Definitions and Metaphors: What is addiction?

In his book, Religion for Atheists: A Non-believer’s Guide to the Uses of Religion1, Alain de Bottom’s opening position is, “The most boring and unproductive question one can ask of any religion is whether or not it is true—in terms of being handed down from heaven to the sound of trumpets and supernaturally governed by prophets and celestial beings.”

There is almost a religious fervor in how the addiction/recovery community grapples with our current disease model. And like any religion, there are loyal adherents and skeptics that denounce the tenet as dogmatic and unsubstantiated by facts. Silkworth’s “The Doctor’s Opinion” in Alcoholics Anonymous uses the allergy idea. “We believe, and so suggested a few years ago, that the action of alcohol on these chronic alcoholics is a manifestation of an allergy: that the phenomenon of craving is limited to this class and never occurs in the average temperate drinker.”2

Perhaps Silkworth and his contemporary’s allergic reaction classification sheltered alcoholics/addicts from stigma of the day that addiction was a moral failing, a lack of character and a self-inflicted condition.

In the 1970s the American Medical Association would deem alcoholism as a mental disease and in 1991 amend their definition to a mental and physical disease. Today, neuroscientists are rattling the cage with a vigorous skepticism about the disease model of addiction. In this religious-skirmish between establishment and rebellious science, both sides claim that the evidence sides with them, while the other is surfing a wave of ideology.

By the book, addiction doesn’t present like its killer cousin, disease cancer. Science can expose rogue cells that destroy their host body. Addiction isn’t like HIV which can be transmitted by intimate contact and identified in our blood. So is addiction a brain disease instead of a blood, bone or organ disease?

Online, displays a list of brain diseases that include Parkinson’s, Huntington’s, Alzheimer’s, Cerebral Palsy, Multiple Sclerosis and Dyslexia. The list doesn’t include alcoholism, gambling, smoking or substance abuse.

Do we call addiction a disease because it is beyond the sufferer’s control? And is that really true? We can kick our heavy drinking habit; we can’t kick cirrhosis.
Alcoholics Anonymous or other 12 & 12 fellowships don’t technically enter the public debate on this or any controversial topic.

Tradition Ten: No A.A. group or member should ever, in such a way as to implicate A.A., express any opinion on outside controversial issues–particularly those of politics, alcohol reform, or sectarian religion. The Alcoholics Anonymous groups oppose no one. Concerning such matters they can express no views whatever.3

Was it evidence or opportunity that the American Medical Association embraced the disease model of addiction? Just to be cynical for a moment, what a glorious franchise to capture exclusive domain over the treatment of people doing what people want to do. As an example of how respected medical establishments followed the party line, from, the Mayo Clinic, here is their definition of alcoholism: “Alcoholism is a chronic and often progressive disease that includes problems controlling your drinking, being preoccupied with alcohol, continuing to use alcohol even when it causes problems, having to drink more to get the same effect (physical dependence), or having withdrawal symptoms when you rapidly decrease or stop drinking. If you have alcoholism, you can't consistently predict how much you'll drink, how long you'll drink, or what consequences will occur from your drinking."4

Dr. Stuart Gitlow is President of the American Society of Addiction Medicine. On January 2013 Dr. Gitlow blogged about the new DSM-5 in his post When Will There Be Definitions and Terminology in Addiction Medicine? “I've heard that it creates definitions for mild, moderate, and severe substance use disorders, something we've not had before and something I've never heard any of our members request. I can't see myself telling a patient that he has a ‘moderate alcohol use disorder.’ And I worry that an individual defined as having a ‘mild’ substance use disorder would not be able to gain access to treatments that would be available if he simply had a substance use disorder. What I've learned from patients is that addiction is something you either do or do not have. There's little middle ground. I've also heard that DSM-5 fails to correct the oversight of earlier editions that separate alcohol use disorders from other sedative use disorders. This means that by definition, individuals' alcohol use disorders are gone once they've switched from Bud to Xanax. They now have another disease state. And that is simply wrong.

“But we've never said that formally. Isn't it time to do so? Isn't it time, now that we have our own Board and our own residencies and our very well established specialty of more than 50 years, to have our own set of terms and definitions?”5

A question worth asking is whether medicine and drug treatment have compatible ethos and philosophy in the first place. The legacy of doctor addicts in legion, if not cliché. Who has not seen the T-shirt with America’s favorite TV doctor, House, addicted to America’s most prescribed pain killer? “Wake up and smell the Vicodin,” the trendy T-shirt reads.

