H U M A N PSYCHOPHARMACOLOCY. VOL.

11, S33-S38 (1996)

Failings of the Disease Model of Addiction

GI0 BATTA GORI
The Health Policy Center, 6704 Barr Road, Bethesda, M D 20816, USA

Colloquially, addiction ranges in meaning from addiction to good deeds to addiction to substances of abuse.
Especially during the last four decades, ‘addiction’ in this extreme pejorative meaning has been portrayed
alternatively as a disease or a sin, and has been subject to social and moral sanctions. In an open society of free
individuals such a coercion cannot be justified unless the condition is defined precisely by the simultaneous attributes
of severe psychotoxicity, severe withdrawal symptoms, and recurrence tied to the loss of self-control and individual
volition. Still, these attributes are open-ended, and an explicit metric of severity at which they may trigger socia]
objection has not been clarified. ASa consequence, ‘addiction’ allegations are left to elicit emotional, subjective, and
value-laden responses ready to be exploited. A clamorous example is the claim by US officials that cigarette smoking
is equal to the abuse of heroin or cocaine. An unequivocal definition of ‘addiction’ may restore some sense of
proportion to official normative intervention.

KEY wows-addiction; smoking; regulation; substance abuse

INTRODUCTION things*. In fact, this has been the meaning of the

What addiction is, whether addiction is a disease-
and if so, what kind of disease-cannot be deter-
mined purely from a medical or behavioural angle,
but rather from more basic considerations, given
the logic and semantic instabilities surrounding the
term.
I believe it was Voltaire who said that an
intelligent discussion beings with a statement of
dialectic premises and assumptions. To d o so, I
propose the following line from Horace, the
prominent Latin poet, who wrote some 2000 years
ago ‘nullius addictus jurare in verba magistri’: [I am]
not in the habit of swearing by the words of any
master (Horace, Epistulcz I, I, 14 (1921)).
First, this line gives a fitting description of the
good-natured scepticism that should inform the
most optimistic scientific analysis. Second, it is a
line in a language that took pride in its conciseness
and precision, as should be the aim of any
intelligent and logically fair analysis. Third, it
mentions addiction as the Latin meant it, namely
to signify a habit, an insistent way to keep doing
word down to this day when colloquially we
describe people ‘addicted’ to good deeds, to
chocolate, to food, to sex, to the good life, as well
as to gambling, alcohol, hard-drugs, and so on.
Such various attributions of ‘addiction’ imply a
continuum of valuations, from the laudable to the
condemnable. Still, more and more during the last
decades in medical, behavioural, regulatory, and
legal talk ‘addiction’ has been assigned the
pejorative meaning of a syndrome identified with
the abuse of psychotoxic substances. It is presented
as a repetition of abuses that eventually cancel
volition and personal responsibility, thus generat-
ing the need of therapies and other interventions,
and leading to social costs and crime. Official and
social sanctions have been assigned to this syn-
drome, even though assorted interests have resisted
a defensible definition of precisely why and in
whose eyes ‘addiction’ becomes objectionable.
Because the resulting ambiguities have been left
open to exploitation and resentment, this essay
explores plausible standards of semantic fairness.

