What Does It Mean to Say that Addiction is a Primary Disease?

By Kevin Doyle, Ed.D.
President/CEO, Hazelden Betty Ford Graduate School

It struck me recently that we may be given lip service to the concept that addiction is a primary disease or disorder, compared to other physical and mental health disorders. We’ve made great progress in the old debate about which came first, the mental health disorder or the substance use disorder. Yet, there is still the temptation to attribute causality to one or the other, or to an external factor, circumstance, or condition, perhaps a situational one.

This can manifest as something like:

· “Well, her spouse died, causing her to become alcoholic.”

· “His drug use was caused by his childhood trauma.”

· “They developed an anxiety disorder due to school-related stress.”

· “That person’s depression caused them to become addicted to cocaine”

While there may be some truth in each of these statements in a given situation, these would not typically meet the standard for a disorder to be labeled as primary. In other words, a primary disorder can be thought of as one that is not caused by another factor or situation but exists on its own.

One of the risks of not embracing the line of thinking of substance use as a primary disorder is that removal of the causal factor may allow the individual to return to safe substance use again. In other words, if the grief, loss, or trauma I adequately addressed, then the individual would be able to use alcohol again. This is in conflict with the basic premise of a substance use disorder as a primary disorder, not secondary to another condition.

The concept of “co-occurring disorders” (previously referred to as “dual diagnosis” or “dual disorders”) may be helpful to consider here. This terminology assists in reinforcing the concept that both disorders exist concurrently, and should be treated as such, in an integrated fashion.

Although this seems intuitive, it is much harder to implement in practice and the behavioral health file continues to try to grapple with how best to do this.

If you are skeptical about the concept of addiction (substance use disorder, or SUD) not being formulated as a primary disease, consider whether mental health disorders (non-SUD) are ever attributed to an individual’s addiction. In other words, it would seem that we would not hear statements like:

· “Well, her use of alcohol caused her to develop depression.”

· “His drug use led to the development of trauma.”

· “Their PTSD was attributed to their use of heroin.”

So, in summary, while it seems logical and even obvious to think of addiction as a primary disease or disorder, in practice one still often hears it referred to as a condition that is secondary, caused by, or attributable to something else. Although this frequently comes from a good or at least well-meaning place, this line of thinking can undermine the understanding of substance use disorder as its own discrete and primary condition, thus worthy of fully developed treatment protocols.