In the first three articles in this series, we reviewed the history of the disease concept of addiction in America from its birth in the 18th century through its collapse, rebirth and rising prominence in the 20th century.
We also noted the emergence and growing stridency of an addiction disease debate and isolated the major points of contention between addiction disease advocates and critics.
In this final article, I will cast aside the role of historian and offer my own conclusions and proposals regarding this concept and its future.
Toward a Better Disease Model
When Alcoholics Anonymous was first publicly criticized in a 1963 magazine article, A.A. cofounder Bill Wilson responded in the A.A. Grapevine. Rather than attacking the author or defending A.A., Wilson took the position that A.A. members should view critics as benefactors and that A.A. should use criticism lodged against it to self-assess and improve A.A.
Those of us who have long-professed that addiction is a disease would be well-served by Wilson's example. Rather than defending an overly rigid concept, it would be better to acknowledge the weaknesses of the disease concept as historically constructed and to reformulate a disease concept that is more clinically and culturally dynamic and more scientifically defensible.
Improving the addiction disease concept stands as a viable alternative to the critics' strident call for its abandonment.
William Miller warned in 1993 that the current disease model was inadequate to explain or resolve the wide spectrum of alcohol-related problems.
This article builds on his proposal to construct a modernized disease concept within the rubric of a public health approach to disease prevention and intervention--an approach that provides a balanced focus on the agent (the drug), the vulnerability of the host (the drug consumer) and the (physical/cultural/legal) environment.
The Tower of Babel.
The new disease concept will forge consensus on a language that can be used to differentiate types and intensities of alcohol- and other drug-related problems.
Any conceptualization of such problems must contain a core set of words and ideas that can simultaneously: 1) help individuals construct or change their relationship with psychoactive drugs, 2) guide professional helpers in organizing and evaluating their interventions into drugrelated problems, and 3) help communities and societies understand and manage these problems in the aggregate.
E.M. Jellinek, in his classic 1960 text, noted that the debate over the disease concept was plagued by too many definitions of alcoholism and too few definitions of disease.
The continued proliferation of terms and their unclear meanings (alcohol/drug dependence/abuse/addiction/ problems, chemical dependency, substance abuse/misuse, disease, illness, sickness, malady, condition, habit) has created a virtual Tower of Babel within the on-going disease concept debate.
To transcend the unproductive rhetorical excesses of this debate, a basic vocabulary of words and meanings must be forged.
One of the first definitions needed is that of disease. The addiction field must follow the rest of medicine in moving away from the depiction of disease as an entity to an understanding of disease as a metaphor. “Disease” is a word and an idea used to convey substantial, deteriorating changes in the structure and function of the human body and the accompanying deterioration in biopsychosocial functioning.
To suggest that disease is a metaphor does not diminish the devastating reality that the term depicts, but it does suggest that this reality may constitute a process rather than a “thing.”
Alcoholism to Addiction
The new disease concept will shift from an alcoholism model to a more encompassing addiction model.
It will define the boundaries of its application to particular drugs, declaring the concept’s relevance or misapplication to tobacco, opiates, cocaine and other stimulants, cannabis, and other licit and illicit psychoactive drugs.
It will incorporate the latest advances in biomedicine to answer the question of whether personal vulnerability to addiction is drugspecific, drug-category specific, or expansive across a range of substances and experiences.
Boundary Integrity
The new disease concept will carefully map its conceptual boundaries, defining the conditions and circumstances to which it should and should not be applied.
The concern here is that a concept can be diluted, distorted, over-extended, commercially exploited, and over-used to the point that its utility is destroyed.
The history of the concept of “co-dependency” provides a vivid example of what can happen under such circumstances. If the concept of co-dependency taught us anything as a field it is that when a concept begins to be applied to everything, it ceases to have meaning applied to anything.
The area of greatest trouble is the application of the concept of addiction and addictive disease to include process addictions - harmful relationships with food, relationships, sex, work, gambling, etc.
It is the “etc.” that is particularly problematic. Americans already speak of being “addicted” to everything from bowling to television shows, self-describe themselves as “chocaholics,” “shopaholics” and every other kind of “aholic,” and apply the term “disease” to everything from violence to the use of profanity.
The new disease concept will carefully reestablish and then guard its boundaries to prevent its continued over-extension and financial exploitation.
To draw this boundary will require nothing short of defining the very essence of addiction and its roots.
Addictions versus Problems
The new disease concept will place alcoholism/addiction within a larger umbrella of alcohol- and other drug-related problems.
The consumption of alcohol and other drugs contributes to a large spectrum of personal and social problems: fetal drug exposure, drugimpaired driving, drug-influenced crime and violence, and underage and binge drinking, to name just a few.
An undefined portion of these problems are not the product of alcoholism and other drug addictions, do not constitute “disease” states, and should not have a traditional disease model of intervention applied to them.
The new disease model will seek to delineate alcohol and other drug “problems” from alcohol and other drug “addictions” and distinguish the prevention and intervention strategies that should be applied to each.
It will seek to clearly specify the conditions that must be present to declare the presence of “alcoholism” or “addiction” and further argue (in the tradition of E.M. Jellinek) that an AOD problem be declared a “disease” if, and only, if certain specified conditions are present.
The field of professionally directed addiction treatment cannot have it both ways. It cannot (without great harm to itself and its clients) continue to clinically define alcoholism and addiction in narrow terms and then, for reasons of professional and institutional gain, misapply this narrow model to an ever-expanding array of drug-related and non-drug-related problems.
If the field continues to rely solely on a narrowly prescribed addiction intervention model, then ethically it must refuse to treat the wider pool of individuals with AOD problems for whom this model is inappropriate and potentially harmful.
If the field embraces the larger spectrum of people with AOD (and other) problems within its purview (which it has), then it must significantly expand its potential treatment goals and intervention technologies (which it has not).
The new disease concept will acknowledge the differences in these populations and create a wider menu of treatment goals and technologies that can be selectively applied to these different but overlapping populations.
Disease Variability
The new disease concept will portray addiction as a cluster of disorders that spring from multiple, interacting etiological influences and that vary considerably in their onset, course, and outcome.
This refined concept will incorporate rather than deny existing research on etiological factors, pattern variability and outcome variability.
The new disease concept will create taxonomies that delineate the clinical subpopulations that make up these divergent patterns and will move to a much more sophisticated approach to differential diagnosis and individualized treatment/recovery planning.
To move the disease concept in this direction is not a call to break tradition but a call to return to earlier traditions, from the 19th century inebriety specialists understanding of “diseases of inebriety” to Jellinek’s “alcoholisms.”
The new disease concept will, for example, proclaim within its framework that:
1. addiction is not caused solely by genetic or biological factors but by multiple interacting factors, a status that places it squarely within the rubric of other chronic diseases,
2. not all addictions are progressive (accelerating), some remain stable but enduring while others decelerate, just like many other chronic diseases,
3. patterns of spontaneous remission and maturing out exist in addiction just as they do with many other chronic diseases, and
4. the movement from an AOD problem to a level of continued alcohol and drug use below the priming dose of problem activation is common in those with transient AOD problems but rare in those with patterns of severe and persistent addiction.
Determining just how common or how rare these variations are is an important question, one that needs to be moved from the arena of rhetorical debate to the arena of research.
The “truth” on many of these contentious issues will be found in the space between the polarized positions of the most rabid disease advocates and critics.
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From longer article [from Counselor, April 2001] with references at
http://www.bhrm.org/papers/Counselor4.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.