Substance Problems is it a Disease?

This question, as divisive as it is, need to be inspected and settled, understanding the problem allows for better treatments.

To understand the problem we first have to define what is known about substance problems and the concepts that surround "recovery."

In order, the concepts are:

• An allergy concept a doctors opinion formulated for Alcoholics Anonymous
• A medical disease concept formulated by Dr Jellinek and approved by the American Medical Association (AMA) in 1966
• A mental disorder concept defined by the American Psychiatric Association (APA)
• "The" brain disease (neurotransmitter dysregulation) Positron Emission Tomography PET/ Magnetic Resonance Imaging MRI scans evidence based neuroscience.

So recovery, the industry, has four concepts, models currently taught in the treatment of substance problems.

Before starting we also need to understand "treatment" the term has many meanings, treatment to a MD doctor would mean a prescription, or medical treatment, like a breathing treatment for an asthmatic perhaps. Treatment to a PH.D or psychotherapist, dealing in substance problems, would include a ‘plan' and depending on the doctor's or therapist's training or area of expertise, would vary in methods or school of thought.

Then there is thing called treatment, where people envision a place, an inpatient treatment facility, or outpatient facility. And to clarify Medical Detoxification or Detox is not treatment in the general use of the word. Detox is a period to evaluate the health, physical and mental of a person that has a toxin or multiple toxins, in their body and it's detoxified from the body. "Getting the toxins out" creates a potential need for "recovery," life after detox, which is the evaluation time.  Typically this is what most considers "recovery" the time after detox.

The use of the word makes sense, if you have been abusing a substance, misusing a substance or become substance dependent, then a period of time is "recovery time" a time period to readjust to life absent of substance or substances.

Before we can discuss treatments, we need to understand the problem. And we need to point out "aftercare" is different than mutual self help groups. Aftercare is part of a medical treatment plan sponsored by treatment facilities and attended by licensed therapists, with attendees being former clients of an inpatient or outpatient treatment plan.  Mutual self help groups are not treatment; it is as it states, mutual self help, without the aid of a professional present, typically called "going to meetings" associated and created by the self help group beliefs or practices.  Both are addressing the life after detox.

Most all agree, there is "no" one treatment that works, for all people. This is possibly the only point of agreement in the treatment industry, and that is subjective, since most treatment offered in the United States, uses one model of treatment, making for a biased start while most will agree the "one" treatment is not working for all people, most all people are offered only one treatment.   And the word integrated treatment, now more than ever will be needed. Integrated treatment is a combination of treatment therapies, shown to or taught, based on an individual's needs. An integrated treatment makes proper diagnosis the key to unlocking recovery and offering successful plans, the goal is to improve upon the overall mental health of the individual.

One example is properly diagnosing, mental disorders with substance problems, as separate issues that may share clusters of similar symptoms, but making sure each is treated, this rarely happens. There are reasons this does not happen. However, common sense tells us if a person has multiple problems, they need multiple solutions. Integrated Treatment is the hope and future of substance recovery, if we are to make it better. This is the hope of most involved in research in the treatment industry. For the industry to improve, instead of blaming the clients as not ready or not willing, the "recovery industry" must adjust to the needs of the client, not the client adjusting to the methods.

To understand the reasons it doesn't happen, you have to understand what does happen.

The four models medical and one nonmedical medical model need to be inspected and described so that people seeking help understand the differences, is it current or not?  Most have never been given a choice, since so few choices are available. Due to the absence of integrated treatment, one can only produce a, "take what you get" as the only choice, which is minus any choice. We start in the negative or wrong side of helping someone, if they are forced to accept the unacceptable diagnosis or improper diagnosis.

Stigma is ever present in the diagnosis, a person typically is given one of two designations upon arrival, mostly using an all or nothing thinking, all drinking problems turn into alcoholics and all illicit drugs are drug addicts are traditional schools of thought,  however false statements. Obviously not true, but typically "the" treatment received by most seeking help with substance problems. This happens in outpatient treatment, inpatient treatment and a requirement in the self help or mutual self help groups, to be a "member" one has to announce their status, as one or the other.

