Addiction as a disease

When it comes to addiction, there are generally two schools of thought. The first is that addiction is a moralistic, behavioural issue – a problem created by our own poor choices, and something we can switch off – if we are simply motivated enough to do so. The alternate theory is that addiction is actually a disease. Like any other disease, there is a defect within a part of the body that we have no choice over. 

Addiction: a choice we make, or a disease we have?

According to Dr Kevin McCauley, Senior Fellow at The Meadows Treatment Centre in Arizona, USA, it’s the latter, and there is neuroscience to prove it. Traditionally there have been long held beliefs that addiction can’t be a disease, because at the crux of issues such as drinking, gambling or drug use is our behaviour, and put simply, behaviours are led by choices we consciously make. Whilst this notion is correct, it’s also reductive. Dr McCauley agrees, which is why he has spent the better part of the last two decades researching the difference between addiction as a disease versus a choice.  

“There are a lot of good arguments out there against calling addiction a ‘disease’. Against treatment, against AA”, he says, “but the things that we’re learning about what happens to the human brain when it becomes addicted to drugs and alcohol call into question long held beliefs about the nature of choice and free will.” This is, he says, because it turns out that the experience of addiction is largely down to what is occurring within one’s brain’s chemistry.

In modern medicine, disease is viewed through the lens of a causal model; an organ within the body becomes somehow defective, and as a result we experience symptoms. For many, it can be difficult to perceive how addiction fits into this model. It brings into question whether the addict chooses to cause harm to their body. Because with addiction, McCauly says that on first glance, the symptoms of addiction don’t look like symptoms, “they look like ‘badness’”, he says. But now, neuroscience tells us that addiction is not a morality issue. 

The neuroscience behind the disease of addiction

The brain is a complex organ, composed of different parts, each taking on different roles in our cognitive functioning. The frontal cortex is where we create meaning about the world around us, where we reason, intellectualise and moralise. If addiction were a question of choice and morals, this is the part of the brain it would correlate with. 

But, McCauley explains that research shows this is not the part of the brain where we experience the pleasurable effects of drugs, alcohol or other dopamine-inducing substances or behaviours. “It’s a very powerful idea, that drugs work in the thinking, decent, law-abiding, spiritual brain. But, it turns out that drugs exert no primary, physiological effect in the frontal cortex. Drugs work deeper down, in the older midbrain – our survival brain,” says Dr McCauley. 

McCauley says this part of the brain isn’t overthinking. In other words, it isn’t concerned with what recipe we’re making for dinner tonight, if it’s healthy enough or whether our family will enjoy that holiday planned for next year. “It’s keeping us alive, helping us survive the next 30 seconds,” he says. McCauley explains that this is the part of the brain where we quickly process life or death decisions and it has kept us alive as a species for millions of years.

In early research using mice, researchers found no behavioural changes occur when the subjects’ frontal cortex were directly administered with the drug cocaine. Yet when the drug was directly administered into two tiny spots within the midbrain, the Ventral Tegmentum and the Nucleus Accumbens, the subjects quickly developed addictive behaviours, eventually self-administering the drug by pushing a lever until deceased from overdose. In later research in people who were in recovery from addiction, fMRI studies showed that the mid-brain lit up when shown drug related imagery, whereas the frontal cortex went offline, swathed in total darkness. 

So why is it that one person can abuse drugs or alcohol, but manage to quit without any support or professional intervention, whilst another person is simply unable to stop? Why is it that some people with a genetic predisposition to addiction will remain clean, whilst those without will develop devastating, life-threatening dependencies? 

Dr McCauley believes that in addition to one’s environment and genetics, one of the significant causal agents in whether or not someone will experience addiction is stress. However whilst it’s true that stress is a normal part of the human, not everyone finds themselves in addiction. McCauley clarifies that it is the type of stress we encounter that makes the difference. Put simply, from individual to individual, we differ in that we don’t:

• Face the same severity of stress
• Face the same pattern of stress
• Have the same coping mechanisms
• Have the same brain 

Stress and addiction 

Although we all encounter stress day to day, many people experience what is known as chronic stress, often a result of traumatic experiences. These experiences continue to live on in the body, long after the threat has subsided and our adrenal glands secrete cortisol, a stress hormone, for long periods of time. McCauley says that the result of experiencing a continual build up of cortisol means the frontal cortex gets overwhelmed, can no longer do anything more to deal with the adverse experience, and subsequently hands over responsibility to the midbrain. 

McCauley explains that for our primitive midbrain, this chronic state of feeling unsafe starts to become a matter of life and death and so it will begin to seek out things that will relieve us – for many this will be alcohol, substances, gambling, sex or other self-soothing, pleasure inducing behaviours. This is where the question of addiction as a ‘choice’ comes into play.

“Pleasure is a morally loaded concept” says McCauley, and explains why many might perceive addiction as not a disease, but rather a choice that people make. However it’s important to understand that research shows that these pleasure-seeking behaviours can be attributed to a midbrain response to chronic, trauma-induced stress. McCauley argues that those experiencing addiction have no choice, because their emotional, reasonable, logical and moral part of the brain is offline. They are in survival mode, and their brains are therefore seeking pleasurable, pain-relieving experiences.  

The disease model approach to treating addiction

If we were to suffer a physiological defect, Western medicine would treat our bodies according to the disease model. Simplistically speaking, the defect has a cause, and by removing the cause the disease is effectively treated. When it comes to addiction, Dr McCauley explains that the same model can be applied to treatment. “Addiction is a stress-induced defect in the brain’s ability to properly perceive pleasure,” he says. 

Dr McCauley explains that the brain has a hedonic set point when it comes to how we experience pleasure. Our pleasure threshold can increase over time and exposure to stimuli, meaning eventually, we can no longer take pleasure from experiences that ordinarily would have satiated us. This phenomenon, known as Anhedonia, means the brain can only experience sufficient pleasure from the massive dopamine hits we receive from drugs, alcohol, sex, gambling, shopping – whatever it is that lights up our brain’s pleasure centre. This is why those in addiction see their tolerance increase, and more of the substance or behaviour is required to have a satiating effect. Unfortunately, when our ability to experience pleasure is defected, once again our morality comes into question and addiction is approached as a choice rather than as a disease.

Unpacking our trauma and learning to cope in a safe, therapeutic environment is key

It’s only when we look at addiction from a disease model and identify trauma and chronic stress as a cause, that we can break free of shame and begin to piece together effective treatment pathways that promote long term recovery outcomes.   

Identifying the role that our past experiences have had on us, our behaviour and our relationships, in the safety of an accredited, trauma-informed treatment centre like South Pacific Private is a proactive first step. Whilst we cannot erase our experience of trauma, we can learn to make sense of it, and to cope with it, lessening our likelihood of picking up a drink, substance or unhelpful behaviour when we are feeling overwhelmed.

If you or someone you know is struggling with addiction, you are not alone. Help is available and recovery is possible. Get in touch by calling 1800 063 332 or take a free online self-assessment.