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.
Neuroscience
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
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.
Emotion
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.
Treatment
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.
Works Cited
Anderson,
Ethan M., et al. “It Is a Complex Issue: Emerging Connections between
Epigenetic Regulators in Drug Addiction.” European Journal of
Neuroscience, vol. 50, no. 3, Aug. 2019, pp. 2477–2491.
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.
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Peterson, Jordan. 12 Rules for Life. Random House Canada, 2018.
Scully, Jackie Leach. “What is a
disease?.” EMBO reports vol. 5,7 (2004): 650-3.
Starkman,
Bela G., et al. “Epigenetics--Beyond the Genome in Alcoholism.” Alcohol
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