The biggest and longest "influence" in treatment is the twelve step model. It is taught in 90% of treatment centers in the United States it is called the Minnesota model. The steps have been creating "anonymous" sub groups, mutual self help groups, for 75 years. All promote the "powerless model" calling for a faith power, required recovery. That separates it from all other models. "Religion and science, the medical models" typically are like mixing oil and water.  This oil and water analogy is another of the reasons integrated treatment is being developed. There is not a system that allows for each to exist. Domain or loyalty to a system creates a feeling of being disloyal if a person practices two or three different models. Choice is missing; if someone is convinced or taught, this is an "outside issue." Creating feelings of "disloyalty" are felt or enforced or implied. This has a lot to do with "memberships," can you feel a part of something, if others point their suspicions at other existing methods? Or that since it was not the groups "focus" or purpose or idea, it was not allowed as a topic or relative to the group's core beliefs.

Peer pressure in mutual self help groups does produce a feeling superiority or certainty, even if it is wrong or uninformed by other's standards, when it compares itself, to the other offers, but if you are one of the "others" and wanted to belong to more than one offer, it turns ‘underground' since peer pressures may see that as being disloyal or impure to the core, absolute, pure, ideals of the original group. What happens most often, someone is forced to "pick sides." While the other "side" may have something you need, it becomes a matter of pride, or taboo, "stick with the winners" is a losing proposition for anyone that is not allowed to partake in multiple solutions.

The problem of matching treatments and medical or non medical concepts needs answers, the main question for decades is, "Is substance dependence a disease? Yes, but the answer took many years of technical advances to show what "dependence" is, in layman's terms it is a brain disease, neurotransmitter dysregulation proven by the science community.

Prior to this discovery, three concepts exist and dominate the thinking in the recovery industry, until the science discovery becomes accepted as the medical fact, people will remain subject to "opinions".

The Moral (spiritual) Disease Model:

Since all step models start with Alcoholics Anonymous the wording of "allergy" is the only medical opine offered in it, solely based on one doctor's opinion, observation based.

The oldest model (non disease model, in current use) describes alcoholism as a physical allergy to alcohol in a book titled Alcoholics Anonymous (AA). The author of Alcoholics Anonymous, Bill Wilson, however, described alcoholism as a fatal malady, an illness and spiritual malady,  of which only a spiritual experience will conquer (thus the moral disease).What few know is the "term" disease only appears once in Bill's writing describing the  "number one problem" as a spiritual disease, "Resentment is the "number one" offender. It destroys more alcoholics than anything else. From it stem all forms of spiritual disease, for we have been not only mentally and physically ill, we have been spiritually sick. When the spiritual malady is overcome, we straighten out mentally and physically." Bill Wilson codified the Twelve Steps in 1938 from its origin, a Christian Evangelical movement called the Oxford Groups. He intentionally avoided the concept of alcoholism as a disease, since he did not have any medical evidence to support it, and that would remove the needed spiritual experience which is its core, the substance alcohol is not the problem, and the "malady" is spiritual.  In 1938, the position of the text has never changed, since its first printing. While the current "members" of Alcoholics Anonymous speak openly of a disease concept its origins is not from Bill Wilson or his works, Alcoholics Anonymous, the book is not the current membership and the membership is not the book. Most of the "membership" currently active is influenced by the treatment industry, with parts of treatment education being repeated amongst the members. A hybrid of more modern information leaks into the membership, but is not supported by the outdated texts.

The Medical Disease Model:

In 1960 Dr. Jellinek's alcohol disease model (in current use)  was accepted by the American Medical Association (AMA) in 1966; Jellinek described alcoholism as dependence, with two stages preceding "alcoholism" in five different stages, alpha, beta, were used to describe "heavy use" therefore not alcoholic, Delta, Gamma and Epsilon were different stages or symptoms of  dependence thus creating  his disease symptoms, basically built on two conditions being met simultaneously or separately, loss of control, or increase tolerance to alcohol exposure, the controversy remains, surrounding   Dr. Jellinek's research since it was based solely from  Alcoholics Anonymous volunteers, selected and funded by Marty Mann, the first female to achieve abstinence via Alcoholics Anonymous in 1940, with intermittent lapses until her death, with strong ties to Bill Wilson, she  founded  the National Council on Alcoholism (NCA)  which is now the National Council of Alcoholism and Drug Dependence (NCADD). What happens here is a national bias, and the argument of disease, has only recently been proven, scientifically in the past ten or fifteen years.

