The Disease Concept of Alcoholism, Addiction, Obesity, and More

     Alcoholism was initially declared to be a "disease" in the United States in order to get insurance companies to pay for treatment. Treatment used to consist of detox followed by an automatic twenty eight days in a rehabilitation center. Insurance companies got tired of paying for anything automatic I think around the early eighties. If the paid addictions counselors said anything too glowing about a patient's progress in rehab, suddenly some insurance company somewhere would decide that the patient was ready to go. "Oh but __________ is so sick," the staff would exclaim, "and needs more treatment." Counselors learned how to record things in the patients' notes so that insurance companies would not be able to force discharge as often. 

     Addiction to other drugs was soon declared to be a "disease" also by those treating addicts. "I have a disease," addicts who have been through treatment would state. This in my opinion was a much harder sell to the American public. These days, some of us know that addiction is addiction and that alcohol is in fact a drug. Some alcoholics don't much care to be lumped in the same vat with the addicts. And the American public could find sympathy for functioning alcoholics and even for stumble bums-- but not for crazed and scary drug addicts.

     Now on television there are commercials advising us that obesity is also a disease. Treatment for being too fat has evolved away from fat farms and gatherings of foodies and more toward the provision of sleeves, lap bands, and by-passes for the morbidly obese. I have no quarrel with that. For some folks, those things can certainly save their lives and their health. Along with surgical intervention, the obese patient must reduce their caloric intake as well as take nutritional supplements as prescribed. [Those that don't can and do die. I've seen that]. Having said that, here is my problem: It's the whole "disease concept" that leaves me pondering certain dark and unpopular questions.

     All of this is my opinion only. If you are happy believing that you have a disease, my hat is off to you. If you are threatened by the idea that your alcoholism/addiction/obesity may not be a disease, you may be better off escaping from this ranting blog post now. Please don't torture yourself on my account. It's simply not worth it.

     In the eighties, alcoholism was compared to diabetes, tuberculosis, and AIDS. [The comparison to AIDS horrified me personally. I am way too close to the devastation that AIDS can cause to the folks who have it, their families and friends, and society at large.]. Diabetes is technically not a disease. Diabetes has more than one etiology [cause or origin]. Diabetes is in fact a condition which has a disease process. Like alcoholism and other drug addictions, diabetes can be progressive and fatal.

     I believe that alcoholism and other drug addictions are also conditions. Like diabetes, there is more than one etiology. Like diabetes, a disease process may be present which dictates progression and fatality unless interrupted. Until further notice, I believe that alcoholism and other drug addictions [and over-indulgence in food] are all behavioral disorders [or what used to be called psychological conditions].

     What medical evidence do we have that these things are "diseases"? None. We do not have a shred of medical evidence that points to alcoholism, other drug addictions, or over-indulgence of food as being diseases. Period. The development of tolerance or progression or fatality or the presence of "stages" is not evidence of a disease. The medical community will have to do more than that in order to convince me of this so-called "disease concept." [And no, I also do not believe that these things are "an allergy"].

     The disease concept proliferated with the development of treatment centers for addictions. Even in the early eighties, it was not common to hear the "I have a disease" refrain in gatherings of addicts who were attempting abstinence. [What I remember hearing is, "Oh I have a disease so I think I will go out and relapse ha ha ha" said in a mocking way]. Now this disease talk has become all too common.

     What is the benefit of believing that this thing "is a disease" or that we have a "genetic proclivity" to over-drink, over-eat, over-drug? Simple. There is an abhorrence to the idea that we may have done this to ourselves. Saying, "I have a disease" avoids any self-responsibility.

     For the Addictions Treatment Industry, the disease concept means that people who are "suffering" from a disease deserve "treatment"-- their idea of treatment. And what is involved in treatment after detoxing?

     Detox is a medical event. I detoxed at home, not knowing any better. People who detox at home can and do die. Some percentage of people who detox in a hospital also can and do die-- but the chance of dying during medical supervision of withdrawal is less than without. Because detox is defined as a medical event, certain criteria must be met for admission. This is why some addicts are denied admission. If they don't meet the criteria, they are judged as medically stable.

     Treatment after detox [or without detoxing first if not medically indicated] may involve any of the following: a thorough history is taken-- sometimes called a psycho-social, interviews of any family members as well as the identified patient, groups, individual counseling, referrals to residential treatment, referrals to aftercare, referrals to day treatment or evening treatment.

