Addictions and Mental Illness Do Not Belong Together

By Marvin Ross

For some inexplicable reason addictions is lumped in with mental illness or, to be politically correct, mental health. Combining the two is, in my opinion, like putting orthopaedic surgery together with chiropractic. Addictions are quite separate from mental illness and combining them does a disservice to the mentally ill.

I do no want to demean the seriousness of addictions but there is a fundamental difference. Addictions at some point involve choice. You made a decision to go into a bar and start drinking or to snort coke, take opioids or inject heroin. No one has a choice to become schizophrenic, bipolar, depressed or any other serious mental illness. There is no choice involved whatsoever.

Before you jump all over me, take a look at a court case before the Massachusetts supreme court called Commonwealth v. Eldred . Ms Eldred admitted to stealing in order to support her drug habit and was sentenced to probation with the term that she not use drugs and submit to regular drug testing. Ms Eldred tested positive for drugs in one of her tests and her probation was revoked and she was put in jail pending the availability of a treatment bed.

She appealed using the argument that the sentence of abstinence was cruel and unusual punishment as she has no choice but to take drugs as she is an addict. Addiction psychiatrist, Dr Sally Satel, co-wrote a brief with others arguing against the grounds for this appeal. Those grounds are that addicts are involuntary drug users who cannot be held responsible for their drug use. If that is upheld then it would “affect the future of successful treatment programs that are based on the verified principle that addicts can and often do say no to drugs” and “it would hobble successful judicial interventions that help addicts stay out of jail by making probation and parole contingent on testing clean for drugs”.

Dr Satel argues that this position runs counter to accepted science in her blog Addiction, she says, is not a chronic and relapsing brain disease. Addicts can and do learn to say no to drugs and recover in large numbers without intervention. Three epidemiological studies done in the US found that “among those who ever met the criteria for addiction to controlled substances, 76% to 83% were at the time of the surveys ex-addicts. They no longer used drugs at levels that met the criteria for substance dependence.”

Dr Satel also points out that the argument that is often used is that the drugs or alcohol change the structure of the brain so that the addiction continues and cannot be controlled. However, as she points out, all actions, including reading an article, change the brain and thus brain changes are not a valid marker for loss of self control.

One analogy that comes to my mind is smoking. It is generally recognized that nicotine is a very strong addicting substance and it is not easy to quit. My generation smoked a great deal as it was socially acceptable and allowed just about everywhere. One brand even advertised that 4 out of 5 doctors smoked whatever. Then, we were given more and more evidence of how harmful it was and it became socially unacceptable. The vast majority of us were able to quit and I don’t recall anyone ever arguing that we suffered from an illness and that we had a brain disease. Once we determined to stop, we did using a variety of methods. What was key in each and every case was a true desire to do so.

During the Vietnam War, it was discovered that 40% of US servicemen had used heroin and that nearly 20% were addicted. Government officials were stunned and worried and Richard Nixon set up a new office called The Special Action Office of Drug Abuse Prevention. Its goal was to prevent and rehabilitate as well as to track troops returning from Vietnam. What they found shocked them. Nearly 95% of the addicted servicemen gave up heroin voluntarily upon return to the US.

They stopped, it was hypothesized because they found themselves in a totally different environment from that of a hostile war zone. In contrast are drug users who go into rehab who relapse at a rate of about 90% once they return to their regular environment. That is an environment and life situation that caused them to become addicted in the first place.

The solution to addiction is not to treat it like it is a brain disease where the addict has no control but to try to change the life circumstances of those who do become addicted.

As Dr Satel said, addiction is not a conventional brain disease like Alzheimer’s. “Addiction is self-destructive drug use, and those who are destroying their lives with drugs deserve our help and sympathy, but they are not helpless victims” like those with serious mental illnesses.

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4 thoughts on “Addictions and Mental Illness Do Not Belong Together

  1. It was often argued that when Addictions and Mental Illness were to go under one umbrella that those who would lose out would be those afflicted with serious mental illnesses, such as Schizophrenia and Manic Depression (and allied condition). The squeaky wheel of addictions got the grease and therefore serious mental illnesss ( brain diseases came in second regarding money allocated. That is pretty evident. Sad to see whilst sitting on various Committees at Queen’s park a couple or so decades ago, it was easy to see this coming.

    It is not to be denied however that people with serious mental illness mostly when untreated dabble or more than dabble with drugs… street drugs and alcohol, but the thing that makes the difference is not so much dealing with the street drugs but first ensuring that the person is given appropriate medical pharmacology to stabilize the mental illness. But this was not politically correct., hence we have stigma busting, words like mental health replacing illness and of course the now old chestnut “issues” Yes there are issues with any disease but we never avoid using the diagnosis.

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  2. Addiction may be a brain disease and still parts of the addiction process are not voluntary when the brain damage or dysfunction is so severe that the pre frontal cortex is crippled in terms of rational, logical decision making. This can be a mixed bag

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    1. I would argue that being an addict i.e.taking dangerous substances especially in excess, likely causes some brain damage. Neurological feedback circuits /cravings etc; go with the habit. But those afflicted with an illness like Schizophrenia ,and a host of other brain disorders have no choice in whether they get ill. NO doubt we shall be better informed in the future. A few years back Concurrent disorders became a big topic,to the extent that some people were excluded from treatment for a psychosis because they were still using street drugs This acknowledgement solved one part of the problem for a few in that they gained access to care. ( allowing access to antipsychotic treatment) But are we seeing less psychotic people on the streets. We are seeing a lot more very seriously mentally ill on our streets now because of less access to appropriate timely treatment . Yet the incidence has remained roughly the same. Prison is now where ill people end up. SHAME SHAME !

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  3. They do not, but they do happen concurrently , some years back, if a person presented signs of addiction and symptoms of mental illness , neither disciplines would accept them for treatment, .The person was told to get rid of the addiction, or to get treatment for their mental illness before they would be addmitted to an addictions program. CAMH published a booklet on concurrent disorders and a few years later Caroline O’Grady and Wayne Skinner put together “A family guide to concurrent disorders” which gave prevalence to addictions ( could be only my own opinion !)

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