ADDICTION DEFINED
* The original Latin meaning was a iegai one. The winner in a Today-when ‘addiction’ becomes of medical or
legal dispute could be assigned property or even the person of normative interest-it invariably carries the
the loser. Whatever this assignment, it was said to be ‘addicted‘
to the winner. The word gradually also took the meaning used pejorative ethical meaning of recurring uncontrol-
by Horace and in current language. lable excess. Because the word has moral
CCC 0885-6222/96/S 10833-06
0 1996 by John Wiley & Sons, Ltd.
s34 G. B. GORl
implications and these qualifiers are prone to
subjective valuation, some questions arise. For
instance: who appraises ‘addiction’: the observer or
the observed? Indeed, it matters if the claimant is a
dogmatic authority, and if the people branded as
‘addicted’ by such an external value judgment
many not feel unsound at all. Elementary fairness
requires that when ‘addiction’ is used to impose
social or medical labels and sanctions, it should be
defined by objective attributes rather than norma-
tive judgments. Fairness further requires that these
attributes not be frivolous. It should not be
sufficient to rely on the mere recurrences implied
by addiction, nor on pleasurable or therapeutic
outcomes in the subjects iqvolved, nor on medical,
physiologic, psychologic, or behavioural markers
of contrived ethical implications. A social language
striving to be equitably normative should explicitly
identify why, to whom, and by which standards
individual ‘addiction’ becomes ‘objectionable’ and
therefore subject to sanction.
For our analysis, ‘uncontrollable excess’ is
defined in the context of some repetitive action
implied by addiction. Here, however, recurrence is
necessary but not sufficient because many actions
in life are or must be highly repetitive-some
actually carrying risks-without being defined as
‘uncontrollable’ or ‘addictive’. Think, for instance,
of keyboard work and metacarpal syndromes,
tennis and tennis-elbows, sweets and tooth decay,
overeating and longevity loss, and so on. Indeed, in
ethical, social and normative parlance ‘objection-
able addiction’ has been specifically restricted to
conditions involving substance abuse. Therefore,
considering the features of these conditions, for-
cible intervention seems justified when ‘repetitive
uncontrollable excess’ leads to objectionable ends
or to loss of personal volition on account-for
instance-of the lure of psychoactivity or because
of withdrawal symptoms, both outcomes of sub-
stance abuse as commonly understood. Still, in
order to be problematic, psychoactivity may not be
a simple pleasurable experience but must be
deranged and psychotoxic, while withdrawal must
be objectively severe. We could propose, therefore,
that ‘addiction’ objectively becomes a ‘repetitive
uncontrollable excess’ when severe withdrawal
symptoms are soon alleviated by renewing a
deranged intoxicating experience, which triggers a
continuing repetition that presumably cannot be
controlled by personal volition. General psycho-
toxicity alone may not qualify ‘addiction’ because
the occasional abuse and intoxication-by alcohol
or psychoactive substances-does not materialize
the recurring loss of volition leading to the
repetitiveness of ‘addiction’. In turn, the severity
of withdrawal must be such that it compels
repetition by any means. Thus, depersonalizing
psychotoxicity, severe withdrawal, and loss of
personal volition seem collectively the necessary
attributes if ‘addiction’ is to justify social objection
and sanction.
These attributes. however, span a domain of
severity and thus require specific definition of the
intensities above which social action is justified.
Unfortunately, such metrics have not been defined
objectively, and as a consequence the limits of a
definition are not always respected. Scientists may
use ‘addiction’ without ethical implications-a
value-neutral technical term defining a tentative
experimental model of behavioural and physiologic
descriptors. Healing authorities and professions,
on the other hand, often use the same tentative
descriptors and pretend scientific objectivity in
calling for social and ethical objections and in
justifying sanctions to ‘addiction’.
In reality, among descriptors of ‘addiction’ only
psychotoxicity may be a relatively narrow attri-
bute. Severity of withdrawal and loss of personal
volition are concepts open-ended to subjective
valuation, even though their features could be
fairly precisely identified for the syndrome of
‘addiction’ to hard-drugs, namely the standard of
‘objectionable addiction’. Yet, there has been
reluctance-official and otherwise-to adopt
measures of these features as the legitimate bench-
marks of this condition.
Behaviour and health scientists have attempted
to seek objective markers for some attributes of
‘addiction’, but the results have not been persua-
sive. The World Health Organization (WHO) and
others have struggled for 40 years with a model
definition of ‘addiction’. In the 1957 WHO
definition:
‘Drug Addiction is a state of periodic or
chronic intoxication produced by repeated
