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What If Addiction Is Not a Disease? (chronicle.com)
77 points by Hooke on Aug 8, 2016 | hide | past | web | favorite | 93 comments

Most addicts quit on their own:


The reason that addiction treatment programs find it so hard to treat 'addicts' is that they're dealing with the small subset of people who, for one reason or another, can't quit on their own. It's sort of the opposite of survivorship bias.

This is interesting, and confirms what I understand about heroin addiction. This is why harm reduction is such a good policy - addicts aren't sitting around waiting for something external to appear and help them quit heroin, if they want to quit they will generally go ahead and seek out the means to do so. Until then, making sure there is a supply of clean needles etc. is the best option, while making sure facilities and medication is available to help those who have decided to fix the problem.

Or you can try to fix the problem, with drug laws that are actually enforced.

You can say addicts are irreversibly damaged, but there is little excuse for the authorities to sit idle while new people become addicted.

This simply doesn't work. There is no level of enforcement which can make it impossible to obtain drugs, merely very difficult. Even in overtly totalitarian countries.

Drugs are available even in prisons.

Singapore is clean, other countries don't have a growing opiate problem.

Singapore is clean because anyone possessing more than tiny bit of any illegal drug automatically gets the death penalty.

We can look at countries that have fierce, well enforced drug laws and see that even they have problems with addiction.

If the aim is to reduce harm to addicts, and the people around addicts, and the victims of crime perpetrated by addicts then authorities need to start treating addiction as a public health problem, with support from criminal justice around acquisitive crime.

Treating addiction as a criminal justice problem clearly, unambiguously, does not work.

Absolutely, and this is why I talked about harm reduction as a drug policy in my parent comment. The thing about addicts is that they will do anything to get their next hit - someone who does not have a heroin habit just has no idea of the strength of the drive to obtain more. As mentioned, drugs are available in prisons. One thing that would make most addict's lives easier and less chaotic would be the ability to obtain their drug of choice without fear of prison; essentially decriminalisation of personal use quantities. I don't think we're ready for legalisation, or prescription of drugs, but it is not considered a bad thing by most drug treatment professionals.

Why doesn't it work? One argument is to say it hasn't historical worked well in the USA, but it might be interesting to actually figure out the reason .

In other places it has for example opiate use in China is 5x less than in the US.

Have you got data that supports the 5x difference of opiate use being solely a criminal justice victory?

Seems like there are many reasons why that might be true.

19th century China was synonymous with opiate use, then they shot everybody. I'm not sure this is the approach America should take, but I am consistent shocked by the wide availability of hard drugs in the USA - and frankly a culture that tolerate their use.

And how is that working out so far?

Exactly! Current enforcement has been terrible, we should fix that.

Not just that, but AA is tailored around a certain personality type. There's a certain type of personality, certain type of big ego, that left to its own devices will always justify itself. We all are rationalizers, but these are the kings of rationalization, and also bullshit. What AA does for these people is provide them with a community of fellow bullshitters who see right through all their bullshit and will call them on it. The whole disease label is first and foremost a way of framing the social function of the group, the actual epidemiological subtleties of what constitutes a disease is really neither her nor there.

What I find irritating about these scientists crusading for "real science" and denouncing AA is that not a one of them would have the first clue how to get through to this type of alcoholic personality. All their ivory tower rhetoric just washes right off their back.

I wasn't sure if you're advocating for or against AA but it all boils down to it being a support system of one addict/alcoholic speaking (getting through) to another. That being said I disagree that there is "a certain type of big ego". Sorry but that is just simply not the case from my own personal experience. There are literally millions of people that walk through the doors of AA and other 12 step programs from all walks of life, all types of personalities and a high variance of ego. It is the last stop on the block...

For. Let me try to clarify, I'm not saying that everyone who goes to AA, or even everyone that AA helps is one personality type. Also when I say "big ego" I don't necessarily mean an externally facing ego in the popular sense, but rather the way the person relates to themselves and how they justify things in their own mind.

What I'm saying is AA is uniquely suited to this personality type in a way that no other program is.

This is a good point, I never thought of it this way before. Then again, that doesn't necessarily mean it isn't a disease.

However I've started to come to think of addiction notice a disease onto itself, but as a symptom of some other underlying "dis-ease", clinical or otherwise.