The good news bad news, depending on who is telling the story, that came from the AMA disease recognition was the creation of a "payer system," government funding, research, and insurance policies could then pay the doctors for their time and energy, and treatment to alcohol and later, drug problems giving birth to a new recovery industry, the drug and alcohol treatment facility. Since the step model was the only formal treatment in that era and the Jellinek research funded by an AA member (Marty Mann), the Minnesota model was adopted in 90% of the treatment facilities. By forming this national treatment alliance, treatment facilities had AA meetings to send their clients to, after they completed their inpatient or outpatient treatment. This alliance created the largest sector called the self help group, run by non professionals called AA meetings. Now, some treatment facilities offer "after care" programs where professionals are present, but this may not be the case, untrained clinicians are often hired to run aftercare meetings, with the criterion of having a substance problem also, making them, sound or feel similar to the mutual self help groups. Most cannot tell the difference from one to the other.

The Behavioral Model(s)

In the same time period 50's and 60's, the American Psychiatric Association (APA) using the terms mental disorders to describe maladaptive behaviors produced the criterion adopted in most medical treatments for substance abuse versus substance dependence. Two controversies start to develop, is substance dependence a mental disorder or a disease? This was also controversial since some saw insurance as the reason to classify substance problems as medical problems, the same issue the AMA continues to battle. The difference being the AMA is a physical disease, the APA sees it as a mental disorder. During this same time period two forms of behavioral therapy were being developed and introduced one being Rational Emotive Therapy (REBT) by Albert Ellis Ph.D., the other Cognitive Behavioral Therapy by Aaron Beck M.D.

We start to see the confusion; we have three very different "medical" opinions base on symptoms, without evidence to prove the opinion. And terminology shifts depending on the group. One is a moral matter, one is a disease and the next is a behavioral problem.

As time goes by, we learn more and know more. Until now, we have spanned seventy five years of medical opinions.

The Neuroscience Model Cracks the Code

Neuroscience: a scientific study of the nerve system, at a molecular and cellular level the nervous system within the brain, behaviors produced by the brain.

In the past ten to fifteen years, neuroscience has produced "the" disease model, the difference here; it is actually based on scientific research, which has not possible with all the preexisting methods. By using Positron Emission Tomography (PET) scans and Magnetic Resonance Imaging (MRI) neurotransmitter dysregulation (brain damage) is being seen, in substance dependence. Where neuroplasticity or neuroadaptive states are being discovered or proven which opens research into genetics or predisposed conditions or long term exposure to a substance. The same progress made with uptake inhibitor drugs with Federal Drug Administration (FDA) approvals, such as Naltrexone, Suboxone (buprenorphine), and acamprosate.  Studies are conducted at all stages of development, with research looking at the effects of early substance exposure to adolescents and the damage caused to cognitive (thought/memory) areas of a the brain.

What does all this mean to you? First, not all models are addressing one "type," being the substance dependent person. The moral model was created for what is called the "real" alcoholic, meaning an alcohol dependent person, the Medical model, is only addressing three stages of dependence, the behavioral model actually address a broader range of problems, which expanded on substance misuse and substance abuse.  The biggest gap in understanding "treatment" is a lack of understanding in the differences, or the "disease/non disease models" which is, not all people develop dependency while most have co-occurring problems or disorders.

The smallest groups create the labels, it is an established fact that ten percent of substance problems reach "dependence" where the active user, would be properly called "alcoholic" since they became "alcohol dependent or drug dependent." Drug addict, is subjective, since nothing delineates the difference between misuses, abuse, or dependence, the street slang for a substance dependent person typically is incorrect.  However these terms only address "active" status. Alcoholism, is the "active state of using alcohol" having formed an alcohol dependence, there not a term to describe the same "status" for a person with a illicit drug "ism" people do not use the term drugism, it is subject to a different term called "addiction". Neither term describes the status of a person in remission, partial remission or any state of abuse, or misuse of a substance.

So, what this means, 90% of the people seeking help with substance problems, are not dependent, but clearly abusing a substance and in some, not all, that can lead to true dependence, and the amounts taken at early ages produces loss of cognitive skills as they reach adulthood, here we see terms such as permanent brain damage appearing proven in cognition testing and seen in medical PET/MRI scans. Meanwhile the medical disease or concepts are all addressing a 10% audience, of the substance problem population, those that actually reach "the criterion of dependence."  Most that seek help are not in active "alcoholism or dependence". That status is reached 10% of the time. So we have a 90% "using" population, best described as "Substance Use" or Alcohol Use Disorder, Cocaine Use Disorder, Opioid use disorders et cetera. That makes "treatment" equal, in nature and allows for an end to "how bad are you" conversations to "qualify" as needing help.