     Groups and individual counseling-- whether in-patient in a rehab or out-patient in the community in a day/evening treatment setting or other-- usually involve one or two counselors who work with the patients/consumers/customers/clients/participants on things like "the disease concept," spirituality, the importance of attending twelve step programs, how to avoid "relapse," identifying "triggers" which may lead the addict "back out," grief, family systems, taking the fun out of dysfunctional, "co-dependency," identifying feelings, motivational counseling, vocational counseling, therapeutic recreation, and pop psychology. 

     By pop psychology, I mean specifically certain New Age-y type ideas which have infiltrated the addictions industry. Pop psychology includes the use of affirmations, showing of certain films or discussion of certain books purporting to reveal ancient secrets that will cause folks to attain higher "vibrations" and succeed at life, the differences between men and women as delineated by certain popular authors and what that "means" for recovery, meditation or trance work, beating on pillows and bitching about woebegone childhoods, inner child work, dream therapy... All of these things are attractive to some folks because they lead away from any ideas involving hard work.

     Is addictions treatment really needed? That depends upon who you ask. Those involved in the addictions treatment industry will say yes. I maintain that we would do better to provide detox to those who are in medical need of such and then dump all treatment programs. What will all these people do without treatment? The able-bodied can work. Unfortunately, being engaged in treatment in the United States means that some professional tells the newly abstinent individual, "Oh you can't work now. You have to concentrate on your recovery." Le sigh. More folks on the public dole.

     The addiction treatment industry tells their patients that they must attend one or more twelve step programs in order to maintain their abstinence or recovery-- and they must do this for the rest of their lives. After all, these patients are powerless over their addictions and must rely on some sort of Higher Power in order to not return to active addiction.

     How can addictions treatment possibly be effective when each and every patient is funneled into attendance at twelve step programs? Some people will respond favorably to attendance at twelve step programs. I'll grant that. Others achieve abstinence through churches or other faith-based organizations and agencies. Some do better with secular programs such as S.O.S. Some may respond to Rational Recovery or other internet-based info. Some achieve success with harm-reduction sessions. Some folks remain abstinent without any attendance at any mutual aid groups at all. [I have two relatives who remained abstinent that way until their deaths from old age]. Self-determination is practically non-existent when "choices" are limited to one way of doing things. Attendance at twelve step groups is not a choice when it is the only option presented as being viable. Is this about people or is it about the cash cow that addictions treatment industry has become? 

 sapphoq needing coffee says: People can and do quit their destructive behaviors without "treatment." Treatment is costly and not effective. If treatment for addictions is to survive, then more research is needed on how to identify the best intervention with the best possible outcome for each individual patient. Until then, twelve step ideology combined with pop psychology and a lack of self-responsibility will continue to dominate the addictions treatment industry. This is truly a sorry state of affairs.

The Fast Food Wars and Exactly Who Is Responsible When We Eat Too Much

N.B.: The words "drug addiction" in this post will include the drug alcohol, as well as street drugs and those prescription drugs that people become addicted to.

     Some time ago, the insurance companies balked at paying for in-patient rehabs for people who were declared by professionals to be in need of treatment for their drug addiction. I viewed this as partly the fault of the rehabs themselves because everyone who was admitted got a twenty eight day program automatically. It was easier to convince staff that one needed an "extension" [a longer stay at the institution] than it was to convince staff that one was ready to be sprung before the scheduled time was up. It was not surprising when the H.M.O.s clamped down. In spite of the protests and tears generated by overly concerned paid professional helpers and profit-driven administrators, list of patients were gone through at treatment team meetings and a few folks were discharged early. Staff became devious skilled with their charting. Notes indicated that their people needed to stay the full twenty eight. Written signs of progress were no longer recorded. [N.B. I worked at a rehab. I saw this with my own eyes]. Staff by and large became concern trolls who were terrified at the prospects of anyone on their caseload being sent out into the cold, cruel world before readiness could be clinically established. There was no criteria for discharge. 

     In the time before there were rehabs and treatment facilities sprinkled all over America, the insurance companies did not want to pay for treatment for drunks, never mind those addicts who admitted to using street drugs. Politics happened and alcoholism was officially declared to be 'a disease' by the American Medical Association in 1956 so that physicians and treatment providers could be paid by the medical insurance companies. [see this: http://www2.potsdam.edu/alcohol/Controversies/Is-Alcoholism-a-Disease.html#.Uv2Is_ldXfI for one such view which also quotes the A.M.A. website in full. Also there, see footnote number 28]. Twelve step programs all over jumped on the disease bandwagon. 

     In 2013, The A.M.A. declared obesity to be a disease. [In 1998, the National Institutes of Health did so. [See this article for more: http://www.amednews.com/article/20130701/house/130709952/1/]. I have recently been 'treated' to a television commercial that staunchly maintained that obesity is indeed 'a disease.' My best guess informs me that this was done for similar reasons-- so that those providing treatment [including but not limited to surgical procedures such as lap bands, sleeves, and gastric bypasses] can be paid by the medical insurance companies.

