By Dr. David Laing Dawson
After recent blogs and comments I thought I would try applying the disease model or the medical concept of disease to the problem of addiction and see if it helps.
The modern medical concept of disease evolved within the 19th century through the 20th. The basic idea is that if a number of people suffer a similar or identical set of symptoms/ailments then perhaps what helps (treats successfully) one person would help the other sufferers as well, and the cause or etiology of this specific ailment might be the same for all.
Similarities of symptoms, signs, course, and outcome, might mean there exists a single cause. And when we speak of causality we can divide that into necessary factors along with contributing factors. For example, a number of factors may contribute to the easy transmission and severity of tuberculosis (poverty, poor diet, crowded housing, dormitories) but there is one necessary etiological factor in the development of tuberculosis, and that, of course, is the tubercular bacilli or mycobacterium tuberculosis.
Competing ideas for understanding ailments and illness, (pre-twentieth century and to some extent still with us) were often couched in moralistic or religious terms: acts of God and/or punishment for immoral behaviour. So the medical concept of disease also removes moral responsibility for becoming ill, but it does not, within the social contract of the medical model, eliminate the responsibility for the sufferer to try to get better.
Drug and alcohol misuse can take many forms, some relatively harmless and others ultimately quite harmful. But addiction can be defined by the development of tolerance (needing more and more for the same effect), craving, and significant physiological consequences of withdrawal.
The extent to which one loses one’s self control or agency over one’s behaviour within an addiction is one of the reasons we might consider it a “disease” and not a personal failure. (As an addict in my extended family once shouted at his sister, “Of course I lie. It’s part of the disease.”)
Now there can be many contributing etiological factors for addiction: trauma, poverty, loss, illness, pain, depression, unemployment, genetics, peer pressure, personality type, family, culture ….. but there are two necessary etiological factors or events: the first is having the addictive substance within reach, or at least available with a small effort, and the second is the act of putting it in one’s body, over and over again.
Therein lies the problem. On one hand we are trying not to blame addicts for their continuing addictions, and yet all existing treatment programs are organized means of focusing on access to the addictive substance and the volitional ingestion of it. They are all sophisticated methods of persuasion that ultimately acknowledge the necessary etiological factors are the availability of the substance and the volitional ingestion/injection of it.
I doubt that this helps very much but I am also sure that thoughtlessly saying “addiction is a disease” as a way of absolving the sufferer from responsibility, is also unhelpful, especially when the only treatments for the necessary etiology of volitional ingestion/injection are either forced abstinence, successful persuasion, and/or medically prescribed safer alternative substances.
We have failed miserably in our attempts to limit the availability of the addictive substances, perhaps causing more of these substances to come from sketchy sources and be potentially lethal.
For those who use them, safe injection sites have reduced some of the consequences of addiction: death by overdose, hepatitis and AIDS. But in the larger communities surrounding these programs the number addicted and the deaths by overdose continue to rise.
Similarly, readily available naloxone in the hands of quickly responding EMTs, has saved many lives (often the same person several times) but overall, the death rate from opioid overdose has risen.
And more and more public education has certainly not lead to a decrease in addictions or overdoses. Blanket “just say no” campaigns aimed at teens and youth can actually produce an upswing in interest and use. (see the High School Stop Smoking programs of the 1950’s)
Targeted education may be more effective: 1. ensure addicts understand that if they stop using they will lose tolerance and, when they relapse, the same dose could be lethal.
2. Quick dissemination within the addicted population of news of a dangerously contaminated batch on the street. 3. Ensure addicts understand the lethality of some combinations of prescribed drugs and illicit drugs.
With limited success targeting the necessary causative factors for addiction we are left with the contributing factors. The question is are any of them sufficiently specific to be targeted and do we have the tools? One of these contributing factors is mental illness and we certainly could do better providing effective acute and long term treatment for this.
But it is hard not to notice that the principal demographic comprising both the majority of addicts and those who die from overdose is the same demographic as the focus of a different concern today: males between 20 and 50 who are being displaced in the classroom by females and displaced in the workplace by females and robots.
Males bereft of fulfilling roles and meaningful activity.
And therein lies a problem that goes far beyond biology, the disease model, and the practice of medicine.
When, on a cold bitter winter day I drive past a man begging on the boulevard near a stop light, and see him there again four hours later, it always comes to mind that almost any activity in a heated store, factory, gas station, office building would be better than being under-dressed and pacing for hours in bitter wet cold. And then it occurs to me that with addictions there comes a struggle, a hustle, some very hard and difficult work (legal or not) to get the money for the dealer. And that very hustle may be a necessary part of addiction. Or, put another way, addiction provides the addict with necessary, though harsh and difficult, meaningful activity.
It is, after all, how the brain functions. Pleasure unearned is unsatisfying. But dopamine increases as we we work toward an anticipated pleasure – whether that be a blackjack at the casino table, the painting of a wall before a glass of bourbon, the finishing of a task before a coffee break, or the hustle to get the money and find a dealer.
Which means a large part of the reduction and prevention of addictions will entail finding meaningful activity for men between the age of 20 and 50. (other than invading Ukraine)