I’m following up my previous post with this brief discussion about addiction and brain disease. I’d like to note that I am no expert and have no practical experience with addicts or psychiatric practice. This is merely an opinion article meant to stimulate thought and discussion. Enjoy!
O Divine Providence! Bestow Thou in all things purity and cleanliness upon the people of Bahá. Grant that they be freed from all defilement, and released from all addictions. Save them from committing any repugnant act, unbind them from the chains of every evil habit, that they may live pure and free, wholesome and cleanly, worthy to serve at Thy Sacred Threshold and fit to be related to their Lord. Deliver them from intoxicating drinks and tobacco, save them, rescue them, from this opium that bringeth on madness, suffer them to enjoy the sweet savours of holiness, that they may drink deep of the mystic cup of heavenly love and know the rapture of being drawn ever closer unto the Realm of the All-Glorious. For it is even as Thou hast said: ‘All that thou hast in thy cellar will not appease the thirst of my love—bring me, O cup-bearer, of the wine of the spirit a cup full as the sea!’~ ‘Abdu’l-Baha (A Baha’i prayer for relief from Addiction)
Erickson (2006) argues that dependency is a brain chemistry disease: “Disease is in the brain. Uncontrolled drinking is just a symptom.” The problem with this statement is that it rescues the user from any responsibility. Erickson continues by stating, “In some cases, genetics are so ingrained in an individual that dependence is almost ordained.”
I have a problem believing that any behaviour (outside of autonomic processes) is “ordained.” How can alcohol dependence be ordained if there is no alcohol available to the individual, or if the genetic predispositions are identified at an early age and the individual is made aware of their vulnerability (a test that is not yet available to science)? Where a sentient being is aware of their past and future, rewards and consequences, there is always an element of choice.
As I argued in my previous post, a disease results when the normal functioning of some part of the body is disturbed followed by structural changes. Alcohol dependence is the result of a physical predisposition (which, we could argue, is a structural abnormality) combined with an external trigger. I don’t think this qualifies.
We can’t identify the predisposition the same way we can identify physical abnormalities associated with disease. For instance, Acute Lymphoblastic Leukemia can be identified with physical examination including a blood count, blood smear, RNA testing, and medical imaging. If the individuals’ physiology is outside of certain parameters than we know they have the disease. Alcohol dependence is diagnosed using behavioural indicators and self-report tests and reinforced with physiological markers such as blood alcohol level. Metaphorically, if we say that addictions are diseases because normal behaviours are disturbed followed by physical changes, okay perhaps. But how does this affect our approach to treatment?
I’m not saying that addictions are totally psychosocial in nature, I’m just saying that the term “disease” doesn’t apply here. Either the health sciences should completely re-evaluated their definition of the term “disease,” or we have to come up with a different term for conditions that result from the combined forces of physical predispositions and environmental triggers.
The National Institute on Alcohol Abuse and Alcoholism (NIAAA; 2005) report clearly demonstrates that alcoholism is a complex condition that emerges from the interaction of many factors. Drinking behavior is highly heritable (Reich et al., 1998), however there is no evidence for the existence of an “alcoholic” gene; rather, a number genes interact and predispose a person to alcoholism. Also, genetic factors do not exist within a vacuum, but interact with sociocultural, psychological, and environmental factors to increase or decrease a person’s susceptibility to alcohol dependence or abuse. Lastly, each individual’s biological make-up interacts with alcohol in different ways (e.g. some metabolize alcohol faster than others), which can determine a person’s risk of developing an alcohol use disorder.
There are just too many variables involved here for me to be comfortable with diagnosing Alcohol dependence as a disease. Satel and Lilienfeld (2010) do a great job demonstrating the difference between a true disease and what alcohol dependence is:
“No amount of reinforcement or punishment can alter the course of an entirely autonomous biological condition. Imagine bribing an Alzheimer’s patient to keep her dementia from worsening, or threatening to impose a penalty on her if it did. It won’t work.”
If we disempower individuals suffering from addiction by unintentionally convincing them that they are diseased then they may falsely assume that any effort on their part is futile. A self-fulfilling prophecy ensues.
“Whether powered by changes in meaning or incentives, the capacity for self-governance is the key to the most promising treatments for addiction. This fact is often obscured, however, by a semantic glitch whereby the state of ‘addiction’ is taken to mean that the desire to use is unmalleable and beyond the reach of environmental contingencies. In circular fashion, then, addicted individuals are believed to be helpless to change their behavior.” ~ Satel and Lilienfeld (2010).
Erickson, C. (2006, April). Distilling fact from fiction: Scientist debunks myths about alcohol dependence to reduce stigma of complex disease.
National Institute on Alcohol Abuse and Alcoholism. (2005). Etiology and Natural History of Alcoholism. Social Work Curriculum on Alcohol Use Disorders (Module 2). Retrieved from http://pubs.niaaa.nih.gov/publications/social/Module2Etiology&NaturalHistory/Module2.html
Reich, T., Edenberg, H.J., Goate, A., Williams, J.T., Rice, J.P., et al. (1998). Genome-wide search for genes affecting the risk for alcohol dependence. American Journal of Medical Genetics, 81, 207-215.
Satel, S., & Lilienfeld, S.O. (2010). Singing the brain disease blues.