March Newsletter: The Disease of Addiction
By John Steinberg, MD, FASAM
Medical Director, The Bergand Group
The Bergand group remains committed to implementing the highest standards in the practice of addiction medicine. One of the most useful and well supported approaches to diagnosing and treating substance dependency disorders has been the use of the disease model or disease concept as a paradigm within which these disorders may best be managed. Dr. Hunt wrote a very insightful article on this topic for our December 2016 newsletter. The following is a variation on a theme, an approach to this topic that I began teaching in 1986 and presented monthly, to the patients at Father Martin’s Ashley, for thirteen years, from 1986 through 1999.
Historically, the substance abuse disorders have been viewed as moral failings, weaknesses, evidence of poor reasoning and poor judgment, etc. The consequence is, however, that manner in which we define a problem influences our choice of potential solutions. As has been noted, when your only tool is a hammer, all problems look like nails. If this is a weakness, one must increase one’s resolve. If this is poor judgment, one could change the behaviors involved. If a moral failing, a choice to be good rather than bad, perhaps aided by clergy and religion would suffice. If defined as a disease, the approach is to find effective treatment while the entire issue of fault is thus obviated.
The analogy of a disease state for addictive disorders can be examine from four perspectives. They are: symbolism, fault, chronicity, and basic definitions.
A symbol is something that is separate from what we are actually observing, but, when in place, or by association, gives us the ability to infer accurate information regarding the object of our interest. As ID badges in a hospital, though separate from the wearer, when in place, distinguish employees from visitors. Uniforms are similar symbols- separate from the wearer, but, able to convey accurate information nevertheless. There are symbols that surround addictive disorders that allow is to infer that whatever else substance dependency disorders may be interpreted as, the disease model has as much validity as any. The symbolic evidence for the disease analogy of substance abuse disorders is as follows:
- Organized medicine recognizes addiction as a disease.
- The state assigns regulation of those who work with this problem to the administrative auspices of the Department of Health and Mental Hygiene.
- The state requires that organizations and entities engaged in working with substance dependency disorders be staffed by health professionals such as doctors, nurses, counselors, etc.
- Health insurers establish eligibility and benefits schedules, but, implicitly, by paying for substance abuse services at all, have accepted that such disorders are diseases and are appropriately managed within a healthcare setting.
Though insufficient to establish proof, the juxtaposition of such symbols nevertheless conveys strong “circumstantial” evidenced that whatever else substance dependency disorders may be, considering them as diseases makes rational sense and affords a utilitarian approach to their resolution.
The assignation of fault in Western civilization requires two aspects, an adverse outcome and the specific intent for said outcome. As an example, a vehicular fatality may be adjudicated as anything ranging from an accident to a homicide.
In the event a law abiding driver has the terrible experience of a pedestrian darting unexpectedly in front of his car, a death results but, the matter is an accident. Truly there is intent- the driver volitionally entered the vehicle, chose the departure time, the route, etc., but, the intent is merely to get from point A to point B, not to cause harm.
In the event of a person deliberately driving his vehicle into pedestrians, as happened only a few months ago in Ohio, the matter could be adjudicated as a homicide. In this case, there is specific intent.
Though in both cases, the victim is equally dead, whether or not fault is assigned is not determined solely by outcomes, but by whether the adverse outcomes themselves were intended.
In the matter of substance dependency disorders, the adverse outcome- addiction- is never intended.
There is however, the argument that the substances themselves were willfully consumed. That, insofar as it goes is true. But, what is the intent with which this action is taken? It is apparent that the intent is to alter one’s feelings, not to get the disease of addiction, to harm self and others. And just as in the first vehicular example, unless and until the actual adverse event itself is intended, there can be no fault assigned.
The last rebuttal commonly heard in this type of discussion is the case that the addicts are thus given a “free pass.” Nothing could be further from the truth.
Each person with a substance abuse or dependency disorder is confronted by the transactional approach that, yes, he is absolved of fault for having the disease, but, he is fully encumbered by the responsibility for treating that disease.
By way of comparison, let us examine any other disease- diabetes, heart failure, high blood pressure, etc.
Let’s examine the last example provided:
It is the doctor’s responsibility, not the patient’s, to diagnose the disease.
It is the doctor’s responsibility, not the patient’s, to select the proper medication for the disease.
But, it is absolutely the patient’s responsibility to fill the prescription and to take the medication as directed.
