Addiction as a Disease

Introduction

In the course of my studies on Addiction at a major University, I have come across varying perspectives on what addiction is. I recall a textbook by Dr. Doweiko which stated the disease model of addiction is fading from use. I recall listening to multiple speeches at an Association of Certified Biblical Counselors (ACBC) conference where the disease model of addictions was lampooned. I remember reading books by Dr. Patrick Carnes, Dr. Mark Laaser, and Marnie Ferree where addiction was called a disease. I have attended 12 step programs where addiction is called a disease.
Because of this lack of agreement across multiple addictions and counseling disciplines, I determined to research the differences and similarities between addictions and diseases and come to my own conclusion. This document is the summary of this research.

Addiction

Addictions are variously defined. The American Psychological Association (APA), in various published Diagnostic and Statistical Manuals (DSMs), includes features of tolerance (needing more), withdrawals, unmanageability (it is out of control), attempts at quitting, life-consuming (the user's free time is mostly spent obtaining, using, and recovering from it), negative social impact, and continuing to use despite the negative consequences.
Ed Welch's book Addictions: A Banquet In The Grave compares addiction to sin and summarily calls it spiritual enslavement. My goal is not to point to how addiction is sin, but because of this book, I will be comparing addiction to disease and to sin.

DSM-5 / ICD-10 Definitions of Addiction

Here are some definitions of addiction, directly quoted from H. E. Doweiko (Concepts of Chemical Dependency, 2015):

DSM-5 criteria (substance use)

Impaired control over substance use.
Multiple attempts to quit or desire to quit/reduce substance use.
Most the individual's activities center around (a) obtaining the substance, (b) using the substance, or (c) recovering from the effects of the substance.
Pharmacological effects of the drug(s) on the individual, including "craving" for the substance when it is not actively being used.

ICD-10 definition:

The view that it is a primary disease,
Has multiple manifestations in the person's life, including social, psychological, spiritual, vocational, interpersonal, and economic spheres of their lives,
It is often progressive,
It is potentially fatal,
It is marked by the individual's inability to control (or at least inconsistent control) of their substance use,
Is marked by preoccupation with drug use,
The individual develops a distorted way of looking at the world so that it supports his/her continued use of that compound(s),
The individual becomes tolerant to the effects of that compound(s) and s/he either must go through "drug holidays" in which s/he loses some of the tolerance to that substance, or must use larger and larger amounts in a manner designed to overcome his/her tolerance, and finally,
That the individual will experience a characteristic withdrawal syndrome if s/he should discontinue the use of that compound(s).

Disease

    I am not a medical professional, but here is what I know. A disease is considered an abnormal condition that affects all or part of an organism (not caused by external forces, such as injuries) that consist of a disorder of a function or structure. Diseases are medical conditions with specific signs.
    There is a category of diseases called lifestyle diseases which are essentially those diseases thought to be more strongly linked to lifestyle than genetic predisposition. Among these are atherosclerosis, heart disease, and stroke; obesity and type 2 diabetes.
    Note that all diseases caused mostly by addictions like drug, alcohol, and nicotine abuse are also in this category.

Disagreement

There is some disagreement within Christendom about whether addiction is a disease. The 12 step programs call addiction a disease. While Alcoholics Anonymous was formed before the medical community began in earnest to research addictions, I actually find that the AA philosophy on disease is rather apt. Indeed, I was against thinking of addictions as diseases until I started doing research. I would like to offer a brief chart on the similarities between the two, with discussion below the chart.