consumption of a drug (natural or synthetic).
Its characteristics include: (1) an overwhelm-
ing desire or need (compulsion) to continue
taking the drug and to obtain it by any
means; (2) a tendency to increase the dose; (3)
a psychic (Psychological) and generally a
physical dependence on the effects of the
drug; (4) detrimental effect on the individual
and on society’ (WHO, 1957).
 FAILINGS OF THE DISEASE MODEL OF ADDICTION
In the same 1957 report, WHO experts felt the need
to distinguish ‘addiction’ from ‘habituation’. the
latter being thus defined:
‘Drug Habituation (habit) is a condition
resulting from the repeated consumption of
a drug. Its characteristics include: (1) a desire
(but not a compulsion) to continue taking the
drug for the sense of well-being it engenders;
(2) little or no tendency to increase the dose;
(3) some degree of psychic dependence on the
effect of the drug, but absence of physical
dependence and hence of an abstinence
syndrome; (4) detrimental effect, if any,
primarily on the individual’ (WHO, 1957).
Because of the subjective vagueness of these
descriptors, WHO experts from 1964 to 1974
abandoned both concepts of ‘addiction’ and
‘habituation’ in favour of a unified concept of
‘dependence’.
‘Drug Dependence. A state, psychic and
sometimes also physical, resulting from the
interaction between a living organism and a
drug, characterized by behavioural and other
responses that always include a compulsion
to take the drug on a continuous or periodic
basis in order to experience its psychic effects,
and sometimes to avoid the discomfort of its
absence’ (WHO, 1974).
This earlier definition still did not satisfy, and in
1993 ‘dependence’ was defined in even vaguer
terms:
‘A cluster of physiological, behavioural and
cognitive phenomena of variable intensity, in
which the use of a psychoactive drug (or
drugs) takes on a high priority. The necessary
descriptive characteristics are a preoccupa-
tion with a desire to obtain and take the drug
and persistent drug-seeking behaviour ...
The existence of a state of dependence is
not necessarily harmful in itself, but may lead
to self-administration of the drug at dosage
levels that produce deleterious physical or
behavioural changes .. .’ (WHO, 1993).
It is apparent that the experts became less and
less comfortable with attributes ‘of variable inten-
sity’ and ended up with an all-encompassing
definition lacking specificity. By declaring that
‘... a state of dependence is not necessarily
harmful in itself ...’ the word ‘dependence’ now
seems to cover the same range of situations as the
s35
generic term of addiction. namely from the
laudable to the objectionable. Sceptics have
surmized that this vagueness might have been
designed to ease the inclusion of otherwise con-
jectural syndromes in medical costs reimbursement
programmes. More likely, it was the outcome of
mounting semantic confusion fostered by multiple
and competing professional interests, and by the
resulting incapacity or unwillingness to identify
objectively a specific scientific, medical, social,
regulatory, and legal construct as ‘objectionable
addiction’.
To make matters more complex, an hypothesis
has been advanced that the definition of ‘addic-
tion’ might not place overwhelming responsibility
on the substances that may be abused, when many
people use the same substances sporadically and
without being socially labelled as ‘objectionably
addicted’. Others may chronically use the same
substances for stress or pain relief, without
‘objectionable’ or ‘addiction’ consequences-for
instance, the users of opiates and benzodiazepines
for pain or mood control. Indeed, and despite the
vagueness of the words, only a small fraction of
people end up being classified as ‘objectionably
addicted’, even though substances that can be
abused are easily available.
Thus, the conjecture surmizes that what makes
‘addicts’ are ‘addiction-prone’ personalities--‘ad-
diction’ being viewed as an endogenous predicate
while the substances abused are seen as contingent
external accessories. In this context, the hypothesis
of causality has invoked the concept of cognitive
dissonance, negative sociocultural influences,
devastating family environments. and so on:
collectively a multifactorial construct of causation,
where the substances that may be abused are
circumstantial complements.
In any event, the WHO expert definitions of
‘addiction’ are unsatisfactory both in a semantic
and scientific context. A certain routine is not
necessarily objectionable if it should have psycho-
active effects-presumably pleasurable, euphor-
iant or even hallucinogenic-which reinforce an
insistence to repeat the experience. It is not
necessarily problematic if it should include the
development of tolerance, namely an assuefaction
to a substance. For instance, the traditional use of
alcoholic beverages as food or entertainment fits
these conditions without social offence. The
occasional drunkenness of otherwise sober indi-
viduals or the occasional experience with hard-
drugs seem to elicit hardly more than raised
S36 G. B. GORl