If anything, the debate over whether addiction is a disease underscores the fact that the people having the debate have a very narrow definition of "disease". If addiction isn't disease, then what is it?

I went through an addiction myself and I agree with you.

Emotions are not super well understood, and I think they are at the root of addiction. If you are chronically unhappy, drugs let you feel good. You start feeling better because of the drugs, and lose the ability to respond to negative emotion in a healthy way. Healthy emotional balance lets people make good choices and fix bad problems. Being chronically unhappy - perhaps as a result of unresolved mental injury - will hamper a persons ability to make good choices, just like being keep in darkness for a log time will make your eyes way too sensitive to handle normal light.

Show me someone who is addicted to drugs, and I'll show you someone who is unhappy about something other than the drugs. The addiction just makes the underlying problem worse.

If you can learn to fix the underlying problem, then fixing the addiction itself is much easier.

Once you are knee deep in drugs, your life becomes awful which gives you more reason to keep using the drugs. It's like a local minimum, or an AI that learns to manipulate it's model of the world, because that's easier than manipulating the world itself.

I have similar beliefs (preference to a theory that appears to make sense to me, but which I cannot readily find supportive scientific evidence for or against).

I suspect that actually curing addiction, or many other mental diseases, will require not just changes within, but also changes externally.

The sooner society can rid it's self of the blame culture, and adopt the more pragmatic 'solve the problems' culture, the better.

And I guess this comes full circle back to the 12 Steps: powerlessness is one way to achieve blamelessness

> This is a good point, I never thought of it this way before. Then again, that doesn't necessarily mean it isn't a disease.

One could argue, all that means is that "it" is addiction that one can't manage on one's own.

The first thing you hear when you go to many treatment centers is that addiction is a disease. The 12 steps are posted on the wall and you are told you are "powerlessness" over it. You will hear, "It's not a problem of willpower." That idea will be driven into your skull many times.

I'm not sure I will ever understand addiction. But I know that when I accepted personal responsibility for the things that I did to myself and others in order to get drunk/high, life became a least a little easier. It's not perfect, but to use AA terminology it's not "unmanageable" anymore, at least not as much as it once was. And I am grateful to be where I am today. I guess, for me, my compulsion to drink and drug was mainly caused by my surroundings and upbringing.

Although I don't go to AA or NA anymore, if it is working for some, I hope they see it through. Whatever is getting you through to the next day as an alcoholic/addict, my advice is to keep doing it. Whether it is spiritual cleansing or acceptance or doses of naltrexone/buprenorphine.

I just recently read the actual 12 Steps for the first time (mostly out of curiosity) the other day, and was very surprised to find that the theme was about admitting powerlessness and giving in to God.

I also think it's mistaken to conflate "power" and "willpower." It may indeed not be a "problem of willpower", but that (at least to me) does not imply total powerlessness over a disease state in one's own body.

The Big Book, as it is called, is pretty clear that, in the writers' opinions, that only through a Higher Power does one become sober. The meaning of powerlessness I think they intended is that without help an alcoholic will not break the cycle. AA teaches that your sobriety depends on your connection to that power. According to them, no amount of self-knowledge or desire to stop will enable one to actually make an alcoholic/addict to put the stuff down. I guess that's how I was intending to describe their version of powerlessness. For me, I believe that was not the answer. I credit my sobriety to that I realize things could be much worse. I am grateful to be where I am and know that, on average, most people that have lived this life would not have made it through or had a chance to even do so.

I honestly don't know if addiction is a disease. Certainly, anybody that has had the dts or benzo/opiate withdrawal will admit that there is a physical component to continued alcohol/drug abuse. I know many addicts (and myself was one) that continued using longer than wanted out of here of withdrawal.

But I didn't need to completely "give in" or submit to the disease, at least I think (others may be able to judge that better though). I wanted and still want so bad to never have to go through some of the things an active addict has to go through again that I am completely terrified to go out again. But at an AA meeting they would probably say that that time will come if I do not develop a spiritual connection to something greater than myself

I don't suffer from addiction, but I can say that a key challenge with almost any "disorder" is recognizing that the disorder is causing leading to consequences in your life that you don't want, yet continue to occur. It's the key distinction between a disorder and a "personality quirk".

Acknowledging that you don't have that kind of control is a huge psychological cliff to get over... it has been likened to mourning. In the end, it is quite freeing, because as you pointed out, it opens up a lot of options (power) to deal with your problem in a different way than you normally would (particularly: acknowledging that you need help).

