Drug Series: Disease, Not Choice
Framing addiction in the "organ/defect/symptom" model. 9th in a series.
by Kim Hancey Duffy
Addiction is not a disease – cancer is a disease. You chose to take drugs, and now you're getting what you deserve." When comments like this come out of the mouths of angry parents, siblings, physicians, or prosecutors, it's understandable-but it's often frustration driven by ignorance. For many addicts the choice to use drugs was made years ago, and their reconfigured brains now call the shots. How long should we continue to blame?
The National Institute on Drug Abuse (NIDA) defines addiction as: "a chronic, relapsing disease characterized by compulsive drug seeking and use, despite harmful consequences, and by neurological and molecular changes in the brain." Yet a stigma persists and most people won't look beyond the addict's detestable behavior. Some individuals have begun to look beyond it though, and have made their life's work educating the public on this disease.
Since finishing medical school, Kevin McCauley, M.D., has taken advantage of a myriad of educational programs which have contributed to his understanding of the human body: internal medicine training at the Naval Hospital in Oakland, flight surgeon training in the Navy, two years caring for the pilots of the Marine Corps Helicopter Squadron and the F18 Hornet Community – which was interrupted by a year at U.S. Disciplinary Barracks at Ft. Leavenworth for his opioid addiction, and followed by eight months of drug treatment. He employs all this training, plus the research he has done in the ensuing years, when he talks to addicts and families about the science of addiction. An interview with Dr. McCauley follows.
If you had one minute to convince a parent that her meth-addicted child suffered from a disease which could be compared to diabetes or hypertension, what would you say?
First of all, the behaviors of addicts are atrocious, and I'm certainly not trying to help addicts escape accountability. Addiction confuses us though, because it's a brain disease and we just don't understand the brain as well as we do other organs. The definition of disease is an organ that gets a defect that leads to certain symptoms. For a long time we couldn't fit addiction to that, and now we can. We've identified the organ-it's a particular area of the brain. We've identified the defect-it's a stress-induced defect in the brain's ability to properly perceive pleasure. We've identified the symptoms – loss of control; terrible, intense cravings for the drug; and persistent drug use despite negative consequences. So addiction is basically a broken pleasure sense in the brain. Addicts can't feel normal pleasure. Disneyland? Doesn't work. Meth does, because it releases so much of that pleasure chemical, dopamine. Why do addicts behave the way they do? Because their brain now equates the drug with survival. So it fits the organ/defect/symptoms model, and that's why addiction can be considered as much a disease as epilepsy or diabetes.
Would you modify that speech if you were speaking to a judge?
No. Addiction medicine is not about avoiding accountability. It's about finding what the addict can control, and then helping them use their control so their behavior becomes a little more reasonable. If you care about decreasing crime then you go the disease route, not the punitive route. If you go the punitive route, we'll always have full prisons. We now have tools that can help decrease crime, decrease case load, and get these people back to meaningful, functional lives.
What do you think about drug court? It encourages sobriety, but also has a punitive element.
Drug court has been a tremendous revolution. But I think the prosecutors believe that what's getting these people sober is the threat of the sentence hanging over their head. Addicts use despite that threat of years in prison. So what's getting them sober? Things that are deeply meaningful to the addict that drug court brings out. You've been to drug court-you see how the judge gets to know the patient, the patient gets to know the judge, there's a kind of consensus decision-making process between the judge, prosecutor, patient, and the defense team.
Exactly right. They work with the patient. If they have a slip – they get back to work. They hold the patient accountable. The graduations from drug court are deeply emotional, moving processes; even the hardest prosecutor can have a lump in the throat seeing someone who had been struggling for years finally make it. I think there are spiritual things going on in drug court.
What if you were trying to convince a physician it's a disease?
I was taught in medical school to tune up alcoholics and get them out, but don't spend a lot of time because they're just going to relapse. And if it's a drug addict? Don't hesitate – throw them out on the street.
They believe the addicts are exercising choice?