Comparison Chart

Disease / Addiction	Caused by lifestyle?	Permanent?	Genetic?	Deadly?	Re-map brain?	Requires lifestyle change?	Environmental?	Trauma-linked?	Abuse-linked?
Alcoholism	Yes	Yes	Predisposition	Yes	Yes	Yes	Influences	Usually	Usually
Type 2 Diabetes	Yes	Yes	Predisposition	Can be	No	Yes	Influences	Indirectly	No
Drug abuse	Yes	Yes	Predisposition	Yes	Yes	Yes	Influences	Usually	Usually
Heart Disease	Yes	Yes	Predisposition	Yes	No	Yes	Influences	Indirectly	Can be
Sex Addiction	Yes	Yes	Unknown	Can be	Yes	Yes	Influences	Usually	Usually
Lung cancer	Usually	Usually	Predisposition	Can be	No	Yes	Can be	Can be	Indirectly
Smoking	Yes	No	Predisposition	Often	Yes	Yes	Influences	Can be	Can be
Gambling	Yes	Yes	Predisposition	Depends	Yes	Yes	Influences	Usually	Usually
Alzheimer's	Can be	Yes	Predisposition	Yes	Sort of	Yes (to slow it)	Yes	Possibly	Possibly
Atherosclerosis	Usually	Can be	Predisposition	Yes	No	Yes	Yes	Indirectly	Indirectly
Stroke	Usually	Yes	Predisposition	Yes	Sort of	Yes	Indirectly	Indirectly	Indirectly
Obesity	Usually	Rarely	Predisposition	Can be	No	Yes	Indirectly	Indirectly	Indirectly
Liver Disease	Usually	Can be	Predisposition	Can be	No	Yes	Indirectly	Indirectly	Indirectly

Both Caused By Lifestyle

    Alcoholism can be caused by a lifestyle of having one or two beers each night. In addition, lack of social and life skills can predispose individuals to seek alcohol to medicate stress, past trauma, past abuse, and/or depression.
    Type 2 diabetes is caused by lack of exercise and being or becoming overweight. I discovered the overweight portion when I noticed that, upon my annual checkups, when I go over 180 pounds, I become pre-diabetic. So I learned that I must regulate my weight.
    Drug abuse can be caused by a lifestyle of drinking and poor friendship choices. In addition, like all other addictions, lack of social and life skills can predispose individuals to seek drugs to medicate stress, past trauma, past abuse, and/or depression.
    Heart disease is caused by high blood pressure (which has components of lifestyle), diabetes (type 2 caused by lifestyle), smoking, excessive alcohol or caffeine, drug abuse, and stress.
    Sex addiction can be caused by lifestyle, such as viewing pornography and a string of serial relationships and/or one-night stands. Like all other addictions, lack of social and life skills can predispose individuals to seek porn or sex to medicate stress, past trauma, past abuse, and/or depression.
    Lung cancer is usually caused by lifestyle, mainly (80%) smoking, but some is caused by choosing to be in an environment where smoking occurs (casinos and bars for instance). Like all other addictions, lack of social and life skills can predispose individuals to seek porn or sex to medicate stress, past trauma, past abuse, and/or depression.
    Smoking (nicotine addiction) is caused by lifestyle (a choice to smoke), and like all other addictions, lack of social and life skills can predispose individuals to seek porn or sex to medicate stress, past trauma, past abuse, and/or depression.
    Gambling addiction is caused by lifestyle (going to casinos, betting, buying lottery tickets, etc), and like all other addictions, lack of social and life skills can predispose individuals to seek porn or sex to medicate stress, past trauma, past abuse, and/or depression.
    Alzheimer's is listed only as an example of other diseases. Early onset of Alzheimer's can be brought about by lifestyle choices (high blood pressure, diabetes, high cholesterol), though predisposition is mostly genetic. About 1% of early onset Alzheimer's is caused by having five specific gene markers together. The rest is mostly due to quality of blood flow in the brain over time.

