To understand what alcoholism and drug addiction are, it’s necessary to first understand what they aren’t — a character flaw, a moral weakness, or a personal decision on the part of an inherently bad person.
Addiction is, for all intents and purposes, a brain disease, one whose causes are multifaceted and whose effects are observable.
“There’s a lot of people who don’t understand it, and so what they say is, ‘How can it be a disease because you just don’t catch it, you do it to yourself.’ So people tend to still see it as a moral weakness,” said Vince Mercuri, executive director of The Open Door Alcohol & Other Drug Treatment Center in Indiana.
However, addiction is not a moral failing, and brain-imaging techniques have helped to show that, according to Ruben Baler, a health science administrator with the National Institute on Drug Abuse, part of the National Institutes of Health.
“From the scientific point of view, there is no doubt that addiction is the reflection of measurable dysfunctions of the brain,” he said.
He said its sometimes difficult to accept addiction as a disease because of the inclination to separate mind from body.
“If we put that aside for a minute, then we are left with an organ that is, for all practical purposes, really no different than the pancreas, the lung or the heart,” Baler said. “And when it goes out of order, when it has imperfections, impairments or disruptions in its inner workings, then we have overt symptoms and diseases, like addiction.”
“So once we move away from the notion of this nonmaterial entity inside our brains that dictates everything we do, then it’s much easier to understand that these dysfunctions in this particular organ can lead — and do lead very often — to all sorts of mental illnesses, drug abuse and addiction included,” he said.
That having been said, it still may seem counterintuitive to call addiction a disease, but the concept is supported by the American Psychiatric Association, which in latest edition of the Diagnostic & Statistical Manual of Mental Disorders places addiction within the spectrum of substance use disorder.
And the American Medical Association has long recognized alcoholism as a medical problem — it labeled it as an illness in 1956. More recently, the American Society of Addiction Medicine redefined addiction as a chronic brain disorder, and not a behavioral problem.
“Simply put, addiction is not a choice. Addictive behaviors are a manifestation of the disease, not a cause,” said Dr. Raju Hajela, a past president of the Canadian Society of Addiction Medicine and the chairman of the committee that rewrote the definition, said in statement announcing the change.
Mercuri said the classification provides a framework for understanding the problem.
He said that for something to be considered a disease, it has to be primary, meaning that it is has symptoms all of its own; progressive, meaning that symptoms will get worse over time if left untreated; chronic, meaning that the underlying problem continues to exist even with treatment; and has the potential to be fatal.
Drug addiction fits that bill, he said.
It is a problem one its own, and it progresses as people move along the continuum from recreational use to a full-blown dependency. Addiction also is chronic — it doesn’t resolve by itself and relapses can occur if the afflicted are not diligent in keeping up with their treatment.
And if addicts don’t receive treatment, they could eventually die from their use.
But Mercuri and others said that the label does not absolve addicts of responsibility for their actions.
“It doesn’t mean people aren’t responsible for their behavior,” Mercuri said. “It doesn’t mean that people aren’t responsible for their recovery, either.
“They do have a disease, but they’re responsible for their recovery just like somebody that has high blood pressure is responsible to eat less salt. If you’re a diabetic you’re supposed to take your insulin. The insulin here is recovery, abstinence and going to meetings.”
Carlton Erickson, a pharmacology professor at The University of Texas at Austin and director of its Addiction Science Research and Education Center, agreed.
“We don’t have to blame people for having the disease, but we can blame them for not going into treatment. We really ought to blame them for not seeking treatment,” he said.
However, he said people who suffer from addiction can’t simply bootstrap themselves into sobriety by “just stopping” anymore than a than a schizophrenic can stop hearing voices.
That, he said, results from the changes that extended use of a drug causes in the brain.
“Neuroscientists have been showing that for over 20 years now, that when you use a drug over and over again, your brain adapts to the drugs and that adaptation causes disregulation of the reward pathway in the brain. That’s where chemical dependence occurs,” said Erickson.
That disregulation, he said, ultimately impairs decision-making, judgment and impulse control.
Dr. Antoine Douaihy, a University of Pittsburgh psychiatry professor and medical director for addiction medicine services at Western Psychiatric Institute and Clinic in Pittsburgh, said that repeated drug use affects the frontal cortex of the brain, where the high-level decision-making functions occur.
In the brains of addicts, that circuitry is impaired, effectively shutting down the brain’s inhibitory abilities.
“In a sense the brain operates with no inhibitory effect. It’s like the brain hijacked. There is no decision-making,” he said.
And that, he said, helps set up a downward spiral in which people become preoccupied with a particular drug, get high and then crash, the only relief for which is to use again.
“It’s a vicious cycle that they cannot get themselves out of,” he said. “The key way to get themselves out of it is to stop using and start really working on change.”
And change can be achieved, especially through some form of extended treatment, according to experts.
“The longer they’re engaged in some kind of treatment, the better the outcome,” said Marty Ferrero, clinical director of adult services at the Caron Treatment Center in Wernersville, Berks County.
