Substance abuse is a pervasive problem throughout the United States. It affects all populations, socioeconomic groups, ages, and races. Within the community of substance abuse treatment providers, there is an ongoing debate on whether addiction is a disease, or whether individuals who abuse substances choose to engage in the behavior. There is evidence to support both positions. This paper will examine the controversy surrounding the issue of whether addiction is a choice, and examine the arguments presented by both sides. Addiction is a Choice
Many individuals view substance abuse and drug addiction as a choice. These individuals argue that addicts choose to put the addictive substance in their body, therefore triggering the subsequent chemical reaction that occurs (Schaler, 2000) Individuals who argue that addiction is a choice, do not dispute that there is a physiological reaction when the drug or alcohol enters the body, and that long-term use alters the addicts brain chemistry. What they take issue with is the disease concept of addiction. Proponents of the choice theory argue that by labeling addiction as a disease, personal responsibility is removed from the equation, thereby allowing the addict to justify continued use as they are “unable” to stop (Schaler, 2000).
Experience with addiction treatment confirms the choice theory, according to proponents of this stance. The most frequently recommended and popular method of recovery from addiction is Alcoholics Anonymous and its various offshoots (Narcotics Anonymous, Cocaine Anonymous, etc.). Alcoholics Anonymous is a program that offers support to the addict and postulates that the individual must undergo a psychic and spiritual change in order to maintain abstinence and achieve physical and emotional sobriety. The 12-steps utilized by Alcoholics Anonymous primarily revolve around an individual becoming honest about their substance use, realizing the damage their use has caused to themselves and others, making amends for the damage, and developing skills to assist them in staying sober and maintaining a healthy life. Critics of the disease model argue that AA and its offshoots talk about an ethical and spiritual solution, not a medical one (Schaler, 2000).
Primary treatment approaches utilized in substance abuse treatment centers revolve around a psychotherapeutic foundation, rather than a medical one. Skill building, cognitive behavioural treatment, psych educational groups, and process groups comprise the majority of treatment in drug and alcohol rehabilitation centers. These are combined with a healthy diet, treatment of any mental health issues, and plenty of exercise. Again, no evidence of treatment of any physical disease (Schaler, 2000). Perhaps individuals who are alcoholics are allergic to alcohol. They still possess choice in whether or not to take the drink, just as individuals who break out in a rash when they eat strawberries, can choose whether or not to eat a strawberry, knowing the potential consequences. Addiction as a Disease
Individuals who subscribe to the addiction as disease model argue that there is a psychological as well as a physical component to addiction. Initially, the argument is made that humans are conditioned to do things that cause them pleasure. Humans will repeatedly engage in an activity that elicits a positive reward. Humans also repeatedly engage in behaviors that allow them to avoid or escape negative consequences or results. Addictive drugs have the ability to reinforce strong behavioral responses and compel conditioned memories (Young, 1999). Addictive drugs produce different effects on body systems and each has a different immediate or long-term health consequence. But what truly separates addictive drugs from other classes of drugs is their ability to alter brain chemistry involved in the processes of reinforcement, learning and memory. Addictive drugs hijack our system’s natural response to rewards (Young, 1999).
Repeated drug use can significantly alter brain chemistry. Three different types of change are important for addictive drug use. Repeated use of the drug can increase tolerance, so that increasingly higher doses of the drug are required to produce the same effect. With some drugs, tolerance occurs because the drug begins to break down more efficiently, requiring more of the drug to experience the high, while in other cases, tolerance appears to occur at the level of the neurons. Another physiological change important to the development of addiction is that repeated use of some drugs can produce physical dependence, wherein the nerves in the brain and body only function normally in the presence of the drug. Failure to use the drug can result in physical withdrawal symptoms. A third way that brain chemistry is altered is in the reward pathways themselves. Repeated use of some drugs, such as methamphetamine, may cause the brain to decrease its production of dopamine and other pleasure inducing chemicals. This can result in intense cravings when the drug is withdrawn, as the individual is unable to experience pleasure any other way (Young, 1999).
One complicating variable with regard to the disease concept of addiction is that for many individuals, exposure to drugs and alcohol does not cause addiction. They are able to use opioids as prescribed and drink alcohol socially. Some individuals seem to be able to use drugs and alcohol recreationally, while others become addicted. Explanations vary. First, individuals vary in their biology, and there may be a genetic component to addiction. Second, the set of expectations associated with drug use may influence how easily one becomes addicted. Third, individuals may differ in learned vulnerability. For instance, an alcoholic, who never took pills of any kind, ceases alcohol use. After a substantial amount of time of sobriety, the alcoholic is prescribed pain medication as the result of the surgery. The alcoholic then becomes addicted to pain medication (Young, 1999). Statement of position
After substantial research I am taking the position that addiction is a disease. It was initially concluded that people naturally seek out pleasurable experiences. Why else would individuals who are functional, sound decision-makers in every area of their life, be unable to control or manage their intake of alcohol or drugs, even in the face of tremendous and unpleasant consequences? Jail, loss of children, loss of jobs and homes, homelessness, engagement in criminal activities; it is hard to perceive anyone choosing to continue substance use in the face of these consequences. The chronic alcoholic or drug addict will continue use of the substance, regardless of consequences, to the point of death. This can only be the result of biochemical changes in the brain as the result of substance use, perhaps combined with a genetic predisposition to addiction.