Disease model skeptics look for a better metaphor. Some liken addiction to be more of a behavioral disorder. Some follow poetic license and liken addiction to love as songwriters and poets do: “I got the love bug” or “love sick” are cliché now. Who said it better than Robert Palmer—“Doctor, doctor, give me the news, I gotta’ bad case of lovin’ you; no pill’s gonna’ cure my ills, I gotta’ bad case of lovin’ you?” Seriously, Robert Palmer was prophesying the future. MRI brain scans show infatuation with another human presenting like addiction and the rituals of love and obsession that come with it.6 Other research corroborates these addictive overlaps in brain patterns in internet and smart-phone enthusiasm.

Damian Thompson, in his book The Fix: How Addiction is Taking Over Your World, looks at how pervasive process and substance addiction is today, from iPhones to cupcakes to retail therapy. This self-admitted alcoholic challenges the disease model, wondering how heroin addiction can be just like chronic alcoholism and how these can both be like a preoccupation with online pornography. If addiction is like being in love, then it’s like a relationship—only an infatuation with a process or a substance that becomes the basis of our primary relationship, snubbing any human connection that comes between us and our fix. Thompson shares what he has been observing and some insights from his favorite reading list.

“Perhaps the crucial feature of addiction is the progressive replacement of people by things. That deceptively simple statement is a brilliant insight, though I can’t claim credit for it. It comes from Craig Nakken, author of the bestselling book called The Addictive Personality, who argues that addicts form primary relationships with objects and events, not with people.

“He writes: ‘Normally, we manipulate objects for our own pleasure, to make life easier. Addicts slowly transfer this style of relating to objects of their interactions with people, treating them as one-dimensional objects to manipulate as well.’

“What begins as an attempt to find emotional fulfillment ends up turning in on itself. Why? Because the addict comes to judge other people simply in term of how useful they are in delivering a fix. And at some stage, everybody lets you down. Therefore the addict concludes that objects are more dependable than people. Objects have no wants or needs. ‘In a relationship with an object the addict can always come first,’ says Nakken.”

Thompson goes on to describe how otherwise well adjusted people around him started behaving in just this way. Any of us who have been affected, maybe even traumatized by a betrayal of trust—sexual exploitation by a parent figure, feeling the brunt of an adult-rage-a-holism or suddenly losing a loved one—we start to consider how fallible the best intentioned humans in our life are and how much more dependable our rituals and substances can be to bring us bliss or oblivion.

Marc Lewis, in his Memoirs of an Addicted Brain chronicles the emotional and physical downward road of his own intravenous drug use. From the vantage point of a neuroscientist, Lewis gives us a rare, firsthand account of the brain chemistry causes and effects as well. Observe as he describes, not just the process of getting high, which he does with shocking candor in his book, but the process of longing to be high and loathing the obstacles in our way.

(Note: At the point of this quote, we are over 150 pages into the book now so there are some scientific terms used that Marc Lewis previously defined. If the terminology is unfamiliar, focus instead on the emotional description of obsessive compulsiveness. If striatal craving and amalgam consolidating don’t paint a picture, the raw desire and incomplete soul should ring a bell.)

“Dopamine creates engagement with life’s pleasures—both natural ones, like the taste of cheesecake, and unnatural ones, like the pulverizing fist of narcotic sedation. But when those pleasures are out of reach, when the goal is beyond your grasp, two things happen. First, if the goal remains attainable, anticipated by not yet present, dopamine flow gets stronger, energizing pursuit, turning obitostriatal connections in the moment and entrenching those same connections over minutes and hours. In this way, oritofrontal value is translated into striatal craving and with repetition, the value—craving amalgam consolidates into a lasting union, a dependency that drives away the competition, perhaps forever. When the object is just out of reach, that gush of dopamine feels like raw desire, a deep itch, the contradiction of an incomplete soul—whether the object of our desire is a girl or a drug. The second stage is when the goal is no longer anticipated, when you’ve given up. This stage brings the addict face to face with the world’s other half: the not-so-good half. Because when the drugs (or booze, sex, or gambling) are nowhere to be found, when the horizon is empty of their promise, the humming motor of the OFC sputters to a halt. Orbitofrontal cells go dormant and dopamine just stops. Like a religious fundamentalist, the addict’s brain has only two stable states: rapture and disinterest. Addictive drugs convert the brain to recognize only one face of God, to thrill to only one suitor. And without that purveyor of goodness, orbitofrontal neurons become underactive, sleepy, deadened.”7

Life is a balancing act for any addict to find sustainable satisfaction. To be either so risk-adverse that we are rigid or so careless that we are self-destructive would be a tragic consolation prize compared to peacefully breathing in a life of wonder. The manic “rapture” and depressing “disinterest” that Lewis describe as the addict’s opposite extremes life is easily relatable to any addict.

