Addiction: Character Defect or Chronic Disease?

by Richard G. Soper, MD, JD, MS, FASAM | March 13, 2014

Recently, numerous media sources have implied that "addicts" ought to make better choices; addiction science cautions that is not always possible. Describing addiction as a reflection of moral character and choice takes us back to an earlier, more ignorant time. Science now shows that addiction, including alcoholism, is not a simple phenomenon. It stems from multiple causes rather than character flaws.

Many of us as medical professionals use a medical model to understand addiction. Drugs, alcohol, and illicit substances activate reward systems in the brain, which cause people to feel pleasure and create memories. Each individual has a unique tolerance to drugs and alcohol; the effects of drugs and/or alcohol are individually specific. Individuals may have genetic predispositions and different brain inhibitory circuits. Addiction is a disease, just like asthma, diabetes and heart disease.

Most drug treatment professionals and facilities speak of stages of change. Those who suffer from substance use disorders are not necessarily aware of the disease of addiction. Recovery is a lifelong process. William White - addiction writer and author of Slaying the Dragon - talks about our need to focus more on recovery. Most people come into drug treatment in a state of unawareness or ambivalence. Stereotyping addiction sufferers as immoral characters is not helpful. It is a shame-based concept that perpetuates the addiction problem and discourages a person from reaching out for help. Who would choose to feel worse about themselves than they already feel? This is why it can be so hard to enter recovery programs.

It is deeply disappointing and disingenuous to see again how the media, professionals, and members of our society repeatedly demonize, marginalize and even re-criminalize a chronic, recurrent, progressive and ultimately fatal brain disease. A recent brochure advertising an upcoming medical professional meeting in my region has a workshop on discussion of medication assisted therapy becoming or being addicting. I respectfully ask again, are we, the addiction treatment professionals, part of the solution or part of the problem?

Richard G. Soper, MD, JD, MS, FASAM
Editor-in-Chief, ASAM Weekly

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  1. Kevin F Aug 04, 2017 - 07:23 AM
    Disease is too broad of a definition. Without sounding too harsh, it takes some responsibility away from the addict, himself, to stop his behavior. While it might be a disease, it's too easy to accept this as a final outcome. In other words, I have people who are enabled because addiction is treated as a disease where all responsibility and fault is outside the addict's purview because he is the victim instead of taking responsibility and starting the journey to recovery. Perhaps it lies in between the broad definitions of disease and character flaw. Without the addict taking responsibility and being the one who starts the road to recovery, all the talk, studies, and rationalizations are useless. You're back at square one.
  2. Steven Jun 08, 2016 - 12:08 AM
    AA calls alcoholism as a disease, then in their 12 and 12, Bill Wilson says it is due to defects of character.
  3. Edward L. Mar 29, 2016 - 10:47 PM
    Speaking as an alcoholic, from the horses mouth: Calling it a disease seems the most apt description.  My last relapse, I walked to the store, bought a bottle of liquor, sat in bed, and drank, and that whole time had absolutely no control over my faculty.  A dark passenger walked my legs and handed the clerk my credit card.  In my head I was saying "I don't want this, this is bad" and I drank.  For whatever reason, AA has been helpful in keeping this in check and helping me stay sober.  I sort of take offense to anyone who claims this is "a choice"; I certainly have my flaws like any other human, but when my depression hits, if I'm not in a safe environment, I become confused, unaware of consequences, and in extreme emotional pain.
  4. Mike B Mar 29, 2016 - 02:41 AM
    Hey Sonya you are not a doctor right? how could you be in any state of mind to say addiction is not a disease? The disease is passed down from generation to generation and if it wasn't , no one would have this disease or problem yet we do. Not all cancer patients are born with the disease , which is highly relatable to addiction . When someone is born an addict then they have no choice . When someone is not born an addict they still have no choice because our brains at such a young age do not perceive the fact that what we are doing is wrong. People do not chose to be cancer patients , nor do addicts chose to be  addicts. If it wasn't a disease why would it be killing off humans the way it does ? Obviously you are not drinking or drugging as soon as you come out of the womb, because we as humans have morals. No one in their life chooses to bring that to the hospital or wherever because they don't plan on having a child that has to live that life. I did not choose to be an addict , that is the life I live and have to always remember that. I do not choose to have cancer so how is it any different . We cannot just stop like you a non addicts . We cannot just stop like these non addict doctors. Everything happens for a reason to make you who you really are. And if you are not here for a reason then why do we exist. Maybe one day a close relative or family member will unfortunately pass away from this DISEASE to make you realize that the disease does not discriminate . Maybe one day these doctors will not be in it for the money aspect and something in their life will make them realize how important this disease really is. Obviously you run on self-will and closed mindedness that is why you justify your excuse . You think you have control when you do not. If you have so much control how about you hold your breathe and see how long you last. I have no control over anyone or anything not even myself and when I think I do my life is over. Maybe you should broaden your horizons and do some important research before you react, because obviously you know everything . One day you will realize that your life happens 1 day at a time. Yesterday is dead, the future is untouchable, you only live 1 day at a time.
  5. John Feb 29, 2016 - 07:46 PM
     I bet Sonya, From July 7th, 2014, is an addict in denial.  I know first hand what it's like to want to stop, but can't. Who ever thinks treatment is a waist of time, is narrow minded if it didn't help them. If it wasn't for treatment, I would probably be dead right now.
  6. Kenneth Anderson Feb 26, 2016 - 11:57 PM
    It was an earlier, LESS ignorant time when we understood that addiction was a choice. The ONLY way to kick an addiction is by choosing to quit; treatment is a worthless waste of time that adds nothing. The good news is that the epidemiological data shows that over 90% of people with addictions successfully quit, the majority without treatment. There is no more success among those who choose to waste their money on treatment than those who choose to quit in their own.
  7. Brandi Roberson Jan 21, 2015 - 07:39 PM

