Addiction is not a disease

The statement, in a CMAJ editorial, 1 that addiction is a disease is not supported by the evidence and reads more like a political policy statement than a reasoned intellectual argument.

There has been a steady erosion of individual responsibility and loss of any concept of personal blame for bad choices. To quote comedian Flip Wilson, “It’s not my fault — the devil made me do it.” Calls to destigmatize addiction remove any sense of personal responsibility.

Addiction does not meet the criteria specified for a core disease entity, namely the presence of a primary measurable deviation from physiologic or anatomical norm.2 Addiction is self-acquired and is not transmissible, contagious, autoimmune, hereditary, degenerative or traumatic. Treatment consists of little more than stopping a given behaviour. True diseases worsen if left untreated. A patient with cancer is not cured if locked in a cell, whereas an alcoholic is automatically cured. No access to alcohol means no alcoholism. A person with schizophrenia will not remit if secluded. Sepsis will spread and Parkinson disease will worsen if left untreated. Criminal courts do not hand down verdicts of “not guilty by virtue of mental illness” to drunk drivers who kill pedestrians.

At best, addiction is a maladaptive response to an underlying condition, such as depression or a nonspecific inability to cope with the world.

The study on the neurobiology of addiction3 referred to in the CMAJ editorial1 looked at the brains of people with addiction after they had damaged them by their behaviour — brains were not examined in their premorbid state. This is analogous to saying that the sequelae of a traumatic brain injury were themselves the cause of said brain injury. Ironically, the title of the referenced article uses the term “disorders” not “diseases.”

Medicalizing addiction has not led to any management advances at the individual level. The need for helping or treating people with addictions is not in doubt, but a social problem requires social interventions.