once seen as a moral failure, addiction has more recently been viewed strictly as a medical problem. The push to regard addiction as a disease is well-intentioned—driven by a desire to lessen stigma—but fails to account for the many facets and facts of the condition. Worse, it robs sufferers of the sense that they can overcome the problem with courage, creativity, and some hard work. Rather, there is significant evidence that addiction is a complex cultural, social, and psychological phenomenon, as much as it is a biological phenomenon.
While addiction is very costly to individuals, families, and society at large, it reflects the brain’s remarkable plasticity—its ability to shape and reshape itself, adapt itself, in response to experience and environment—as well as the deep human need for joy and rewards in life and opportunities for accessing them. The fact is that the brain changes that are the hallmark of addiction are set in motion by the behaviors of substance-seeking coalescing into near-automatic habit. The evidence indicates that they can be reversed by changes in behavior and environment.
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Because addiction is such a complex phenomenon, there are many theories about what addiction is. They are of more than academic interest. It matters how people view addiction because that influences what they are willing to do about it, or even whether they believe they can do anything about it.
Seeing addiction as a disease can make individuals feel hopeless about change and helpless, with no possibility of control over their own behavior. That doesn’t mean it is easy to gain control of the behaviors involved in addiction—but it is possible, and people do it every day. The disease model of addiction also suggests to people that they existing in a fragile state of recovery forever, always in danger of failing. It keeps them focused on the problem more than the solution.
Perhaps most of all, regarding addiction as a disease and not a deeply ingrained habit defies the evidence and obscures the true pathway out—discovering personally rewarding goals and activities that, repeated again and again because they are meaningful, help rewire the brain. People have to discover new goals worthy of pursuit for them. In pursuing them, new habits override old ones.
Addiction is considered a disease largely as a way to remove stigma, guilt, moral blame, and shame from those who use substances or certain behaviors repeatedly to feel intense euphoria and as a way to encourage humane treatment. It is also viewed as a disease in order to facilitate insurance coverage of any treatment.
Unfortunately, at the very same time, it prods people to see themselves as hapless victims of a process beyond their control. Addiction is definitely difficult to understand, because it starts out as a voluntary activity but, for many people, the brain adapts so quickly to that activity it becomes difficult to control. Changes in neural circuitry make the reward extra compelling; it becomes difficult to pay attention to anything else and difficult to stop, even when use creates problems and there is a desire to quit.
The fact that addiction changes the way the brain works lends credibility to the idea of a lifelong disease, even though, according to the National Institute of Drug Abuse, the changes are “persistent”—which is not the same as permanent. But turning addicts into patients keeps them from doing what is essential for recovery—discovering a personal goal deeply, individually meaningful and rewarding enough to satisfy the neural circuitry of desire.
Addiction changes the circuitry of the brain in ways that make it difficult for people to regulate through deliberative efforts the allure of a concentrated chemical rush of reward. Continued use of a drug increasingly dysregulates reward, motivation, and executive control systems. But the brain changes are not a malfunction of biology, which is the defining feature of disease. Rather, the brain changes of addiction reflect the normal plasticity processes of the brain, its every-day capacity to change in response to experience, the basis of all learning. Unlike other organs, the brain is designed to change.
The act of repeatedly using a highly pleasurable experience—drugs, gambling—alters neurons; they adjust their wiring to become increasingly efficient at the experience. They prune away their capacity to respond to other inputs. It is a form of deep learning. As problematic as the consequences can be in someone’s life, the process can, through effort, be reversed. Recovery also relies on neuroplasticity; changing behavior rewires the brain.
Habits are behavioral routines that are repeated so often they get wired into the brain as a matter of efficiency. The brain is always changing and adapting to experience—even now, as you read this. Habits are a kind of mental shortcut, fast-tracking the neural connections involved in an activity so that you don’t need to consciously think out every step. The brain is designed to work that way. Unfortunately, that wired-in efficiency is what makes habits hard to break.
Consuming certain substances or engaging in certain activities is so pleasurable for some people they are driven to repeat the experience. Habits make behaviors near-automatic in response to any elements related to that activity—in other words, hard to control. Recognizing that addiction is a habit in the scientific sense of the word makes clear that recovery is possible with deliberate action to change, which reverses the changes to the brain.
No one chooses to get addicted. The process of addiction is set in motion automatically, by the brain’s response to a behavior repeated often enough because it is reinforced by the very pleasurable—but, alas, short-lasting—reward of dopamine surge. What starts out as a voluntary choice gets quickly encoded in the neural circuity and relegated to automatic processes that leave little room for conscious control.
In addition, the part of the brain focused on goal-pursuit and reward (nucleus accumbens, or ventral striatum) actually changes and gets ever-more sensitive to dopamine, making the cocaine or gambling increasingly attractive and all-consuming—compelling, you could say. And the prefrontal cortex, the area of the brain responsible for rational decision-making, judgment, and control of behavior gets weakened, its connections to other parts of the brain pruned away.
While there is an element of choice in substance use, the neural actions of dopamine tilt the brain to be so interested in the immediate reward that it can’t even contemplate longer-term goals or exert control. That is why those who are addicted repeatedly act against their own best interests, frustrating everyone around them—and themselves.
Neuroscience research supports the idea that addiction is a habit that becomes quickly and deeply entrenched and self-perpetuating, rapidly rewiring the circuitry of the brain because it is aided and abetted by dopamine. Because the surge of dopamine reward is very short-lasting, it drive frequent repetition and habit formation. In many ways, addiction is like a disease: It causes serious problems in functioning. It creates feelings of helplessness, whereby those in the grip of addiction feel like they can’t get better of their own accord. The problem is incredibly persistent. But “disease” might best be seen as a metaphor when it related to addiction. As a habit, addiction can be seen as a form of deep or extreme learning, operating through the brain’s remarkable powers of neuroplasticity, as all learning does.
Most people who meet the clinical criteria for an alcohol or other drug use disorder achieve full recovery, data show. Perhaps the most interesting proof of the curability of addiction came from a natural experiment, when soldiers returned home to America from Vietnam, where heroin use and addiction were widespread, affecting 15 to 35 percent of enlisted men. Heroin use was so common that soldiers were required to be tested for heroin addiction before being allowed to depart Vietnam.
As soldiers left the strange mixture of fear, boredom, combat tensions, and poor living conditions of the battle zone in the early 1970s, the vast majority—95 percent, according to studies—left their addiction behind, despite opportunities to become readdicted. The Vietnam experience highlights the significant role that factors other than human biology and the nature of the addictive agent play in addiction. Environments and opportunities for other experiences matter—they also shape brain pathways of reward. They are critical to helping those recovering from addiction find a new sense of purpose.