The Arc of Addiction – A Disease Model

Addiction is a disease.  Our program is going to discuss this disease on a very deep level over many sessions.  We will help you understand some of the pathways in your brain connected to opioid addiction or alcoholism.  We will explore avenues of therapy such as insight-oriented therapy or cognitive behavioral therapy.  We will help you feel comfortable with peer support programs and work a program more effectively.

To start our discussion, let’s lay out some of the data around the most common addiction – alcoholism.  It is the most common addiction treated in medical centers, and about 85% of inpatient rehab patients meet the criteria for this condition.  Each year, Alcohol Use Disorder (the medical term for alcoholism according to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5)) afflicts 14-15% of men and 5-7% of women.  Over a person’s lifetime, it affects between 41-43% of men and 17-19% of women.[I]

This session will look at the most basic components of alcoholism as it has been viewed in a cultural context.  These principles are easily transferrable to you if you have primary opioid addiction or any other addictive process.  The disease components seem to be the same from addiction to addiction.

It is common for people to feel confused about the concept of alcoholism being a disease.  We often think of diseases as passive conditions that will affect ‘innocent’ people.  Because of the stigma in the way people view addictive disorders, it is common to describe alcoholism as someone’s ‘fault.’  This session will help dispel common arguments against alcoholism being a disease.  By fully embracing this concept, we will help you to view recovery as a commitment to health.  Therefore, any path of recovery must emphasize this goal of health above all.

Let’s begin by listing the core ingredients making alcohol use disorder a disease process.

Alcoholism impacts the body on a cellular, tissue, and organ-system level

• Cells in the body are impacted by alcohol consumption. For instance, chronic alcohol intake will affect your exercise capacity and how the cells in your body transition from aerobic to anaerobic energy production.
• Tissue such as nervous-system pathways in the brain and body will gradually distort from chronic alcohol consumption. Examples of this include elevated brain levels of glutamate, an activating or excitatory neurotransmitter.  This basically means that chronic alcoholics can have heightened anxiety, irritability, and sleep disturbance connected to their drinking patterns.
• Organ-system issues are what we tend to think of when acknowledging alcohol’s impact on the body. Liver disease from chronic tissue inflammation can lead to scar tissue (cirrhosis of the liver) and the need for liver transplants in the most severe cases.

Alcoholism has about 50% genetic links

• If you have some family members with alcoholism and are struggling yourself, this is all too common. Genetic factors seem to play out in how the brain and body respond to drinking patterns.  Examples might include someone being less vulnerable to hangovers or able to have greater tolerance than peers.  Those traits are genetic and are linked to more and more overall drinking.

Alcoholism is effectively treated with a medical model of care

• Chronic disease management is the standard of care for severe alcoholism. You may not have a condition this severe, but it is always important to understand the multiple levels of treatment.  You may use these as needed, over your lifetime.  Also, medication approaches have a good impact on alcoholism recovery rates.  This style of care is called Medication-Assisted Treatment or MAT.  We will discuss these over your sessions.

Models of the Past

The following are some of the historical models to describe alcoholism.  It is important to understand where these theories came from and our approaches today.  The discussion around alcoholism connects to religious, political, psychological, and public health arenas.

The Morality Model

In the early part of the 20^th century, alcoholism was described as being a condition of ‘poor moral character’ and lack of integrity.  Prohibition, beginning in 1920, was popularized by the temperance movement in an attempt to improve multiple social problems in the United States.  By preventing access to alcohol, the country would in theory be more productive and with greater moral character.  Religious groups strongly condemned alcoholism as a path of sin and the alcoholic was seen as someone who had not fully embraced the love of God.

Even 1940’s textbooks on psychiatry listed moral failings as a common cause of alcoholism.  It wasn’t until the first 1950’s laboratory studies on rats that this started to change.  Experiments showed that a rat would preferentially pull levers to receive cocaine in such a repetitive fashion that the rat would eventually starve to death.  These pioneer animal models ushered in the beginning of the disease model of addiction.  It was hard to convince anyone that the cocaine-addicted rats had some deficit in moral fiber.  Maybe humans who had developed addiction were struggling with similar brain dysfunction issues as these rats?

