Mental health experts are nearly unanimous in endorsing the disease model of addiction. Alcoholism (now alcohol use disorder) was declared a disease in 1956 by the American Medical Association, and drug addiction (now drug use disorder) was declared a disease in 1987. The AMA was later joined by the American Psychological Association and many other professional organizations in defining addiction as a disease.
Like other diseases, addiction has a strong genetic basis that’s often triggered in high-risk environments. Those with genetic vulnerability are likely to develop addiction in cultures where alcohol and other drugs are readily available and frequently used. Where alcohol and drugs are less available and rarely used, genetic risk may never develop into addiction.
Many other diseases behave similarly. Genetic vulnerability to type II diabetes, for example, places people at high risk for diabetes in cultures like the United States, where diets are high in processed sugar. Genetic risk is far less likely to advance to diabetes in cultures where sugar intake is low.
When both genetic vulnerability and environmental risk are necessary for a disease to develop, the disease model can be difficult to grasp. Why doesn’t everyone with genes for addiction develop a substance use disorder? Isn’t it traumatic environments that cause addiction? And what about personal choice and people’s character?
These and other questions about the causes of addiction follow from what people see with their own eyes. Unlike patients with other diseases, many of us with addiction engage in behaviors while drinking or using that are just as harmful to people around us as they are to ourselves, engendering legitimate anger and distress. This explains why half of Americans view alcohol and drug addictions as moral failings, not as diseases.
U.S. health officials who are familiar with stigmatizing perceptions among the public have launched messaging campaigns to normalize addiction by comparing it to other chronic diseases, like diabetes. Such messaging, now almost two decades old, has been largely unsuccessful, with stigma only increasing during this time.
Why hasn’t anti-stigma messaging worked? One reason is that by attempting to normalize addiction, we sweep the very consequences that hurt other people under the rug. I’ve noted how downplaying the side effects of medications for addiction undermines the field’s credibility. Downplaying the consequences of addiction does the same. Addiction is different than other diseases, and the public knows it, even when they’re told otherwise.
Addiction Versus Other Chronic Diseases
Few people hold more sway over America’s public health messaging about addiction than Dr. Nora Volkow, director of the National Institute on Drug Abuse. Early in 2013, Volkow, in a brief video posted by the White House Office of National Drug Control Policy, summarized addiction science for the public. She described genetic vulnerability to addiction, the role of brain dopamine systems in our desire to use drugs, and the compulsion to use despite sometimes devastating consequences.
Volkow closed by comparing addiction relapse rates to those seen in “classic,” readily treatable diseases like asthma, high blood pressure, and type II diabetes. People with these diseases abandon their treatments at about the same rate as people with addiction relapse. Although Volkow’s normalizing intentions were and are sincere, the parallels are superficial and far from reassuring.
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Type II diabetes and hypertension kill hundreds of thousands of Americans each year. Both are devastating public health concerns we have little effective control over, despite treatments that are far more potent than existing interventions for addiction. Yet even with such treatments, deaths from hypertension and type II diabetes are expected to rise through at least 2050.
The picture for addiction is even bleaker. Overdoses kill tens of thousands of adolescents, young adults, and parents in their childrearing years—much earlier in life, on average, than deaths from other chronic diseases. Addiction also affects family members and others in society in ways most diseases don’t. Large proportions of domestic violence, sexual perpetrations, and other criminal offenses are committed by those who are under the influence of alcohol and/or drugs. Most offenders do none of these things while sober.
Those of us working on the streets see the consequences daily. Estranged families, deserted children, infidelity, homelessness, financial ruin, and criminality. Harm to fellow citizens who are maimed or killed by impaired drivers—more than 12,000 deaths and 360,000 injuries every year.
My point isn’t to stigmatize addiction further. Rather, it’s to challenge the notion that normalizing addiction can be effective, or is even possible. Addiction’s social consequences are far too harmful and sweeping, and virtually everyone is aware of them. Given this, health officials’ comparisons between addiction and other chronic diseases, however well-intentioned, often ring hollow.
Research shows that stigma is reduced when we humanize mental health problems, not when we normalize them. This, paradoxically, requires transparency, full self-disclosure, and person-to-person contact with those who are struggling with or have recovered from addiction. Efforts to normalize addiction through comparisons to other diseases, by downplaying addictions’ consequences, do the opposite.
What we’ve been doing for two decades isn’t working. It’s time to try something new.