Addiction: How Should It Be Defined?

Well for the short term future I'll be back to posting on a more regular basis and with that I'll get to the titled topic. How to define addiction is a question that has drawn my interests for a long time, but I never really begin to appreciate the complexities of what was actually going on until recently. There seems to be a growing body of work that refers to addictions as a disease, handicap, disability or various other things. The pronouncement comes from a variety of places which each has a somewhat different take on what makes up an addiction. To address the question of what an addiction is, I’m going to look specifically at alcoholism and use it to create an understanding of the many descriptions of addiction and then try to pick out the understanding that works best.

To start the search for an accurate description it would be handy to look some of the pitfalls other descriptions have had. The American Medical Association for instance seems to be a little wishy-washy in their understanding of Alcoholism stating first that the AMA, "Believes it important for professionals and laymen alike to recognizing alcoholism is in and of itself a disabling and handicapping condition." They go on to call Alcoholism a handicap or disability 9 more times and sating in conclusion that, "Hopefully, this language clarification will reinforce the concept that alcoholism is in and of itself a disabling and handicapping condition."

Well that is a clarification is great until you get to the very next paragraph where the AMA states it,

"Endorses the proposition that drug dependencies, including alcoholism, are diseases and that their treatment is a legitimate part of medical practice," and "Encourages physicians, other health professionals, medical and other health related organizations, and government and other policymakers to become more well informed about drug dependencies, and to base their policies and activities on the recognition that drug dependencies are, in fact, diseases."

So in one short address of the issue the AMA has called Alcoholism a disease, handicap, disability, and condition. It consistently claims that it would be fair to characterize alcoholism in any of those terms. This trouble is not unique to the AMA, because addiction’s is a hard term to define. That difficulty makes it seem like a shotgun approach would be the correct way to look at addiction.  Throw a bunch of different terms at the problem and you’ll get a usable framework for what it is. That being the case it would be handy to see what the shotgun was loaded with.

It is quasi-handicap because there does seem to be a genetic predisposition to addiction that leads people to become addicted more easily.  Researches have even have gone so far as to claim that they have identified what the alcoholism gene is. That gene is the CREB and it is linked with both alcoholism and anxiety. When rats were bred without that gene they drank 50% more than usual, showed a higher preference rate for alcohol over water compared with normal rats, and displayed more anxiety than normal rats that decreased while they were drinking. So there is evidence that addiction can be a natural handicap a person has, at least in some cases.

Alcohol could also be described as a disability, although it wasn't included in the Americans with Disabilities Act and the Rehabilitation Act of 1973 nor is it a covered disability for Social Security. The World Health Organization describes a disability as,

"An umbrella term, covering impairments, activity limitations, and participation restrictions. An impairment is a problem in body function or structure; an activity limitation is a difficulty encountered by an individual in executing a task or action; while a participation restriction is a problem experienced by an individual in involvement in life situations."

So this definition is vague enough for alcoholism to be included, because when a person is drunk they are impaired, but disability, like the term handicap, is a rough description and it might be a miss-characterization.

The third term, disease, is probably the most controversial of the terms listed to describe addictions, but it is also the best documented. There is also a good body of evidence for calling addictions a type of disease. Yet, before that evidence can be looked at it a useful definition of disease should be given. Medline Plus gives the definition of disease as,

"An impairment of the normal state of the living animal or plant body or one of its parts that interrupts or modifies the performance of the vital functions, is typically manifested by distinguishing signs and symptoms, and is a response to environmental factors (as malnutrition, industrial hazards, or climate), to specific infective agents (as worms, bacteria, or viruses), to inherent defects of the organism (as genetic anomalies), or to combinations of these factors."

I think that is a fair description of what characterizes a disease and Nora Volkow and Joanna Fowler show how addiction meets that criterion. In Addiction, a Disease of Compulsion and Drive: Involvement of the  Orbitofrontal Cortex, they show how addiction not only works with the reward centers of the brain, but also has an affect on the part of the brain active in people who are obsessive compulsive. They argue that

"Intermittent DA stimulation secondary to chronic drug use leads to disruption of the orbitofrontal cortex via the striato-thalamo-orbitofrontal circuit, which is a circuit involved in regulating drive (Stuss and Benson, 1986 ). The dysfunction of this circuit results in the compulsive behavior in addicted subjects and the exaggerated motivation to procure and administer the drug regardless of its adverse consequences. This hypothesis is corroborated by imaging studies showing disruption of striatal, thalamic and orbitofrontal brain regions in drug abusers (Volkow et al., 1996a )."

Basically, chronic drug use subverts the brains thinking and creates a compulsion for use, which would be near the same level as other compulsions. Volkow and Flower go so far as to conclude that, 

"It would therefore appear that during addiction the chronic drug administration has resulted in brain changes that are perceived as a state of urgency not dissimilar to that observed on states of severe food or water deprivation."

So the body/mind would have cravings the way that starving people would crave food. This is a diseased state where choice is subverted to the drives of reward and compulsion. It is due to this that the AMA and virtually every other drug treatment site can say that addiction is a disease. Addiction follows a pattern that is like that of a disease, it can be debilitating and leads to impaired brain function, especially in how it creates a compulsion in some people.

Yet a certain word is left out completely of Volkow and Flower's article. 'Choice' is never mentioned once, that is the word that breaks the disease line of thinking. All the above is true about how an addiction to something like alcohol works, but it still doesn't account for how a person becomes a chronic addict before the compulsion is created, at some level the word 'choice' has to be addressed by anyone who supports the disease model of addiction.  The role of choice is often overlooked by supporters of that model, but their critics often fail to understand that there is a credible background for referring to an addiction as a disease.

In the end I think it is somehow perverse to put alcoholism in the same category as HIV, cancer, and numerous other afflictions that don't have the same level of control. I admit that some addicts don't have total control, but it still seems like a miss-categorization. There has to be a more fair and accurate way to describe addiction.

Why can't an addiction just be referred to as an addiction? If it was we would be rid of the vague yet all encompassing definitions that addictions are trying to be squeezed into. It would be an apt characterization of what is going on, while also bringing none of the extra baggage that comes with those other terms. While it might be fair to describe addiction in disease like terms, it isn't the best description, and it does a disservice to disease.

Set down your shotgun and be more direct. Addiction doesn’t need the other labels and instead of spending time worrying about where it fits and how it can be defined worry instead about the actually affects of addiction socially, physically, and personally.

Thanks for reading,
-the moral skeptic