chronic disease?
Andy Reviews the literature
Is addiction a chronic disease, or is it a disorder of habit & learning? Can a person “get over” addiction, or is recovery a lifetime of treatment? How does one really, literally, lose control? Is that possible? Do things cause you to act in certain ways, or are there just “reasons” that influence your decision-making?
These questions matter a great deal to me. They form my concept of the problem I had, my responsibility for it, and my future “prognosis.” So I’ve done a deep-dive into the peer-reviewed mainstream literature to see what I could learn about addiction and recovery.
Much of the medical establishment views addiction as a disease, which could be phrased as:
“Addiction is a chronic, progressive, relapsing brain disease, just as diabetes is a chronic disease of the pancreas. Both have genetic correlates. Substance use causes changes in brain scans that are associated with uncontrollable drug use.”
“Once addicted, it is almost impossible for most people to stop the spiraling cycle of
addiction on their own without treatment.” (former head of NIH National Institute of
Drug Abuse, Dr. Alan Leshner)
“Addictive disorders should be considered in the category with other disorders that require life-long treatment.” (O’Brien & McLellan; Lancet article).
However, there are other takes on addiction by highly regarded NIH-funded researchers. In fact, virtually none of the data on the course of addiction is consistent with the above statements!
“Widely held and stated ideas about addiction are at odds with what research says about addiction. Addiction as a “chronic, relapsing disease” is not supported by epidemiological data.” – Gene Heyman, PhD, Boston College
➤Everything presented here is from peer-reviewed, mainstream scientific literature.
➤It represents the most current information about addiction that I can find.
➤I am not a conspiracy theorist!
➤You will learn that many scientists and recovery therapists misrepresent the facts. I believe they do so primarily with good intentions; to help patients. But there’s also some degree to which they likely want to maintain funding, status and control.
“…this notion of [addiction as] a chronic, progressive brain illness… [is] one of the biggest frauds that’s been perpetrated on the public.” – Carl Hart, PhD, Columbia University
What does the literature tell us?
Early & mid-20th Century Addiction Data/Research
➤Almost all data collected during this time was collected on institutionalized individuals in hospitals, prisons, and “mental institutes.” This population was likely more complex from the standpoint of comorbidities (psychiatric illnesses as well as socioeconomic challenges) and certainly did not include people in the community who were either recreational users, moderate users, or who quit on their own.
➤Suffice it to say that outcomes for this population were very poor, and gave good reasons for skepticism and great concern about their likelihood for recovery.
Vietnam Veteran Heroin Addiction Studies – 1974; ‘77; ‘98. Washington University Professor Lee Robins, PhD (Harvard).
➤43% of enlisted soldiers tried heroin & opium in Vietnam.
➤20% report being “addicted”
➤There was great concern about what would happen when they returned, so it was carefully studied.
➤5% of the addicted soldiers were treated at the Federal Narcotics Hospital.
*67% of these men relapsed into heavy use during the first year after treatment.
➤95% of men who received no treatment were free from addiction 1 year after returning.
➤During the first 3 years back, 12% of them reported some period of heroin use.
➤96% of addicted soldiers were in long-term recovery 24 years later.
National Epidemiological Survey of Alcohol & Related Conditions (NESARC; 2006)
➤43,000 people were surveyed between 2001-2005.
➤80% of people who previously had a diagnosed substance use disorder (SUD) were in remission from addiction for >1 year.
➤90% of people with SUDs resolve their problem eventually
➤85% of people quit drugs & alcohol with no formal treatment.
➤Treatment slightly decreased the success rate for alcohol use disorders.
Quitting Drugs: Quantitative and Qualitative Features (Heyman, 2013)
➤Study of pooled data on 60,000 people (NESARC, ECA, NCS).
➤SUD patients overwhelmingly resolve the problem, most without treatment.
*90% of alcohol users
*96-99% of opioid, meth, cocaine, marijuana users
➤Factors that correlate with quitting: financial, legal, family issues; involvement in support groups; personal goals; spiritual/religious beliefs.
➤Workplace drug testing required for employment decreases use by 80-100%
➤Quitting “cold turkey” is common and effective
➤All types of SUDs decrease steadily over time
➤Contrast all of this with the fact that virtually all other chronic illnesses increase over time.
National Recovery Survey (Recovery Research Institute/Harvard, 2017)
➤39,800 people surveyed/25,200 responded.
➤1 in 10 Americans consider themselves to have formerly had a SUD.
*more than half of them do not consider themselves “in recovery”
➤46% had no formal addiction treatment; 54% used some type of support
➤AA is the most common & most cost-effective support.