So, while you are write that "powerlessness" probably is far too sweeping a word to use... it's helpful for getting people over that mental cliff and into a place where they can, ironically, exert some degree of power over their problems.

This is what I was taught in University is the defining trait of addiction: engagement in a behaviour despite the recognition that it leads to negative consequences.

Personally, I think that this is enough to justify addiction as a true 'disease' that merits outside help. It takes a belief in some kind of strong definition of free will in order to maintain that people are suffering from character defects or should just pull themselves out of it at that point.

Many people do not understand why or how other people become addicted to drugs. It is often mistakenly assumed that drug abusers lack moral principles or willpower and that they could stop using drugs simply by choosing to change their behavior. In reality, drug addiction is a complex disease, and quitting takes more than good intentions or a strong will.

The genes that people are born with––in combination with environmental influences––account for about half of their addiction vulnerability. Additionally, gender, ethnicity, and the presence of other mental disorders may influence risk for drug abuse and addiction. -- drugabuse.gov

Maybe you got lucky that a combination of your genes and lack of certain mental disorders helped you get out of your addiction with sheer effort. Others may not be that lucky. If you had the same predisposition to getting addicted as other people you might not have made it no matter how hard you try. So, you can't generalize your individual experience with others.

> Researchers will track how various factors — including diet, sleep patterns, gender, race, economic circumstance, air quality, and exercise habits, as well as substance use — correlate with changes in the subjects’ brain scans over the years.

> "How cool will it be if we can collect data on 9- and 10-year-olds that will help predict how all young people will function in later life?" asks Garavan. "This is the sort of information that will truly help people parent, and legislate, and educate, and live healthy lives."

I'm not as enthusiastic about that future as Garavan is, and especially not the idea that it could shape legislation in any kind of significant way. Doubly so if it's going to be done via statistical models and correlation, rather than a deeper understanding of the mechanisms involved.

Oh it could shape legislation: "low-functioning" children would be kicked out of school, watched closely and sent to jail for their "anti-social" tendencies, while "high-functioning" children will get expensive education, and their mishaps forgiven.

I hate this cynical "they're trying to get us" view on politics and laws. Yes, there's potential for misuse of data. There's also the potential for correct use of data. It took scientific data to get leaded gasoline banned.

Opposing scientific studies because they could be misused is no better than opposing scientific studies because they might not support your views. Both cases are fundamentally anti-science and there are no bonus points for trying. If you support science, then you support it. If you oppose science when it might not yield the results you want, then you are anti-science and have no place in a progressive society.

Scott Alexander wrote something short but sweet on these kinds of questions: http://lesswrong.com/lw/2as/diseased_thinking_dissolving_que...

Almost all discussions of whether something is or is not a disease could be usefully replaced by a link to that article.

Excellent article; expresses exactly why it drives me crazy to see people arguing over a word. Also, it seems in this case the people who study brains are saying it happens in the brain ("disease"); the people who study minds are saying it happens in the mind (emotions etc): given that humans have been aware for some time that the brain is the seat of the mind, it should be obvious that the two possibilities not only aren't exclusive, but even cannot occur independently. I guess they are so focused on their own areas of expertise they apparently forget that the other field is looking at an equally real aspect of the same phenomenon.

Now that I've finished reading the link I see that the determinism aspect is discussed, but for the general public. In this case the people having the disease debate are highly educated, many of them in hard-science fields; I would assume most of them would claim to espouse the non-dualistic mind/body model, yet participation in the debate requires not having fully internalised the implications of non-dualism. I think this is explained by being too entrenched in their own fields to see the whole picture. I've met a lot of people working on advanced degrees who had forgotten swathes of the basics in their own fields that weren't necessary to their specializations, let alone survey courses from undergrad. Tunnel vision is the cost of focus.

Nailed it.

Thanks. I wasn't familiar with that piece. It'd save me a lot of talking/typing.

Not seeing this here so I wanted point it out: from my own experience and 1st hand witnessing in others, that addiction is a Symptom, not a disease.

Underlying emotional pain is what causes people to literally self medicate.

This is not to say that substance abuse doesn't create actual physiological necessities to then continually consume the substance. It does- i.g. body stops producing it's own opioids when it starts to get them from the outside.