Chronic alcoholics and drug addicts should be treated with the same care that one treats a diabetic or someone with hypertension. Treatments involve behavioral changes, as well as medications, dietary changes, and exercise (McLellan, 2002). But like many with chronic disease, patients do not always cooperate with treatment. This is recognized in the medical community with regard to diabetes and hypertension, however when the alcoholic or drug addict behaves as others who have a chronic disease would, it is considered a moral issue.
The argument concerning Alcoholics Anonymous and treatment centers does not hold water with regard to those with a chronic condition. Individuals enter treatment or AA programs with varying degrees of addiction. An individual may enter AA after receiving his first DUI, and decide that he has a problem and needs help to stay sober. He arrests the disease before it progresses. This is similar to the diabetic, who prior to be diagnosed with Type II diabetes, is warned by her physician that she is pre-diabetic. She proceeds to make lifestyle changes that arrest her disease, and she never becomes a full-blown diabetic. The AA program will help the addict change their lifestyle making it easier for some addicts to resist behaviors that encourage use, and eventually addiction. Multicultural Considerations
Addiction is viewed differently in a variety of cultures. Within the United States, the African-American community experiences high rates of alcoholism and drug addiction. This is typically viewed as the result of genetics, combined with socioeconomic factors such as poverty, unemployment, and high educational dropout rates. The Native American community experiences rates of alcoholism much higher than any other North American culture. Hispanic culture, particularly Mexicans and Puerto Ricans show higher rates of substance use; however individuals from Cuba and Central American countries show a reduced rate of substance use (SAMHSA Office of Applied Studies, 1998). Cultural considerations need to be taken into account when providing treatment services to addicts, as different cultures view addiction differently. Some cultures, like Native American and African-American, tend to view addiction as a disease; while other cultures, like Asian or Hispanic, may view substance abuse as a moral issue or an issue of choice. How the addict sees the disease can help determine a route of treatment. Critical Literacy
The two primary positions presented in this paper regarding addiction, both attempt to determine causes of addiction. They utilize scientific methods, literature reviews, and deductive reasoning to come to their conclusions. There is a strong psychological component to addiction, combined with biochemical changes. Both views attempt to shape the existing science and research to support their positions; one from a medical framework and the other psychological/sociological framework. Civic Literacy
Costs related to substance use and abuse is astronomical in the United States. The US criminalization of drugs accounts for millions of dollars spent annually on police forces, trial lawyers, judges and correctional facilities. Other financial factors to be considered are the rise in crime rates in areas where substance use is prevalent, the increase in theft and property damage; the cost in failed marriages and children neglected and abused; the cost to emergency rooms which are required to treat individuals who present in crisis, regardless of their ability to pay. Socially, substance use destroys families and undermines the values that the US was founded on.Citizens can help by educating themselves about addiction and understanding that it is a disease. The majority of addicts need treatment, jobs, housing and a variety of other services to assist them in staying clean and sober. Citizens can vote for legislation that provides funding for treatment centers and necessary social services, rather than increasing the number of jails and correctional facilities. Science Literacy
The medical aspects of addiction require that science be actively involved in contributing to a solution. Scientists study brain chemistry and are now able to take pictures of individual’s brains that demonstrate the dramatic changes that occur when substances are introduced to an individual’s body. Medications are being tested that may reduce the cravings that addicts experience when they withdrawal from drugs. The field of psychology contributes to the reduction of addiction by providing addicts with cognitive-behavioral restructuring with regard to substance use, and assisting with any co-occurring mental health disorders. Values Literacy
Many people consider addiction a moral issue. They believe that if an individual just had enough willpower, they could choose to not use a substance they are addicted to. Many in North America believe this, and there are articles and books written regarding the topic of addiction as a choice. However, the science is clear, once a person is addicted, a variety of treatments are necessary to assist them in addressing the biochemical changes that have occurred in their body. Most of these treatments are not medical; they are psychological and involve restructuring an individual’s thought process as well as teaching them skills to cope with their addiction. Individuals with addiction should be treated as if they are a sufferer of a chronic disease, with the same level of care and compassion one would treat someone with diabetes or hypertension. Conclusion
In conclusion, there exists within the United States, two views regarding addiction. Some believe that addiction is a choice and that individuals who are addicts can choose whether to use or not. Others believe in the disease model of addiction. While strong arguments are made on both sides, the science is clear with regard to the disease model, although it is likely that the truth lies somewhere in the middle.