    I actually have a video on my youtube page that I entered in the contest on ATTC website about addiction and mental health. I am in college getting my Bachelor of Science in Psychology because I want to help people like me, and raise awareness. I am all for Addiction being a disease because I am in recovery. I know first hand. I am also bipolar. If people could look at it like they do people with mental illness, then maybe they will see. If they can believe that mental illness is because of a chemical embalance and it is not a persons fault, then why can they not believe that Addiction is the same. It messes with the chemicals in our brains to where each time we have to have more and more until the chemicals in our brain are so low that we need it to replace them. Does this sound like a good question and argument Doctor?? I am writing a paper on it for just that.

    and to Sonya who posted in July saying that we learn from our surroundings....fine. But there is a difference in us learning and you learning. The difference is when we pick up that drink or drug, like you other people do, our brain does not let us stop like you who socially do it. There is something different that you totally do not understand. 

  8. Steven Slate Jul 13, 2014 - 01:14 AM

    Assuming someone is freely choosing to use massive amounts of substances on a daily basis - what about that makes them a bad person?

    Why is it that those who believe addiction is a disease are stuck on believing that heavy substance use necessarily implies badness or immorality if it's freely chosen?

    I resent, and take offense to the notion that heavy substance users could only be diseased or bad. And that definitely is the foundational assumption of this article. 

    It's a false dichotomy that smuggles in a bunch of judgments about how other people should be living their lives. It smuggles in a bunch of moralizing - and then attributes these actions to those who believe "addiction" represents freely chosen behavior. In fact, it's the disease-mongers who are judging and moralizing.

    The disease model is built on the assumption that the sober or moderate user's lifestyle is right and good - and the heavy substance user's lifestyle is wrong and bad. It's the assumption that no sane, non-sick, mentally healthy, good person would do such a thing as heavy substance use, so it must not be freely chosen. Isn't that a bit judgmental?

    The disease model is built on busybodyism. It comes from people sticking their noses into other people's lives, and deciding for them how they should be living. This is nowhere more apparent than in the act of "confronting denial."

    There are people who are happy with heavy substance use. Leave them be. Then there are people who are dissatisfied with the negative consequences of it, yet they continue. Both of them are doing what they believe is their best feasible option for living a happy life. They are both freely choosing. The former might tell you they can't control themselves - in order to get you off their back and be able to keep doing what they want. The latter are truly conflicted, and may feel genuinely out of control, and tell you as much. However, it's hard to know whether they would've come up with this idea of being out of control, if you hadn't provided them with it in the first place.

