Is Addiction a Disease, Disorder, or a Choice?

March 14, 2024 PCI Centers

Over 19 million Americans struggle with substance addiction, costing the U.S. an estimated $6.6 billion in 2022 for substance use prevention along with millions and billions more appropriated funding for mental health care and state-level opioid epidemic response programs (SAMHSA).

Is Addiction a Disease?

Diseases are characterized as having a physiological or biological basis. They typically have a specific cause such as infection, genetic mutation, or injury. Following the medical model of addiction, some substances are believed to have biological and genetic underpinnings (American Psychiatric Association, 2013).

The National Institute on Drug Abuse (NIDA) and National Institute on Alcohol Abuse and Alcoholism (NIAAA) characterize substance abuse as a disease, comparing it to diabetes, asthma, and heart disease (Branch, 2011). A disease can change the way an organ functions, sometimes permanently with risk of relapse in recovery. The idea of addiction being a chronic disease of the brain organ stems from the notion that while diseases may have treatment, they do not have cures.

To illustrate, problematic alcohol use is closely linked to ADH1B and ALDH2 genes (Slaughter, 2024). In fact, genes and genes expressed (due to environment) account for 40 to 60 percent of a person’s risk of addiction (National Institute on Health). Signs and symptoms of a disease can usually be detectable or seen. There may be tests or a diagnostic criteria for assessing the disease. Addiction is viewed as a medical disease due to changes in the brain’s reward, stress, and motivation systems. These changes contribute to compulsive substance seeking and use despite negative consequences affecting various domains of one’s life (e.g. occupational, social). Treatment is available to foster the disease to go into remission. However, if steps aren’t taken to strengthen maintenance of disease remission then relapse is highly possible.

Limitations of the “Disease” Model:

• Oversimplifies the complex nature of addiction while offering a limited understanding of how social, psychological, and environmental factors develop the disease
• Lack of personal responsibility for people struggling with addiction
• Treatment focuses too much on biological and medical treatments while neglecting other approaches like social support, psychotherapy, and behavioral change
• Stigma of addiction can label people as “diseased” or “sick”
• Limited attention to social determinants such as poverty, housing, and employment which can influence trajectory of addiction
• Treatment primarily focuses on individual-level interventions while neglecting broader population-level and structural interventions

Is Addiction a Disorder?

Disorders are conditions that impair normal functioning or well-being, but might not always have a pathophysiological basis. Disorders can be caused by psychological, behavioral, or environmental factors. The diagnostic criteria often has more gray areas. The signs and symptoms might involve disturbances in thoughts, emotions, or behaviors. The Diagnostic and Statistical Manual of Mental Disorders classifies substance-related addictions as disorders with a standardized diagnostic criteria and threshold for specifying severity based on the number of symptoms endorsed by the affected person (American Psychiatric Association, 2013).

The National Institute on Drug Abuse or NIDA defines addiction as a “chronic, relapsing disorder” of the brain (National Institutes on Health). They assert that the addicted brain develops major changes in function and morphological structure, thus perpetuating “compulsive drug seeking”.

There is no clear consensus on whether addiction is a disease, disorder, or both. Some conditions, such as diabetes, can be both a disease and a disorder whereas other conditions may be better explained by one model. The two terms are often used interchangeably, but their difference can be summarized the following distinction:

• Disease: A particular distinctive process in the body with a specific cause and characteristic symptoms
• Disorder: Irregularity, disturbance, or interruption of normal functions (Nasrallah, 2009)

Limitations of the “Disorder” Model:

• Overemphasis on individual pathology while neglecting social and environmental factors contributing to addiction
• Lacks attention to context: neglecting the cultural, social, and economic context in which addiction develops and is maintained
• Focuses on psychological and emotional aspects while leaving out biology and neurology
• Stigma, where people are viewed “abnormal” or “disordered”
• Ignores how social and environmental factors like trauma, stress, and social pressure develops addiction. Lack of attention to power dynamics like power imbalances and systemic inequalities in the context of health disparities.
• Blames the person for having cravings and not being able to cut down, and not the complex factors leading to the addiction

Is Addiction a Choice?

This model argues that people choose to administer drug or alcohol use and can choose to stop. Some reasons why people initiate substance use are to feel good (e.g. pleasure, euphoria) to feel better (e.g. less anxiety and stress), to do better (e.g. focus, energy), and out of curiosity and social pressure (e.g. developmental pressure among youth, with earlier onset correlating with more serious problems) (National Institutes on Health). It is asserted that while the initial decision to use substances is voluntary, the subsequent impairments in functioning such as in self-control, judgment, decision-making, memory, and learning continue to perpetuate habitual use. While some believe substance use is a choice, infrastructural cognitive impairments hinder the process of making alternative choices and challenge the position of it actually being a choice. Besides, if someone used substances to cope with physical and psychological pain, then the removal of the substances would leave the affected person suffering.

The National Institute of Health constructed a list of risk factors contributing to the development of addiction including genetic vulnerability, mental disorders, gender, aggressive behavior in childhood, lack of parental supervision, low peer refusal skills, drug experimentation, availability of drugs at school, community poverty, chaotic home and abuse, and, parent’s use history. They also present protective factors such as self-efficacy (belief in self-control), parental monitoring and support, positive relationships, good grades, school anti-drug policies, and neighborhood resources.

Limitations of the “Choice” Model:

• Oversimplification of the complexity of addiction
• Ignores the role of biology and environment in addiction
• Blames the individual for their addiction
• Fails to address underlying issues that may contribute to addiction

Patterns of Addiction and Strategies for Prevention:

• Quitting substance use is hard and can take multiple tries, including multiple attempts at treatment programs
• Environments, such as place of prior use, a commonly frequented liquor store on the coroner, or even a local grocery store can all trigger relapse.
• Low self-control is common in addiction, as it is difficult to maintain abstinence of a substance that might provide instant gratification and pain relief.
• Substances might be used to reduce withdrawal symptoms or simply to satisfy a behavioral ritual. There may be little to no pleasure in administering substances yet the behavior is continued
• Self-awareness of triggers, thoughts, and underlying psychological processes is key to combating addiction. Attending AA meetings, therapy, or treatment will amplify self-awareness and promote positive coping skills.
• Sometimes substances are used with other co-occurring habits like sex or gambling. Besides enhancing performance or euphoric impact, people might also use to reduce insomnia, anxiety, chronic pain, boredom and lack of stimulation. In any case self-medication becomes cyclical and maladaptive, deepening the chemical dependency while capturing brief relief.

(Heshmat, 2017)

In summary: Addiction is Multifaceted

The definition of addiction is continually evolving, with various useful models developed to understand and treat it. The Disease Model views addiction as a physiological ailment akin to other medical conditions, while the Disorder Model emphasizes its psychological and behavioral aspects. Conversely, the Choice Model places emphasis on individual agency and decision-making as leading to substance misuse. Each model has its limitations, highlighting the inadequacy of singular explanations for addiction.

It is essential to adopt a holistic perspective of addiction that integrates biological, psychological, and social determinants. At PCI, we utilize a truly biopsychosocial approach to treat addiction, and adopt a holistic understanding of our patients’ history, struggles and goals. Our medical director conducts comprehensive evaluations that consider how your biology and medical history factor into your use of substances to cope. By fostering a more nuanced understanding of addiction, we can better support individuals affected by addiction and provide more effective prevention and treatment strategies to lead a life of sobriety.

If you or a loved one are struggling with addiction, contact PCI today to speak with a care coordinator that can get you the help you need right away.