Permanence

    Alcoholics Anonymous started calling addiction a disease before very much was known about how addiction works. We now know that addiction (as well as some trauma and some abuse) re-maps the brain. AA was right to say that we are always addicts: the neural pathways created by addiction remain over the lifetime. So now neuroscience says that all addictions are essentially permanent: their influence is lifelong, and therefore the addict in recovery will always want to return to his addictive behavior (though over time the urge begins to fade away). Addictions are basically permanent, even though recovery is always possible.
    Type 2 diabetes is usually permanent once you get it, though reversal is possible with weight loss.
    Heart disease is usually permanent once you get it, depending upon the specific details. Atherosclerosis, i.e. plaque on the walls of blood vessels, can sometimes be reversed through diet and exercise, or at least treated (i.e. preventing it from getting worse). If associated with a stroke, and brain cells die, those lost brain cells are usually permanent. Also, damage to the heart muscle from the effects of heart disease is often permanent.
    Sex addiction is permanent, in the sense that though recovery is possible, the sex addict will always be tempted, and always have cravings.
    Lung cancer caused by smoking is often permanent, even if treated: often, pieces of the lungs must be removed, which is permanent.
    However, the damage caused by smoking can sometimes be reversed by quitting and maintaining good diet and exercise, assuming the cilia lining the lungs are not destroyed. Also, studies show that quitting around age 30 can reduce the chance of dying by smoking-related disease (such as lung cancer) by 90%.
    Gambling addiction can be overcome, but income lost due to gambling is permanent. Lost relationships due to gambling could be permanent. And the cravings could be permanent, again due to re-mapped brain pathways.
    Alzheimer's is permanent, though it can be treated and slowed to a point. There is research into a possible cure, but so far no scientifically proven cure exists.

Genetic Predisposition

    Almost every disease or addiction listed has credible scientific research showing a genetic predisposition is possible. However, understanding how predisposition works is important.
    First, merely having the "alcoholic gene" does not make one an alcoholic if the user never drinks. The influence of genetics (and epigenetics) is not fixed nor inescapable.
    However, predispositions are best compared to odds. You could have some, but not all five, of the genetic markers for Alzheimer's but, if you live a lifestyle including exercise and proper diet, avoid ever getting Alzheimer's.
    But also, you could have a predisposition to alcoholism and drink all the time but then get killed by a bus while crossing the street.
    Predisposition does not guarantee you will or will not get a disease. Especially as we start to understand epigenetics, we understand that DNA is not the only influence on whether you get a disease.
    For addictions, predisposition seems to influence how easy or difficult it is for someone to break their addiction. Someone with all of the possible markers for alcoholism could in theory break the habit with proper help and support.
     Having none of the genetic markers for a disease does not exempt you from the disease or addiction. If you try hard enough, you can increase your risk of getting a disease.
    Lastly, all human beings die. As our bodies age, even individuals without genetic markers predisposing them to diseases or addictions could more easily get diseases or become addicted simply because the human body becomes less efficient with age. This explains the phenomenon, for example, of people who become alcoholics in their 50s and upward: the body is less efficient at breaking down alcohol, hence the body becomes "sensitive" to it, which could also increase the risks associated with all diseases caused by alcoholism.
    When viewed in light of sin in the Bible, human beings are already predisposed to all sins, diseases, and addictions as a function of the fall.

Diseases as Deadly

    Some diseases are deadly. Because most people already understand this, I will skip explaining how diseases can kill you.
    As well, some addictions are also deadly, directly or indirectly. Alcoholism can kill you: it destroys your liver and several other organs. You can become too intoxicated too quickly and die. You could also die in a car wreck or while doing almost anything while under the influence.
    Nicotine addiction can kill you in that it can cause lung cancer. And in theory, you can overdose on nicotine.
    Other abused drugs can kill you, such as cocaine, heroine, etc, often through overdose. Some drugs kill your organs through their side effects.
    Sex addiction can kill you. For example, some sex addicts commit suicide out of shame, or being caught. Some sex addicts are killed in revenge by spouses and former spouses, either their own or those with whom they may have had sex.
    Gambling addiction might be the least likely to directly kill an addict, but there are remote possibilities, such as getting caught up in the crime that often surrounds casinos.
    We know from the Bible that, ultimately, sin leads to death.