Caron is a nationally recognized, nonprofit organization that provides treatment for alcoholism and drug addiction. In addition to Berks County, it has treatment centers in Florida and Texas.
Ferrero knows a few things about treatment — he recently celebrated the 21st anniversary of his recovery.
In his younger years, when he was studying to be a teacher, Ferrero wrestled with a serious addiction. He credits an intervention staged by family and friends with helping him get on the path to treatment. He was initially resistant to the 12 steps used by many recovery programs and not knowledgeable about treatment options, he said.
Ferrero soon learned, however, that with treatment, it was possible to turn his life around.
“For many people, it’s lifesaving, and it’s certainly been for me,” he said. “I was dying. And thank goodness, my friends intervened when they did.”
He said the 12 steps became an important part of his treatment and recovery, and he continues to value them today.
More than three years into his recovery at a treatment center in Minnesota, Ferrero decided to become a counselor. He received training at that location. Since then, he has worked in the field for about 17 years.
Primary treatment — offered for at least 31 days at Caron — is really just the beginning of recovery, he said.
And recovery doesn’t always occur in a straight-line trajectory. Relapses do occur, but Baler said that does not mean treatment is ineffective or has failed.
“If we understand addiction as a chronic and relapsing disease, then we understand the limitations of any treatment. This is no different than asthma and diabetes, which are also chronic and relapsing conditions. So if sugar goes up again in the diabetic patient, it doesn’t mean the treatment has failed, it means that we need to keep up with the treatment,” said Baler.
“The situation is exactly the same in addiction,” he said.
“Having said that, this is a very difficult disease to treat, and it’s different for the different drugs (a person uses).”
And, according to Douaihy, treatment is not as available as it should be.
“The majority of people who have addictions are not in treatment. Access to treatment is huge. We’re not doing enough to improve it. It’s an embarrassment,” he said.
There are many barriers to treatment, according to a 2012 report by the National Center on Addiction and Substance Abuse at Columbia University.
Among them: a misunderstanding of the disease, insufficient insurance coverage of the costs of treatment, lack of information on how to get help, limited availability of services including a lack of addiction physician specialists, and insufficient social support.
The report found that addicts often have to break through several at once before entering treatment.
“Rarely is there only one obstacle to a person receiving needed treatment,” it stated.
For many treatment includes working a 12-step program, which originated with Alcoholics Anonymous. Abstinence is a key component of those programs, but it should not be confused with recovery. An addict can’t do in alone.
While abstinence refers to putting down the addictive substance, recovery is about addressing many factors the chemically dependent person may face. These include psychological and spiritual areas as well as family dynamics and social stressors.
Those seeking treatment benefit from a “jump-start” of an in-patient treatment program that includes a multidisciplinary approach, Ferrero said.
The initial treatment, he said, is really just the beginning of a person’s recovery process.
And there are programs that provide a number of ways to support an individual in recovery over a 12-month period, and beyond. Alumni events keep graduates of programs connected, which helps when one is on the path of long term recovery.
While treatment approaches continue to evolve and advance, one important factor stays the same when it comes to a program’s success.
“It’s up to the individual,” Ferrero said. “We do our best to heal them and point them in the right direction. It’s up to them.”
The method of treatment aside, the U.S. isn’t spending as much on treatment in general as it is on other diseases. And that’s in spite of addiction being a larger problem than diabetes, cancer, and heart disease, according to the CASA report.
According to the report, although addiction affects 40.3 million Americans, it spent $28 billion on treating it.
Meanwhile, diabetes affects 25.8 million people, and the country spent $43.8 billion on treatment. Cancer, the report said, affects 19.4 million people, but the U.S. spent $86.6 billion on treatment. And there are 27 million people suffering from heart conditions, on which the U.S. spent $107 billion.
And of the money the government does spend on addiction, researchers found that most of it, 95.6 cents on the dollar, is put toward paying for the consequences, such as prosecution and incarceration.
“Only 1.9 cents was spent on any type of prevention or treatment,” the report said.
The country’s criminal justice system would probably save a lot of money, too, if steered inmates into community treatment programs instead of prison, according to a 2012 study by Temple University and RTI International, a nonprofit research group.
According to the study, the criminal justice system could save $4.8 billion if it put 10 percent of eligible offenders into a community-based treatment program instead of prison.
Findings such as that are not lost on local law enforcement officials, who have been rethinking the wisdom of simply locking up the addicts.
U.S. Attorney David Hickton, for one, said he believes the right approach is steer the people suffering from addiction toward treatment, while continuing to aggressively prosecute dealers, who essentially are profiting from the illness of others.
That aside, even if spending were significantly increased on addiction treatment, it alone wouldn’t be enough, according to Douaihy. Along with more treatment, society also needs to address its other ills, he said.
“What we really need to understand is addiction does not happen in a vacuum,” he said.
“If we don’t address poverty, homelessness, if we don’t provide opportunities for people to be able to work and to get educated … and we send them back to an environment that isn’t supportive, all that you’ve done would be nullified.”