    The only way either of them will change is if they come to believe they have a better feasible option than heavy substance use. Even when things get really bad, if they still believe it's the best shot they have at enjoying life, they'll continue to do it - despite the consequences.

    As far as I'm concerned, that's their right, and it's none of our jobs to say they're bad for doing so. It's their life - not ours. But for those who are dissatisfied - identifying the behavior/desire as a stable unchangeable part of themselves (i.e. admitting you have an imaginary disease) doesn't seem like it points the way to happier life options. It certainly doesn't offer hope, or a sense of self-efficacy. It offers doom and gloom. And as they battle this boogie monster of a disease, they necessarily aren't focused on developing more satisfying life options.

    What those who want to change need is a way to expand their perceived feasible life options, so that they might find something better. If they are convinced that they've got better choices available to them, they will be motivated to change.

    As it stands, addiction treatment takes the motivation to use substances as a given that can't be changed. It then focuses people on schizophrenically fighting this motivation to use.

    In fact the motivation to use is the basic human desire to be happy - and it can be redirected (rather than fought), if we accept it, and ask ourselves if their are happier possibilities, and whether we think those possibilities are feasible for us.

    None of this needs to enter the realm of determining whether a person is good or bad - yet it's all about choices, and finding the choices that work best for the individual.

    BTW - the brain disease model of addiction doesn't add up:

    -Steven Slate

  9. Sonya Jul 07, 2014 - 07:22 PM

    Im not a doctor pardon me but I completely disagree with addiction being a disease. It is not something you are born with. You dont come out of the wound drinking alcohol and doing drugs you learn from your surroundings   I disagree with it being a disease and taking a lifetime to get over. You people are all programmed and think the same you are the reason addicts stay addicts " addiction is a disease"is a metaphor just like saying "jealously is a disease". Addiction and disease do not run hand and hand maybe hand and foot.  

  10. Joeg Voll Apr 03, 2014 - 02:44 AM

    Jim Clark, that was an excellent continuation of this article. I felt the same way and you put what I was thinking into words. 

  11. Steve Snyder Mar 24, 2014 - 10:28 PM

    I, like Dr. Mott, am involved with Lifering Secular Recovery. We support the latest in biomedical research, and the findings it is already delivering, such as the first generation of anti-craving medications, as well as ongoing research on the neurochemistry of addiction. We also support whatever new findings and research come along about the help that professional, informed, psychological counseling may offer.

     We welcome medical professionals and the general public to learn more at

  12. Joseph A. Mott, M.D., J.D. Mar 24, 2014 - 08:36 PM

    I very much agree with Dr. Soper.  In an secular society increasingly disillusioned with organized religion, I think it's time for our professional societies to embrace secular alternatives to 12-Step, which is a program -- despite all objections by adherents to the contrary -- with deep roots in evangelical Christian theology (i.e., the Oxford Group).  There are secular mutual aid groups like LifeRing (I am on the board of directors of this organization) that completely avoid the notions of higher powers and character defects, confession and amends, sponsors and prayer, and focus instead in a very present-centered way on the practical challenges of "not using or drinking, no matter what."  

  13. Jim Clark Mar 24, 2014 - 11:38 AM
    As a person in long term recovery, clean and sober 29 years, and an addictions counselor, my experience tells me that both "factions" are correct.  Addicts have a brain disease, and need to be treated for, and encouraged to acheive abstinence, and to continue the maintainance stage of change.  This stage includes, for most  long term recovered persons, significant and deep change of behaviors, beliefs, intentions, as well as approach to life.  These changes are predicated on some form of inventory, I do not like the wording "defects of character" however rather than rebel against that, have come to understand it simply means elimination of,or modification of actions and attitudes that do not benefit and enhance my recovery, and my personal value system.  So while there are actions that are out of alignment with my core beliefs and values, and require change, that does not imply that I, or any diseased person , is defective.  Let us not let semantics keep us from the truth that any person facing a life threatening illness, needs to adopt attitudes and changes that support complete recovery and enhancement of quality of life, for that is the reward for doing the recovery work- greater enhancement and enjoyment.
  14. Roy D. Clark, Jr., M.D. Mar 22, 2014 - 11:14 AM
    Always disappointing when prevention of addiction is not mentioned.  Those at risk who "Just Say No" do not become addicted. This is different from  the other disease examples mentioned - even those at high risk of diabetes mellitus who maintain suggested diet, weight, and exercise goals still progress to the disease at about 15%. 
  15. Edward H Katz MD Aadictionologist Mar 22, 2014 - 10:37 AM

