Annual U.S. overdose deaths recently topped 100,000, a record for a single year, and that milestone demonstrates the tragic insufficiency of our current “addiction as disease” paradigm. Thinking of addiction as a disease might simply imply that medicine can help, but disease language also oversimplifies the story and leads to the view that medical science is the single best framework for understanding addiction. Addiction becomes an individual problem, reduced to the level of biology alone. This narrows the view of a complex problem that requires community support and healing.
Once I was a few years into my recovery, I began studying addiction medicine, in no small part to make sense of what had gone wrong with me and my family — both of my parents were alcoholics. I found little help from my own field, which is divided into sometimes clashing schools of thought about how addiction works. As a result, I looked beyond medicine and science to history, philosophy and sociology; addiction is an idea with a long, messy and controversial history, dating back more than half a millennium. That history deepened my understanding of addiction and helped me make sense of my own experiences.
Around 500 years ago, when the word “addict” entered the English language, it meant something very different: more akin to a “strong devotion.” It was something you did, rather than something that happened to you. For example, an early writer counseled his readers to “addict all their doings towards the attainment of life everlasting.” My experiences and those of my patients seem more in line with how 16th- and 17th-century writers described addiction: a disordered choice, decisions gone awry.
Benjamin Rush, a founding father of the United States and one of the most influential physicians in America in the late 18th century, was particularly focused on mental illness. He was famous for describing habitual drunkenness as a chronic and relapsing disease. However, Rush argued medicine could help only in part; he recognized that social and economic policies were central to the problem. It was the later temperance movements of the 1820s and 1830s that emphasized a harder language of disease, insisting that people with drinking problems had been damaged by a sort of reductionist biology, that “demon rum” took you over, as in a possession.
It’s imperative to be careful about these types of deterministic stories. Such reductionistic narratives were repeatedly used as a justification for racist, oppressive crackdowns in the United States, on Chinese opium smoking at the turn of the 20th century and on crack cocaine in the 1980s, which was painted as a problem primarily in Black neighborhoods. Today, amid the opioid overdose epidemic, addiction is more likely to be called a disease, but the language of disease has not done away with the misleading notion that drugs hold all the power.