Editorial Comment  2/18/2020: Models of Addiction

All efforts to describe addiction as an illness - comparable to those others suffered blamelessly, from misadventure, or from neglect - invariably fall back on models or analogies.  The models are useful from a public health standpoint, in devising populational interventions.  Heuristically analogies can be examined for flaws, as well, in order to come to a clearer notion of how the disease does not resemble another condition or process; and so prevent investigators from going down blind alleys. They can also clarify descriptive language.

In my time, I have seen terms such as dipsomania and heroinism give way to “addictive disorder” (in an effort to better include alcoholism), then to “substance abuse and dependence”, and more recently to “substance use disorder [specify].”  The argument is not fatuous.  To a large extent, it revolves around causation: is it a process, is it related to the specific substance, is it volitional or an illness whose origins are blameless?   Colleagues in my department employ a variety of models:  Gerry Busch finds an infectious disease model useful from a public health stance, Miki Kiyokawa  reveals her internal medicine origins by invoking the parallels with chronic, recurring, progressive illnesses such as diabetes mellitus.  They are, of course, equally correct.  Interestingly, ASAM has been less conflicted about this than the rest of the medical world.  Since its inception, ASAM has advocated inclusivity of the patient populations under one heading of “addiction”. This attitude was further abetted by its re-christening in 1989 as the American Society of Addiction Medicine (ASAM), happily supplanting the cumbrous and inelegant “American Medical Society for Alcoholism and Other Drug Dependencies (AMSAODD)”.

But then there is the matter of how many addictions exist*.  Are there many, or is there one, a corporate process held in common among the many expressions of substance use (drug A through drug Z)?  Of compulsions (sex, gambling, running)?  And what of the behaviors with a foot in both camps, such as over-eating?  My beloved colleague Howard Wetsman and many others in ASAM would hold that there is one Addiction (I would offer without intent of blasphemy, “There is but One God, and His Name is Yaweh”); and while that motivates our seeking a therapeutic final common pathway, it still wants for an analogy that our patients can readily grasp.

I found myself speaking casually with an oncologist last week, about two distinct neoplasms:  pulmonary and dermatologic.  Never mind why; hospital lounge stuff is either football or pathology or reimbursements. …And as we discussed the categories and stages and origins of the cancers, it struck me that the world of the oncologist is not so troubled by our little linguistic problem.  For all the differences (and similarities) among the tumors, the variance in etiologies and in outcomes of treatment, There is but One Cancer.  And while the oncologists do not all march shoulder-to-shoulder, through legislative corridors and the lobbies of charitable corporations, seeking support equally, there is no real ambiguity in their respective missions:  the enemy is the illness.   For our patients, their employers and families, we can certainly add this analogy.  “What you have can be very serious, it may cause impairment or even death, it may be manageable or even capable of remission; it may certainly vary in severity and expression according to your resources and your heredity and the state of our science.  In whatever form it takes, your prospects will certainly improve to the extent that you invest your efforts and time.

“And yes, it may also be contagious and chronic.   Those efforts must begin now.”

- Editor-in-Chief: Dr. William Haning, MD, DFAPA, DFASAM