If you saw Matt’s post last week on that Icelandic model for reducing drug use amongst youth–if you didn’t, read it here–you might be wondering: Why can’t we do that in North America?
Well, one of the reasons is because the healthcare systems in the US and Canada are heavily invested in what’s known as the “disease model” of addiction. The American Society of Addiction Medicine’s definition of addiction begins with the statement that: “Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry.“ [You can read the rest of the definition here.]
We’ve labeled it as a chronic illness, one that’s rooted in brain circuitry. And it’s a “primary” disease, meaning that it isn’t the result of another disease, injury, or event. So this shapes how we treat it: We focus on affecting brain circuitry, we try to help people manage it for life, and healthcare professionals needn’t worry about any external issues when it comes to treatment or prevention because addiction is a primary disease.
For people with lived experience of addiction, and in the psychiatric consumer-survivor community in general, this disease model of addiction (and mental illness), has long been unpopular. It dismisses all of the other challenges and external factors in a person’s life or history and labels them as having a diseased brain with unpreventable problems. Iceland’s example of reducing youth substance abuse lends hard data to the argument that other factors have a significant effect on a person’s relationship with substances. By investing in fitness and arts infrastructure for youth, Iceland has seen dramatic falls in substance abuse. Amongst 15-16 year olds, from 1998 to 2016, the percentage that had been drunk in the past month fell from 42% to 5%, the percentage that had used cannabis fell from 17% to 7%, and the percentage smoking cigarettes every day fell from 23% to 3%.
It’s arguable that there’s a difference between “substance abuse” and “addiction” but in terms of impairment and how an individual interacts with the justice or healthcare systems, I’d argue that there’s limited distinction if the person has a low income or belongs to a racialized community.
As Columbia University professor and psychiatrist, Carl L. Hart, explained in a recent editorial in Nature Human Behavior, “The view of drug use and drug addiction as a brain disease serves to perpetuate unrealistic, costly, and discriminatory drug policies.”
As Hart explains, in the US, more than 80% of those being sentenced for crack cocaine offences are black, but white people make up the majority of users. Those people getting sent to jail are also being processed through the lens of the disease model of addiction. They have a problem. Rather than viewing the problem as a societal failing, we’ve passed the problem onto their brains. Now they have a criminal record and a chronic illness. There’s nothing we could have done!
The disease model approach to addiction perpetuates injustice while pouring money into research dead-ends and incarceration programs that fuel a cycle of poverty and community degradation. Meanwhile, the addiction treatment industry continues to grow. The Substance Abuse and Mental Health Services Administration estimated its size at $35 billion dollars in the US in 2014. In recent years, one factor fuelling industry growth has been the rise of addiction psychiatry–using drugs to treat addiction. Medications like Suboxone have been huge successes for investors and pharma companies, but it’s questionable if they help alleviate the issues that fuel the drug addictions. This is another side-effect of the disease model. If you believe it’s a problem originating in an organ, then it makes sense to throw medications at it (indefinitely) to change and manage the organ.
But there’s a key problem with that when it comes to addiction, there simply isn’t data to support the disease model. You can’t look at a brain and identify addiction in the same way you can for a disease like Parkinson’s. There’s nothing to measure in the blood as you would with a disease like diabetes. Addiction and other mental health issues are very real biological issues, but that doesn’t mean they must originate from a problem in the body. Our bodies are complex interfaces. When that world affects our bodies, we certainly need to treat the impacts of that, but we also need to tackle the issues impacting us. Approaching addiction as a primary disease of the brain misses so much that we can do (more cheaply and permanently) to address and prevent these issues.