When someone begins using, then abusing, they are trying to relieve an underlying issue. The action is a symptom of a deeper problem expressing itself (the actual dis-ease). These issues are usually severely repressed and suppressed, so much so that one cannot articulate them-- only medicate them.

Digging out and resolving the root emotional issues goes a long way to curing someone. Afterwards, physiological damage still needs to be addressed.

> trying to relieve an underlying issue

Often enough that might simply be hunger and thirst, eg with coffee and cigarettes.

With other addictions a physical dependence is less apparent and I wondered before, why obsessive compulsion is never mention in this regard. Take gambling for example.

As the comment about rat-park points out, nicotine or opiate addiction do have an extrinsic physical aspect. In any case, the internal chemistry always plays a role.

There's really good School of Life video on addiction that talks about society and environment and doesn't touch the "d-word."


Addiction is something that makes me fairly curious.

I smoked for about a year straight, and then one day quit cold turkey and had no problems. I drink more than moderately - I'm a craft beer and whisky snob, and my SO loves wine as well. Most weeks, I'll average at least one drink a day, sometimes more. But sometimes I'll get busy and go a week, a month, with nothing or barely anything to drink across the period without really feeling the need to drink any more.

I've done a variety of drugs, and much the same - never felt an urge to do anything beyond mild recreational use.

Yet I'm completely and totally addicted to the internet. I am basically nonfunctional after prolonged lack of connectivity. if kept busy, I can go a weekend, but an unplugged camping trip for a week is a completely unpalatable idea for me.

I kind of agree with this quote from the article (even though the article slants against this viewpoint):

ultimately I should be able to replicate your findings and you should be able to replicate my findings, otherwise it’s not science, it’s bullshit."

I absolutely, 100% support searching for alternative methods to help people who are drowning and suffering in addiction, but if a method doesn't work, there's no point in following it.

...except "method doesn't work" really just means, "generally doesn't work for people who are classified as having the same problem as you", and when all the other approaches that are classified as working for that group are, you start to consider the possibility that you are an outlier and some of these other options might work. It's a desperate move, but given the high failure rates and low understanding we have of the problem, I wouldn't categorically say there is "no point in following it".

Sure, if you find something that works for you, then good job, do it.

Here's an interesting idea. What if addiction is not something that falls on the binary classification of "choice|disease"? What if it's some other kind of phenomenon?

The article isn't about classifying addiction as disease or "choice." The debate is between disease and "not disease."

seems like a debate about semantics. Why can't the answer be a multi-variate model in which disease like factors get a weight and non-disease like factors get some kind of a weight? What's the point arguing about these non continuous binary options?

  >seems like a debate about semantics.

The article specifically addresses that point:

a slim majority of the panelists, including Murphy, did not want to emphasize the word "disease," because it implies that chemical dependence is primarily a function of pathology, when in fact environmental factors (dysfunction at home, stress at work), learned behavioral patterns (binge drinking, for instance), and economic disparities have been shown to play a significant causal role. Clearly, the debate was not just semantic.

environmental factors (e.g. bad air), learned behavioral patterns (hygiene) and economic disparities (to afford a doctor) all play a role in the course of a lung infection, even leading to death, too. I don't think it isn't a prime example of a disease.

understood. But what matters to me when I am in the hospital with a lung infection is how to treat it so that it goes away, not what it's called

> semantics

here we go

dis-ease: not being easy, uncomfortable, sickness

> (pathology) An abnormal condition of a human, animal or plant that causes discomfort or dysfunction; distinct from injury insofar as the latter is usually instantaneously acquired.

There is no debate to be had at all. I get where this comes from, the scientific definition is more involved, but then addiction is just a symptom, while the damage, eg. to the nervous system, is material. Would ignorance count as disease?

That's the way I have always heard it framed,as what is your definition of disease?

in my experience it is more of a "dis-ease"

It's natural for compassionate people to prefer to characterize addition as a disease, because it gives a powerful argument for treating people with addiction compassionately. But this is deriving an "is" from an "ought".

In fact its very common in this kind of discussion to see an argument like "If you believe <positive statement> then you must support <morally abhorrent policy>". But mostly the morally abhorrent policy doesn't actually follow from the positive statement, and if the person making this argument were forced to accept the positive statement, they would not in fact support the policy. In this debate

  <positive statement> = addiction is not a disease

  <morally abhorrent policy> = people with addiction don't deserve any sympathy or help

There's no positive statement, there's a not in there. I do believe this makes a difference.

when I say "positive statement" I mean in the positive/normative sense.

