Ethical Tensions in Formalizing Substance Use Disorder as a Chronic Disease: A Health Systems Leadership Perspective

Substance Use Disorder (SUD) is widely recognized as a chronic, relapsing medical condition by major authorities, including the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC), supported by clinical and neuroscientific evidence. Despite this recognition, health systems often respond through episodic, crisis-driven, or punitive models of care. Like other chronic diseases, SUD unfolds through stability, relapse, and recovery, requiring sustained, coordinated, person-centred care. Formalizing SUD as a chronic disease may reduce stigma, attract resources, normalize treatment, and shift systems away from crisis-oriented responses. However, Chronic Disease Management (CDM) is grounded in principlism, emphasizing autonomy, beneficence, non-maleficence, and justice. When applied to SUD, these principles can conflict. Respecting autonomy may challenge efforts to promote beneficence, while preventing harm can limit individual choice. Commitments to justice may also be constrained by finite resources. The chronic disease framing is double-edged: it can foster hope by emphasizing recovery and long-term support yet may reinforce perceptions of permanence. Equity remains foundational, as housing, income, and trauma shape vulnerability and recovery. Reliance on coercive or mandated treatment raises additional ethical concerns given limited evidence of benefit and potential harm. We argue that formalizing SUD as a chronic disease can strengthen CDM by demanding continuity, humility, proportionality, and care systems for people as they are, not as we wish them to be.