Sick or Sinning?

I found the following source during our in-class scavenger hunt. This article is extremely balanced and offers arguments on both sides of the biological vs. moral debate. I copied and pasted the parts of the article that apply to this issue, however left out big chunks of the article that discussed insurance and government policy issues. While that was all very interesting to read, I believe my paper is going in a different direction. 

Clemmitt, M. (2007, February 9). Combating addiction. CQ Researcher, 17, 121-144. Retrieved from http://0-library.cqpress.com.skyline.ucdenver.edu/cqresearcher/

Addiction is a compulsion — not only to use an addictive substance like tobacco or cocaine but also to gamble or even shop — despite serious negative consequences. Addicts generally feel a loss of control over their behavior, and many give in to their compulsions after quitting.

The brain rewards certain behaviors — such as eating sweet food or having sex — with an evolution-ensuring payoff: pleasure. Many scientists believe drugs like cocaine hijack that reward system, skewing the brain to prefer a drug to other experiences. But skeptics say it's not surprising that some people habitually seek a predictable, intense drug reward. Others point out that psychological problems or a stressful environment may predispose some people to develop addictions.

Nevertheless, “most people who try any drug, even heroin, use it only experimentally or continue use moderately and without ill effect,” according to analysts from the Drug Policy Research Center at the Rand Corporation think tank.  Only about 9 percent of marijuana users become clinically dependent on the drug, as do 15 percent of alcohol users, 17 percent of cocaine users and 23 percent of heroin users. But 32 percent of those who use tobacco — considered the most addictive substance — become addicted. 

Not all substance abusers remain addicted, however. In a long-term study of heroin addicts, for example, after 33 years just under half of the surviving participants said they'd been off heroin for five years or longer. At the same time, 11 percent of the original participants had died from a drug overdose; 10 percent from homicides, suicides and accidents — many probably related to drugs — and 7 percent from a chronic liver disease that afflicts injection-drug users. 

No one knows why only a small percentage of people become addicts or how best to help addicts kick their habits for good. “We basically know how to get people off drugs for a month,” says Alexandre B. Laudet, director of the Center for the Study of Addictions and Recovery at the New York City-based National Development and Research Institutes. “But we know there are people in recovery for 35 years.”

Finding out how to help kick addictions permanently is vital, not just for addicts but also for society, says David C. Lewis, a professor of medicine at Brown University. “When people get into treatment, crime costs and accident costs both dive,” he says. “A family's health-care costs also go right down within the first year or two, along with absenteeism” from work. A Brandeis University study found that addiction costs the American economy $400 billion a year. 

New neuroimaging techniques are enabling scientists to learn more about how addictive substances affect the brain, possibly eventually leading to new drugs or other treatments foraddiction. Recent studies have found, for instance, that:

• Stroke patients with damage to a particular brain area were able to quit smoking without experiencing cravings or relapse;
• Socially dominant monkeys are less likely to overuse cocaine than more passive monkeys;
• Drug addicts show impaired function in several brain regions that are important for distinguishing the relative value of different rewards and behaviors.

Researchers also have learned that social and personal environments can influence people in unexpected ways to either seek or avoid treatment, Laudet says. In a study of women addicts, for example, researchers initially thought husbands and boyfriends might reinforce women's efforts to kick drugs and encourage them to stay in treatment. Not so, one study participant said of her partner: “Actually, he likes me better when I'm high.” 

Americans have long debated whether addiction should be viewed as a disease or a moral choice. “We're really torn as a society on whether we want to help addicted people or punish them,” says Scott Kellogg, a psychotherapist and clinical assistant professor of psychology at New York University.

Advocates of the “disease” point of view note that current science shows high levels of drug use change brain function. They also cite the value of removing addiction's moral stigma so substance abusers will come forward and seek help. Opponents of the disease label argue thataddiction science remains fuzzy and that calling addiction an incurable disease robs abusers of hope that they can change.

Addiction is more serious than substance abuse and indeed qualifies as a disease, according to John T. Schwarzlose, president of the Betty Ford Center. “There is a well-defined criterion that distinguishes between the abuse of alcohol and alcoholism,” he said. “Once someone is addicted . . . there is a change, an alteration, of the neurochemistry of the brain. And you cannot go back once you've become addicted.” 