Re-Mapping the Brain

    Addictions re-map the brain. I will adapt an illustration by Dr. Michael Lyles to demonstrate how this works.
    Let's say your brain is like a car that's designed to go no faster than 100 mph. Most of the time, the highest speed it will reach is 70 mph on the highway. Normal life could be thought of as 35 mph in city traffic. The speed is basically how happy or high you are. So maybe on your birthday, when your wife throws a surprise birthday party, you reach 100 mph. Normal life is 35 mph. Maybe having a good day at work is 70 mph.
    Drugs of abuse take a car that's meant to go no faster than 100 mph and take it to 200 mph. This causes damage. The car wasn't meant to go that fast. The longer we do that, the more damage it will cause.
    In addition, the brain, unlike a car, decides it likes to go this fast and wants to keep doing it. When we have to slow down (the drugs wear off), the brain complains and demands to go 200 mph again.
    The brain, in addition, doesn't just take the changes without action. First, neural pathways form that cause us to become more likely to engage in the behavior again. It felt good.
    Second, the brain, depending on the drug or behavior, usually forms tolerance, meaning it is either resisting the influence of the drug, or it is embracing the drug. Either way, however, it will then take more of the drug or behavior, or more exotic behavior, to achieve the same high. Indeed, for example, with crystal meth, the user never achieves the dramatic first high ever again; however, their brain continues to "chase" this high.
    Now I say this cautiously: this means that maybe the first, second, maybe even up to the 50th time we use drugs or alcohol or engage in the behavior is a choice. But at some point (depending on the addiction) our choice gets subverted and we become a slave (addicted) to the drug or behavior. Where that choice gets subverted can be slightly different for everyone. For example, some people may not become alcoholics even though they drink from time to time; however, they may be very susceptible to porn or gambling. Every person is slightly different. This does not absolve the individual of their responsibility to choose not to engage in the behavior or use the drug: it merely explains why it is so difficult to quit.
    Now, in regards to a sermon by John Piper, the addict cannot "just quit." He uses an illustration such that "if a man held a gun to your wife's head and threatened to kill her, you'd find the power to quit", etc. First, if that was the case, drug use interventions could just be kidnappings, but that's not how it works. Second, that's actually how addictions work: the addict can "white knuckle" and stop using for maybe up to a month, but the addiction always overpowers them and they return to their problem. Often this is because the addict has other "defects of character" (12 steps) or sins (Bible) that trip them up and cause them to return to addiction. As well, often addicts have mental disorders that they are self-medicating (anxiety, depression, etc).

It Takes Lifestyle Change

    Diseases take a lifestyle change to slow or stop their progression. Some diseases can even be reversed by lifestyle change.
    For example, type 2 diabetes can sometimes be reversed, or at least stopped, by weight loss and exercise. In addition, keeping a healthy weight and exercise, for those with family history of type 2 diabetes but who have not gotten type 2 diabetes yet, can prevent them from every being diagnosed with it, or at least push back its occurrence.
    Likewise, heart disease can be prevented with proper diet and exercise, as well as with medication (such as cholesterol medicine). For those diagnosed with heart disease, proper diet and exercise can slow or even stop its progression.
    Lung cancer can sometimes be treated medically or through surgery, and these can sometimes stop its progression. Quitting smoking can vastly reduce the likelihood that someone will get lung cancer (related to smoking).
    This is why addiction treatment requires a drastic lifestyle change. The first step, depending on severity, can be in-patient detoxification. For the rest who do not require detox, changing one's lifestyle (going to 12 steps, seeking counseling, changing friends, changing jobs, moving) is vital in kicking the habit. It takes a while for the brain to return to a "new normal" which doesn't include addiction, but it is quite possible. For some, these changes are harder than for others.
    So the parallel between disease and addiction, in terms of treatment, is easy to see. In addition, when compared to sin, again lifestyle change is vital in the Biblical sense. Sinners need to repent and accept Jesus Christ, for the only total cure is the indwelling of the Holy Spirit (although becoming perfectly sinless is unlikely even if it is possible).