A foot in a bucket of ice and the other in boiling water may be statistically balanced but try it… Now try doing your job or being present to your children while you are simultaneously being poached and frozen. This is how addiction becomes a demanding mistress, forbidding other love-interests or life-interests. Other people, whom we say we love more than anything, to an addict are reduced to enablers that maintain our primary relationship or, a deterrent that becomes the target of our wrath or passive aggressiveness.

Where does that leave us, other than with a belly full of doubt? The debate over articulating the illusive experience of addiction rages on and so it should. Dogma is deadly when it comes to a phenomenon that continues to ravage so many lives and homes. It’s always a shame to hear cranky 12 Step old-timers telling newcomers to unlearn the head full of vocabulary that 28-day treatment center instilled in them. “Sit down and I will show you how it worked for thousands of drunks ½ a century ago, a la Big Book.”

Group think is suspect in every institution—scientific or spiritual. It is easy and lazy to create a legacy out of what has already been discovered. We need our laboratories, our dedicated thinkers and worker-bees pushing the envelope.

But where the rubber hits the road—where each addict wrestles with their own conundrum of addiction—what is in a metaphor? Going back to what Botton offered us at the beginning—what does it matter if disease isn’t a clinically accurate truth when describing addiction? It’s easy to poke holes in folklore and mock tradition. Looking for fault and contradiction as if there is a reward for it isn’t the same as presenting a superior alternative. If, for the sufferer, the word “disease” is a stepping stone to a “personality change sufficient to bring about recovery...” or a “profound alteration in his reaction to life,” as is described in Appendix II of Alcoholics Anonymous, then how important is semantics to the addict?

Yes, holding up the disease model as a sacred truth is wrong. So is being apathetic about surging forward towards better understanding. But it works as a metaphor—for now.

“I am not a bad person trying to get good,” we hear for 12 Step armatures, “I am a sick person, trying to get well.” Robert Palmer might sing about addicted to love. Bob Dylan might sing, “It might be the devil or it might be the lord but you’re going to have to serve somebody.”8 These are not intended to promulgate either a medical or theistic worldview. They are artistically sharing the language of the heart, from their heart to ours.

What is addiction; is it a bad habit or an environmental or hereditary disease? I don’t know, although I am curious. However mysterious this phenomena remains, there is a solution that has been found and shared by millions who aren't so fussy about a clarification. A hallowed tradition, that predates both modern medicine and guitar picking, is the transforming power of storytelling—from one peasant to another.

Every day, rational alcoholics or addicts in recovery are not married to illness, disease or disorder as a strict clinical definition for our addiction any more than crying out “Oh God,” during sex is a sincere prayer to our creator. Rather, it is just what we say to describe our experience. Other people seem to get it, so as any storyteller will confess, “Why let the facts interfere with a well told story?”

It is our nature to seek. We ought never grow complacent. But while we invest in better language with the ultimate goal of relieving more suffering, let’s try not to get reactive or judgmental about our flawed but functional current system. Our leaky boat needs replacement but in the mean time it still rescues the drowning and brings them to shore. Wouldn’t that be just like the addict to bite the hand that feeds us, abandon our ship and swim towards the horizon with visions of a more luxurious ride over the horizon? Let’s not forget who are, after all. As Carl Jung cautioned us, “Every form of addiction is bad, no matter whether the narcotic be alcohol or morphine or idealism.”

(1) De Botton, Alain, Religion for Atheists: A Non-believer’s Guide to the Uses of Religion. Toronto, McClelland & Stewart Ltd. 2012
(2) A.A. World Service, Alcoholics Anonymous Third Edition, p. xxvi
(3) A.A. World Service, Alcoholics Anonymous Third Edition, Appendix I Tradition Ten(long form) p. 565
(6) Ortigue, Shephanie, Ph.D., Bianchi-Demicheli, Francesco, MD, Pastel, Nisa, MS, Frum, Chris, MS, Lewis, James W., Ph.D., Neuroimaging of Love: fMRI Meta-Analysis     Evidence toward New Perspectives in Sexual Medicine, The Journal of Sexual Medicine DOI: 10.1111/j.1743-6109.2010.01999.x
(7) Lewis, Marc, Memoirs of an Addicted Brain. Toronto: Double Day Canada, 2011 pp. 158 – 159
(8)Dylan, Bob, Slow Train Coming, Columbia (1979)


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