If we revisit each model and apply it is a disease, now how to treat it would depend on the stage of misuse, abuse, or dependence a person has reached or showing signs of reaching. Up to 75% of dependence problems quit on their own, without the help of a professional therapy or mutual self help groups, however that statistic can be misleading since public perception of "dependence" is so often misunderstood, the person misusing or abusing a substance is often mislabeled "alcoholic/ addict." Most that have substance problems, up to 90% have co-occurring disorders. With integrated treatment, the co-occurring disorders are treated, perhaps more aggressively than the substance problem, which is harms reduction. Reducing the harms a person experiences becomes the focus of treatment rather than, labeling or mislabeling. This would immediately increase "recovery rates" since all problems would be treated. Proper diagnosis, instead of opinion, treats the issues, where substance problems are seen as a self medication practice, a person's attempt to treat a symptom of a disorder that is often confused with the symptoms associated with substance withdrawals. This false positive, would and often does mislead diagnosis, since deeper set disorders, or preexisting conditions,  typically are designated with the same symptoms seen in substance dependence such as depression, anxiety, or manias.

Notice what happens to the "disease" the symptoms occur as behavioral problems, not physical problems once the substance is removed via medically safe detoxification processes. The "symptoms" of craving, sadness, depression, loneliness, anger, fears, boredom, complacency,  et cetera often are ignored, since the focus is myopic, "don't use, No matter what" is often "repeated" but the issues of depression, anxiety, anger, fear, boredom, complacency, stress, are not seen as mental disorders, but merely something that will "pass" in the "this too shall pass" mentality. This places people in harm's way, if they have mental conditions, but are told "It will pass on its own".  This type of "treatment" actually is in denial of the underlying issues. This can help explain why so many return to substance use, early on in their treatments, since integrated treatment is often, not available.

What does all this mean as far as "older concepts," to some degree, they were and are correct, human observation is a valid research, but it lacks "evidence" to prove to the opposing concepts. To quote SaulRosenzweigthe dodo bird classic analogy of therapies, he proposed Alice in Wonderland by Lewis Carol, seeing all therapy through one simple statement "they all win, they all deserve prizes".

The "disease" while doing damage, is not progressive while dormant or absent of the change agent, the drug of use it is not a rouge gene such as cancer.   Brain damage (neurotransmitter dysregulation)  occurred or becomes permanently mapped in memory while active over different periods of time, based on the substance, alcohol being a much slower agent than something injected, or taken directly into the circulatory system, where the term neuroadaptive, or Neuroplasticity comes into play, is the brains ability to adapt or try to adapt to whatever levels of a change agent is administered, how it is administered the amounts administered leads to or can lead to true dependence.

Who does this? Psychosomatic problem solving skill set, "self medicating" leads to the false positives, and often a misdiagnosis occurs, "I am depressed" so I treat myself with a substance to fend off my depression.   If an untrained person, saw or hears "the substance" as the main problem and not the depression a person could easily be labeled "alcoholic or drug addict" while the cause of the depression goes untreated.

Now, take the person depressed at age 12, and binge "uses" a substance for ten years? It would look like "progression" while what we really have is a brain developing with a foreign chemical causing the brain to adapt, "plasticity" adapts now we see neuroplasticity our body is not the problem, the brain's ability to self regulate becomes the main problem. Now we have a brain damaged from long term exposure to a substance. Did it treat the depression? And do we have two problems that both need serious attention. Where does a person go to treat depression, where is the disease? And now add "anxiety" the fear of not using the substance to treat the depression. Here we see a thought, a disease and behavioral problem, the perfect storm, which gets treated? will, not using the substance, treat the depression? Will treating the depression treat the brain disorder, will the behavior "readjust" by its self?

Now we see the problems of not using the correct "medical model" depending on the severity of the problem will determine the proper treatment or miss it by a country mile.

Lean more about treatment and recovery "life after detox" at

www.recovery2day.org