The Psychic Theory Model

The first peer support group for alcoholism was Alcoholic’s Anonymous, developed in 1935 by founders Bill Wilson and Dr. Bob Smith.  A few years earlier, in 1931, one of the initial members of AA was a young man named Roland who had undergone 1 year of psychoanalysis under the care of Dr. Carl Jung, the renowned psychiatrist from Switzerland.  As psychoanalysis and in-depth therapy were being developed to treat conditions such as depression and hysteria, it was also believed that this form of psychological remodeling would cure alcoholism.

There were numerous initial psychological theories of why alcoholism developed in the brain.  One included a sense of an unmet oral need from childhood for which alcohol consumption would meet.  Another theory involved a developmental sense of inferiority which would become masked through the defense mechanism of alcoholic inebriation, a dysfunctional coping skill.

It was Jung who first objected to the use of psychoanalysis to treat alcoholism when he stated to the above-named Roland that he could not offer anything to resolve this man’s alcoholism from a psychological perspective.  The only bit of advice he did give, which has become a core theme of healing amongst many AA participants, was that a spiritual awakening experienced by the alcoholic could prompt a drive to remain sober.  So in a sense, Dr. Jung helped promote some of the earliest cases of recovery not through his treatment of choice, psychoanalysis, but rather through a spiritual and group support mentality.

Not Cause-and-Effect

More recent literature on this topic has compartmentalized psychology and alcoholism as highly associated but not cause-and-effect based.  This basically means that insight-focused psychotherapy can aid someone in their recovery but that it may not be enough to help establish recovery at first.  For initial recovery to happen, the brain needs some basic healing including progressing through some early sobriety days.

The Criminal Justice Model

This past depiction of alcoholism has, in many ways, held the poorest prognosis for those afflicted.  The assumption in an old-fashioned public health model was that ‘the inebriates’ would continue drinking alcoholically and that we could not offer them much as a health community.  Instead, efforts to sequester alcoholics from the rest of the population were promoted.  These ranged from the pub system to sanitariums for locking away alcoholics, and ultimately incarceration for chronic alcohol abusers.  Significant punitive measures around public intoxication or drunk driving would help decrease some binge behaviors, but would not really improve the outcomes for the true alcoholic.  Eventually, that person would just be incarcerated for repeated drunk driving offenses.

It is important to note that the criminal justice system is starting to utilize scientific evidence to improve outcomes, the most notable of these being the emergence of Drug Courts.  These programs acknowledge the chronic disease nature of addiction and the need to foster supportive treatment and goal-based progress rather than simply incarceration.  The success of Drug Courts has been significant in that 18-month participants in these programs have shown as high as 42% full abstinence from alcohol and drugs over that time.

Moving from an Arc of Alcoholism to an Arc of Recovery – The Diabetes Metaphor

We will be using the chronic disease model of alcoholism to explain the science behind your addiction and the path of healing.  Overall, this model can be the most comforting to patients in that it reduces the stigma around your health problems and emphasizes sensible, evidence-based roads to change.  It also provides the greatest view of hope in recovery.  Recovery is all about making a health commitment while holding honest acceptance of the disease process.

The most applicable metaphor to consider for yourself is the chronic disease of Diabetes.  This condition runs most parallel with addiction.  The take-home points for this metaphor are as follows:

Comparison

As we move onto upcoming sessions, we will revisit much of the chronic disease model and connect back to this diabetes metaphor.  The value in this educational content for you will be strong and sensible.  Use the information discussed in each session to enhance your discussions with your doctor, improve your therapy, work more closely with your sponsor, or reflect on your recovery needs by yourself.  This program is meant to help all sorts of people struggling with their substance use and will review the best science has to offer.

[i] Streem, D. “Alcohol use disorders.” Cleveland Clinic Center for Continuing Education. 2014