➤The aspects of AA that were identified as specifically contributing to recovery:
*Providing a group of peers & a sponsor who are modeling and supporting control of drinking
*Cognitive behavioral coping skills; identification of irrational/unhelpful thoughts and beliefs
*Maintains motivation for sobriety
*Benefit of volunteering/helping others
Genetic Factors & Brain Imaging
➤Addiction does cause brain changes, and has genetic factors.
➤Political affiliation & musical ability have genetic determinants.
➤Piano lessons, juggling practice, and taxi driving cause brain changes.
➤Structural and neurochemical changes occur in the brain as part of every activity that involves learning and/or movement.
➤These neurological changes disappear over time when the activity is discontinued.
➤The fact that a steady percentage of users stop every year over long periods of time argues against there being a primary underlying role for inborn genetic factors “causing” addiction, and against the idea that drug use causes neurologic changes that become permanently ingrained.
Free Will, Choice & Addiction: research by Gene Heyman, Carl Hart & others.
➤As noted above, Heyman points out that the vast majority of drug users do quit, and typically without formal support.
➤The factors that affect cessation are all psychosocial factors that impact decision making (choices).
➤Inpatient SUD patients choose better living conditions and money in exchange for verified abstinence.
➤AUD patients given alcohol disguised in other drinks do not report increased craving, nor do they drink excessive amounts of the drink when it is freely available.
➤The largest predictors of relapse after rehab treatment (Miller, Univ. of New Mexico):
*belief in the disease model of addiction (learned helplessness?)
*poor coping skills
➤Contingency management: motivating users to abstain by providing rewards. Higgins (‘93) compared outcomes between 12-step support group vs. a group that received behavioral counseling plus rewards (merchandise voucher).
*68% abstinence rate in reward group at 2 months.
*11% abstinence rate in 12 step group at 2 months.
*60% of reward group completed 6 months of the intervention
*11% of 12 step group completed 6 months.
➤No difference in relapse rate between the 2 groups after intervention.
➤75-85% of drug users do so “recreationally” and do not meet criteria for problem use.
(This speaks to the sentiment that “drug users cannot stop once they start)
Is addiction a chronic, progressive, relapsing brain disease?
✔Addiction decreases in prevalence by >90% over time unlike every other chronic disease.
✔Addiction is affected most by personal goals and beliefs, financial and legal issues, support group attendance, and spiritual/religious beliefs. All of these factors are psychosocial determinants involved in behavior choice, not medical, pharmacological or physiological variables.
✔The arc of diabetes, schizophrenia, cancer, etc. are not substantially affected by any of those variables, and in no cases do people “quit” other chronic diseases “cold turkey.”
✔Brain activity (shown on scans) and neurotransmitter changes occur with all types of repetitive learning and behaviors. This is a normal function of the brain, not a sign of disease.
✔Heritability is associated with both voluntary and involuntary behaviors and characteristics, and is not a definitive indicator of “disease.”
✔Voluntary behaviors are influenced by factors such as values, social opinions, costs and benefits. Involuntary behaviors (blink and deep tendon reflexes, coughing, etc.) are not impacted by costs or benefits or social reinforcers. Addiction cannot be said to be “involuntary.” Not to say that anyone chooses to have a SUD. But it is most consistent with the literature to say that SUDs result from choices, which in turn are influenced by psychosocial variables and beliefs.
✔Is there truly a loss of control? Users moderate their use frequently – to save for a binge, or in exchange for rewards. 50% of problem drinkers become moderate drinkers. At least 75% of all people who use drugs occasionally do so recreationally, not daily or weekly or even monthly. When users are given the substance without their knowledge, they do not compulsively seek more or keep taking more when it is available. *Free will and choice underlie ongoing SUDs.
✔Psychotherapy and support groups are human interactions in which ideas are communicated and behaviors are modeled. Could talking or thinking predictably and reliably treat degenerative neurological diseases, infections, tumors, type I diabetes, or any other typical “disease?” Certainly these things can affect behavioral choices – e.g., smoking, overeating/food choices, exercise, etc. – that are factors in diseases such as COPD, lung cancer, obesity, atherosclerosis, and type II diabetes. But they are not the primary factor in the disease or in treatment.
➤Addiction is often harmful and self-destructive. Humans choose to do harmful and self-destructive things all the time that are related to many other things, such as money, love, food, thrill-seeking, etc. None of these actions would be referred to as “disease states.”
I cannot view addiction as a chronic brain disease after learning all of these facts!
➤I concede that we could call addiction a disease in a metaphorical sense. But that is problematic and unhelpful on several levels that I will explore in the next section, “What It Is.”