Discovery Service for BYU - Idaho: https://eds.p.ebscohost.com/eds/delivery?sid=c8928cad-42bd...

EBSCO Publishing Citation Format: APA 7th Edition (American Psychological Assoc.):

NOTE: Review the instructions at http://support.ebsco.com/help/?int=eds&lang=&feature_id=APA and make any

necessary corrections before using. Pay special attention to personal names, capitalization, and dates. Always
consult your library resources for the exact formatting and punctuation guidelines.

References
Lembke, A. (2018). Why Addiction Should Be Considered a Disease. Judges’ Journal, 57(1), 4–8.
<!--Additional Information:
Persistent link to this record (Permalink): https://search.ebscohost.com/login.aspx?direct=true&
AuthType=ip,sso&db=ofs&AN=127674546&site=eds-live&scope=site&custid=s8406107
End of citation-->

Why Addiction Should Be Considered a Disease

The Silver Lining of the Opioid Epidemic
The silver lining of the opioid epidemic--if a silver lining can be found for a public health tragedy that
has killed more people than the Iraq and Vietnam wars combined--is the medical profession is finally
forced to contend with the problem of addiction. Our complicity through egregious opioid
overprescribing, and the sheer scale of drug overdose deaths, has meant we can no longer turn a
blind eye.

Yet for hundreds of years we did. The fight to get addiction recognized as a bona fide illness within
the U.S. health care system has been a long and losing battle. Almost 200 years ago, Dr. Benjamin
Rush published An Inquiry into the Effects of Ardent Spirits upon the Human Body and Mind: With an
Account of the Means of Preventing, and of the Remedies for Curing Them (1819), in which he
argued that chronic drunkenness is a biological disease, a radical belief for its time. Most of his
contemporaries still viewed excessive and problematic substance use as a moral failing, a sin.

Today, addiction affects 16 percent of the U.S. population, about 40 million people, far exceeding the
number of people afflicted with heart disease (27 million), diabetes (26 million), or cancer (19 million).
The number of people dying from and addicted to opioids is rising every year. In 2016 alone, more
than 50,000 Americans died from drug overdoses (53,000 per the Centers for Disease Control and
Prevention, 65,000 per a New York Times report), as compared with 36,000 from car crashes and
35,000 from gun violence. Four million Americans are addicted to opioids, 11 million are using
prescription opioids recreationally, and more than 2 million are using heroin recreationally. Disease
burden due to addiction exceeds half a trillion dollars annually. Yet only 1 percent of the total health
care budget goes to treating addiction, and fewer than 1 in 10 persons with addiction receives
treatment.

I believe the opioid epidemic has made the debate over whether addiction should be treated as a
disease a moot point. We must embrace addiction as a disease and treat it as such within

1 of 7 5/29/24, 13:03
Discovery Service for BYU - Idaho: https://eds.p.ebscohost.com/eds/delivery?sid=c8928cad-42bd...

mainstream medical care, even if we don't believe it is one. Here are three reasons why.

First, addiction has long been the neglected stepchild of the progressive pathologization of everyday
life, wherein we turn everything from indigestion to sexual drive to high energy into a disease.
Biologizing problems is how contemporary culture solves them. The disease model of addiction is the
model for our time. It destigmatizes, legitimizes, and opens the way to health insurance and research
dollars.

Second, the disease model is the best response to a public health crisis that otherwise shows no
signs of abating. Addiction treatment, when integrated within the house of medicine, works better
than siloed care in specialty addiction treatment centers. We need a robust infrastructure within
mainstream medical care, such that anyone struggling with a substance use disorder (SUD) can walk
into any primary care clinic, maternity ward, or emergency department in the country; say, "I have
addiction; will you help me?"; and hear a resounding, "Yes!"

To make this vision a reality, insurance companies and other third-party payers must pay for addiction
treatment on par with other medical conditions. Despite the passage of the Mental Health Parity and
Addictions Equity Act of 2008, getting insurance companies to pay for addiction treatment is still a
bureaucratic maze of "carve-outs," "prior authorizations," and "fail first criteria," making it
cumbersome and in some cases impossible to get this care reimbursed. If doctors and hospitals
aren't reimbursed to provide this kind of treatment, it won't happen. On the other hand, if you pay
them, they will come.

Third and most importantly, if we in the medical profession fail to take the lead in addressing what
many have rightly likened to the modern-day plague, we will continue to perpetuate the problem. The
rise in opioid overdose and addiction directly correlates with the rise in doctors' prescriptions for
opioid analgesics. One of the biggest risk factors for addiction is sheer access to that drug. What
began as a well-intended effort to improve the care of patients in pain has led to a runaway train of
opioid overprescribing, which puts many more people at risk for addiction and accidental death.

