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Linda Rosenberg

Former President and CEO, National Council for Behavioral Health

If Addiction is a Disease, What kind of Disease is it? Join the Conversation!

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Addiction is a chronic disease that changes the structure of the brain and how it works. This understanding helped fuel our fight for parity, promote evidence-based treatment and recovery services, and now supports a $35 billion drug treatment industry.

But critics – including renowned addiction psychiatrist and NatCon18 speaker Sally Satel – believe that calling addiction a brain disease may make it harder to treat. They believe the disease model:

  • Discounts the social and psychological contributors to addiction, in general, and to the opioid crisis, in particular. Poverty, trauma and the breakdown of community have a critical role to play.
  • Implies that we know more about the biological underpinnings of addiction than we really do. In fact, the etiology of most mental disorders is not well understood.
  • May hinder recovery for individuals who believe that biology is destiny and they have no control over the course of their disease.

This debate is critical as we develop strategies to combat the opioid epidemic. A simplified model of addiction leads to equally simplistic but ineffective responses. Many have neatly identified the principle cause of the crisis: the over-prescription of opioid painkillers. The resulting solution is equally straightforward –– stop overprescribing.

But Dr. Satel points out that prescription opioids are not the principle cause of overdose deaths. Since 2011, the total number of prescriptions has gradually declined, yet the number of opioid related deaths continues to rise. In 2016, prescription opioids were responsible for one-third of opioid related deaths. Fentanyl and heroin were responsible for the remaining two-thirds and were also present in one-third of prescription opioid deaths. Today, people are increasingly becoming addicted to heroin directly, bypassing painkillers entirely.

Further, though addiction alters a person’s brain chemistry, it does not completely take away their ability to make decisions. Compared to a disease such as brain cancer, Dr. Satel says, addiction “is a complex set of activities whose course can be altered when the user confronts foreseeable consequences.”

Eschewing the brain disease theory does not, however, imply that medical treatment isn’t warranted. In fact, opioid medications cause physical dependence that can and must be treated appropriately. We know how to do that – medication-assisted treatment (MAT) is the gold standard in treating opioid addiction. The problem is that too few people have access to this lifesaving medication. In 2016, according to a review of data compiled by the Substance Abuse and Mental Health Services Administration, only 41 percent of substance abuse treatment facilities offered at least one form of MAT and fewer than 3 percent offered all three currently approved medications.

Both proponents and critics of the disease theory agree that individuals with addiction need comprehensive, science-based prevention, treatment and recovery support services, and we know how to do that, too. Certified Community Behavioral Health Clinics (CCBHCs) authorized by the Excellence in Mental Health Act are hiring addiction specialists, expanding MAT and working with a broad range of community providers to offer the full range of services that individuals need to recover. Dr. Satel has voiced her strong support for the bipartisan Excellence in Mental Health and Addiction Treatment Expansion Act, which would extend CCBHC operations by an additional year in the current eight states and allow 11 additional states to participate.

How does your understanding of addiction affect your work and the services you provide? Come to NatCon18 to continue the conversation!