Addiction: Disease or Choice?

The disease model of addiction is the prevailing opinion of most professionals in the treatment community today.  However, there are those who reject the notion that addiction is a disease: some believe that addiction is a choice made by the user. This group believes that the disease model only takes away personal responsibility from the addict, giving him a reason to continue using drugs and alcohol.  Who is right? Is addiction a disease, or a choice?

The idea that addiction is a disease has been considered since ancient times; references to chronic drunkenness as a disease can be found in ancient Greek and Egyptian cultures.  In the United States, the shift from drinking fermented beverages to distilled spirits tripled the consumption of alcohol almost 3 fold during the late 1700’s / early 1800’s.  Social reformer Anthony Benezet challenged the prevailing view that alcohol was a “Gift from God,” describing alcoholics as “Unhappy dram-drinkers bound in slavery.”  By the 1830’s, physician Samuel Woodward described intemperance as a “Physical disease which preys upon the drunkards health and spirit, making him a willing slave to his appetite.” Doctor Woodward recommended the creation of special asylums for the treatment of inebriates.

In 1829, Doctor William Sweetser stated “That intemperance becomes a disease, but then it is a disease produced and maintained by voluntary acts, which is a very different thing from a disease with which providence inflicts us.”

Opiate addiction became prominent in the 19th century, as it was believed that opium could alleviate that which medicine could not yet cure. Growing awareness of opium addiction led to such euphemisms as “It is not the man who eats the opium, but it is the opium that eats the man.” Drugs such as cocaine, chloral, and ether became popular drugs of abuse as well.  By 1864, specialized treatment for addiction was born at the New York State Inebriate Asylum. Dr. Joseph Turner, the founder of this asylum, had long advocated the disease concept of addiction. The superintendents of several such asylums established the American Association for the Cure of Inebriety, whose principles were as follows:

• Intemperance is a disease.

• It is curable in the same sense that other diseases are.

• Its primary cause is a constitutional susceptibility [to alcohol.]

• This constitutional tendency may be either inherited or acquired.

Early critics of the disease concept of addiction considered it to be a moral failing, a habit, and a sin.  Some considered the disease concept to be a blasphemy against God: addiction could only be cured by religious conversion.  The concept of free will was called into question – if addiction was a disease, then the inebriate was being given license to use when his ability to choose was removed by the disease model.  It was no longer a matter of his will. It was also believed by early critics, that drug and alcohol use was a problem with the product, and not with the man.  The aggressive promotion of alcohol and drugs by the companies that sold them was also called into question, as it was believed these were corrupt industries that were encouraging the use of these products. 

The Harrison act of 1914 brought narcotics under federal control, and Prohibition in 1919 banned the use and sales of alcohol.  Addiction was not only a disease or a moral failing, it was now a crime.  Making drug and alcohol use a crime has done little (In early or modern times) to stop the use of drugs and alcohol.  By the 1920’s care of the addict fell to penal institutions as the disease concept fell from favor.  With the advent of modern psychiatry, the disease concept had changed; treat the underlying psychological causes of addiction, and the inebriate will become clean and sober.  Addicts were subjected to whichever psychiatric treatments were in vogue: electroconvulsive therapy, frontal lobotomies, and treatment with barbiturates, amphetamines, and LSD.  Needless to say, none of these methods worked.

The modern disease model of addiction suggests that the brains of addicts are different than those of non-addicts.  Whether these differences are there before the addiction or if these differences are caused by the substance abuse is unclear.  Modern science, through the use of technology such as the PET scan, can now show that the addict’s brain structure is changed in response to the chronic use of drugs (Including alcohol.)  The brain’s circuits are literally rewired in response to drug use, causing major differences in brain function between addicts and non – addicts. The addict cannot control his addiction because of changes in his brain.  What does this mean – is addiction a primary disease, or a disease caused by the use of drugs?

Modern critics of the disease model reject the notion that addicts “Can’t help using drugs.”  Addiction is considered to be a behavior that can be changed, and not a disease at all.  These critics question the concept that addicts lose freewill, asking why so many addicts are able to stop using in spite of this “Fact.”  It is also suggested that the disease model is popular because of the treatment industry, which stands to lose much if the disease model is shown to be false.  Many believe that addicts are antisocial people who use their addiction as an excuse to justify their own behavior, and that the disease model just reinforces the excuse to continue using drugs.

Some of the most successful and popular methods of recovery are the 12 step programs, such as Alcoholics Anonymous or Narcotics Anonymous. Alcoholics Anonymous (A.A.) changed the disease model of addiction.  It is widely believed that the disease model of addiction was started by the founder of A.A., Bill Wilson. This is not true. However, the members of A.A. and other 12 step programs have played a role in spreading and popularizing the opinion that addiction is a disease.  The Narcotics Anonymous Basic Text states that “Addiction is a disease that involves more than the use of drugs.”  12 step programs state that “We are not responsible for our disease, but we are responsible for our recovery.”  Members of 12 step programs believe that they have a disease of body, mind, and spirit; the disease can never be cured, but it can be arrested and addicts can recover.  The 12 step model of recovery involves the use of spiritual principles to teach the addict how to live without the use of drugs. Addicts rely upon one another to stay clean; meetings and social events are used as a place for addicts to share their experience, strength, and hope with one another. Critics of 12 step programs often label these programs as “Cults,” reject the spiritual nature of the program, and believe the addict trades his addiction to drugs for an addiction to the 12 step program.