Actress Mariette Hartley, a long-time spokesperson for alcoholism recovery who wrote a book about her own struggle with alcoholism and depression, calls alcoholism “a self-diagnosed disease” in which sufferers realize they are powerless over their own desire to drink. For an addict, “it's very, very hard to try to drink like a normal drinker. I find it impossible,” she said. “A lot of people who've tried . . . desperately to control their drinking, can't physically control their drinking.” 

Most who see addiction as a disease view it as a “primary” disease — not a symptom of another medical or psychological condition — and believe it afflicts those who are “biologically susceptible,” according to William L. White, a senior research consultant for Illinois-based Chestnut Health Systems, a mental-health and substance-abuse treatment organization. “One either has or does not have the biological risk for addiction.” 

Laudet, of the Center for the Study of Addictions and Recovery, contends that addiction is not just a disease but a chronic disease — similar to diabetes and high blood pressure — characterized by a tendency to relapse if the sufferers go off their treatment.

“There is a behavioral component” to developing addictions, as with other chronic diseases, says Laudet. Addicts who relapse are like someone who has had a heart attack and goes back to eating unhealthy foods, she says. “But we don't blame people” with chronic disease for their relapses the way we do addicts who fall off the wagon, she notes. “As long as society — at least in the back of its mind — thinks addiction is a moral failing, it's very difficult to sell enhanced treatment.”

In fact, brain scientists are finding, among other things, that drugs change the brain and that different brain structures may give people different predispositions to begin or relapse into drug abuse.

Michael A. Nader, a professor at North Carolina's Wake Forest University School of Medicine, studies the relationship between brain function and behavior. Among his findings: Cocaine use changes the brains of laboratory monkeys, and socially dominant monkeys have fewer of certain neuroreceptors in their brains and are less prone to use large amounts of cocaine. This research and a series of other studies are showing that drug addiction “is at main a disease,” Nader says. “It's clear as day” that addiction is not the result of “some moral weakness.” 

The new science is “guilt-relieving,” says Brown University's Lewis, and may give people hope to continue or re-enter substance-abuse treatment instead of giving up because they think they are doomed to failure. The new findings allow people to see that a drug relapse, for example, “isn't 100 percent within their control, that people relapse despite their best efforts,” Lewis says.

He is quick to point out, however, that by calling addiction a disease scientists are helping people to better understand the condition — not trying to justify substance abuse or abuse-related bad behavior.

Furthermore, treating addiction as a “disease” may imply that it can be treated with drugs — such as methadone for heroin addicts — and “this creates controversy,” Lewis says. “Using a drug to treat a drug-related problem seems like a moral issue to some people.” In its “wishful, utopian view of itself, the United States is an abstinence-based society,” he says. “There can be almost religious overtones to abstinence only.”

Some critics of the disease model say that neurological research shows such wide variations in the way different substances affect brain structure and function that the science can't possibly lead to the conclusion that addiction is an actual disease.

In fact, “recent research on the effects of drugs points us toward the conclusion that . . . addictionhas little to do with what drugs contain, although it has a lot to do with what we think drugs can do to us,” according to New Jersey psychologist Stanton Peele, the author of several books on substance abuse.  This means that addiction is not a disease in which drugs alter brain structure in a way that forces addicts to seek more drugs, as some argue, Peele says.

Peele argues that brain research actually provides evidence that addiction is not a disease, because brain studies find different drugs acting differently in many different regions of the brain. Many neuroscientists “try to unify all drugs of abuse around their impact on dopamine,” which they “regard as the mediator of pleasure in the brain,” he says. But since other behaviors, like eating, having sex, winning a competition or being praised, also affect the brain's dopamine system, just as drugs do, “drug use cannot be distinguished from a hundred other activities.” 

Instead, Peele says the variety of responses to drug and alcohol use — some people growing addicted, some not, some breaking away from addiction on their own or with treatment — shows that “addiction is caused by environmental factors” that lead people to feel insecure or unhappy. Increasingly in modern society, people don't have a personal sense of “joy and competence,” according to Peele. Developing a regular, ritualized habit of using pleasure-producing substances like drugs and alcohol, often in a social situation, or engaging in activities like gambling, shopping, or overeating, provides “a soothing sensation that everything is all right,” Peele said. As such, it is experienced as a difficult-to-end addiction by people plagued with “uncertainty, self-doubt and anxiety.” 