     Frankly, I maintain with vigor that any sort of addiction or habituation is not in and of itself 'a disease.' I view all addictions as being conditions which may or may not have a disease process. This allows for a certain percentage of people who discover that they can indeed engage in their special hobby socially and safely at some time after their exposure to the addiction industry. Those people do exist, in spite of protestations otherwise. I suspect that usually by the time that someone comes to the attention of law enforcement personnel or medical personnel due to the effects of his or her special hobby-- be it over-eating, over-drinking, over-drugging, over-gambling, over-sexing, or any other overage-- it is most probably too late for that patient to moderate. That is only my opinion which means that I may be wrong.

     Addictions by their very nature have multiple and varying etiologies. Some folks started doing something too much because there is an obsessive side to their nature. Others report that their home lives were miserable or that they lacked the tools to effectively deal with some sort of major challenge presented to them so their special hobby raged out of control. There may be a genetic link to addictions in some people but we do not know that yet. [In an extremely general way, the younger someone is when a chronic condition develops, the more likely it is that a genetic component exists.] I've heard people identifying peer pressure, abuse, poverty, an un-diagnosed psych condition, grief, traumatic brain injury, a desire to fit in, genetics, and environment as various causes of their particular addiction. Any of these things may be causative, or they may be triggers [rather than causative] which pushed them beyond the point of social acceptability.

     When I was in my heyday of prolific partying, absolutely no one forced me to ingest any substance that I did not want to ingest. No one forced me to drink or use other drugs. I did that to myself. I did not wake up one day and declare to myself that I was going to strive to become addicted. I did enough of the stuff that I was doing to cause my body to warp out and I became physically addicted. At first, I was relieved to be deprived of the responsibility of what I had done to myself. I was told that I did not "do this" to myself. I was encouraged to believe that if my addiction did not happen as young as it did, it would have happened at any time that I started to drink or use socially later on in life. There was no way out of this being an addict. I was a victim of biology, or perhaps of a neurological process that demanded that I destroy myself through chemicals. I was slated to be trapped in addiction and that was the way of it. 

     I have a problem with that sort of excuse-making now. Anyone who used as much alcohol, pot, hash, pills, and other stuff as I did was bound to have problems. My using became just another problem on a long list of problems that I had. I suspect that had I not been in such a rush to alter my state of being with substances outside of myself, perhaps I would not have become an addict. I still think that if I had the gumption to directly address the problems that I was having as a young adult, perhaps my story would have had a different ending. But I didn't and my history is what it is.

     There was no return to social using for me. The moment I got my hands on as much as I wanted to drink or drug, I was off to the races. I tried to moderate my intake. I was not successful, period. 

     Most people are not addicted. The vast majority of people are not addicted to drugs, gambling, sex, food, or any other sort of physical thing or process. That is one thing that we do know. And just because I cannot safely do something, it does not follow that no one should do it. Thus, I am in favor of legalizing marijuana [especially since the drug cartels in Mexico stand to lose significant amounts of American cash if pot is legalized] and I am strongly against regulating what we eat via anti-obesity laws or fat taxes.

     During the times in my life that I have been overweight, I was the one who chose to eat more and exercise less if at all. No one forced me to consume massive quantities of food, period. There is not a commercial written that was capable of compelling me to go down to the local fast food shop and super-sizing everything that I ordered if I did not want to do so. I had to have the desire first. A commercial [maybe] might have struck a sympathetic chord in me which 'made me' crave something laden in salt, sugar, and fat. If I didn't have it in me to over-eat, no one or nothing could have forced me to do so. At the times in my life when I wanted to mess up my body via over-consumption of food, I did not care about the consequences.

     When someone like me is determined to give in to stuffing myself with something [alcohol, other drugs, or food], I don't think things like "I'll lose my health, my relationships, and life as I know it now if I do so." A fat tax will not stop me from consuming junk if I want to do that to myself. The law means nothing to me when I want to get f'd up. What stops me is me.

     Any changes that any of us make-- in order to be long-lasting changes-- are fueled with our desire to have something better or different or other than what we have now. We are not hapless victims of our environment. We are not incapable of taking care of ourselves. As adults, we have rights and responsibilities. When we do not take responsibility for our own lives, we become proficient in the language of victimology. To be sure, some of us had been victims of crimes committed against us. Part of recovery is to move beyond the state of victimhood into survivor mode and then into the state of thriving. Being stuck in the role of a victim limits us from experiencing the wonders of living. [Note: And we also become boring to others when we cannot successfully integrate and then move beyond the trauma.] When we refuse self-responsibility, we invite others to dictate to us how we ought to live. By necessity, that dictation is not self-affirming.

