Addiction: Disease not Choice
Copyright Laura Bellman December 2020, all rights reserved
“…addiction … an attempt to shed my existential burden instead of carrying out the struggle…” (12 Rules for Life 323).
To define addiction as a disease is important because it is a national health problem and to help addicts receive treatment. A deep understanding of the disease is necessary to achieve better treatment results. It is not just that addiction should be defined as a disease, but that the meaning of the word disease must be recognized. To understand addiction as a disease, first, the counter-argument of neuroscience is discussed. Then, the disease concept is explored, including the definition of a disease, the epigenetic changes, and emotional components. Some comments on treatment follow the emotional discussion. Addiction is a disease when all of the components of the definition of the disease are considered. The key to the disease of addiction is the compounding of neuro patterning with epigenetics.
An existential burden is a condition of neuroscience and epigenetics, not a choice. Going deeply into epigenetics, also known as gene expression, we find the roots of behavior, emotion, and thought. Most people don’t know about gene expression, or perceive their gene expression as an existential burden; so they proceed unknowingly into addiction. A radical change in outlook on life is required to begin the change process necessary for recovery from addiction. The radical change is a decision to shoulder the existential burden, deal with the epigenetics, and carry out the struggle to live life on life’s terms. This total psychic change, sometimes perceived as a spiritual experience, is mistaken by the non-addicted as an ordinary choice. The total psychic change is a radical change to the electrical impulses of the diseased brain.
For many years, Lays potato chips had the slogan, “No one can eat just one.” Watching the commercial and listening to the slogan, one’s brain formed a desire for a Lays potato chip. Indeed, the behavior of going to the kitchen and getting the bag of chips was difficult to resist. The same feeling of desire occurs in today’s world with the behavior of checking social media for updates and likes. Desire, or more technically the dopamine reward mechanism, plays a role in behavior. Overuse of the dopamine reward mechanism with any one behavior leads at least a distraction, or at worst to disease. For instance, extreme overuse of potato chips could lead to obesity, now identified as a disease. Too much social media distraction impedes the ability to do one’s homework. But it is the epigenetics plus neuro circuits which express as a failure of choice, not the failure of choice itself. Managing the dopamine reward mechanism is part of the existential burden of every human. Resisting immediate gratification is the struggle.
Whether it is too many potato chips or shots of heroin, a disorder develops in the body and brain. At some tipping point, the addict has lost control, and the behavior is involuntary. The tipping point distinguishes a disorder from a disease. A full definition of the disease promotes effective treatment. Addiction is a disease characterized by an entrenched dopamine reward loop. While not everyone becomes an addict, epigenetic or emotional comorbidities predispose an addict. The aim of treatment should be accurate knowledge of the existential burden, followed by enough time for new neurocircuits to be developed, and gene expression to be modified and strengthened, in essence, a whole new way of life built.
The counter-argument to addiction as a disease comes from neuroscience. Neuroscientists argue that addiction is a disease of choice. Learning, plasticity, and choice are concepts critical to neuroscientists. Neuroscientists do not account for the action of drugs on receptors in the brain which is different from eating too many potato chips. Also, neuroscientists do not account for gene expressions. Below are three examples of neuroscience arguments for addiction being a habit, not a disease.
Neuroscientists look scientifically at desire and choice. Addiction is merely a result of the brain learning through repetition. The book The Biology of Desire is written by Marc Lewis, a university professor of neuroscience. The book explains why addiction is not considered a disease, but rather a result of repetition. Lewis believes that “Addiction results, rather, from the motivated repetition of the same thoughts and behaviors until they become habitual. Thus, addiction develops—it’s learned—but it’s learned more deeply and often more quickly than most other habits, due to a narrowing tunnel of attention and attraction” (x). This book does not agree that a disorder is a disease if the disorder is a normal outcome of the brain’s operation. According to this book, the process of strengthening a neural circuit with drugs is the same for any human learning. Therefore, a drug habit is not a disease. The habit is the normal outcome of the brain’s learning function. The author does admit that a drug habit is learned quickly and deeply, but insists that any habit is just a habit and any person can choose to quit. The book does not account for any other factors related to addiction. For instance, drugs actually fill receptors in the brain and cause physiological changes beyond the neurocircuits.