    Drug or alcohol dependency has a unique set of symptoms signs and course fitting the definition of a disease state. A person inflicted with a terminal disease must understand it , and accept it, before givin the course of treatment. In my experience was the gravity of untreated substance disorder only than can a person inflicted make the correct ordere to cure or place in remission the unshaken reality no longer should be debated..


  16. walid mikhail Mar 19, 2014 - 08:28 PM

    excellent editorial. continued perception problem in the medical community and a lack of understanding between how addiction and dependence are different, (a diabetic is dependent on insulin... not addicted to it..etc)


  17. Timothy Lee MD Mar 19, 2014 - 07:38 PM

    I agree with Merens that ultimately it is about developing healthier ways of coping with life's adversities. 

  18. Greg Merens Mar 18, 2014 - 08:42 PM
    The disease model will ultimately be regarded a failed approach to addictive disorders. It is too simplistic, rigid, and not reflective of actual client experiences.  Why are so many opposed to seeing substance users as thinking,  Even with addiction clouding thought processes, substance users act decisively in behaviors we addiction professionals regard as manipulative, calculating, and even relentless.  When confronted about their behaviors they acknowledge these tendencies.  They know why these behaviors result in condemnation.  OK, yes, their brain chemistry is out of whack; they have become maladaptive in regard to healthy coping systems, but we should consider that self-defeatism is driven mostly by the mood irregularities that produce dysphoria and anhedonia. Our clients are looking for relief from the stresses of life and the stresses of early recovery, which they will almost all describe (and clearly) the consequences of continuing addictive behaviors.   For the addiction field to evolve, we must move into holistic treatment regimens that reinvigorate and normal brain activity.  We need a dramatic increase in the number of sober living residential options to support the holistic practices long-term.  We need ways to keep people away from the environments and people that continually trigger maladaptive thinking and engender relapse.  To date, we've only scratched the surface in developing such a comprehensive, long-term, addiction treatment philosophy and system.  This is where we should be going, not arguing about whether addiction is a disease.  Ultimately, addicts and alcoholics will have to develop healthy systems of living to overcome the life area impacts their faulty thinking and compulsive behaviors have brought them.
  19. Kevin Kirby Mar 18, 2014 - 03:09 PM

    When I read the title of your piece, I was disappointed in ASAM for encouraging yet another author to suggest that there is even an issue here.  I was pleased that you quickly moved on to a discussion of the disconnect between reality and perception.  As CEO of an organization ( working to, among other things, mainstream addiction care into primary care, we are learning that nobody is immune to the shroud of ignorance surrounding addiction.  We don't and can't hold medical professionals to a higher standard of comprehension than the general public because our medical schools have largely ignored this disease.  One of our greatest challenges as we build an addiction chronic care model in partnership with health care systems is to educate medical professionals.  For that, we lean significantly on The ASAM Criteria.    

  20. Keith Flower, MD Mar 18, 2014 - 02:20 PM

    The choices we humans make cause or exacerbate numerous diseases, e.g., cardiovascular disease, diabetes mellitus, and cancer.


    We do not ordinarily characterize these diseases as indicative of some moral failing. As Dr. Soper points out, it's not *effective* to do so. Why then is addiction singled out as reflecting some defect in character?



  21. Lyndee Retzlaff Mar 18, 2014 - 12:47 PM

    I did not read anywhere in Dr. Soper's article that twelve step programs promulgate that addiction is a character defect, so I am unsure of where a couple of commenters are coming from.  AA & NA state plainly that addiction is a disease. I would recommend the book "Alcoholcs Anonymous" by Bill W. to anyone wanting more information.

    I agree with Dr. Soper 100%, especially this quote ".Recovery is a lifelong process."  We are too concerned with getting treatment "over and done with" and pay little attention to the aftercare needed. I would like to think that I am part of the solution,  I try to be part of the solution, but the success rate for treatment is low. The reasons for that include the moral judgements made by society, and the media, that a recovering individual has to deal with at the same time as making major changes in his or her life. Sadly, those judgements are also made by professionals who should know better.

