Addiction is a disease. That’s the view of the vast majority of addiction experts today. A “primary, chronic disease of brain reward, motivation, memory and related circuitry,” says the American Society of Addiction Medicine.
“Addiction is defined as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences,” we read on the website of the National Institute on Drug Abuse. Alcoholics Anonymous speaks of the disease of alcoholism.
The disease model emerged in recent decades, mostly as a rejection of the notion that substance use is a choice and thus a moral failure. Some experts think, it’s neither.
Journalist Maia Szalavitz has covered addiction for almost 30 years and has come to the conclusion that addiction is a learning disorder rather than a disease.
In her new book Unbroken Brain, Szalavitz describes addiction in terms of a “coping style that becomes maladaptive when the behavior persists despite ongoing negative consequences.”
“This persistence occurs because ‘overlearning’ or reduced brain plasticity makes the behavior extremely resistant to change,” plasticity being the brain’s ability to learn from experience.
“The capacity for such overlearning is a feature of the brain’s motivational systems, which evolved to promote survival and reproduction,” explains Szalavitz. It’s behavioral reinforcement: humans are biologically primed to repeat positive experiences but avoid pain and danger.
For Szalavitz addiction is not a disease like diabetes or cancer but closer to developmental disorders like obsessive-compulsive disorder (OCD) or Asperger’s. That has important consequences for the role the “drug of choice” in substance misuse.
“OCD is not driven by the wonderful anxiety-reducing properties of, say, hand washing. There is not something hidden in soap or water that makes people wash and wash again. People don’t ‘catch’ OCD by simply washing their hands—and, by the same token, they don’t develop drug addiction by just taking drugs.” (Unbroken Brain p.71)
That means the presence of an addictive substance alone is not enough to cause addiction.
“Addiction Isn’t Just Taking Drugs”
“Addiction cannot happen without learning,” Szalavitz told Gizmodo, “because learning shapes values over the course of development. If you don’t learn that the drug comforts you or creates pleasure, you cannot become addicted. So on a very basic level, addiction clearly involves an aberrant form of learning.”
For Szalavitz the most common underlying cause for this aberrant form of learning is trauma.
“For many, if not most, people with addiction, trauma is perhaps the critical factor that causes the problem,” she writes. In her long career she has interviewed many people who had “the unspeakable and unthinkable happen very early in life, and often, more than once.”
Many addiction specialists agree on the importance of trauma as an underlying condition. Physician Gabor Maté has treated many patients with addiction, the author of In the Realm of Hungry Ghosts told the The Fix that “in all cases of addiction that I have seen, there’s deep pain that comes out of trauma. The addiction is the person’s unconscious attempt to escape from pain.”
Addiction specialist Stephanie Covington views trauma-informed addiction treatment as essential, especially for women in recovery, because “addicted women have a high rate of abuse in their lives.” But despite giving trauma a central role in addiction like Szalavitz, Covington subscribes to the disease model of addiction.
The term disease implies to a certain extent the patient caught the disease by using alcohol or other drugs. In other words, the addict falls victim to the substance which “hijacks the brain.”
In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), substance-initiated activation of the brain’s reward system is described as a crucial component of addiction.
“All drugs that are taken in excess have in common direct activation of the brain’s reward system, which is involved in the reinforcement of behaviors and the production of memories. They produce such an intense activation of the reward system that normal activities may be neglected.” (DSM-5 p. 481)
That is clearly not how Szalavitz views addiction. For her “drugs are powerful primarily when the rest of your life is broken.”
“By itself, nothing is addictive; drugs can only be addictive in the context of set, setting, dose, dosing pattern, and numerous other personal, biological, and cultural variables. Addiction isn’t just taking drugs. It is a pattern of learned behavior.” (Unbroken Brain p.135)
More Research Required
“All of the current research being done around brain function, learning disabilities and their relation to addiction is exciting because it expands our thoughts about, and tactics used to address, people with substance use disorders,” says Gary Hees, Vice President of Professional Relations at Decision Point. “In clinical terms, addiction certainly resembles other obsessive-compulsive patterns of behavior.”
“However, we know from the difficulties involved with, and possible life-threatening consequences of, detoxification, that there is a component of physical dependence that exists and must be addressed. After physical dependence is addressed, there does remain a pattern of behavior involving pleasurable response to a harmful behavior or substance. Whether the etiology of that pattern is physical, developmental or the result of a learning disability is yet to be determined. Learning a dysfunctional pattern of coping is usually the result of a combination of stressors, limited options for achieving the learning goal and the opportunities presented within a given individual’s environment,” says Hees.