From system thinking perspective, addiction can be described pretty well with a fairly simple model of a few feedback loops. Regardless of the exact feedback structure, the mechanisms are both social and bilogical, human biology will get hurt in the process and the entire thing is likely to behave chaotically. This is why you can argue it's a disease (because you get biological causes and effects) and that it's not (because AA works by providing a balancing loop designed to be tolerant to substance abuse). And this is why you probably won't get to a clean medical diagnosis - a very similar set of factors can lead to a wide range of outcomes. Unless addiction is seen as a systemic issue, I can't really see how it could be better understood beyond describing less and less significant factors in more and more detail.

A lot of formerly beneficial adaptations have become "diseases" in the modern world (sugar cravings for instance).

> the authors of AA’s Big Book, first published in 1939, helped reduce the stigma of addiction

A truth with modifications. It both individualized alcoholism, and made it more acceptable in a sense. Before, alcoholism wasn't a thing, "drunkenness" was, and it was societies that had a drunkenness problem, not individuals.

In A Nutshell, has a nice [video] about addiction:


Note: below is a link from reddit about their opinions from the video (maybe or maybe not they are actually a neuroscientist ¯\_(ツ)_/¯ )


>ctrl+f "rat park"

Not found!? Well, I'm just the motile conglomeration of vermin for the job! "Rat Park", a utopia for rats, is (IMO) a critical component of the pushback against the disease model of addiction. An illustrated summary can be found in this lovely comic [0], while more interested parties can peruse the works of Dr Bruce Alexander, in the form of a blog-retrospective [1], or a slightly more technical presentation to the Canadian Senate [2], or his excellent book, The Globalization of Addiction: A Study of Poverty of the Spirit [3].

A layman-readable synthesis goes something like this: folk wisdom holds that some drugs are insanely addictive, as an inherent property of the drug. But this has generally [4] been borne out by introspective interviews of inveterate drug abusers and highly technical experimentation on lab animals (mostly social animals, like primates and rats). Introspection, for most domains of psychological study, is never used and treated as hearsay (it's not a contentious claim in psychology that people aren't good at examining their own mental states in a scientifically useful way). The methods of the experiments on social animals like rats and primates often dictate cramped, isolated and impoverished conditions. The "Rat Park" study took normal lab rats and placed them in an enormous array filled with nesting-boxes, large open areas, wheels and toys. The control rats, by contrast, were treated in every way identically to a standard addiction study -- tiny cage, no comforts, no stimulation but for a human changing their litter tray. Various experiments ensued, but even with different experimental treatments, the researchers couldn't induce addiction in the rats of Rat Park, while even fiercely bitter, heavily-diluted morphine-water was the choice of the isolated, imprisoned rat.

The orthodoxy of invincible permanent addiction was vanquished in these animals (and the minds of the researchers), by providing a more stimulating, spatious environment filled with fellow rats with whom to interact. This might say something important about the nature of addiction in other social animals, like humans.

[0] http://www.stuartmcmillen.com/comics_en/rat-park/

[1] http://www.brucekalexander.com/articles-speeches/rat-park/14...

[2] http://www.parl.gc.ca/content/sen/committee/371/ille/present...

[3] https://scholar.google.com/scholar?q=The+Globalisation+of+Ad...

[4] It IS true that you can see pretty drastic rewiring in the ventral tegmental area (which covers, generally, reward systems, drug addiction, strong emotions) with things like nicotine and cocaine, so the picture is probably more complicated than 'it's purely a social problem', but the ascendancy of the dogma of the disease model of addiction functionally prevents further study. Note that the Rat Park paper was very difficult to publish and received no attention for years.

I think lack of stimulus at work is why addiction is (mostly) a poverty problem. I have even worked at factories where people got high to get through an inhumanely boring day.

Do we have data to suggest the poor have more problems with addiction?

Flourishing requires more than wealth. Think of all the celebrities who have struggled with addiction.

Suffering is a human universal.

I didn't say lack of wealth, I said lack of stimulus at work. I don't actually believe that wealth makes you flourish.

Rat park is unreplicatable. It's a sham. I'm sorry.