  22. Allen Lapin MD Mar 18, 2014 - 12:38 PM

    Have you seen Dr. Satel on Heritage Foundation sponsored programs and C-SPAN promoting her book that addiction is not a brain disease? The conservatives like that kind of talk from doctors-a psychiatrist no less. And she even works or has worked in Methadone clinics!! Addiction specialists must fight this thinking or they will lose the battle to continue treatment.  Alcohol, tobacco and obesity are what are really killing us.   Most of the country are in denial of what really causes diseases and drives up medical costs 

  23. GORDON HYDE MD Mar 18, 2014 - 11:07 AM


  24. Paul Thomas MD ABAM Mar 18, 2014 - 10:12 AM

    For those tempted to think addiction is a moral defect, then they should also consider that along those lines of thinking, so is poverty, obesity, heart disease, cancer and most chornic diseases we all eventually die from.  Reason: all these conditions, including addiction, involve genetic vulnerabilities and environmental factors.  We don't choose our genetics, we don't choose the environment we are born into, we can learn to reduce risk factors, eat better, avoid toxins, avoid substances of addiction.  For most of our addicts and substance - dependent patients, they were well past the point of choice, by the time they realized there was a problem.  Much like it is for all of us with diseases that are chronic. 


  25. Carol Rogala D.O. Mar 18, 2014 - 10:11 AM

    I agree with your statements; however, when it comes to the attitudes of others about addiction, you will simply have to be more understanding of  human nature.  I have been an Emergency Physician for 20 years.  There are still doctors who don't believe it is a 'real' specialty and think anyone can do it. Despite the number of female physicians, there are still plenty of male physicians and patients who treat us differently.  And what about the attitudes towards gays by certain political and religious groups in this country?  In these  examples, it is not as bad as it was 20 years ago, but it seems to take a long time for attitudes to change. Because of the recent media attention towards prescription drug abuse, now would be excellent timing to bring Addiction Medicine doctors and nurses into the high schools for lectures and to have public service announcements describing it as a brain disease and how to get help.   Since CNN is hell bent on promoting marijuana for seizures, why not have ASAM approach them to have a segment on current trends of addiction in high school and the heroin epidemic?   Or approach Oprah to do a segment on her cable network show, The Next Chapter.  We have to start somewhere with public education and we have to have patience. 

  26. Rick Campana, MD Mar 18, 2014 - 09:06 AM
    I agree 100% w Dr. Soper! I have always taken issue with the 12 step program that claims addiction is a character defect. Addiction is a chronic progressive brain disease, and as such, must be approached and treated like any other chronic progressive disease! Unless we educate our fellow colleagues, the legal profession and the general public at large of this fact, addiction will be destined to remain in the dark ages of ignorance, stigma and under treatment.
  27. Steven Kassels, MD Mar 18, 2014 - 07:26 AM
    As a physician with 30 years of practicing Emergency Medicine and Addiction Medicine, it is unfortunate how little progress has been made to demystify the disease of addiction. There are endless commercials about medications for erectile dysfunction, but when was the last time there was a public service announcement about addiction as a chronic disease or the benefits of medication management.  Over the years, when I would give a lecture on addiction, whether to medical students/residents or the local PTA, it was like preaching to the choir.  We must implore our public officials to to advocate and educate and the medical community must think of more creative ways to reach people who would not willingly choose to read or listen to topics related to this brain disease. I wrote Addiction on Trial as a way to reach a wider audience, to lend support to our patients, to assist them in educating family members and to use it as a resource to educate through the "back door".  I encourage others to do the same.
  28. James Clarke Mar 18, 2014 - 06:39 AM
    I agree with the understanding of the disease concept and that many entering our facility do not know they are having difficulty with substances.  Their environment adds to the issue. Many grew up with people using all around them. That's "normal" for them.  Increasing the awareness of what is a Substance Use Disorder is the first part.  Brain Chemistry is another.  Anyway that we can assist in changing the thought process is a possibility of recovery and allowing that person to be in life.

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