Recently, a reader wrote to me with the following question:
“You state that alcoholism can be a chronic progressive disease but is not most of the time. So, do you still believe addiction is a disease or that for the 1% of hard core drug addicts and chronic alcoholics who are literally killing themselves, that at this extreme end of the continuum their brains are no longer able to change without abstinence?”
This is a sophisticated question, which means that the answer is complicated. It's clear I will need to address this question in more detail over a series of blogs, but let me at least take a stab at a relatively straightforward answer. In order to do so, I'm going to break this question into smaller bits and answer them in sequence.
“You state that alcoholism can be a chronic progressive disease but is not most of the time.”
Yes, that's true.The NIAAA Epidemiological Study of Alcohol and Related Conditions (NESARC) is a very large (n=43,000) study of a random sample of the US adult population age 18+. So far participants have been interviewed at two different times 3 years apart, and the third wave is underway. One thing that makes this study unique is that it is following the same very large sample over time, something that has never been done before. Deborah Hasin of Columbia University and her colleagues examined the natural history of alcohol dependence (AD), and determined that about three-fourths of people who had an episode of AD in their lifetime had a single episode lasting on average about 3-4 years, and the disorder then went away and did not recur. The remaining quarter had an average of five episodes, each one of decreasing length. So their appears to be two forms of AD, one relatively mild and self-limited and a more chronic or recurrent form.
“So, do you still believe addiction is a disease...?”
Yes, I do, not the simplistic disease model that has been part of the Minnesota Model, but a disease in the same way that asthma, diabetes and depression are diseases. Why do I think this? 1) It is a genetically influenced disorder. About 50-60% of the variation in who gets or does not get AD is due to heritable factors, which is very similar to these other disorders. Not everyone with a family history gets the disorder, and not everyone with the disorder has a family history, but the same is true for heart attacks. 2) Both genetic and environmental factors are usually necessary in order for the disease to develop. Some people can drink a lot for a long time and never lose control of their drinking (impaired control over use is the hallmark of addiction,) but vulnerable individuals are more likely to. 3) There is a broad spectrum of severity, ranging from mild to moderate and severe. 4) Need for and response to treatment is predicted by severity and other patient factors. 5) As a clinician, treating addiction feels the same to me as treating any other disease, I use the same basic approach and skills and the response is similar. So, in short, AD resembles other diseases in many ways.
“... or that for the 1% of hard core drug addicts and chronic alcoholics who are literally killing themselves, that at this extreme end of the continuum their brains are no longer able to change without abstinence?”
NESARC and many other studies have shown that the more severe the dependence, the less likely that anything other than complete abstinence will lead to sustained remission (recovery.) Most of the people who are in treatment programs or AA have the more severe, recurrent, familial form of the illness. Thus, for them, abstinence is by far the best, safest option. For them, any drinking is likely to be very dangerous. However, for the people who have the mild to moderate, self-limiting form, non-abstinent recovery (low-risk drinking without any alcohol related symptoms) eventually occurs in about 40%.
Finally, I'll just briefly comment on the issue of addiction as a “brain disease.” Addiction is a dysregulation of a specific behavior. Where does behavior come from? Is there an organ involved? What organ might that be? Right, behavior is regulated or through the brain. Trying doing, thinking or feeling something without a brain. You won't get very far. So if addiction is characterized by dysregulated behavior, it naturally follows that self-regulatory systems in the brain are out of whack. If you think about it, you'll recognize that we don't need a brain scan to know that. How else could it be? New scientific tools are giving us a more refined view of which systems are involved and in what ways they are dysfunctional. This can be useful in leading us to develop new more powerful tools for aiding recovery, such as medication. With addiction, chronic or frequent exposure to high levels of intoxicants leads the brain to adapt in an attempt to normalize itself (in technical terms homeostasis.) Given enough time these adaptations are not easily reversed, such that if you take away the intoxicant you develop “symptoms” such as acute withdrawal, craving and preoccupation and an exaggerated response to stress. If you take a single dose of the intoxicant, you may lose control and binge even though that was not your intention. This whole topic requires more space than I want to devote here, but I'll just end by noting that this hypothesis does not in any way explain that wide variation in intoxicant use among people. But it is a decent place to start and probably applies pretty well to severe recurrent addiction.