Although opioid prescribing has decreased by about 15 percent since its peak in 2012, U.S. doctors
today continue to prescribe three times as many opioids as they did in the late 1990s, four times as
many opioids as are prescribed in Europe, and more than 10 times as many opioids as are
prescribed in Japan. Europe and Japan are apt comparisons for the United States because they too
are rich countries with aging populations and comparable rates of physical pain in the population, yet
they consume far fewer prescription opioids. Indeed, the United States is reported to consume over
80 percent of the world's opioids, while representing less than 5 percent of the world's population.

I recently got a phone call from a colleague, a pain medicine specialist who works for a large
integrated health care center, who had been tasked by her institution to identify all patients in the
system taking Opana ER. Opana ER, an opioid painkiller, was at the center of the HIV outbreak in
Indiana in the spring of 2015, and due to its high risk of misuse and addiction, the Food and Drug
Administration recommended it be pulled from the market in July 2017.

My colleague was seeking my advice on the case of a 28-year-old man with chronic pain. This young

2 of 7 5/29/24, 13:03
Discovery Service for BYU - Idaho: https://eds.p.ebscohost.com/eds/delivery?sid=c8928cad-42bd...

man had no identifiable organic pathology for that pain. Young, otherwise healthy people showing up
to doctor's offices describing crippling full-body pain, despite the absence of any known trauma or
disease process to explain that pain, is an increasingly common phenomenon. The patient was
taking the following medication, prescribed by a single doctor: Opana ER (an opioid) 40 mg twice a
day, Dilaudid (an opioid) 30 mg once a day, oxycodone (an opioid) 60 mg once a day, phenobarbital
(a barbiturate) 65 mg once a day, Valium (a benzodiazepine) 20 mg once a day, Restoril (a
benzodiazepine) 30 mg once a day, and Xanax (a benzodiazepine) 8 mg once a day.

This young man with no objective reason for being in pain was being prescribed 450 morphine
milligram equivalents daily of opioids (four times as much as the average heroin-addicted person
consumes in a day), in combination with powerful sedative-hypnotics (phenobarbital and three
different benzodiazepines), also at extraordinarily high doses. His immediate problem was risk of
death due to accidental overdose. His longer-term problem was iatrogenic (doctor-caused) addiction.
When I asked my colleague if she knew anything about the doctor prescribing these medications, she
said, "She's his primary care physician. Really nice. Really caring. She inherited him from an older
doctor who retired, and she just continued the same regimen."

Only whole-scale institutional denial of addiction explains how a "really nice, really caring" physician
could continue to prescribe these drugs in this way to this patient. But I'm finally beginning to see the
seeds of change: medical students and residents expressing an interest in learning how to treat
addiction; continuing medical education courses on addiction treatment quadrupling in size and
number, mostly catering to mid-career practicing physicians who are seeing more and more patients
with substance use problems in their practice; the American Board of Medical Specialties declaring
"addiction medicine" its own medical subspecialty in March 2016, a major milestone in the
recognition of the need for specialized treatment of patients struggling with SUDs. So as tragic and
devastating as the opioid epidemic has been for its victims and their families, at least medicine is
standing up, taking notice, and doing something about it. Dr. Benjamin Rush would be proud.

Arguments Pro and Con for the Disease Model of Addiction

The scientific argument in favor of addiction as a brain disease goes like this. Approximately 50
percent of the risk of becoming addicted is genetic, more than for any other mental illness. A child
with a biological parent or grandparent with a substance use disorder ("substance" being the general
medical term to refer to any addictive molecule) has a two to four times increased chance of
developing addiction when compared to the general population, even when raised outside the
substanceusing home. Chronic heavy substance use changes the brain over time, such that the
individual needs more of the substance to get the same effect (tolerance), and "natural rewards"
(food, clothing, finding a mate) are no longer reinforcing.

Proponents of the disease model often compare addiction to type 2 diabetes mellitus. Both are
chronic, relapsing, and remitting diseases with a behavioral component. In the case of diabetes, the
behavioral component is the ingestion of a high-sugar diet. In the case of addiction, it is the user's
"drug of choice." In both cases, the ingestion of that substance can lead to irreversible chemical and
morphological changes in the body. In the case of diabetes, insulin resistance leads to an inability to
properly absorb sugar from the bloodstream. In the case of addiction, chronic, heavy exposure to

3 of 7 5/29/24, 13:03
Discovery Service for BYU - Idaho: https://eds.p.ebscohost.com/eds/delivery?sid=c8928cad-42bd...

addictive drugs changes the brain's reward threshold, creating intense dysphoria when the drug is not
available. In other words, the brain's reward pathway has been "hijacked" by the substance, not only
when intoxicated or withdrawing, but also in the in-between time, when the craving for drugs can
crowd out rational thought and propel behavior beyond that individual's willful control. A patient of
mine likened it to being very, very thirsty, to the point where you too might go outside your moral
compass to obtain a small drink of water. Acquiring and using the substance becomes synonymous
with survival itself.

