In 2015, 16.3 people per 100,000 died of drug overdoses. That was more than 2.5 times the rate in 1999.Recent reports suggest that number is only getting worse.
In the face of this epidemic, researchers struggle to find a solution. From the disaster that was the DARE program to the mixed bag that is the War on Drugs, you cannot say that the crisis comes from lack of trying. But if we are to cure or at least treat addiction, we must understand it—its scope, its causes, and its identity. Is addiction a disease or not?
Addiction by the Numbers
In 2016, the United Nations Office on Drugs and Crime (UNODC) reported that 247 million people used drugs in the past year. Of that number, 29 million people were suffering from drug use disorders. And yet only one in six people with drug use disorders were in treatment. In 2015, the CDC reported that 10.1 percent of Americans ages 12 years and older used illicit drugs in a single month. The UNODC also reports that men are “three times more likely than women to use cannabis, cocaine or amphetamines, whereas women are more likely than men to engage in the non-medical use of opioids and tranquilizers.” However, the UNODC notes that the disparity is due to social opportunities to use drugs, not a natural inclination.
According to the National Institute on Drug Abuse, abuse of alcohol, tobacco, and illicit drugs exacts “more than $740 billion annually in costs related to crime, lost work productivity and health care.”
Of course, the financial costs pale in comparison to the cost in human lives.
The UNODC reports, “With an estimated 207,400 drug-related deaths in 2014, corresponding to 43.5 deaths per million people aged 15–64, the number of drug-related deaths worldwide has also remained stable, although unacceptable and preventable.” However, these numbers may only be painting an incomplete picture; the UNODC points out that many countries only report deaths resulting from overdose. “This definition is framed from a health perspective, considering drug-related deaths in the context of the burden of disease. However, a broader perspective could also include deaths resulting from the functioning of illicit drug markets and could include, for example, deaths as a result of violence associated with the illicit supply of and trafficking in drugs.”
One of the most difficult hurdles in treating addiction is the debate surrounding how to classify it. Is addiction a disease or isn’t it? Let’s take some time to explore both sides of the debate.
Addiction IS a disease.
Lorelie Rozzano, guest writer for Addiction Campuses, found it difficult to think of addiction in terms of disease despite struggling with addiction herself. Looking back, she recognizes how her addiction changed the way she thought and felt. She writes,
Clean and sober, I felt different than other people. I felt less than. I was not equal but inferior. Looking at me you wouldn’t know it. Mine was a disorder that lied below the surface. I was anxious, needy and fearful. When I took my first drink, that feeling of dis-ease fled.
Here’s a tip. People who struggle with substance abuse feel in control when they use. Non-addicts feel out of control.
My drug addiction was progressive. It got worse over time. The same way diabetes, heart disease and cancer do. As my addiction flourished, my thinking deteriorated. I was unable to make logical, rational, decisions. Instead, I adopted an impaired thought process of denial, dishonesty, minimization, deflection and blame. I continued to use and put my life (and the life of my family) in jeopardy.
If addiction really was my choice, why would I choose it?
Rozzano’s experiences are in line with current definitions of addiction. In 2011, the American Society of Addiction Medicine (ASAM) formally defined addiction as “a primary, chronic disease of brain reward, motivation, memory and related circuitry.” They further stated that “dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.”
According to ASAM, addiction has five main characteristics: lack of self-control; inability to abstain consistently; craving; lack of self-awareness, especially concerning personal behavior and relationships; and impaired emotional response. Addicts go through cycles of relapse and remission similar to patients with other diseases. Without treatment or “engagement in recovery activities,” an addiction is “progressive and can result in disability or premature death.”
Adding to the argument for disease is the role of genetics in addiction. David Sack, psychiatrist and chief executive of Elements Behavioral Health, writes,
The genetic risk for the various drug addictions has been estimated to range from 40 percent to 60 percent for alcohol, and other common drugs of abuse. Genetic studies have been interpreted to support the hypothesis that multiple genes contribute to this risk rather than a single recessive or dominant gene. Genetic variations in specific genes offer an explanation of why some populations are so susceptible to alcoholism and others are not.