Twelve-step programs like Alcoholics Anonymous (AA) and Narcotics Anonymous rely on two vital tools for recovery: mutual support and the acknowledgment that addicts are “powerless” to combat their addiction alone. But critics argue that most people who beat addictions do so without such groups and that the idea of being “powerless” over drugs or alcohol may make some people more rather than less likely to go on using.

Twelve-step programs insist that abusers keep up their participation in a program and help other recovering addicts, says former addict McDaid, the Washington lobbyist. “In treatment, they tell you, 'When you're not using, your addiction is doing pushups,' ” she says, so staying involved in a recovery group is a crucial source of ongoing support — even for addicts who are not currently using.

And helping other addicts keeps recovering abusers conscious of their own vulnerability toaddiction's dangers, says McDaid. “If I'm not working with new people, I'm much less likely to stay tuned in” to that fact, she says.

Most of the low-income addicts she knows who are kicking their habit say their success is due to mutual support and reliance on some higher power, says Laudet, of the Center for the Study of Addictions and Recovery, and “most go to 12-step” programs. Ex-addicts continually talk about the need for support from family and friends, and many are involved in churches. “People draw enormously on religion,” she adds.

Twelve-step groups also subscribe to the addiction-is-a-disease theory, says Brown University's Lewis. “They've always gravitated toward the medical explanation, in part because it's guilt-relieving.”

Addicts go to 12-step programs because they identify with the model of addiction presented by such programs, says psychotherapist Kellogg, at New York University. According to AA, addicts cannot control their response to the addictive substance, he says. “Some addicts respond to this idea very deeply, and others are troubled by it.”

Current science may be leaving some AA doctrine behind, Kellogg says. For example, 12-step groups have long stressed the “mysterious” nature of alcohol and its hold on addicts. “But scientists are finding now that relapses are very predictable.”

Some 12-step critics say that by emphasizing quitting “one day at a time,” 12-step groups let addicts off too easily. “American society at large is now the carrier of AA doctrines,” says Trimpey, always assuming there is a hidden reason for misconduct. This theory has contributed to a creeping national philosophy of powerlessness that makes addicts less likely to end their addictive behavior, he says.

By suggesting that an addict commit only to staying substance-free one day at a time, 12-step programs “inexplicably reserve the privilege of relapse,” says Trimpey, making it more likely that they will do so. That approach robs people of their belief that “they have free will, that humans have a choice in the matter.”

Saying “no” one day at a time gives the abuser an excuse for any future failures, so it doesn't have the good effect of saying “never,” Trimpey continues.

Mutual-help groups aren't needed to beat the most physically addicting substance, nicotine, which suggests that they aren't the answer for other addictions either, according to psychologist Peele.

Surveys indicate that nicotine is the most hard-to-quit addictive substance — harder than crack or alcohol, he wrote. “Yet . . . a large percentage (half or more) of people ever addicted to smoking have quit,” says Peele, most without any group work or treatment.

Historically, the debate has been characterized by ambivalence. For example, in an 1825 sermon, the Rev. Lyman Beecher, a Presbyterian clergyman and temperance leader, simultaneously dubbed uncontrolled drinking “a disease as well as a crime.” Were “any other disease as contagious . . . and as mortal, to pervade the land, it would create consternation,” Beecher said. Despite calling addiction a disease, however, he condemned intemperate drinkers as being “addicted to the sin,” and enmeshed in “an evil habit.”

In 1829, Boston-born physician William Sweetser wrote of alcoholism as both a medical and a moral problem. Chronic drunkenness has bad physical effects, creating a “morbid alteration” in most bodily structures and functions, and some alcoholics have inherited vulnerability to the problem, he wrote.

But he worried about the implications of the “disease” label. It's clear that chronic drunkenness “becomes a disease,” he wrote, but a “disease produced and maintained by voluntary acts.” Thus, he wrote, “should the opinion ever prevail that intemperance is a disease like fever, mania, etc., and no moral turpitude be afflicted to it, drunkenness . . . will spread itself even to a more alarming extent than at present.”

Similar ambivalence attended public views of other drugs. For example, women and higher-income Americans widely used opium-based drugs like morphine in the late 19th and early 20th century, and most had been introduced to the drugs by their physicians. In fact, most “opium eaters” were women, partly because doctors widely prescribed opiates for menstrual pain and menopausal symptoms. An 1885 survey in Iowa, for example, revealed that 63.8 percent of opiate users were female. Many opium users became addicted. A 19th-century adage attested to opium's power: “It is not the man who eats opium. It is opium that eats the man.”