eyebrows. The occasional loss of volition and ‘free addictive power of crack versus powdered cocaine
will’ is not a controlling determinant of social (US Code). By all measurable evidence, if cigarette
disapproval. Indeed, excluding ever present pur- smoking-or chocolate craving, for that matter-
itanical fringes, ancient and current mores seem is to be called addictive, it should be accorded a
largely indifferent to occasional psycho-intoxica- comparatively more extreme reduction of intensity
tions of individuals. when compared to powdered cocaine.
Nevertheless, ‘addiction’ defined by an ever An explicit gradient of intensity is apparent in
recurring triad of severe psychotoxicity, with- the definitions of ‘addiction’ and ‘habit’ advanced
drawal symptoms, and loss of personal volition by the healing professions. In fact, the World
control is bound to create personal, social, and Health Organization has characterized smoking as
material concerns. Still, we have seen how vague a habit, not an ‘addiction’, and even statements by
the medical and behavioural definitions of ‘addic- previous Surgeon Generals in the US also qualified
tion’ have been made. ‘Addiction’ can be defined smoking as a habit. For instance, the original 1964
dialectically but apparently not in precisely quan- Surgeon General’s report reads:
tifiable scientific terms, ljkely on account of the ‘The tobacco habit should be characterized
ethical value implications of the word. A legitimate as an habituation rather than an addiction, in
operational definition would be possible by adopt- conformity with accepted World Health
ing as benchmarks the intensities of psychotoxicity, Organization definitions, since once estab-
severe withdrawal and loss of volition, at the levels lished there is little tendency to increase the
that characterize the classic ‘addiction’ to hard- dose; psychic but not physical dependence is
drugs. Yet, this has not happened. Semantic developed . .. No characteristic abstinence
ambiguities have been left festering arguably with
syndrome is developed upon withdrawal ...
intention and-given human nature-they seem Discontinuation of smoking . . . is accomp-
ready-made for exploitation. A clamorous example lished best by reinforcing factors which
is the 1988 claim by the US Surgeon General that interrupt the psychogenic drives. Nicotine
smokers are as addicted to cigarettes as others are substitutes or supplementary medication
to heroin and cocaine. have not been proven of major benefit in
breaking the habit’ (USSG, 1964, p. 354).
CIGARETTE SMOKING, HEROIN, AND ‘The overwhelming evidence points to the
COCAINE conclusion that smoking-its beginning, hab-
ituation, and occasional discontinuation-is
In an effort to discourage cigarette smoking, the
to a large extent psychologically and socially
US Surgeon General in 1988 declared that- determined’ (USSG, 1964 p. 40).
behaviourally-cigarette smokers are on the same
level as heroin or cocaine addicts. On the face of it, To smokers, smoking is pleasant in many ways
this incredible assertion defies common sense and therefore it could be expected to be mildly
because the daily experience of everyone tells that reinforcing as any pleasant experience tends to be.
smokers and hard-drug addicts are not the same There is no good evidence of tolerance in smokers.
people. In effect, the Surgeon General trivialized A certain dose is attained early when people start
the pejorative behavioural connotations of heroin smoking and that dose is not exceeded because
and cocaine addiction. Could anyone show that exceeding it makes smoking unpleasant. Un-
cigarette smoking comports such an extreme a controllable, compulsive use is not apparent in
behaviour as heroin and cocaine addiction? Should smokers: the Surgeon General acknowledges that
we invent other words for substance abuses with over 40 million smokers quit on their own in the
true objectionable sequelae, when common lan- United State alone, in a climate where cigarettes
guage itself separates different habits in different are legally and readily available. The all important
categories of intensity? In the context of fair qualifier of psychotoxicity is absent in smokers.
policies we should rather demand a precise use of Finally, there is no evidence of physical depen-
definitions and language, insisting that if a generic dence: withdrawal symptoms are usually absent,
‘addiction’ attribute is to be used ubiquitously, transient and mild at best when present, and less
then its intensity should be graded in each instance. noticeable than the withdrawal symptoms experi-
Official precedent recognizes this need, implicit in enced by people on strict diets. Jack Henningfield,
the legal distinction of a 100: 1 ratio for the a principal architect of the US Surgeon General’s
 FAILINGS OF THE DISEASE MODEL OF ADDICTION
claim of smoking ‘addiction’, himself wrote a few
years ago that:
‘The following constraints and inconsisten-
cies should be noted when considering the
evidence for a tobacco withdrawal syndrome.
First, a syndrome of reliable physiologic
signs ... has not been described ... w i t h
the exception of the desire to smoke ... other
phenomena typically occur only in a fraction
of all subjects abstinent from cigarettes . ..
For instance . . . weight gain, gastrointestinal
disturbances, or anxiety may each occur in
less than one-third of all subjects; and up to
one-half of abstinent subjects may report no