In the broadest sense, diseases can be divided into two categories: those than can be cured and those that must be managed. Examples of the former are a strep throat (streptococcal pharyngitis) or a fractured arm. The condition is diagnosed. Treatment is provided. The matter is resolved. To be sure, one can have a second episode, but, this is not usually the course. So too with some cancers, such as an early colon cancer which can be surgically excised and can be considered cured. Examples of the latter type of disease would include hyperlipidemia, high blood pressure, and diabetes. These diseases can be managed. To some extent, they can be induced into remission. But, they cannot- at present- be cured or surgically extirpated. Once diagnosed, they are lifelong conditions.
Substance dependency disorders have a course that more closely resembles a chronic disease rather than an acute, self-limited disease amenable to cure. These disorders tend to place the individual so diagnosed at lifelong risk for recurrence. Many individuals who stabilize and report long term continuous, uninterrupted remission of the active substance dependency disorder will report several treatment episodes and periods of remission punctuated by relapse prior to stabilizing in a pattern of long term recovery.
There are five elements used to define a “disease.”
- Diseases can be characterized as abnormal states of health; deranged or disordered health. Anyone with even passing familiarity with substance abuse and dependency disorders will have no quarrel with this aspect of disease definition.
- Diseases are characterized by objective, measurable physical findings, called “signs.” The signs of high blood pressure, as an example, can include measured blood pressure elevations, changes to the blood vessels observed in the retina, and a measurably enlarged heart. The signs, or objective evidence of substance dependency disorders can range from subtle or even absent, to florid and profound. A person early in the course of dependency on smoked cocaine may have no signs whatsoever. Later in the course, lung changes may be heard on auscultation and seen on imaging studies. At the end stages of alcohol dependency disorders, dramatic changes in liver size and texture, dilated blood vessels, an enlarged heart, etc. can produce a plethora of easily observed physical changes or signs.
- Diseases may manifest themselves in patients by virtue of producing subjective complaints characterized as symptoms. Soreness on swallowing, as an example, can be a sign of a strep throat infection. The symptoms of substance related disorders are legion and encompass the entire range of human perception: physical, mental, emotional, and spiritual. The physical symptoms, such as fatigue or irritated nasal mucosa are, at least for those whose disease is arrested early in its course, often among the first to resolve. of course, long standing disease may, even in remission, have physical symptoms, such as an enlarged liver that remain for quite some time. The mental symptoms are ones of disordered reasoning ability, an inability to connect cause and effect. This is often described as “doing the same things again and again and expecting a different result.” The emotional symptoms span the full range of subjective unpleasantness: depression, despair, anxiety, panic, apprehension, anger, etc. Finally, the spiritual symptoms can best be described as an overarching sense of incompleteness or emptiness- that nothing makes sense, that hope has been lost, that purpose in life is lacking.
- Diseases are characterized by their “natural history” or course, if left unabated. Just as the natural history of a solid malignant tumor is to more aggressively invade and destroy its area of local origin, and then to spread to distant sites, to metastasize, and begin wreaking havoc in other areas, so, too, does an addiction to a substance produce a disorder with a malignant natural history. It aggressively destroys the site of origin- such as self-esteem, or family relationships. It then metastasizes into every area of the patient’s life, such as work and employability, health status, legal status, financial, etc. and produces further damage until ultimately, the disease process may prove fatal, whether by accident, health damage, or suicide.
- Diseases, while not required as part of the definition, may have specific treatments to which they respond. As certain infections respond to certain antibiotics, there is a three-tiered structure to at least one treatment approach. It begins with abstinence from the offending substance, proceeds through stabilization (medication, residential treatment, a structured course of self-help or other group attendance, etc.), and concludes with a maintenance phase that can be tailored to the lifelong needs of each individual patient.
In summary, no one can prove or disprove that substance abuse disorders are or are not diseases. This is a matter of subjective interpretation and perspective, a matter of choice. This brief treatise is not intended to make an argument or to prove a point. Rather it serves as a template within which addictions may be interpreted and modeled as treatable diseases. There are two fundamental advantages to using the “disease model” of substance dependency disorders:
- These conditions exhibit a type of plasticity in that if they are treated as diseases, they respond as diseases. Thus, this model has great utility in that patients and therapists can utilize it to great effect, and many have found this approach of practical value in helping patients achieve long term recovery and stability, free from relapses of active disease.
- Societal stigmas surrounding these disorders may never be erased, but, the use of a disease model, with freedom from fault, guilt, and shame in fair trade for full acceptance of responsibility for behavior can help tremendously in restoring mental and emotional equanimity as fault is left behind and responsibility for one’s life is assumed.
With these two complimentary approaches to the topic of “the disease of addiction,” it is hoped that the approaches used by therapists and doctors at the Bergand Group may be of value, of use to the community at large.
By John Steinberg, MD, FASAM
Medical Director, The Bergand Group