>Rat park is unreplicatable

Much of social science is unreplicatable, psych especially. Is this because it's wrong, or because of other factors? Take the easiest, most commonly replicated, least contentious conclusion one can come to in a drug study, namely [0]: "rats will intravenously self-administer (IVSA) cocaine". As you can see if you read the link, there's all kinds of caveats to this statement! If you're not very scrupulous about everything from catheter diameter to the cleanliness of your lab coat (yes, seriously), even this piece of orthodox obviousness can suddenly become "unreplicatable".

>It's a sham

It's very difficult to get funding for a large-scale drug study that goes against the underpinnings of the grant, hypothesis and conclusion of almost all the other drug abuse rat-studies of the last forty years. Publish-or-perish culture is no less pervasive in psych, and generally speaking, heterodox opinions don't get a lot of airtime in grant application review, let alone academic journals. How many other institutions have even tried to replicate Rat Park, let alone actually achieved some shadow of its methodology? I think the answer might surprise you. edit: or not, you've looked it up! Great! See?!

>I'm sorry

I'm sorry, too.

[0] http://drugmonkey.scientopia.org/2014/07/08/the-most-replica...


https://en.wikipedia.org/wiki/Rat_Park#Reaction_to_the_exper... http://www.ncbi.nlm.nih.gov/pubmed/9148292?dopt=Abstract

I should say, the results have not been replicated. There's only been a few attempts. Maybe the replicators screwed up!

To quote the root article: "But ultimately I should be able to replicate your findings and you should be able to replicate my findings, otherwise it’s not science, it’s bullshit."

So far Rat Park has not be replicated.

https://www.ncbi.nlm.nih.gov/pubmed/2616610?dopt=Abstract found that isolated rats took more heroin earlier than rats in "group housing". It's not clear from the abstract how the "group housing" compares to "Rat Park", but it may be the case that even better housing would delay heroin ingestion even longer. Rat Park has been under-studied.

Yet again, my take away is that most psychology experiments are mostly bullshit. If there were 12 attempts to replicate, with the same setup, and 10 of them failed succeeded, we might actually be able to say something...

Transmogrifying destructive habits into `disease' is public policy, and there is far too much establishment invested to tolerate this blasphemy. One can easily picture the furrowed brows of our elites as they quietly note the names of the latest additions to the unwritten list of pariah.

There are opioid antagonists that reduce cravings and drug and alcohol use. That combined with CBT or other therapies can help people move from a state of suffering as part of the disease towards remission.

The idea that addiction is a disease was reinforced by decades of trying to help people with strategies that don't work. ... Pellagra is only cured with Vitamin B3; scurvy is only cured with Vitamin C. Treating diseases of nutritional deficiency with anything but the missing nutrients is an exercise in futility.

Addictions are not simple like Pellagra or Scurvy, but when you figure out what a specific person actually needs, they can rapidly recover. I've done it twice - my alcoholic friend is doing quite well; my poly-addict (opiates/cocaine/alcohol) would be doing quite well if she hadn't been captured and court-ordered to endure palliative Psychiatric treatment.

The Alcoholic became an alcoholic when she discovered that Vodka helped her anxiety more than Xanax. Benzodiazepienes lose effectiveness after about 4 weeks - when a person who is addicted to this class of drugs tries to quit, their anxiety is worse than it was before. She was peri-menopausal at the time, which was probably a huge factor...

As for the poly-addict.... When I met her, I said to myself, "this woman is 'high as a kite'..." As the months went by, she gradually invited me into her world, and I learned that she really was self-medicating with the street pharmacy.

She latched on to me like a life preserver. After almost six months of my influence, and a little non-quantifiable hocus-pocus, she called to share three insights, spread over 3 days:

  - "I wish I wasn't a drug addict..."
  - "I should only use substances which are legal!!! *Alcohol is legal...* "
  - "I hate methadone, I hate everything about it."
Before these insights, drugs were fine, because they'd always been there to help when she was suicidally depressed. Her alcoholism started a month after she began treatment with Methadone... The problem with methadone is that it has all of the addiction of heroin, but none of the thrill.

So after six months, she was doing rather well. But alcohol is hard to kick on your own, and she was taken to the hospital as "psychotic"... The psychiatrists got hold of her - it's been a disaster. . They pretend that the symptom of withdrawal from substances ("psychosis") justifies the use of so-called anti-psychotics in perpetuity. Robert Whitaker has looked at the evidence, and has concluded that there is no benefit to the routine use of these drugs [1]...

