Addiction Medicine: Closing the Gap between Science and Practice

Models for Understanding Addiction ................................................................................

The model for how we understand addiction is
critical because it influences how individuals
with addiction are treated in society and guides
the nature of the services provided to address the
disease.^110 The current model of addiction
recognizes that it is a complex brain disease^111
and that multiple determinants and systems
influence substance use and its progression to
addiction.^112 Although this model is based on a
large and growing body of scientific evidence,
treatment practice and public attitudes still
reflect earlier models of understanding the
condition.

Since the 1700s, with few exceptions,^113 two
different models have dominated society’s views
on addiction, driven in large part by
sociopolitical influences and also by developing
knowledge about the science of addiction.^114

The moral model of addiction framed addiction
primarily as a failure of personal responsibility
or morality. It asserted that addiction could be
addressed simply by requiring personal
responsibility and accountability on the part of
the person who is addicted. This approach has
contributed to:

 The stigma associated with addiction,
attaching blame to the individual, creating
shame and embarrassment, increasing the
likelihood of discrimination and decreasing
the chances that the addicted individual will
seek or receive effective treatment.^115

 Restrictions in benefits for addicted
individuals. In 1995, a Congressional vote
discontinued Supplemental Security Income
(SSI) disability benefits to individuals
whose primary diagnosis was addiction
involving alcohol or other drugs.^116 And,
the majority of states in the U.S. currently
are proposing or adopting legislation that
condition the receipt of public services
including welfare, unemployment
assistance, job training, food stamps and
public housing on passing a drug test.^117

The disease model of addiction, in contrast to the

moral model, acknowledged biology and

genetics as significant contributors to addiction,

drawing on advances in genetics and brain

research.^118 This approach has contributed to the

concern that viewing addiction as a disease

might:

 Release the individual from personal

responsibility and the need for self-

control,^119 and

 Engender feelings of hopelessness with

regard to effective treatment and the

possibility of recovery.^120

These concerns, however, rarely are raised in

relation to other health problems and appear, at

least in part, to be reflective of the moral model

of addiction.

Evolving Approaches to Addressing Addiction ................................................................

America’s approach to addressing substance use

and addiction has been filled with contradiction.

For example, at the turn of the 20th century,

cigarette smoking was frowned upon.^121 Thanks

to effective marketing by the tobacco industry,

that view was replaced by one of tobacco use as

glamorous and even healthful,^122 only to be

supplanted in the mid-1960s by a growing

understanding that cigarette smoking is a

significant contributor to poor health and

disease.^123

Physicians prescribed marijuana and cocaine for

a variety of ailments in the late part of the 19th

century only to scale back in the first decades of

the 20th century in response to increasing

recognition of the adverse effects of these drugs

and increasing regulatory restrictions on their

use; today, there is a return to attempting to

frame marijuana as medicine.^124 Similarly,

opium was used in the early part of the last

century to treat diarrhea, dysentery and

coughs.^125 In response to the proliferation of

marijuana, hallucinogen, cocaine and heroin use

in the late 1960s and early 1970s--and their

association with political protest, crime and