Is addiction really a disease?

[Jemmons]

14. Pre-addiction stages are very interesting

Myself, I have a big interest in understanding what the brain is like before the addiction begins, or in the very early pre-addiction stages (recognizing that some people are hooked from the very beginning). Why do some people manage to moderate or quit before things get too far along, while others just progress and progress?

This is indeed where things get interesting.

And there are several ways that people can be vulnerable or less so.

Some are related to diseases. For instance the link to diabetes:

Additional evidence that low glucose reduces drinking
restraint comes from studies showing that people with
diabetes are more likely to have alcohol-use disorder than
people without diabetes (e.g., Goodwin, Hoven, &
Spitzer, 2003; Rehm et al., 2003). To be sure, the link is
a correlation, and the causal arrow could point in either
direction. However, several studies suggest that alcohol
use does not cause diabetes (e.g., Saremi, Hanson,
Tulloch-Reid, Williams, & Knowler, 2004; cf.
Wannamethee, Shaper, Perry, & Alberti, 2002), and so
diabetes might lead to excessive alcohol use if, in fact,
diabetes and alcohol use are causally related. Thus, low
glucose and poor glucose tolerance might undermine
efforts toward restraining alcohol consumption.

From
http://www.ncbi.nlm.nih.gov/pubmed/18453466

So this points to some people getting into addiction because an underlying vulnerability that is physiological in nature. Not because they have disease that makes people desire alcohol, but because their general ability to withstand desire is compromised to some degree and the balance between the prefrontal cortex (aka PFC) and the limbic brain tilts towards less cortical and more limbic control.

In this case you do have a disease, just not a disease that always lead to alcoholism.


ADHD also seem to predispose people for addictions. And ADHD is not just a sign of dysregulated glucose. So it doesnt make alcoholism a disease, just one of many negative effects of something else gone a wrong.

Sleep disorders also seem to predispose people towards addiction:

"Age-related sleep deficiencies may encourage the use of alcohol to promote sleep, while increasing an older person's susceptibility to alcohol-related sleep disturbances"
http://pubs.niaaa.nih.gov/publications/aa41.htm

But this is a case where it is hard to see what is cause and what is effect. While sleep disorders can motivate drinking alcohol, alcohol can produce sleepdisorders.

There are many more examples of things that predispose people to alcohol addiction. They all seem to affect your chance of having the pcf dominate the limbic brain in order to abstain.

Which leads to the tentative suggestion that addiction is based on a relative weakness of the PFC.

But this is where a disease model of addiction is a bit of a problem: PFC function is something that is easily disturbed by so many factors that it doesnt make much sense to call weak PFC function a disease. A bit of stress and the PFC shuts down. A bit of malnurishment and the PFC shuts down. A bit of infection and the PFC shuts down. A weak PFC function is a sign of a million different things that could all be causes if their own way.
There is also the the fact that you can compensate for weak PFC function in a lot of non medical interventions. Like stress reduction or by training people to use certain coping strategies.

When you find more and more ways that a bad balance between the PFC and the limbic brain (desire) can come about, it make less and less sense to see addiction as a disease. As some of the causes are diseases, that need not bother you, but it might.
I think the disease model will make it harder to understand addiction because it is hard to square the disease concept with some of the factors that will make your pcf function weak and might cause addiction.

But it is worth looking at the requirements for PFC function. If you need a million things to go right in order to have good PCF control, then there is a million things that can go wrong. But if you start sorting out what is necessary and what is sufficient causes of good PFC function, you might get somewhere. Then you can then have vulnerabilities, compensation and enough PFC function to stay on a chosen course. But this focus goes a bit beyond diagnosing a disease.