[1] http://www.madinamerica.com/wp-content/uploads/2016/07/The-C...

The mental health field needs a clean-sheet redesign. Nothing else will help.

(edits: formatting, clarity )

One thing that has always puzzled me.

If addiction is a disease why wait for an addict to hit rock bottom?

Would you wait for a diabetic/heart disease patient to hit rock bottom before treatment?

If they deny the problem and refuse treatment, what else can you do? The rock bottom part is usually the catalyst to change their view (for a moment).

There needs to be a distinction made between addiction and dependence, neither of which necessarily implies the other.

Dependence is when your body depends on a substance (generated internally or externally), and suffers withdrawal when it's missing.

Addiction is any repetitive self-reinforcing behavior.

Whether an addiction is "good or bad" is a value judgment which is very dependent on sociocultural and legal context.

Going to work every day to a job you love, can be considered a "good addiction". Same for a "runner's high".

Addiction occurs when the behavior is self-reinforcing and other behaviors of the same or less cost cannot produce the same relative reward that the addictive behavior does. The reward can be decreased pain, distraction from stress, euphoria, or other conditions which subjectively feel better than the status quo. Usually this means there's a stressful situation or lack of pleasure in the status quo. Addiction can be viewed as a rational economic decision based on limited information or time preference, with benefits and costs which are totally subjective to the addict. The benefits and costs do not need to appear to be rational to an outside observer, who has different subjective values and time preferences. [5]

The AA model of complete abstinence and submitting to a higher power is bad for several reasons: It can trigger painful or life-threatening withdrawal symptoms; it denies the person the power to control their addiction, causing learned helplessness; and it does not allow the person to learn to moderate their own addiction.

People behave rationally towards satisfying their addiction, such as by taking complex steps to buy drugs, and they rationally avoid law enforcement and/or medical intervention which prevents them from satisfying their addiction. Their behavior may not be legal, wise, moral or safe, but it is rational towards their immediately perceived needs. They are not hostage to a "disease" which makes them behave uncontrollably, like a seizure does. A disease does not involuntarily make one correctly drive a car down a complicated route to satisfy an addiction. Addiction is a choice. [0] [1] [2]

To say "addiction is a choice" does not imply any moral failing of the addict. In societies where addiction is not tolerated and is viewed as a moral failing, this can either help or hurt the addict, depending on their temperament and situation.

Conversely, saying "addiction is a disease, and not a choice" does not help a person gain control of their addiction, and it delivers an underhanded moral judgment against them, similar to calling someone a sinner but praying for them.

In some societies, ingesting psychotropic substances like coca tea is common, even among children, and does not generate social stigma. There's also not an expectation of intoxication, which decreases the somatic effect it has on the person, and lowers its addictive potential. Zinberg called this "Set and Setting" [3].

In societies where certain behaviors are severely punished, there can be a higher rate of addiction, because of the "forbidden fruit" syndrome, and because the addictive behavior is one of only a few ways out of an seemingly oppressive situation, giving the person a temporary feeling of self-control.

The disease model of AA is unscientific. It presupposes a biological disease, without any demonstrable etiology or mechanism.

When addiction researchers describe changes in body chemistry, MRI scans, etc., they are rarely controlled experiments, so it is uncertain whether the observed changes are due to: 1) random variation among the population, 2) a preexisting condition which increased the chances of the addictive behavior, 3) a symptom of the addictive behavior itself, 4) the effects of (sometimes involuntary) medical treatment post-addiction, or 5) the stress of simply being tested. [4]

Addiction is a learned behavior which provides a temporary subjective reward over not doing the behavior. There is no disease or involuntary lack of control over the behavior. The reward is extremely subjective, and depends on the biology of the person, their social/psychological state, the effects of the behavior on the person's biochemistry, and the social/legal consequences of others learning about their addiction. Everyone will value the multitudes of factors differently. But they always make the final decision of whether to continue the addictive behavior or not.

[0] https://www.amazon.com/dp/081269404X

[1] http://www.psychiatrictimes.com/addiction/addiction-choice

[2] http://www.macleans.ca/society/health/addiction-new-research...