     By anecdotal evidence only, there were times when I wondered if treatment staff were collectively suffering from a group form of oppositional-defiant disorder. A mental health client wants a therapist of one gender and is automatically assigned a therapist of the other. An in-patient at the local hospital or addictions treatment center wants to go home and is pressured into entering a halfway house-- or a community residence if there is a 'serious behavioral health diagnosis'-- instead. Someone decides to return to school for pre-med. He or she wants to be a shrink. Oh no, you cannot handle that. Here's a job at a factory putting together urinary catheter bags. Fascinating stuff really. Take that job. You can start next week. I've seen things like this happen over and over again. I hope it's just my geographical location where helping professionals are like this but I don't think so.

     Now we have the increasing presence of a Spy Nation. First, build a huge facility to store all of the meta-data being collected on each one of us. Then carefully explain that it's really nothing. First, disarm as many citizens as possible. Then keep vast records on those who have guns. First, mess up the Internet. Then tell us that the censorship is really for our own good. First, make fast food the bogeyman. Then pass laws dictating what and how much we should eat. It didn't work during Prohibition. It's not going to work now.

     We live in a place that does not distinguish between hunger and over-eating. Here's a clue. I did not over-eat out of hunger. Most fat people also do not over-eat due to hunger or even due to concerns about when and where the next meal will come from. I did not come from an over-eating family. [I don't know what percentage of foodies do.] We are not so utterly powerless over our impulses that we are victimized by the advertisement budgets of the fast food restaurants in our neighborhood. No amount of laws or fat taxes is going to make a dent into the 'obesity epidemic' that we are facing in the United States. 

     If you want me to change, you have to give me some good reasons why I ought to change. You have to convince me to change. You have to get my attention. If your message is dull, I won't listen to you. If you take away my ability to order a large soft drink, I will find a way to drink as much of that soft drink if I want to. If you complain about the calories in a coffee-flavored drink with whipped cream available at a fast food chain but say nothing about the calories in a similar drink offered at the local upscale Starpukes, I will laugh at you and call you a hypocrite. Figuring that I should eat a diet chock-full of legumes, veggies, selected carbs, chicken and fish ignores the fact that I am allergic to fish and the fact that I have to eat beef three times a week in order to hold iron deficient anemia at bay. If you endeavor to tell me what to eat, I will ignore you and mock you. If you endeavor to tell me what to think, I will inform you that this is my life and not yours.


           


References:

my three favorites among the stuff I read:

http://www.theatlantic.com/magazine/archive/2013/07/how-junk-food-can-end-obesity/309396/?single_page=true

http://www.forbes.com/sites/paulroderickgregory/2013/09/23/the-problem-is-obesity-not-hunger-thoughts-on-the-food-stamps-debate/

http://www.iwf.org/files/ab250f06f05ee349a5c2347d6c5a926b.pdf



the rest:

http://money.howstuffworks.com/fat-tax.htm

http://www.usatoday.com/story/news/nation/2012/11/05/americans-obesity-rate/1684507/

http://www.nber.org/bah/2009no1/w14721.html

http://www.debate.org/opinions/do-you-think-fast-food-restaurants-are-responsible-for-child-obesity

http://watchdog.org/100330/have-at-it-would-a-fast-food-tax-help-or-hurt-the-poor/

http://newsbusters.org/blogs/kyle-drennen/2010/11/09/cbs-government-needed-stop-fast-food-industry-wants-get-kids-hooked

http://www.cnbc.com/id/101322761


and the worst of the bunch that I read, i.m.o.:

https://www.commondreams.org/view/2013/02/11-8

http://www.studentpulse.com/articles/320/the-obesity-epidemic-in-america-and-the-responsibility-of-big-food-manufacturers

http://www.stopcorporateabuse.org/sites/default/files/resources/slowing_down_fast_food_corporateaccountabilityinternational.pdf

http://www.seriouseats.com/2013/07/usda-bans-junk-food-schools-help-fight-obesity.html

http://content.healthaffairs.org/content/22/6/207.full

http://frac.org/initiatives/hunger-and-obesity/why-are-low-income-and-food-insecure-people-vulnerable-to-obesity/

http://www.foodispower.org/fast-food/

Thinking of alcohol as different...

Thinking of alcohol as different from other drugs has caused a great many addicts to relapse. Before we came to N.A. many of us viewed alcohol separately, but we cannot afford to be confused about this. Alcohol is a drug. We are people with the disease of addiction who must abstain from all drugs in order to recover.