Some neuroscientists lump choices about costs and benefits in the same category as the choice to take a drug in the moment. Neuroscientists don’t acknowledge the involuntary nature of the disease when the addict has placed themselves beyond ordinary choice. The book Addiction: A Disorder of Choice is written by Gene Heyman, a research psychologist, and lecturer at Harvard medical school. The book explains the aspects of choice, the biological basis for disease, and examples of addicts recovering based on choice. Heyman suggests that “Voluntary acts are guided by costs and benefits, such as concern about family, cultural values, self-esteem, fear of punishment, and so on; the same holds for drug use in addicts” (113). Neural plasticity is normal for the brain. This book also explains the strengthening of frequently used circuits as well as the weakening of non-used circuits. From this information, one gets the idea that a strong circuit is difficult to resist, however, Heyman posits that a person can choose their behavior regardless of the strength of the neuro circuit. This book’s conclusions land firmly on the concept of choice even for addiction. It doesn’t claim that choice is easy, but that choice is the way out of addiction, just as it was the way into addiction. This book comes short of properly acknowledging the type of radical change needed for an addict beyond the tipping point of disease.
Neuroscientists do not distinguish addiction as separate from any other habitual behavior. The book The Craving Mind is written by Jud Brewer, a university professor of medicine and psychology affiliated with three universities. The book is not focused on addictive drugs, but the brain\’s reward-seeking capability. Reward seeking could be directed towards cell phones, chocolate, or any number of things including drugs. Brewer observes that “Simply put, the more that a behavior is repeated, the more we learn to see the world in a certain way—through a lens that is biased, based on rewards and punishments from previous actions…”(7). This idea of perception could indicate that an addict can no longer determine behavior other than the addicted one. The words “lens that is biased” could be restated as a disordered brain or diseased brain. Brewer, however, looking only at reward-based learning and the dopamine reward cycle, addiction is not perceived as a different sort of problem than gambling or eating too many potato chips. Brewer’s arguments support the idea that addiction is not a disease because it treats addiction the same as any other reward-seeking behavior.
Neuroscience is the state of the art research. The ability to scan the brain and understand what happens to a brain on drugs is a recent development. Such information was not available to doctors 80 or 90 years ago when the idea of addiction being a disease first surfaced through the foundation of Alcoholics Anonymous. For most of human history, addiction was a matter of weak moral character. After understanding the neuroscience, it is necessary to return to the definition of disease to better understand why the addict’s habit is a disease.
Definition of Disease
The definition of what is considered a disease changes with time, based on culture and diagnostic capability. According to the dictionary, a disease is any harmful deviation from the normal structural or functional state of an organism, generally associated with certain signs and symptoms and differing in nature from physical injury. A diseased organism commonly exhibits signs or symptoms indicative of its abnormal state. The stereotypical addict could be identified as a person destroying their life and family by insanely pursuing drugs. They may swear off, but by the end of the day, they are looking for a score. Tremendous health problems along with crime and homelessness are the most obvious signs and symptoms. Looking at an addict from the outside, it seems easy to identify a diseased organism or an abnormal state of life.
It may be surprising to many people to learn that defining disease is not a black and white decision. Social factors do influence science. The article “What is a Disease” by Jackie Leach Scully, a research scientist, concludes:
“…science never simply reflects cultural understandings; it simultaneously helps craft the definitions as well. Choices of such mundane things as disease models and diagnostic criteria, then, are not just about research agendas or commercial influences. At their heart they embody profound ethical debates about identity, human rights and the tolerance of difference.”
The article supports the disease of addiction by expanding the definition of disease and explaining its etiology. To define something as a disease, one must account for more than neurocircuits. Culture and ethics are embodied by gene expression, epigenetics. Culture and identity are passed along through generations as well as early childhood learning. The soft concepts of culture, identity, difference, and human rights, make up a gene expression that must be struggled with consciously. If a drug has taken over one’s life, then the existential burden is not shouldered.
Most addicts receive treatment in the form of psychological counseling. Psychologists rely on the disease definition provided by their professional association. Also, insurance companies rely on the professional diagnosis of disease. The disease of addiction is defined by the American Psychiatric Association (APA). The APA publishes the Diagnostic and Statistical Manual of Mental Disorders (DSM5) where addiction is defined: “Addiction is a complex condition, a brain disease that is manifested by compulsive substance use despite harmful consequence. People with addiction (severe substance use disorder) have an intense focus on using a certain substance(s), such as alcohol or drugs, to the point that it takes over their life.” Careful reading of the DSM5 definition reveals that addicts are defined by behavior, not by scientific diagnosis. Although at some point in the future, a brain scan might do this job. Observing addicts from the outside, one can see how the addiction has taken over their life. People end up in treatment for addiction after harmful circumstances like job loss, family loss, arrests, and health problems.