[3] http://www.psychedelic-library.org/zinberg.htm

[4] http://www.thecleanslate.org/myths/addiction-is-not-a-brain-...

Edit: Added:

[5] https://www.wiso.uni-hamburg.de/fileadmin/bwl/rechtderwirtsc...

The AA model of embracing helplessness needs to die in a fire. I've never seen such a depressing pseudoreligion, denying people agency in their own lives, promoting a bizarre sort of monasticism (if you actually do the stepwork as fanatically as you're supposed to).

It's not pseudo-religion, it's actual religion. I can't say whether or not it works, and my stance on religion is neither here nor there, but it's why I'm so very, very against court-ordered AA. Not only is it cruel to people who are there for actual help, but it's state-sponsored religion.

court-ordered AA is illegal. court-ordered rehab is not:


Hey, look at that! That's good to know. Sad that it's not followed by many (some?) courts (I personally know someone required by court to attend AA specifically, although this was at least 10 years ago).

I have been to AA, it was not for me for the reasons you mention, also I received thinly veiled threats when they found out I was an atheist (making it clear I was not welcome if my personal "God" wasn't literally the Christian God).

However, that doesn't mean AA doesn't work for some people.

I have read somewhere it has a 10% success rate, so we can't ignore that for some people, as flawed as it might seem to some, it does work.

Anyone that talks about AA like this isnt really doing what AA is... the helplessness thing also isnt true.

Powerlessness is just about "I dont have power over X" where x=other people, other circumstances, etc etc.

All you have power over is your OWN actions. And thru that you gain immense power.

The steps are just about clearing out the shitty character your developed lying and cheating your way to get high/drunk... So you can start making decisions without trying to cover up 100 other shitty decisions.

The higher power thing is just about not being so self centered and framing the world from a point of view where the addict isnt in the center of it, but a participant equal to all others.

Theres lots of crazy everywhere, and AA attracts alot of them. But people who have found true freedom outside of addictions thru the process. And many people just build new frameworks to be assholes with.

"The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry" puts it at 5-8%

How many of those are people that would have successfully quit on their own, but instead of trying to fix it themselves when they realized they had a problem, almost immediately went to AA?

I don't think a 5-8% success rate is really indication on its own that AA provides any positive benefit

Although I think the disease model is wrong and destructive, there's a certain logic to AA's thinking that can't be easily dismissed.

An addiction researcher put it like this:

> If the consumer's sole motive for changing his level of patience is to escape an allocation that is dictated by his first order preference (including time preferences), but that contradicts his second order preferences, he will not be able to achieve this by rational means.

The researcher proposed that it might be possible to escape this conundrum by seeing patience as valuable in itself. If you only value patience because you'd like to escape your addiction in the long term, you won't succeed, because you do in fact value the thing you're addicted to more in the short term.

Yet, can you just choose to value patience in itself? What things you value can force you to change the things you value? Isn't it all dictated by our biology anyway, even if it isn't a disease?

There are a lot of paradoxes about willpower. It may not be something you can think yourself out of, no matter how smart you are. It's not really surprising Robert Smith threw his hands up and decided he needed a miracle/supernatural help to break out of it.

But maybe this is all the more reason to try to solve addiction as a social problem, not on an individual level as a problem of willpower (or disease).

It would seem to work because it's an antecedent to the religious ceremony beer is spirited with. Strong alcohol is even called spirit.

People talk about religion like it's been with us since the dawn of man for no good reason at all.

What do you mean by "good reason"?

If you mean reasons that make sense, sure, of course there's a reasonable explanation for why religion is so prevalent throughout history.

If you mean reasons that involve benefit to humans, I'm rather skeptical. There may be, but the mere fact that it's common doesn't mean that there must be. Cancer and broken bones are pretty common too.

If only we could find a way to engineer more of the humanity out of being human. Humans would be great if they just weren't so human. I have high hopes for humankind, it's just that first we have to figure out what to do with the human part.

So I agree with you. I too am skeptical being human is beneficial to being human, it's just that I'm not really sure what we'd do without it, either.


I've never heard the word "disease" used that way before. Does it get confusing using such an unusual definition?

The Chronicle? Who wrote the article, dr dre?

Oh come on. I can't yet downvote articles and posting comments while not upvoting the title is my vent, but if I'm being down voted I will have to continue.

No one can downvote articles.

I expected to be downvoted anyway

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