[First in a series on the history and future of the disease concept of addiction.]

Are alcoholism and other addictions diseases? If so, what manner of diseases are they, and how can they best be treated? If not, then how can we understand and respond to such conditions? Do we need more than one organizing concept to embrace the myriad patterns of harmful alcohol and other drug (AOD) use?

What personal, professional and social consequences flow out of these different frameworks for viewing AOD-related problems?  Such questions have been the subject of heated debate in America for more than 200 years. 

The heightened crescendo of this debate leaves open the question of how this country and its citizens—and we as addiction counselors—will understand and respond to AOD problems in the 21st century. 

This article will explore the way in which disease concepts of addiction emerged and coexisted alongside the more popular perceptions of chronic intemperance. We will examine the application of this concept to drugs other than alcohol, and the major role the concept played in 19th century addiction treatment.

We will also hear from some of the earliest critics of the disease concept.  Ideas and Language The ideas and words we use to frame AOD problems matter, and they matter at many levels. 

At the personal level, such concepts can serve a preventative function, facilitate early selfrecognition and self-correction of AOD problems, or provide a metaphor for transformative change for those in serious trouble in this person-drug relationship.

When ill-chosen, these concepts can fail to perform these important functions.   At the community level, these concepts declare what people and institutions we want to have cultural ownership of AOD problems.

Whether such ownership is in the hands of a priest, a police officer, a physician, a psychiatrist, a social worker or a political activist affects the community as a whole, the fate of individual organizations and whole fields of professional endeavor, as well as innumerable careers.

The debate over the disease concept and its alternatives cannot be easily separated from these broader interests.  For those who have been given ownership of AOD problems, these concepts, at their best, offer precision in problem diagnosis and the selection of effective interventions.

The nature of interventions into people’s lives, for good or for bad, flows directly from these conceptual foundations.  The concepts we use to portray AOD problems also serve larger cultural, social and economic agendas as they are differentially applied to people of different ages, races, genders, social classes and sexual orientations.

It is only in viewing such contextual influences that we can understand how one drug-involved person is viewed as suffering from a disease and offered health care while another is viewed as a criminal and incarcerated. 

The debate over the disease concept of addiction is not a meaningless intellectual exercise, for any framework for understanding AOD problems exerts a profound influence on the lives of individuals, families, social institutions and communities.

The fact that these concepts must “work” at so many levels and the seeming intractability of AOD problems in the history of America have contributed to the conceptual instability of the AOD problem arena.

No addiction model has ever fully replaced its competitors; radically different conceptualizations of AOD problems have always co-existed; and Americans have always been ambivalent about whatever model claimed temporary prominence.

Birth of the Disease Concept

The conceptualization of chronic drunkenness as a disease did not originate in America. References to chronic drunkenness as a sickness of the body and soul, and the presence of specialized roles to care for people suffering from “drink madness,” can be found in the civilizations of ancient Egypt and Greece.

Isolated and periodic references to chronic drunkenness as a disease, and even occasional calls for state-sponsored treatment, continued through the centuries before the first European migrations to America. It took a lot to birth a disease concept of alcoholism in America.

The breakdown of community norms that had long contained drunkenness in colonial America and a shift in consumption patterns from fermented beverages to distilled spirits led to a dramatic (nearly three-fold) increase in alcohol consumption between 1790 and 1830.

In the face of these changes, several prominent individuals “discovered” addiction and called for a new way of understanding and responding to the chronic drunkard.

In 1774, the philanthropist and social reformer Anthony Benezet expressed his alarm at changing drinking practices in colonial America.

In the first American treatise on alcoholism, Benezet challenged the prevailing view of alcohol as a gift from God. He christened alcohol a “bewitching poison,” described “unhappy dram-drinkers bound in slavery,” and noted the tendency for drunkenness to self-accelerate. (“Drops beget drams, and drams beget more drams, till they become to be without weight or measure.”)

Benezet’s warning was followed in 1784 by Dr. Benjamin Rush’s Inquiry into the Effects of Ardent Spirits on the Human Mind and Body.

Rush achieved five things with this highly influential pamphlet: • He medically catalogued the signs of acute and chronic drunkenness.
• He introduced a more medicalized language into the discussion of intemperance by describing “persons addicted to ardent spirits” and by declaring that chronic drunkenness was an “odious disease” and a “disease induced by a vice.”
• He medically confirmed Benezet’s observation about the progressiveness of intemperance by noting that such episodes “gradually increase in their frequency.”
• He offered medical speculation about the causes of this disease.
• He provided the first recommended treatments for chronic drunkenness based on a disease concept of addiction.

Rush later used this embryonic disease concept to call for the creation of a special facility (a “sober house”) to care for the drunkard.

In the Rev. Lyman Beecher’s Six Sermons on the Nature, Occasions, Signs, Evils, and Remedy of Intemperance, delivered in 1825, we find a growing bridge between moral and medical views of drunkenness.

Beecher declared that the intemperate are “addicted to the sin,” referred to intemperance as an “evil habit” fueled by “an insatiable desire to drink,” observed that intemperance can “hasten on to ruin with accelerated movement,” and detailed the warning signs of addiction to drink.