The brain disorder of addiction is a process that begins with a single dose. Enough doses and control is lost. The article “Initial rewarding effects of cocaine and amphetamine assessed in a day using the single-exposure place preference protocol” explains the changes to the dopamine reward circuit, and associated plasticity, which occurs from even a single dose of cocaine or amphetamine:
“By applying this protocol, we show that despite being exposed to both compartments of the apparatus on the same day, a single exposure to cocaine is sufficient to alter place preference towards the cocaine-paired compartment. In spite of different pharmacokinetics, a single dose of amphetamine is able to induce a place preference in the condensed sePP [Single Exposure Place Preference]” (2157).
The experiments were done on mice and included both observed behavior changes and brain dissection. Despite the different effects of cocaine and amphetamine, the rats showed behavior changes after one dose. Where repeated doses are used, stronger learning behavior is witnessed. Addiction is a process that begins with the first dose of a drug. This article’s results lead one to understand that, unless there is an intervention, a drug user would proceed to drug addiction. This outcome would be expected because the brain chooses additional drug stimulation without some overriding outside force. Choosing additional drug usage leads to the behaviors characterized by the DSM definition of a disease.
Epigenetics research is beginning to show addiction is a disease. While an addiction gene hasn’t been found, epigenetic mechanisms are being discovered by researchers. Epigenetics is a new field of scientific discovery. This field was not possible before the discovery of the human genome and gene sequencing. The epigenetic code is another set of instructions that reside on top of DNA. Epigenetics control the activity of genes by switching them on and off. Before epigenetics was discovered, the term gene expression was used to describe the function of epigenetics. Pre-disposal to addiction may be epigenetically passed along through generations. Chronic stress and addiction can introduce epigenetic changes. An epigenetic fact alters the person’s ability to choose their behavior.
Changes in DNA can lead to diseases. Epigenetic researchers have been able to construct changes to the proteins riding on the DNA through repetition and show changes to gene expression. The article “Epigenetics — Beyond the Genome in Alcoholism” posits that the cycle of extreme alcohol consumption followed by excruciating detox followed by relapse alters gene expression. This author classifies alcohol use disorder as a disease, thus supporting the disease concept:
“Genetic and environmental factors play a role in the development of alcoholism. Whole-genome expression profiling has highlighted the importance of several genes that may contribute to alcohol abuse disorders. In addition, more recent findings have added yet another layer of complexity to the overall molecular mechanisms involved in a predisposition to alcoholism and addiction by demonstrating that processes related to genetic factors that do not manifest as DNA sequence changes (i.e., epigenetic processes) play a role. Both acute and chronic ethanol exposure can alter gene expression levels in specific neuronal circuits that govern the behavioral consequences related to tolerance and dependence.”
Epigenetics adds an amazing explanation for the addict’s seemingly insane behavior. Histone acetylation and histone and DNA methylation play a role in gene expression. Modification of microRNAs is a major factor in brain disease onset processes. Chromatin remodeling in the amygdala may regulate the development of anxiety-like behaviors during ethanol withdrawal after chronic exposure. Altering gene expression means thought, feeling, and behavior changes. Addiction changes gene expression. Gene expression is our reality, how we behave and show up in the world.
Epigenetics is investigated biochemically, adding weight to the idea that addiction is a disease. Biochemical evidence can be found through rodent studies or biopsy of deceased humans. The biochemical changes are different for different drugs. The article “It Is A Complex Issue: emerging connections between epigenetic regulators in drug addiction” explains mechanisms important for gene transcription. Biochemical evidence shows: “The transition from casual drug use to a Substance Use Disorder (SUD) might occur through epigenetic mechanisms, and numerous studies report changes in the brain following chronic drug use.” Gene expression, how we think, feel, and behave, provides a strong rebuttal to the neuroscientist’s claim that addiction is a choice. The article is comprehensive in presenting biochemical changes due to a large number of drugs. The gene expression of addicts is various, however, biochemical changes are somewhat definitive. This researcher finds that epigenetics predispose one to addiction as well as continuing the epigenetic changes towards the tipping point of addiction becoming a disease.
Emotional stress reactions are gene expressions that someone can’t think their way around without intervention. How humans feel is formed early in life. When faced with defeat, what do many people do but head to the bar for a drink? A life that begins in defeat stress may search for the easy out which substances bring. Searching for an escape refers one back to the failure to shoulder the existential burden. This behavior is frequently carried out semi-consciously. Many people don’t think about the remodeling of their brain through repetition. In the article “Social Defeat Stress: Mechanisms Underlying the Increase in Rewarding Effects of Drugs of Abuse” the changes due to environmental stress have been experimentally investigated using rats:
“Social interaction is known to be the main source of stress in human beings, which explains the translational importance of this research in animals. Evidence reported over the last decade has revealed that, when exposed to social defeat experiences (brief episodes of social confrontations during adolescence and adulthood), the rodent brain undergoes remodeling and functional modifications, which in turn lead to an increase in the rewarding and reinstating effects of different drugs of abuse.”