I chose this topic because I am a recovering addict.  I used drugs for most of my adult life, from the age of fourteen through the age of forty – one.  My own experience has shown me that while I was using drugs, I had lost the ability to stop on my own.  Drug use became an obsessive – compulsive disease, one that I had no control over.  I had rejected the notion that addiction was a disease; I believed that I was simply weak, and that there was something wrong with me as a person.  I quit a thousand times, only to pick up drugs again in time, and with each relapse, my use of drugs accelerated.  Ironically, I also believed that people who belonged to 12 step programs were just weak, couldn’t “handle their drugs,” and that they were just people who were marginal to begin with.  I managed to work, have a family, and maintain an appearance of “Functionality” during my active drug use.  This allowed me to live in denial for more than 25 years; in spite of the appearances I put forth, the reality was that my life was unmanageable.  Like most addicts, I had to “Hit Bottom” before I was able to admit that I am an addict.  Today, I am a recovering addict.  I am an active participant in a 12 step program, which has taught me how to live without drugs.

I believe I have a disease called addiction.  I don’t know if I had this disease before I started using drugs, but I am certain of one thing – I will always be an addict, whether I use drugs or not.  I do not believe that I can use drugs in moderation; I do not believe that I am “Cured” simply because I do not use drugs today.  Today, I choose whether or not I will use drugs again – I never chose to become a drug addict.  I don’t agree with the critics who say that my addiction  was a “Choice;” in the beginning, it was my choice to try drugs.  I did not choose to become an addict.  Once the disease of addiction became a reality in my life, I literally did not know how to function without drugs. Drug use ceased to be a choice in my life – drug use became an integral part of how I lived.  I am not a bad person trying to get good; I am a sick person trying to get well.  Addiction does not make itself known until it is too late.  I believe that drug use has caused my brain to change in such a way that I now have a disease.  There are other diseases that manifest this way – type II diabetes, for example, is a direct result of lifestyle choices made by the diabetic.  People don’t overeat with the aspiration to become diabetics any more than they use drugs in order to become drug addicts. Both groups suffer from a disease, and both can find relief with treatment.

I reject the notion that addiction is anything but a disease.  Perhaps it is a disease induced by the poor choices of the addict, but it is a disease nonetheless.

Penelope - 10/27/05

Works Cited:

William L. White, MA.  “Addiction as a Disease.”

Counselor Magazine. October 2000.  October 18, 2005.

William L. White, MA. “Addiction Disease Concept: Advocates and Critics.”

Counselor Magazine.  February 2001.  October 18, 2005.

Firshein, Janet. PBS.org. “Introduction: Addiction as a Disease.” October 19, 2005.

Narcotics Anonymous Basic Text, Pocket Edition.  2005

Message Board. Methamphetamine Abuse Discussion Forum.

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Hello Penelope, 

Thank you for sending in your essay. It is one of the best-researched and clearest explanations of addiction as a disease that I have seen. While I personally tend to lean more towards the addiction is a choice camp, I do recognize fully that there is often a genetic component to addiction that is either inherited or a result of the individual’s drug using behavior. I saw some really scary research a few years back on teenage alcoholics and the physical changes to their brains that their use had caused.

My own belief in the personal responsibility issue is that the person is always responsible for the choices that they make but they may not always be in control (especially after they have begun using – or even contemplating using). The control needs to be exerted well before any kind of use thought about or the person put them self in an at risk situation.

While the criticism most often leveled at the disease model is that it absolves the person from personal responsibility, I do not think that argument is totally valid. The largest benefit of the disease model is that it removes addiction from the realm of being a moral defect and the stereotypical town drunk, or skid row addict. The second and related advantage to the disease model is that it facilitates the seeking and receiving of treatment, rather than just placing the person in an asylum or labeling them as incorrigible.

Even Doctor Sweetser’s definition of addiction being “a disease produced and maintained by voluntary acts”, does not account for genetic predispositions, or the perhaps involuntary compulsion of an active addiction.

While I encourage my clients to embrace an understanding of freewill, it is from the perspective that they can learn to live another way, and can indeed make different choices. It is the recognition and acceptance of their need for help or that their life is unmanageable is just part of being honest with themselves and their humanity. I also stress that they need to be an active participant in their own recovery and maintain an active mind that questions and challenges everything, especially their past beliefs that supported their addictive behavior.

You stated that: “Modern science, through the use of technology such as the PET scan, can now show that the addict’s brain structure is changed in response to the chronic use of drugs (Including alcohol.)” This is interesting in light of recent medical interventions, such as the Prometa protocol which seek to reset the user’s brain by targeting and blocking specific receptors that induce cravings or compulsions. Such treatments are not a cure in themselves but may make it easier for the individual to make the other lifestyle changes needed to maintain their sobriety.

The freewill argument that some people can stop so why not others, does not take into account that addicts are unique individuals just like non-addicts and may have a huge range of personal locus of control capabilities. In other words, some addicts need highly structured environments such as jails, long-term treatment, and continuous community support (12 step meetings or family support)—while other former addicts are able to make sufficient personal changes to reduce the high risk situations and increase protective factors in their lives.

I could go on, but I just wanted to commend you on an excellent essay.

Doug