~ from the N.A. Recovery Text reproduced on-line at  home.mchsi.com/~ciana/NA_Basic_Text_Fifth_Edition.doc

A close friend of mine recently decided to drink again after more than a decade of being abstinent from all drugs.  Art's justifications [not his real first name] for drinking were many and varied.  At the top of the list was the disclaimer, "I never really had a problem with alcohol.  I could take it or leave it."  But marijuana, he told me, was an entirely different story.  He had been unable to moderate his use of pot back in the days of active addiction.  He decided three weeks ago to take up drinking again.

"How's that working for you?" I asked.  [N.B.  I did not ask with a snarky tone of voice].  "Great!" he replied.  Art assured me that he was not overdoing the drinking, that so far he wasn't having a problem with it, that he was enjoying a social drink when out at the bar with a few buddies.  He told me that "no one wants to hang out with" someone who doesn't drink.  He said if he starts to develop a problem with alcohol, then he will "cut back."

Art was not asking for my help in this his latest endeavor.  I had to accept that.  In many ways, I would be the worst person for him to ask for assistance.  We've known each other since high school days, although we ran in different crowds and consequently never used together. 

There is a problem with thinking that an addict can return to using one drug safely, or can pick up a new drug and use that safely.  What we do is what we become.  If we've done it before, we will get in trouble with it again.  If we haven't done it before, we will get in trouble with it for the first time. 

"Trouble" does not necessarily indicate legal involvement or loss of income or relationships or stuff.  Trouble at the most basic level indicates being in trouble with oneself.  We can lie to others as much as we care to about anything.  [Most of] us do not get away with lying to ourselves.

Alcohol is a drug.  It is a chemical with a specific chemical formula.  It is physically addictive.  The addict who has never drank ought to endeavor to stay clear of alcohol.  Similarly, the alcoholic who has never used marijuana [or another street drug] ought to strive to not go out and experiment. 

A high percentage of people [90% is the commonly quoted number, but the number may actually be higher than that] are not addicts.  They don't experience any consequences from social drinking or social drug-taking.  That's great news!

A minority of people [10% is the commonly quoted number, but the number may actually be lower than that] cannot drink or use safely.  Bad things happen to them and around them when they do.  The addicts among us-- including those who are addicted to the drug alcohol-- may repeatedly endeavor to do it differently with or without excuses, justifications, or rationalization.  And just because addicts [including this one] cannot use safely, it does not follow that no one should.  I am not a prohibitionist.

To be honest, I also do not believe that addiction is a "disease."  I understand the sort of thinking behind this claim but I do not agree with it.  Labeling addiction, obesity, co-dependency, and other conditions as a "disease" is a legal and dimly medical argument to get insurance companies to pay for treatments.  I think that there are some numbers of etiologies underneath addiction.  I prefer to think of addictions as being conditions rather than disease entities. 

I am vaguely aware that some work has been done [in Canada, after being run out of the United States] by the Sobels in re-educating known alcoholics to healthy patterns of drinking.  I don't know enough about it to proffer an opinion about harm reduction in general.  I do know enough to know that I am myself beyond the point of being able to return to social usage.  My social use period was over with almost immediately after I first picked up.  I almost died and I am not willing to risk my life or my health on something that might kill me this time.

I am an addict.  I cannot control my usage once I've begun using.  There are drugs out there today that were not out there when I was using-- crack, beer with lime flavoring, hard lemonade, certain "designer" drugs-- but the bottom line for this addict is that what I do is what I become.  So I don't even flirt with the idea of trying them.  The powerlessness over my addiction for me specifies that now that I am an addict, I personally cannot go back to a state of being a non-addict.  I cannot use safely.

That is not to say that I am powerless over "everything."  I certainly am not.  I have a lot of personal power [N.B. power is not the same thing as control] and I intend to use it to my benefit and probably to the benefit of some other people around me.  Systems-change work involves the use of personal power of many members of a community of activists and stakeholders in order to challenge an archaic system.  I have hope today that justice can be had by people who have been and are being denied justice.  I have hope today that a closed system which demands compliance in order not to suffer set consequences can be mediated to include the freedom of individuality and self-expression.  I have hope today that we can create change.  I've considered the possibilities and I have picked my battles.  We need to change the systems that stifle us.

I wish the best for Art.  I really do.  I hope that his flirtation with drinking proves that he can drink safely or I hope that he is able to stop drinking [again] if he needs to.  And I hope he does not return to street drugs or to the abuse of legally prescribed drugs.  Meanwhile, I have some living to do.

                             Where's the coffee?