The brain can be remodeled to accept and crave the escape. This rat research models the disease of addiction as repeated usage of drugs plus epigenetic modifications. Addicts demonstrate the same behavior as rats. Repeating the behavior, one falls into the disease. While rats don’t have existential burdens, humans do. Drugs became the answer to the struggle; the existential struggle was not shouldered.
Many diseases are treated with medications. A condition treated with medication helps us to understand that condition as a disease. Substance Use Disorder (SUD), as a result of the opioid epidemic, can be treated with medications. Most often, the medication is a substitute for the drug which fills the necessary brain receptors, satisfies cravings, and helps the associated consciousness focus on something besides obtaining drugs. By satisfying the brain, the associated consciousness buys time to change their life. Yet still, the consciousness has to want to carry out the work of change.
It is astonishing to realize that meditation can modify the electronics such that an addict can weaken the drug craving circuits. The brain is essentially a system of electrical impulses, and that stronger impulses get attention from the associated consciousness. In his neuroscience research, the scientist Dr. Brewer (introduced above) completed numerous brain scans of trained meditators and persons newly trained to the practice. In the article “Mindfulness-based treatments for co-occurring depression and substance use disorders: what can we learn from the brain?” Dr. Brewer concludes:
“Mindfulness training [MT] has shown promise in the treatment of both SUDs and MDD. Examination of the common neurobiological and behavioral dysfunction in these disorders suggests the promise of MT for dually diagnosed individuals. MT may help those with dual diagnosis decrease avoidance, tolerate unpleasant withdrawal and emotional states (stress-related), and unlearn maladaptive behaviors (rumination). Additionally, it may lessen the interactions between these processes, thus weakening their additive effects on depression and substance use” (1702).
Brewer’s book (cited above) contains the brain scans of seasoned meditators and newly trained meditators. This evidence triggered the realization that there is a connection between the meditating consciousness and the associated brain electrical firing pattern which could change entrenched neuro patterns. Looking at the brain scans, one can see that the electrical characteristics of the brain do change during meditation. Meditation reduces the electrical strength of some neurocircuits. This weakening allows other circuits to be thought or felt by the addict. The entrenched brain circuit is knocked out of first place. This activity can be the beginning of a psychic change, allowing the addict to grow emotionally, and change the gene expression. One could say that while meditation is used to quiet the electrical impulses within the brain, it allows the associated consciousness to take over the apparatus and make a radical choice to recover.
Beginning with Alcoholics Anonymous and progressing through 80 years of scientific development, addiction has been redefined as a disease instead of a moral weakness. Alcoholics Anonymous called the problem of alcoholism a malady of body, mind, and spirit. What Alcoholics Anonymous also got right was the treatment of the disease with spiritual practices, including meditation. These practices form the basis of building a psychic change, changing neurocircuits, and changing gene expression. When neuroscience and epigenetics are integrated, they form the explanation of addiction as a disease. The disease is complex and presents variously in each individual. It is through both science and psychology that recovery will be found: radical choice plus changes to gene expression and neurocircuitry, over some time. The time is purchased with treatment, medically assisted treatment, ongoing counseling, and participation in a treatment community. Medicine, counseling, mindfulness practices, and 12 Step groups all work together to treat the disease.
In the end, it is not so much whether addiction is a disease as understanding the complexity of the disease and responding accordingly. The definition of a disease changes with culture, and the evolution of science. Neuroscience and epigenetics have changed the perception and diagnosis of substance use disorder. Psychology can make use of these perceptions to effectively treat addiction by combining both the notions of choice and disease.
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Brewer, Judson A., et al. “Mindfulness-Based Treatments for Co-Occurring Depression and Substance Use Disorders: What Can We Learn from the Brain?” Addiction, vol. 105, no. 10, Oct. 2010, pp. 1698–1706.
Brewer, Judson. The Craving Mind. Yale University Press, 2017.
Diagnostic and Statistical Manual of Mental Disorders, 5th, ed. American Psychiatric Publishing, 2013.
Heyman, Gene. Addiction —A Disorder of Choice. Harvard University Press, 2009.
Lewis, Marc. The Biology of Desire —Why Addiction is Not a Disease. PublicAffairs, 2015.
Montagud, Romero, Sandra, et al. “Social Defeat Stress: Mechanisms Underlying the Increase in Rewarding Effects of Drugs of Abuse.” European Journal of Neuroscience, vol. 48, no. 9, Nov. 2018, pp. 2948–2970.
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