Beecher concluded his sermons by declaring: “Intemperance is a disease as well as a crime, and were any other disease as contagious, of as marked symptoms, and as mortal, to pervade the land, it would create universal consternation.”

Where Benezet and Rush had described the consequences of chronic drunkenness, Beecher described the process of becoming a drunkard and offered his listeners and readers a remarkably modern checklist of the warning signs that mark the loss of volitional control over alcohol consumption.

In the 1830s, the prominent physician Samuel Woodward recommended the creation of special asylums for the treatment of inebriates. Woodward described how intemperance was a “physical disease which preys upon [the drunkard’s] health and spirits ... making him a willing slave to his appetite.”

He aptly described the paradoxical entrapment of the drunkard whose greatest woe and greatest comfort were both to be found in alcohol. He spoke of the role of heredity as a causative factor in chronic drunkenness, evoked powerful images of “the neverdying worm of intemperance ... preying upon [the drunkard’s] vitals,” and described the way in which the quantity of alcohol consumed by the intemperate must be ever increased to sustain its effect.

Woodward believed that the drunkard should be taught the nature of his disease:

Show to him ... the reason why the case is not controllable by the will, that it is a physical evil, a disease of the stomach and nervous system, and entirely incurable while the practice is followed.

Dr. William Sweetser reflected a very modern understanding of disease and the complexities of viewing chronic drunkenness in this framework when he argued in 1829 that intemperance directly and indirectly created a “morbid alteration” in nearly all the major structures and functions of the human body.

He believed many individuals “addicted to intemperance” were vulnerable to such alterations as a result of heredity or accidental circumstance. Sweetser viewed cycles of compulsive drinking for such individuals as the product of a devastating paradox: The poison–alcohol–was its own, only antidote.

Sweetser had great difficulty reconciling his emerging medical understanding of addictive disease with American ideas of free will and personal responsibility. His worries reflected tensions that would continue for 170 years until our own time:

Now that [intemperance] becomes a disease no one doubts, but then it is a disease produced and maintained by voluntary acts, which is a very different thing from a disease with which providence inflicts us. ...I feel convinced that should the opinion ever prevail that intemperance is a disease like fever, mania, &c., and no moral turpitude be affixed to it, drunkenness, if possible, will spread itself even to a more alarming extent than at present.

Roots of Addiction Medicine We can see in these late 18th and early 19th century writings a cluster of ideas that would become the building blocks of an emerging disease concept of alcoholism:

• biological predisposition
• drug toxicity
• morbid appetite (craving)
• pharmacological tolerance
• disease progression
• inability to refrain from drinking
• loss of volitional control over quantity of alcohol intake
• a detailed accounting of the biological, psychological, and social consequences of chronic drunkenness

We also see in these early writings the struggle to distinguish drunkenness as a vice from drunkenness caused by disease.

Early disease-concept advocates did not view intoxication itself as a disease, but as a potential symptom of disease. The disease itself was portrayed as: 1) the cluster of physical and social problems produced by chronic drunkenness, and 2) the “ungovernable appetite” that overwhelms willful choice and control of alcohol intake.

We also see (in everyone after Rush) a clear opinion that the only hope for the diseased drunkard is complete and enduring abstinence from all forms of alcohol and other drugs. (As Woodward advised, “nothing stimulating, both now and forever.”)

These early writings stand out not because they represented the dominant view of their day, but because the then controversial ideas of these men marked the beginning of an experiment in conceptualizing drunkenness and the drunkard in a fundamentally new way.

The gadfly call for a medicalized view of intemperance in the late 18th and early 19th centuries was bolstered by rapidly expanding knowledge about the physical effects of excessive alcohol consumption.

This new knowledge, which ranged from the first studies of delirium tremens to the discovery of the toxic effects of alcohol on the stomach, blood, and nervous system, reached a pinnacle in 1849 in the work of the Swedish physician Magnus Huss.

His landmark study bolstered this emerging disease concept and gave the condition a new name: alcoholism.

After detailing the multiple organ systems affected by chronic alcohol exposure, Huss noted:

These symptoms are formed in such a particular way that they form a disease group in themselves and thus merit being designated and described as a definite disease. … It is this group of symptoms which I wish to designate by the name Alcoholismus chronicus.

The works of Rush, Woodward, Sweetser and Huss called attention to chronic drunkenness as a problem that physicians should study and treat.

As physicians took up this challenge, the terms “drunkenness” and “intemperance” gave way to a more medicalized language that designated this newly formulated disease and the sufferer: inebriety/inebriate, dipsomania/dipsomaniac, and alcoholism/alcoholic.

It was during this time that the term “disease” (of alcoholism) was used to designate a real thing that was believed to have a power and life of its own. It was destined to play a limited role in the mutual aid societies.  

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This article is from the first of a four-part series on the history and future of the addiction disease concept. The full citation is: White, W. (2000) Addiction as a Disease: Birth of a
Concept. Counselor, 1(1):46-51, 73.

From longer article with references at
http://www.bhrm.org/papers/Counselor1.pdf

From site of Behavioral Health Recovery Management
http://www.bhrm.org/

Excerpt published here thanks to author William L. White, MA, a Senior Research Consultant at Chestnut Health Systems, and the author of Slaying the Dragon: The history of Addiction Treatment and Recovery in America.