The Influence of Environment

    Environment in the sense of this article can include some of the person's patterns of life, but mostly refers to social and living environment, and upbringing. Diseases can come from our environment, such as asbestos exposure (lung cancer), bad nutritional habits learned in childhood, working at a bar, not learning stress relief or other life skills, living in a bad part of town, not having access to medical treatment, lack of income to effect a healthy diet, social norms and/or expectations, family turmoil, lack of one or both parents, etc. So someone could end up with type 2 diabetes because they didn't learn nutritional skills and didn't have the money (or so they think) to have a good diet, hence they became overweight and got type 2 diabetes. This doesn't mean they can blame these things, for they still had control over what they ate. But they contribute to it, nevertheless.
    Understand that these are not excuses, but they do influence us. Our environment does not control us, but it nevertheless exerts an influence on us.
    Addictions are also influenced by environment. If a man's circle of friends smokes and drinks, and your society associates that with being masculine, the effects of these influences are obvious. For this person to kick the smoking habit would include changing their thinking and realize the truth about their addiction, and to learn to ignore the lies of their friends and society. This could mean they might even need to find new friends and new life hobbies (replacing going to the tavern with playing tennis, etc). As well, it would be illogical to suggest that they could continue hanging out in a bar with friends and yet not drink. They can, but that's a bad environment in which to try to quit drinking. This is one of the ways the 12 steps are helpful: the addict finds new friends and new support groups. The porn addict should stop using the internet so much and/or obtain filtering software. The drug user should stop hanging around the area of town where drug dealers congregate and/or drug use is common. The gambler should stop going to casinos and other businesses where gambling is prevalent.
    Sin is no different. One can refrain from sin, but the Bible has many recommendations about not putting oneself in an environment in which sin could easily occur. We see this in Psalm 1. The parallels between disease and environment, addiction and environment, and sin and environment are easily established.

Trauma and Abuse

    Medical and psychological researchers are discovering more and more about the link between trauma and abuse (referred to together as "trauma" in this section) and disease and addiction. For example, trauma can cause people to learn unhealthy coping skills (overeating, smoking, drug use, anorexia, etc) in an attempt to self-medicate past mental and emotional hurt. Overeating as a coping skill can easily lead to type 2 diabetes and heart disease.
    Addiction is often the same. Smoking is often a person's attempt to self-medicate anxiety or other past hurts. One vital component in addiction treatment is often teaching the person new, healthy life skills to replace unhealthy coping mechanisms. A high percentage of alcoholics have diagnosable depression. Even some schizophrenics have been discovered taking LSD or other hallucinogens in an attempt to gain control over their schizoid episodes. Victims of childhood sexual abuse or incest often end up becoming sex addicts. Again, this does not mean the addict has an excuse, so much as it explains part of why they engaged in the behavior or drug use.
    Sin can sometimes be thought of in this way. We live in a fallen world and we have a sin nature. This explains at least part of the Biblical concept of generational sins: a child experiences neglect because his parents are alcoholics, he grows up without knowing how to cope, ends up drinking, then becomes hooked. Again, this is not an excuse so much as it helps us understand why.

Conclusion

While I do not believe that the disease model of addiction is a perfect fit, I can see how it makes sense. I think well-meaning Christians who attack or oppose the disease model of addictions are wrong, in that they're splitting hairs. There are far too many similarities to dismiss it as "wrong", and saying that the disease model gives addicts excuses is a lie. I prefer Dr. Doweiko's biopsychosocial model to the disease model, but I am not offended when addictions are referred to as diseases, for it's very close to the truth.
If you're a Christian and you're reading this, please stop calling the disease model of addictions "evil", "of the devil", or "an excuse." It doesn't help addicts: if anything, it harms addicts and makes Christians look insane.

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