Disease model theory, serving as the paradigmatic basis for a treatment programme advocating abstinence, rests on the belief that addiction as a disorder originates from a neuro-biological dysfunction located in the midbrain and its cortical connections. It is postulated that dysfunctional nuclei within the midbrain and associated pathways give rise to the observed phenomenon of impaired control over the consumption of mood altering drugs and behaviours, which is the diagnostic hallmark of an addictive disorder. Impaired control, which is difficult to measure, is the problem that causes the problems for people identified as having a substance related disorder. `
The Role of Neurobiological Impairment in Addiction
Disease model theory suggests that only people with this neurobiological impairment manifest as drug addicted. The vulnerability precedes the using. While many people might find themselves locked into a physical dependence cycle as a pharmacological property of certain substances and their ability to induce dependence, this must be distinguished from those who are locked in to substance use through their addiction.
Abstinence as a Prudent Solution
It is this very notion of impaired control that informs abstinence as the most prudent way out of the problem for people suffering with a substance use disorder. In my opinion, identifying someone as an addict is the only cogent reason for them to abstain from substance use. This does not imply that using substances is without intrinsic risks, but those risks are evident on their own.
It is with this understanding in mind that we strongly recommend clients seeking help with their addictive behaviour to abstain from substance use. They should behave cautiously with other potentially addictive behaviours. Disease model understanding of addiction makes abstinence a rational non-judgemental solution. Simultaneously, we must address underlying psychosocial issues and collateral damage from the addiction to reduce the high risk of relapse. We should not confuse these factors with the cause of the addiction itself.
A cohort of previously diagnosed individuals with substance use disorders has resumed controlled use after abstinence. It is, as if, the midbrain reward system has repaired itself. There are many individuals who return to out of control using after a similar period of abstinence. In fact, up to 50% of clients in our treatment program have been admitted after previous treatment and a relapse. They cannot claim to be addiction naive. We do not yet have the tools to accurately predict which of the two groups a client will belongs to. So we perhaps err on the side of caution with the “sobriety, one day at a time” advice to everyone.
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