Is Drug Dependency a Disease?

January 15, 2018 The Noffs Team Comments

Drug Dependency and the Disease Theory

The disease theory describes drug dependency as a chronic neurological and biomedical disorder of the brain, where harmful substance use alters brain chemistry and structure which triggers a dependence on that substance. Proponents of the disease theory argue that once dependent, the individual can never really be cured, but their dependency can be managed over time [1]. The disease theory has gained much traction amongst scientists and specialists studying drug dependency, and has been championed by politicians and the media particularly in the US [2]. However, it is also the subject of much criticism, particularly over what critics see as a further negative framing of drug dependency and individuals experiencing it [3 ALSO 4], and its narrow, clinical focus that oversimplifies the nature of dependency with a one-size-fits-all treatment approach [5].

How Disease Theory became the status quo

The popularity of neuroscience in the 1990s - known as the “decade of the brain” [6] - may go some of the way towards explaining how the brain disease model came to have a significant influence over drug policy [7]. The media used neurological terminology to describe people with a dependency as “dopamine heads” living “subcortical lives”, the latter suggesting people dependent on drugs have inferior brains. This newfound interest in the brain led to the theory that human identity and behaviour is closely tied to our “neurochemical self” [8]. As a result, brain chemistry was used to explain drug dependency and the reasons behind it.

Around this time, then-director of the US National Institute of Drug Abuse (NIDA) Alan Leshner declared the Institute’s position as supportive of the disease theory, stating that drugs “flick a neurochemical switch in the brain” which makes it difficult for those dependent on drugs to stop using [9]. Considering many scientists in the field of drug research depend on NIDA for funding, the assumption can be made that research favouring the disease theory received higher priority, and was promoted more heavily as the accepted scientific view.

Beyond the world of science, the disease theory has been particularly championed by Alcoholics Anonymous (AA) and its 12-Step philosophy, which operates under the theory that dependency is an “involuntary disability” [10] and recovering individuals are always teetering on the edge of relapse. Established in the US in the 1930s, AA is now a worldwide organisation, referenced frequently in popular culture and spawning Narcotics Anonymous (NA), similar to AA but with a focus on illicit drugs. AA and NA’s long-established presence in the field of drug treatment and their promotion of the disease theory enabled it to become the basis for many drug treatment services.

Dr Carl Hart, a professor of psychology well known for his research on drug dependency, stated that the disease theory is popular because it is viewed as a compassionate explanation for drug dependency [11]; that it is not a moral failing on the part of society, but instead the result of an extremely powerful chemical hijacking the brain [12]. From the perspective of politicians and the media, drug dependency is a complex problem, and it is easier to blame the drugs themselves and be seen to be taking a tough stance against a societal ill, rather than factor in poverty, disadvantage and mental health - issues requiring fundamental changes in society and government expenditure. [13].

The Benefits?

Proponents of the disease model argue there are two main benefits for its establishment: the first is to de-stigmatise dependency and frame it as the result of an individual powerless against a potent chemical, and challenge the perception that those with a drug dependency are weak-willed or bad people [14]. Secondly, describing drug dependency as a legitimate, diagnosable disease classifies it as a medical condition, making it eligible for treatment and research funding particulary in the US, where the lack of a subsidised health system makes it extremely difficult for people to access treatment under health insurance without a diagnosable condition [15].

Some scientists have also stated that the perception of drug dependency as a disease, in the way that cancer is a disease, removed some of the moral stigma surrounding research into it and therefore encouraged other scientists to contribute research to it [16].

A critique of the disease model

The reality of drug dependency is that it is a complex issue influenced by a number of factors - cultural, social, psychological and biological [17]. In seeking to use brain chemistry as the sole determinant for why an individual becomes dependent on a substance, the disease model not only fails to account for the numerous other reasons people become dependent, it also cannot explain other studies that have shown dependence can be treated without necessarily becoming abstinent, going to 12-Step programs, or seeking treatment full stop.

Much of the scientific theory behind the disease model is based on animal studies - rats in particular. However, the behavioural patterns displayed in rats exposed to drugs are not entirely consistent with the behavioural patterns of drug dependency posited by the disease model. For instance, rats taught to self-administer opiates continue to do so in standard conditions for dependent behaviour, though they do not do this in more natural conditions, and abstain when offered natural rewards, such as food or mating [18]. This suggests that it is not the drugs themselves, but an unfavourable, high-pressure environment devoid of more natural pleasure-inducing activities that compels an organism towards dependent behaviours. If we consider this, along with the argument that there exists in all humans a deep desire to form connections with others [19] and that trauma and social disconnect inhibit healthy development that helps foster healthy coping mechanisms in times of hardship [20] , we perhaps reach a deeper understanding of factors driving dependency.

By claiming that drugs “hijack” parts of the brain, proponents of the disease theory imply that these parts lie dormant until they are activated by a powerful chemical found only in drugs. In truth, the reward-seeking areas of the brain are activated by the human desire to feel pleasure and avoid pain [21], and are energenised by any number of experiences that naturally release dopamine, such as falling in love, or even eating something that tastes good. The fact that other, non-chemical dependencies such as sex and gambling activate the same regions of the brain is a further indication that dependency is a learned pattern of behaviour to seek pleasure and avoid with pain or stress, not simply a response to the chemicals in drugs. A number of studies have identified that a dependence on anything is a coping mechanism for stress or trauma, and that over time this becomes pathological as the individual’s natural desire to feel pleasure and avoid pain latches onto their dependency [22 ALSO 23].   

Further, suggesting that drug dependency is an incurable relapsing brain disease ignores plenty of epidemiological evidence suggesting that many people dependent on drugs end up recovering without treatment [24 ALSO 25 AND 26]. This can depend on comorbidity factors such as mental illness and trauma experience, but it does refute the assertion that, “once an addict, always an addict”, perpetuated by proponents of the disease theory such as AA.


Drug dependency is complex, with multiple causal factors and differing experiences for each individual. The disease theory is one hypothesis for why people become dependent, however, based on available evidence its focus is too narrow to be accepted as a comprehensive theory.

We know that drug dependency is not the result of chemicals in drugs permanently hijacking parts of the brain. If that was the case, all people who had ever tried drugs would quickly become dependent, and there is plenty of evidence asserting that this is not true [27 ALSO 28 AND 29], and it does not explain why the same areas of the brain can be activated by non-chemical addictions. And we know that proclaiming the drugs themselves to be the driving factor behind drug dependency fails to acknowledge the very real links between drug dependency and trauma, mental health problems, and social isolation.

There is no doubt that proponents of the disease theory, such as AA and NA, have helped many, many individuals overcome their dependence on drugs. However, they - and the disease theory - are part of a plethora of options alongside harm reduction. As long as drug dependency remains multifaceted, so should options for those seeking help.

































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