What is Addiction?
ADDICTION AS A PSYCHIATRIC/MENTAL HEALTH DISORDER
In 1950, Dr. Bob, the cofounder of Alcoholics Anonymous (AA), advised AA members,
"But there are two or three things that flashed into my mind on which it would be fitting to lay a little emphasis; one is the simplicity of our Program. Let's not louse it up with Freudian complexes and things that are interesting to the scientific mind, but have very little to do with our actual AA work." (Dr. Bob, 2004, para. 3)
Since then, the world has changed, and what may have been advisable and successful in a self-help group 60 years ago may not be appropriate in a formal treatment setting today. Given our deeper understanding of the addiction experience and the diverse problems confronting so many drug-using individuals, it may be more than fitting to say that “Complex problems require complex solutions” (Tatarsky, 2002, p. 136).
What, then, is the nature of this new understanding of addiction? The former head of NIDA, Dr. Alan Leshner, used to say that “They should be called patients, not clients” (personal communication, January 21, 2008). By this he meant that given the growing understanding of addiction as a brain disease, it is more appropriate to conceive of addicted individuals as suffering from a true medical illness. Strikingly, though the addiction treatment field has long referred to addictive disorders as a “disease,” this was, in fact, more of a metaphor than an actual biological condition. The long-standing opposition to methadone maintenance and, in some cases, psychiatric medication, would not have occurred if the field had embraced a “true” disease model. If addictions were actually understood to be illnesses, then the use of medication would have been an essential part of treatment. 1
Why is this important? In a sense, all addiction treatment functions on two axes: one of health and illness and the other of good and evil (Kellogg & Triffleman, 1998). This means that a fundamental question that confronts all who wish to work with those who have drug problems is: Are these sick people who need treatment or bad people who need punishment? In the world at large, punishment has often been a favored approach (Jacobs, 2010; Mydans, 2010). Given this, the widespread adoption of the termpatient and the championing of a “true” disease concept will go a long way toward humanizing treatment and improving its quality.
This “new” disease model is currently being championed by many forces in the field. For example, NIDA (2008) said that addiction is a “brain disease” and a “chronic disease” (NIDA, 2011). The ATTC (2011a) also agreed with NIDA's (2011a) perspective by affirming that it is a “brain disease,” that it involves a “changed brain,” and that is a “chronic disorder” (ATTC, 2011b). The National Institute on Alcoholism and Alcohol Abuse (2007) said that alcoholism is a “chronic disease” while not saying that it is a brain disease. Last, CSAT (2005) described it as a “medical condition,” as an illness, and as a “chronic, relapsing disorder” (CSAT, 1994).
If an addiction is a disease, the next question is: What kind? We believe that understanding it as a psychiatric/mental health disorder is the most accurate and most useful way of conceptualizing this problem. In a sense it already is one as the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000) classifies addictive and problematic substance use as substance dependence and substance abuse disorders. In addition, NIDA (2009a, b) labeled it a mental illness. Given that the disorder (1) has a strong behavioral component, (2) utilizes the brain as its primary organ of action, (3) benefits from the development of new medications that target or involve the brain, (4) occurs in the context of many other psychiatric disorders, and (5) requires the same treatment skills that are needed in other forms of psychotherapy, it clearly seems the most appropriate paradigm to use. Last, studies have shown that 60% to 80% of patients with an addiction have another mental health disorder, and 40% to 60% of those with a mental illness also have a substance abuse disorder (Sciacca, 2009). Above and beyond this, the rest of those who use substances do so for reasons that may also need specific attention. Centering addiction treatment in psychiatry and mental health also has certain treatment advantages. First, it provides a strong foundation for the judicious use of addiction-related medications (i.e., methadone, naltrexone, suboxone, topiramate, acamprosate, and disulfiram) and psychiatric medications, while also providing the medical base necessary for the use of such harm reduction and public health interventions as naloxone distribution. Second, it supports the purposeful and creative use of the cognitive, behavioral, psychodynamic, and experiential therapies not only in the treatment of the addiction but also in work with the underlying causes and the co-occurring disorders.
To further advance this new understanding of addictive disorders, there are three specific steps to consider. The first is to take action to ensure that all who work with addictive disorders have formal training in psychotherapy and a discipline-specific credential in addiction treatment. The second is to merge the addiction and mental health agencies and treatment programs so that this artificial separation, which does not serve patients, finally comes to an end. The third is to find, create, or develop effective and deeper ways of treating patients based on this new paradigm and understanding.