But others fought the notion that addicts were powerless over drugs. “That the responsibility of taking the opium or whiskey . . . is to be excused and called a disease, I am not willing for one moment to admit,” wrote Chicago physician C. W. Earle, in the 1880s. “I propose to fight this pernicious doctrine as long as it is necessary.”

Today, brain imaging and other neuroscience research have revealed much about how some drugs operate, and decades of experience offer clues about what treatment techniques work. But the question of what addiction is and how best to deal with it remains cloudy.

“Addiction is a mystery, and it continues to be a mystery,” says New York University psychotherapist Kellogg, even though addiction knowledge has advanced substantially. “We're like the blind men and the elephant,” taking on an issue too complex for simple conclusions.

For instance, drug use may be different for different people, and “some drugs may have more biological issues involved,” he continues. “Because of genetics, perhaps, some substances may be more reinforcing for some people.”

Many different models exist, all with different consequences for how addicts and addiction are viewed, he says. For example, he says, there is a significant difference between the traditional “disease” model promoted by 12-step programs and the “medical” model pursued by neuroscientists.

Calling addiction a “disease” has been interpreted as saying, “once you're an alcoholic, you can never change, and it's impossible to control your alcoholism,” says Kellogg. “Many people experience that as true. They talk about their disease as a metaphor for the part of themselves that wants to keep drinking. It could be the brain, or a spiritual part of the self.”

Brain scientists may or may not buy that idea, but they have their own “medical” — or “pharmacological” model — whose key goal is to develop addiction treatments, especially anti-addiction drugs, Kellogg says. So far, studies show that chronic substance abusers are especially vulnerable, because there are changes in the brain that could increase the strength of drug cravings.

“Ten years ago, people believed everything was genetic,” says Brown University's Lewis. With time has come a different understanding. While everyone is born with certain inherited brain structures, “ 'genetic' is not a fixed entity,” he says. Increasingly, scientists believe vulnerability toaddiction is due to an interaction between genetic and environmental factors. Rather than being a disease that's biologically determined, “a 50-50 equation looks closer to the mark,” Lewis says.

Substance-abuse researchers hope neuroscience and behavioral research will yield new medications to treat substance abuse and a better understanding of what treatments help which people. But most agree that addiction's complexities will not be easy to crack.

Independent researcher Peele believes addictions arise mostly from social conditions that leave people feeling powerless and directionless and that addiction may be more prevalent in the coming decades. During speeches to parents around the country, he often asks if they think there will be more addicted kids in the future. “About 90 percent raise their hands,” he says.

Americans increasingly have been “medicalizing” more and more conditions, such as childhood hyperactivity, Peele explains. “In college, kids swap pharmaceuticals.” That all adds up to more future addiction, he predicts.

Others say it is more likely there will be a future boom in addiction treatments rather than a jump in addiction rates. Over the next decade more and better anti-craving medications will be on the market, says Brown University's Lewis. “The big pharmaceutical companies have figured it out, especially with alcohol. There are a lot of people out there who want these treatments.”

Meanwhile, the addiction-as-disease theory may extend to more behaviors, says Lewis. “I suspect that when the science is in, most similar things — like gambling — will show some of the same neuroceptor changes as drug addiction.”

“Gambling, sex and shopping will probably get in,” says New York University's Kellogg.

When it comes to treatment, today “we're stuck with the reality that everything works with somebody, and nothing works for everybody,” he says. While many who recover do so entirely on their own, many different kinds of help — from 12-step programs to medication — also seem to work for some people.

“We're seeing greater flexibility” in how treatment professionals and researchers view theaddiction and recovery landscape, he says. For instance, while it was once unthinkable, he predicts that the U.S. substance-abuse paradigm may slowly shift toward “an increased emphasis on moderation” in substance use, rather than immediate total abstinence. “It's kind of moving that way now,” he says.

Researchers will continue their quest to “tailor treatments” to the right people, says Laudet, at the Center for the Study of Addictions and Recovery. In the complex landscape of addiction, that's a top goal, but it will be difficult to reach, she says.

Ending social stigma so addicts are more willing to get treatment may be even more important, but that depends on the public — not on medical researchers, says Laudet. “If all of these people in respected roles in society could come forward and show a positive face of recovery, it would probably do more to change things than all the research we can do in our lifetimes.”