symptoms at all.
The second major issue is that while
tobacco withdrawal is commonly equated
with nicotine withdrawal, there is little evi-
dence that nicotine produces physiologic
dependence ... Administration of nicotine-
receptor antagonists .. . has not been shown
to evoke a withdrawal syndrome ... [Plrovid-
ing abstinent smokers with a nicotine-
containing chewing gum only partially
attenuates physical complaints ... [and] in
animal studies, abrupt abstinence is not
followed by . . . a withdrawal syndrome.
These inconsistencies ... impose constraints
on the comparison ... of tobacco withdrawal
with that of withdrawal from opioids, seda-
tives, and ethanol ... The relevance of this
point goes beyond semantic issues of classi-
fication .. . [because] when withdrawal is
considered in the context of drug dependence
it generally connotes a more narrowly
specified set of conditions (viz. a reliable
syndrome of behavioural and physiologic
changes)’ (Henningfield, 1984, pp. 147-148).
Such a statement amounts to an admission that-
by comparison to withdrawal from hard-drug
abuse-smoking withdrawal simply does not exist.
Most smokers quit without consequence whatso-
ever. A few may experience some discomforts that
quickly disappear spontaneously or are curable by
the mildest intervention. Severe cases are said to
exist, but are undocumented in the scientific
literature, even at the anecdotal level. If anything,
it can be argued that at present smokers may be
somewhat less comfortable about quitting because
the ‘addiction’ label and the proliferation of
cessation clinics and devices makes them think-
consciously or not-that quitting has become a
s37
difficult ordeal-a view supported by prominent
anti-smoking advocates (Chapman, 1995).
Smoking may be a habit comporting some risks,
but does not qualify as ‘addiction’ under the terms
discussed above. In fact, if persistent abuse of
hard-drugs exemplifies the ‘uncontrollable excess’
that includes psychotoxicity, severe withdrawal,
and loss of volition-then the use of the term in
connection with smoking is improper, loses force
and impact, and must descend at the level of a
habit, as earlier Surgeon Generals in the US have
recognized (USSG, 1964). Other than in jest,
‘addiction’ cannot apply to common pleasant
habits, without generating semantic confusion.
IS ADDICTION A DISEASE?
A true ‘addiction’ syndrome with its attending
social costs indeed poses some crucial questions. Is
it that a proliferation of ‘addictions’ is inevitable in
an age of plenty and relative idleness? Is crimina-
Iization of ‘addiction’ likely to remedy or to worsen
the situation? Is it Utopian to think of medical and
behavioural fixes? What may be the useful psycho-
logic, sociologic and educational remedies?
Despite much that has been written and argued,
answers to these and other questions are by no
means clear, although it may be fair to conclude
that control of socially costly ‘addiction’ problems
may not be attained without new social structures,
In this context, if ‘addiction’ is a disease, it is more a
social than a medical disease. Sociology and
psychology may hold the key to its control,
although not likely to its eradication-given
inevitable human frailties. To begin with, it may
be necessary to remedy the anarchic decay of
western civility at the hands of laissez-faire New
Age sociologists (Adorno ef af., 1950; Memmi,
1968; Ryan, 1971). Under their influence in the last
four decades, traditional virtues of individual self-
control and accountability have been spumed to
the point of contempt (Sykes, 1992). How much
this has contributed to the proliferation of ‘addic-
tions’ may be difficult to measure, but a return of
individual responsibility could only presage
improvement.
Our analysis also raises broader concerns.
‘Addiction’ is a value-laden perception with ethical
implications. In the absence of defensible intensity
qualifiers of recurring psychotoxicity, withdrawal,
loss of volition, and social cost, ‘addiction’ is
ambiguously defined and open to semantic manip-
ulations by special interests-the healing-industry
S38 G . B. GORl
interest in fostering victimization syndromes; the
regulatory-industry interest in creating phantom
health and safety hazards; the funding interests of
the research establishment. Lewis Carroll had
Humpty Dumpty saying that: ‘When I use a
word, it means just what I choose it to mean-
neither more nor less’. If addiction might be a
social disease, we unquestionably have a disease of
words in current public discourse, a disease of
rhetoric and semantic ambiguities. In this context,
‘addiction’ has rightfully become an abuse of
language.
Here, as always, the caveat emptor admonition-
buyer beware-is paramount. We undoubtedly
buy government and regulations, and health
services: both essential$ unregulated businesses.
The perennial and still unresolved question is: who
controls the controllers? Beware of contrived
ambiguities. Is it ethical to intervene on the basis
of heuristic hypotheses and of subjective-and
likely interested-ethical judgments? Can a free
society survive deceptive public policies even if
allegedly issued with good intentions? I think not:
straight public talk should be a minimum require-
ment of social fairness. Until that may be achieved,
Horace still offers excellent advice to the common
man and to the scientist: nullius addictus jurare in
verba magistri.
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