Addicted by Choice

Once and Addict, Always an Addict. Yeah, Right.

Long ago the medical and political establishments persuaded themselves that human addictions were diseases. It is easy to see how they came to that conclusion. If it is universally believed, as an article of faith, that the only reality is matter, all human experience and conditions must, in the end, be reduced to electrons and their peculiar behaviour.

If someone is addicted to, say heroin, it is because the electrons are functioning a certain way. To deliver the afflicted addict one has to treat the syndrome, using the same medical methods and disciplines as one would approach the treatment of other corporeal diseases such as heart disease or Alzheimers.

Every so often, however, someone from within the Academy rages against the machine. The latest is Gene M. Heyman, whose book Addiction: A Disorder of Choice has just been published by Harvard University Press. Sally Satel, reviewing the book for The New Republic, commences with these arresting paragraphs:

n 1970, high-grade heroin and opium flooded Southeast Asia. Military physicians in Vietnam estimated that between 10 percent and 25 percent of enlisted Army men were addicted to narcotics. Deaths from overdosing soared. In May 1971, the crisis exploded on the front page of The New York Times: “G.I. Heroin Addiction Epidemic in Vietnam.” Spurred by fears that newly discharged veterans would ignite an outbreak of heroin use in American cities, President Richard Nixon commanded the military to begin drug testing. In June, the White House announced that no soldier would be allowed to board the plane home unless he passed a urine test. Those who failed could go to an Army-sponsored detoxification program before they were re-tested.

The plan worked. Most GIs stopped using narcotics as word of the new directive spread and the vast minority who were detained produced clean samples when given a second chance. More startlingly, only 12 percent of soldiers who were dependent on opiate narcotics in Vietnam became re-addicted to heroin at some point in the three years after their return to the states. “This surprising rate of recovery even when re-exposed to narcotic drugs,” said the epidemiologist who collected the data, “ran counter to the conventional wisdom that heroin is a drug which causes addicts to suffer intolerable craving that rapidly leads to re-addiction if re-exposed to the drug.”

The story of returning Vietnam veterans overturned the conventional wisdom of “once an addict, always an addict.” The data were hailed as “revolutionary” and “path-breaking." Alas, the lesson became a casualty of generational amnesia. “Once an addict, always an addict” has merely been replaced by a newer and more sleekly scientific version of the same concept, namely, “addiction is a chronic and relapsing brain disease.”

Satel claims that Heyman's book is a "devastating assault on the brain-based model of addiction". While it is certainly true that drugs cause changes in the brain's functioning and behaviour--changes which can be measured and observed--it is most certainly not true that drug addiction is in the same category as genuine disease. The reason is that taking drugs remains a voluntary act, whereas Alzheimer's clearly is involuntary. How do we know that?

Heyman’s answer is that "voluntary activities vary systematically as a function of their consequences, where the consequences include benefits, costs, and values.” Take, for example, the case of addicted physicians and pilots. When they are reported to their oversight boards they are monitored closely for several long years; if they don’t fly right, they have a lot to lose (jobs, income, status). It is no coincidence that their recovery rates are high. Via entities called drug courts, the criminal justice system applies swift and certain sanctions to drug offenders who fail drug tests—the threat of jail time if tests are repeatedly failed is the stick—while the carrot is that charges are expunged if the program is completed. Participants in drug courts tend to fare significantly better than their counterparts who have been adjudicated as usual. In so-called contingency management experiments, subjects addicted to cocaine or heroin are rewarded with vouchers redeemable for cash, household goods, or clothes. Those randomized to the voucher arm routinely enjoy better results than those receiving treatment as usual.

Contingencies are the key to voluntariness. No amount of reinforcement or punishment can alter the course of an entirely autonomous biological condition. Imagine bribing an Alzheimer’s patient to keep her dementia from worsening, or threatening to impose a penalty on her if it did. This is where choice comes in: choosing an alternative to drug use. Heyman realizes how odd this might seem. How can otherwise rational people choose self-destruction unless they are diseased? This question was raised in colonial America. Dr. Benjamin Rush, also known as the father of American psychiatry, was among the first to promote the notion that alcoholism was a disease. And he did so not on the basis of medical evidence, Heyman reminds us, “but rather [upon] the assumption that voluntary behavior is not self-destructive.”

The classic mistake of Dr Rush and his (now) legion of followers was to assume that human beings will not willingly choose death and destruction--as a lifestyle choice. Their naive model dismissed the existence of human sinfulness. "Those who hate Me," says the Lord, "love death". Dr Rush said that could not possibly be the case. If someone acted so as to destroy himself, it must be against his will; it had to be involuntary; it had to be a clinical disease.

It may strike some as insensitive to insist that addiction is a disorder of choice. “I have never come across a single drug-addicted person who told me [he or she] wanted to be addicted," Nora Volkow, the current director of NIDA says. Exactly so. How many of us have ever come across a person who wanted to be fat? So many undesirable outcomes in life are achieved incrementally. In a choice model, full-blown addiction is the triumph of feel-good local decisions (“I’ll use today”) over punishing global anxieties (“I don’t want to be an addict tomorrow”). Let’s follow a typical trajectory. At the start of an episode of addiction, the drug increases in hedonic value while once-rewarding activities such as relationships, job, or family recede in value. Although the appeal of using starts to fade as consequences pile up—spending too much money, disappointing loved ones, attracting suspicion at work—the drug still retains value because it salves psychic pain, suppresses withdrawal symptoms, and douses intense craving.

At some point, however, even these benefits come to be outweighed by adverse fallout. The balance shifts and the addict tips into recovery. The idea is to accelerate the process by, as Heyman says, “chang[ing] … conditions that markedly reduce the value of the drug relative to the nondrug alternative.” This can be achieved through treatment, imposing credible threats—recall the case of impaired pilots and physicians—or the development of new modes of gratification that compete with drugs.

In treating addictions a fundamental watershed is to recognise its voluntary character at root. If the addict wants to change, then there is something to work with. The objective then is to help the addict discover those things which are more valuable, more important than the "benefits" of the drug and which the drug will destroy (career, community respect, love of family, etc.) The underlying theme always has to be, "You are responsible. You make the choices. The buck stops with you." Ironically it is a message underpinned with a belief in human dignity and freedom, whereas the consensus view of the Academy is a message of slavery and tragedy. Instinctively we all know that one can be both dignified and heroic in succumbing to a genuine involuntary disease--and whilst battling a genuine sin, in the case of a voluntary addiction.

But there is nothing dignified and heroic in succumbing to alcoholism or heroin addiction.