“At its core, addiction isn't just a social problem or a moral problem or a criminal problem. It's a brain problem whose behaviors manifest in all these other areas,” says former ASAM president Dr. Michael Miller. "Many behaviors driven by addiction are real problems and sometimes criminal acts. But the disease is about brains, not drugs. It's about underlying neurology, not outward actions.”
Addiction IS NOT a disease.
However, there is a growing counter movement to the disease theory. One skeptic is Dr. Marc Lewis, professor of developmental psychology and a longtime addict. In his book The Biology of Desire: Why Addiction is Not a Disease, Lewis argues that addiction fails to meet the basic qualifications of being a disease and that addicts have more control than they’ve been led to believe.
Lewis does not deny that an addicted brain undergoes changes. Quite the opposite, actually. “It’s not that all these brain changes aren’t involved in addiction,” he says. “They are, but they’re also involved in becoming a basketball fan, falling in love, in becoming a jihadist, in developing any new passion. So why would we call addiction a disease that requires medical treatment?
Both Lewis and his colleagues are quick to emphasize that they are not attributing addiction to “moral failings.” To do so would be an unfair oversimplification. Instead, they believe that addiction is more along the lines of a bad habit: powerful and constant, but not irreversible.
As Lewis explains it, addiction as a habit forms as an individual repeatedly pursues “the same highly attractive goal,” such as the feelings of ease and control Rozzano described. The repetition forms new pathways in the brain, as it would for any activity, like playing the piano or studying for a test: practice makes perfect.
However, the process of rewiring the brain goes much faster thanks to increased levels of dopamine. “As the addiction grows, billions of new connections form in the brain,” Lewis says. “This network of connections supports a pattern of thinking and feeling, a strengthening belief, that taking this drug, ‘this thing,’ is going to make you feel better—despite plenty of evidence to the contrary.” This repetition gives way to what Lewis calls “deep learning.”
But if the brain changes that drastically, isn’t it now diseased? According to Lewis, no—it can still bounce back. “Deep ruts in the brain don’t make the brain damaged,” he says. “And new ruts can be formed on top of or beside old ruts.”
For evidence, Gene Heyman of Boston College points to numerous studies conducted with addicts and recovered addicts, investigating their recovery process. “Since 1991, four major national surveys of psychiatric disorders and their correlates have been published. Each found that most of those ever addicted to illicit drugs were ‘ex-addicts’ by about age 30,” he says. “Moreover, most of those who quit did so without professional help.”
Again, Lewis, emphasizes that calling addiction a choice is as wrong as calling it a disease. Overcoming addiction is not a matter of deciding to quit smoking, drinking, etc. It is a matter of reprogramming themselves. “Addicts need to modify their environments, rejigger their opportunities, so that temptations are minimized and habits lose their footing,” he says. “You learn not to drive by the liquor store on your way home from work. The philosopher Marc Slors calls this self-programming: using forethought to change future behaviors by redesigning the day-to-day environment.”
Dealing with Addiction
Whatever side of the debate you fall on, it doesn’t really matter. What matters is how you carry yourself, whether you’re struggling with addiction yourself or know someone who is. No amount of arguing will make your or another’s addiction go away. Only action will have an effect.
If you’re a family member:
Provide a sober environment—one without triggers or opportunities to relapse.
Do not enable or make excuses. This will be hard, especially since you’re also trying not to judge or make accusations.
If you’re providing financial support, buy the goods and services yourself instead of lending money.
If you are struggling with an addiction, the most important way to start your recovery is by asking for help. Your personal doctor is a great first resource; he or she can direct you to the right therapist or service to get you started. There are also many private services you can reach out to yourself.
Confronting addiction, whether your own or another’s, takes courage. It also takes love and understanding, not giving up on yourself when you make mistakes, and supporting someone as they struggle to get healthy. Michael Botticelli, former director of the White House Office of National Drug Control Policy, says, “When you see someone with an addiction, don't think of a drunk or a junkie or an addict or an abuser—see a person; offer them help; give them kindness and compassion. And together, we can be part of a growing movement in the United States to change how we view people with addiction.”