In both diabetes and addiction, a radical lifestyle change--a change in diet or the cession of drug
use--can restore the body to baseline. When the damage is irreversible, a medication can be used to
treat it. Insulin, for example, is used to treat diabetes. Long-acting opioids like buprenorphine or
methadone are effective treatments for opioid use disorder. A seminal paper by McClellan and
colleagues published in the Journal of the American Medical Association in 2000 shows that
addiction and type 2 diabetes have the same rates of response, recurrence (relapse), and adherence
to treatment when addiction too is treated like a medical disease.

Dissenters of the disease model argue that brain changes are not sufficient to categorize addiction as
a disease. Piano virtuosos also exhibit brain changes after years of practice. More importantly, no
other disease involves the element of choice in recovery the way addiction does. People with cancer
can't decide that their malignant cells should stop dividing. On a philosophical level, the disease
model cannot answer what many consider to be the root cause of addiction: the psychospiritual
search for transcendence in an increasingly materialistic and socially transgressive world.

It is this last point that resonates most strongly with me. I agree that the disease model does not
begin to address the psychosocial and psycho-spiritual challenges of modern-day life that have given
birth to the terrible problems of addiction we are facing today. Nonetheless, embracing addiction as a
disease and building an infrastructure within the house of medicine to treat it are the best ways out of
the worst drug crisis in U.S. history.

If Addiction Is a Disease, Should People Be Punished for Addiction-Related Crimes?

If we are to embrace addiction as a disease, how do we reconcile the legal, interpersonal, and moral
transgressions that are common in persons who become addicted, with a traditional sick role that
absolves sick individuals of responsibility for their actions?

This question is all the more pressing because people with addiction are well-known to lie, cheat, and
steal in the process of acquiring substances or hiding use. While intoxicated or withdrawing, they can
perpetrate shocking acts of violence and harm on others. Addiction is the only disorder in which
immoral, illegal, and violent behavior are a consistent and pervasive "symptom" of the disorder,
distinguishing addiction from all other illnesses and disorders, including other forms of mental illness.

Last year, I was asked to provide expert medical consultation in the case of an individual who, under
the influence of a prescription drug, got behind the wheel of his car, swerved off the road while
driving, and killed a teenager who happened to be walking along the side of the road at the time. The
case hinged on whether that individual had knowingly taken those pills midmorning with the intent of
becoming intoxicated, or whether the ingestion had been accidental, in which case his altered mental

4 of 7 5/29/24, 13:03
Discovery Service for BYU - Idaho: https://eds.p.ebscohost.com/eds/delivery?sid=c8928cad-42bd...

status was also unintentional, absolving him of some degree of responsibility.

Looking at the evidence, I determined that this individual had intentionally and knowingly taken a
larger-than-therapeutic dose of the drug in order to get high. In essence, my testimony contributed to
his burden of guilt. I also surmised that he was likely struggling with a covert addictive disorder, given
his prior history of driving while under the influence and evidence of long-standing prescription drug
misuse. He seemed to have no insight into his addictive problems and apparently felt little or no
shame for the crime he had committed, repeatedly endeavoring to blame the victim for "walking out
into the road," which was contrary to witnessed reports.

It was only later, after I had written my opinion, that it occurred to me that if we are going to take
seriously the notion that addiction is a disease that "hijacks" the individual's ability to choose whether
or not to use substances, and compels them to use even after periods of abstinence and in a state of
clear sensorium, and if I believed that this individual was suffering from the signs and symptoms of
addiction, then shouldn't his "disease of addiction" mitigate his burden of guilt? According to the
Model Penal Code provisions, "a person is not responsible for criminal conduct if at the time of such
conduct as a result of mental disease or defect he lacks substantial capacity either to appreciate the
criminality [wrongfulness] of his conduct or to conform his conduct to the requirements of the law."

Yet, even after realizing the inherent contradiction between my advocacy for the disease model and
my judgment in this case, I was loathe to invoke the disease model. Why? I could not at first
understand it. When I began to puzzle it out, I realized that my differential application of the disease
model in this circumstance was driven by my own sense of righteousness (no doubt one of my many
character flaws), my deep-seated pragmatism, and my gut instinct born of experience and intuition
from decades of treating people with addiction. Let me explain.

First, the crime involved the death of a human being, an innocent child no less. To my mind this
warranted severe punishment, independent of intention or mental capacity. Simply put, he deserved
it. (Remarkable how deep the human desire for revenge can go, an eye for an eye and all that.)