In 1950, Dr. Bob, the cofounder of Alcoholics Anonymous (AA), advised AA members,
"But there are two or three things that flashed into my mind on which it would be fitting to lay a little emphasis; one is the simplicity of our Program. Let's not louse it up with Freudian complexes and things that are interesting to the scientific mind, but have very little to do with our actual AA work." (Dr. Bob, 2004, para. 3)
Since then, the world has changed, and what may have been advisable and successful in a self-help group 60 years ago may not be appropriate in a formal treatment setting today. Given our deeper understanding of the addiction experience and the diverse problems confronting so many drug-using individuals, it may be more than fitting to say that “Complex problems require complex solutions” (Tatarsky, 2002, p. 136).
What, then, is the nature of this new understanding of addiction? The former head of NIDA, Dr. Alan Leshner, used to say that “They should be called patients, not clients” (personal communication, January 21, 2008). By this he meant that given the growing understanding of addiction as a brain disease, it is more appropriate to conceive of addicted individuals as suffering from a true medical illness. Strikingly, though the addiction treatment field has long referred to addictive disorders as a “disease,” this was, in fact, more of a metaphor than an actual biological condition. The long-standing opposition to methadone maintenance and, in some cases, psychiatric medication, would not have occurred if the field had embraced a “true” disease model. If addictions were actually understood to be illnesses, then the use of medication would have been an essential part of treatment. 1
Why is this important? In a sense, all addiction treatment functions on two axes: one of health and illness and the other of good and evil (Kellogg & Triffleman, 1998). This means that a fundamental question that confronts all who wish to work with those who have drug problems is: Are these sick people who need treatment or bad people who need punishment? In the world at large, punishment has often been a favored approach (Jacobs, 2010; Mydans, 2010). Given this, the widespread adoption of the termpatient and the championing of a “true” disease concept will go a long way toward humanizing treatment and improving its quality.
This “new” disease model is currently being championed by many forces in the field. For example, NIDA (2008) said that addiction is a “brain disease” and a “chronic disease” (NIDA, 2011). The ATTC (2011a) also agreed with NIDA's (2011a) perspective by affirming that it is a “brain disease,” that it involves a “changed brain,” and that is a “chronic disorder” (ATTC, 2011b). The National Institute on Alcoholism and Alcohol Abuse (2007) said that alcoholism is a “chronic disease” while not saying that it is a brain disease. Last, CSAT (2005) described it as a “medical condition,” as an illness, and as a “chronic, relapsing disorder” (CSAT, 1994).
If an addiction is a disease, the next question is: What kind? We believe that understanding it as a psychiatric/mental health disorder is the most accurate and most useful way of conceptualizing this problem. In a sense it already is one as the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000) classifies addictive and problematic substance use as substance dependence and substance abuse disorders. In addition, NIDA (2009a, b) labeled it a mental illness. Given that the disorder (1) has a strong behavioral component, (2) utilizes the brain as its primary organ of action, (3) benefits from the development of new medications that target or involve the brain, (4) occurs in the context of many other psychiatric disorders, and (5) requires the same treatment skills that are needed in other forms of psychotherapy, it clearly seems the most appropriate paradigm to use. Last, studies have shown that 60% to 80% of patients with an addiction have another mental health disorder, and 40% to 60% of those with a mental illness also have a substance abuse disorder (Sciacca, 2009). Above and beyond this, the rest of those who use substances do so for reasons that may also need specific attention. Centering addiction treatment in psychiatry and mental health also has certain treatment advantages. First, it provides a strong foundation for the judicious use of addiction-related medications (i.e., methadone, naltrexone, suboxone, topiramate, acamprosate, and disulfiram) and psychiatric medications, while also providing the medical base necessary for the use of such harm reduction and public health interventions as naloxone distribution. Second, it supports the purposeful and creative use of the cognitive, behavioral, psychodynamic, and experiential therapies not only in the treatment of the addiction but also in work with the underlying causes and the co-occurring disorders.
To further advance this new understanding of addictive disorders, there are three specific steps to consider. The first is to take action to ensure that all who work with addictive disorders have formal training in psychotherapy and a discipline-specific credential in addiction treatment. The second is to merge the addiction and mental health agencies and treatment programs so that this artificial separation, which does not serve patients, finally comes to an end. The third is to find, create, or develop effective and deeper ways of treating patients based on this new paradigm and understanding.