Is the Disease Concept of Addiction Real, or Just a Trick?

Four reasons we see addiction as a true disease.

Posted Sep 03, 2020

The modern theory of addiction holds that drug and alcohol dependence both results from and causes disease of the brain, characterized by altered brain structure and function. The American Medical Association first declared alcoholism a disease in 1956, but opposition to this idea remains strong. Most opponents believe addiction results from weak character and stigmatize alcoholics and drug addicts. Belief in character weakness is often accompanied by a sense of moral superiority to, and therefore denigration of, addicts.

The psychologist and lawyer Stanton Peele became a leading opponent of the disease theory of addiction with the publication of Love and Addiction in 1975 and Diseasing of America: How We Allowed Recovery Zealots and the Treatment Industry to Convince Us We Are Out of Control in 1989. The first book introduced the idea that we can be “addicted” to things other than drugs. According to Peele, addiction is a universal part of the human condition. Nearly everyone becomes addicted to experiences and behaviors at some point in their life and most naturally outgrow their addictions. The descendants of this idea today are such concepts as love and internet addiction. 

I submit that Peele mixed apples and oranges when he considered drug and alcohol dependence under the same rubric as non-drug induced behavioral addictions. The word “addiction” first appeared late in the sixteenth century and meant having a proclivity toward something. “Alcoholism” was coined in 1849 to mean a person who has a proclivity, or addiction, to drinking alcohol. In severe alcoholism, drinking becomes the central organizing principle of a person’s life.

It is unfortunate that the word addiction ever became associated with alcohol and drug dependence. The disease of alcohol and drug dependence is altogether different from a mere proclivity. The disease concept is based on physical changes in the body and brain that result from introducing an alien chemical from the outside.

First, some people are prone to chemical dependence for purely genetic reasons. Twin studies show that sons of alcoholic fathers raised in non-alcoholic families have the same rate of alcoholism as if raised by their alcoholic parent. When sons of non-alcoholic fathers are raised with an alcoholic father, they have the same rate of alcoholism as they would have if raised by a non-alcoholic father. There is no dispute that genetics play a role in the susceptibility to developing alcohol and drug dependence. 

Second, sons of alcoholic fathers respond differently, physically, and experientially, to alcohol. Low dose alcohol has less effect on balance, stress hormones, and a sense of intoxication in sons of alcoholics than in sons pf non-alcoholics. These lesser reactions to low dose alcohol mean that an early warning system of impending greater intoxication is missing. This raises the likelihood of consuming higher amounts.

Third, the offspring of alcoholics are far more likely than family history negative offspring to experience a blackout in the first year of their drinking. This is further evidence that their brains’ reaction to alcohol is abnormal. Many stories parallel Bill Wilson’s, one of the two founders of Alcoholics Anonymous. He described an immediate and profound transformation in his sense of identity and comfort, both in the world and in his own skin, with his first drinks. His brain was prewired in some as yet ill-defined way to respond to alcohol differently than the norm.

None of the above is meant to deny that people without any extra genetic push toward alcoholism cannot become alcoholics. We all have the capacity to be alcoholic. Given enough consumption, everyone’s liver will increase enzymes that metabolize alcohol, producing tolerance, and eventually cirrhosis. Given enough consumption, everyone will develop withdrawal symptoms, including tremors, delirium tremens, and seizures.

Many people drink and use drugs irresponsibly, whether for pleasure, to compensate for lack of direction and meaning in their lives, or to “medicate” underlying psychiatric difficulties. Whether this irresponsibility stems from a weak character or is facilitated by socioeconomic and/or traumatic family dysfunction can be debated for any given individual. However, it does not have to be debated that very few people set out with the intention of becoming alcohol or drug dependent. As their brain is bathed in chemicals, its structure and function are involuntarily changed, usually in ways beyond a person’s awareness. These changes within the brain are the fourth reason for considering chemical dependence to be a disease. 

Just as Alzheimer’s and multiple sclerosis attack the brain to produce profound physical and psychological disease, chemical dependence also changes the brain to create physical, behavioral, and psychological changes. In the extreme, alcoholics become demented, lose their memory, and walk unsteadily. Methamphetamine users become psychotic. And daily cannabis users may have measurable memory, emotional, and cognitive impairments. When the brain is not working well, whether from infection, chronic intoxication, or trauma, a person is ill. When I encountered a minister in the emergency room swearing like a drunken sailor because sudden, catastrophic liver failure was filling his brain with toxins, no one stigmatized him. No one accused him of weak character. Instead, he was treated with empathy despite his having foolishly believed he could avoid death cap fungi while foraging for wild mushrooms. He had voluntarily taken a risk and now was deathly ill.

The most insidious change in the brain wrought by alcohol and other drugs happens in the reward center. All drugs capable of creating dependence stimulate the reward center an order of magnitude more than evolution’s design. As a consequence, an urgent desire for the offending chemical is experienced. Wanting and needing replace thinking and planning. Compulsion greater than most people ever feel rises to the level of illness. The brain has been hijacked by an altered reward system. No one seeks this at the onset of their use. Like so many diseases, it sneaks up on people until their ability to recognize its presence and understand its cause becomes too much for a diseased brain to comprehend.

Chemicals that change the brain create more than a mere proclivity or behavioral addiction. They cause disease.