Second, it seemed imperative to remove this individual from the public sphere, at least temporarily, to
protect the public health and safety. This reasoning is consistent with what most courts have resolved
regarding the question of whether the "disease of addiction" absolves the individual of responsibility
for his or her crime. According to William L. Corbett from the University of Montana School of Law,
"Courts have been unwilling to hold that the addict or alcoholic consumed intoxicants involuntarily,
because to do so would be to hold him not liable for any criminal activity; this would be contrary to
public policy."

Third, and this was the hardest to understand, I was reluctant to invoke the disease model because
of this individual's lack of insight and remorse for what he had done. After many years of treating
persons with addiction, I have come to realize that without some degree of insight and the capacity to
experience shame, recovery is not possible. Not that insight and shame are enough and indeed
shame itself can be an obstacle to recovery from addiction. But without insight and the capacity for
remorse, a lighter criminal punishment in the spirit of providing treatment in place of punishment
seems like an exercise in futility. The point of conceptualizing addiction as a disease is because to do

5 of 7 5/29/24, 13:03
Discovery Service for BYU - Idaho: https://eds.p.ebscohost.com/eds/delivery?sid=c8928cad-42bd...

so provides the promise of a solution. To make the disease model worth pursuing, addiction
treatment has to work. Addiction treatment, even mandatory treatment, works, but not unless that
individual is willing and able to engage in an authentic way with the treatment provided.

Were this person to acquire insight and an appropriate sense of remorse at some later date, would I
be more willing to apply the disease model in his case? I believe that I would. And the two
approaches need not be mutually exclusive. Punishment can be provided alongside a "treatment"
plan that focuses on promoting insight, motivation to change, and prosocial behaviors (honesty,
reliability, commitment, follow through), all of which are fundamental to addiction recovery.

One of the most consistent findings in the field of addiction medicine is the effectiveness of
contingency management in the treatment of people with SUDs. Contingency management is a
system of rewards and punishments to curb substance use, relying on a set of overriding principles:
(1) certain punishment is more effective at shaping behavior than uncertain punishment, (2) swift
interventions work better than delayed ones, (3) the punishment should be commensurate with the
transgression, and (4) individuals should be rewarded for good behavior. Anyone who has ever been
a parent will recognize these familiar, commonsense principles.

Contingency management is at its core a behavioral contract between two people/ parties, which
recognizes the inherent tendency of all individuals to behave in ways that are self-serving (lying,
cheating, stealing). Indeed, the original conception of "sin" was not individual transgression but the
propensity in all humans to stray. Contingency management is relational and attachment oriented.
Those who play by the rules will be rewarded by a strengthened attachment and growing mutual
trust.

Effective real-world examples of contingency management can be found in drug courts. Hawaii's
Opportunity Probation with Enforcement (HOPE) is one example. HOPE uses contingency
management to reduce drug and alcohol use among nonviolent offenders on parole for drug- or
alcohol-related crimes. Urine drug testing is done at parole meetings. If the parolee tests positive and
subsequently admits to having used substances, he or she immediately spends two to three days in
jail--swift and certain punishment. If the individual tests positive but denies having used substances,
he or she spends 15 to 20 days in jail. Note how lying, an antisocial behavior, is punished more
severely as a way to promote truth telling in the future, even when the behavior (having used
substances) is the same. If the parolee fails even to present for a parole meeting, he or she is
apprehended by law enforcement and spends 30 days in jail. The punishment is commensurate with
the transgression. Using this strategy, HOPE has been able to cut arrests and failed drug tests by
more than half.

This approach differs from the failed War on Drugs that has marked our nation's drug policy for the
past three decades. The War on Drugs got it wrong. Jailing a person for a decade for carrying an
ounce of marijuana, two years after the original request, defies all of the rules of contingency
management and does not change behavior.

I advocate for the conceptualization of the disease model of addiction inside of medicine because it is
the most expedient and practical approach for our time. Yet, the model feels inadequate when

6 of 7 5/29/24, 13:03
Discovery Service for BYU - Idaho: https://eds.p.ebscohost.com/eds/delivery?sid=c8928cad-42bd...

considering the moral, interpersonal, and legal transgressions that are so common in persons with
addiction. We know punishment alone doesn't work, given three decades of the failed War on Drugs.
Perhaps the answer is punishment combined with treatment and consequences that are thoughtfully
crafted to reduce substance use and promote prosocial behavior, similar to contingency management
strategies used to treat SUDs. By studying the active ingredients of programs that are working, like
HOPE in Hawaii, we may find answers.

~~~~~~~~
By Anna Lembke

Dr. Anna Lembke is the medical director of addiction medicine at Stanford University School of
Medicine and author of Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why
It's So Hard to Stop (Johns Hopkins University Press, 2016).

Source: Judges' Journal, Winter2018, Vol. 57 Issue 1, p4, 5p

Item: 127674546

7 of 7 5/29/24, 13:03