Yes. I think that that's a consequence of using organ/defect/symptoms to define disease. It makes doctors focus on things that are easy to figure out. Diabetes is an easy disease to figure out. It's in an easy organ and has a straightforward cause. Addiction doesn't have a straightforward causation and it takes place in a hard organ – the brain. So for the 90 years that we've been using the disease model, it's focused on other things, and addicts were just not considered patients. This prejudice of medicine is one of the major hurdles to overcome. We physicians have a moral duty to these patients, especially as the information rolls in and we see that addiction meets the disease criteria. But here's what I'm hopeful for: there's a new generation of people coming through medical school who have grown up with these concepts of the brain. They're going into addiction medicine, not because they're in recovery, but because they think it's an interesting clinical problem.
And the patients are exceedingly grateful when it works.
They respond well, and they can get sober. They don't need much, just regular medicine.
How strong a role do genes play in addiction?
A strong role. Genes can get you to addiction faster, but they don't cause addiction. What does? Stress. Chronic, severe, unmanaged stress, or trauma and undiagnosed psychiatric disorders which actually act on the genes to produce addiction. Genes are important, but people with terrible genetics for addiction can get sober and live a normal life. I don't focus a lot on genes in my lectures because I'm afraid people will seek refuge in it.
Right – like I'm a Scorpio, so I'm bound to misbehave.
Yes. And if you're a parent with an addiction, don't waste energy worrying about passing along those genes. One of the best things a parent can do for his or her children is to get sober, and let them see it happen.
Do you think convincing the public that addiction is a disease is going to help move treatment forward?
It's hard to say. Another big hurdle we face is that we say addiction is a disease, but everything we do shows that we don't believe it ourselves. In the way we speak to the patient, in the body language we use, and in throwing them out on the street when they get worse. If we really want the public to get behind treatment, if we want insurance companies to save money by treating this addiction now not later, we have to lead by example in addiction treatment. All that punishment and degrading talk has to go.
Won't funding for addiction treatment have to queue up behind standard healthcare and mental health care?
Or stand with them, side by side. The three greatest killers of Americans are cancer, heart disease and stroke. How much of those are really caused by untreated addiction? How much heart disease and cancer are caused by unchecked tobacco and alcohol use? How much hypertension, which causes strokes, is really due to unmanaged stress? You fix addiction, you fix the others. If we have to ration health care, we should focus our efforts upstream and realize that addiction is a major cause of a lot of other morbidity.
If addiction is a disease, then why does talking and listening in a 12-step meeting help?
Because those things really do change the brain. They change the neurochemicals and the structure of the neurons. When people go to meetings, and they work a program, and they find a sponsor, and develop a spiritual life, and they get tools to manage their stress, inside a community – that changes the way a brain functions. It doesn't fix addiction, but it keeps the disease quiescent, much like a diabetic manages their disease with diet, insulin, and exercise. That's essentially what's going on in an Alcoholics Anonymous (AA) meeting. There's group therapy, spiritual therapy, stress coping, a little individual counseling, and it's all under one roof, in one hour, for one buck. Many of the things we do in medicine, psychiatry, and psychology are going on in those meetings. For most patients, AA will be a part of a larger clinical plan to keep them sober.
Where does the god concept fit into the disease model?
You just put your finger on one of the big controversies. Did you see HBO's addiction special? It comes from a certain perspective, more of the psychiatric research angle like NIDA's or The American Academy of Addiction Psychiatrists. Even though it is respectful of AA, it doesn't focus a lot on the spiritual. I think that's because doctors are still focusing in the midbrain, the survival part of the brain. But the frontal cortex, the part of the brain where we have our morals, social values, and spirituality – that's important too. And what AA or LDS Family Services does – it turns that part back on. Spirituality and meaning go one step further past the midbrain, to turn the frontal cortex on so it can keep the midbrain in check. The HBO special talks a lot about what eases symptoms and keeps people stable, but it doesn't talk a lot about what really fixes this problem, really creates recovery. This reflects the turf war between the lay treatment recovery, like AA, and psychiatry. How do we bring this new neuroscientific understanding of addiction as a brain disease together with the wisdom that is set down by the old-timers and the basic text of AA?
This interview will be continued next month. Dr. McCauley's website is: addictiondoctor.com.
Kim Hancey Duffy is a freelance writer in Salt Lake City, and is also a member of Salt Lake City Mayor's Coalition on Alcohol, Tobacco and Other Drugs: