Addiction: A Disorder of Choice
In a book sure to inspire controversy, Gene Heyman argues that conventional wisdom about addiction—that it is a disease, a compulsion beyond conscious control—is wrong.
Drawing on psychiatric epidemiology, addicts’ autobiographies, treatment studies, and advances in behavioral economics, Heyman makes a powerful case that addiction is voluntary. He shows that drug use, like all choices, is influenced by preferences and goals. But just as there are successful dieters, there are successful ex-addicts. In fact, addiction is the psychiatric disorder with the highest rate of recovery. But what ends an addiction?
At the heart of Heyman’s analysis is a startling view of choice and motivation that applies to all choices, not just the choice to use drugs. The conditions that promote quitting a drug addiction include new information, cultural values, and, of course, the costs and benefits of further drug use. Most of us avoid becoming drug dependent, not because we are especially rational, but because we loathe the idea of being an addict.
Heyman’s analysis of well-established but frequently ignored research leads to unexpected insights into how we make choices—from obesity to McMansionization—all rooted in our deep-seated tendency to consume too much of whatever we like best. As wealth increases and technology advances, the dilemma posed by addictive drugs spreads to new products. However, this remarkable and radical book points to a solution. If drug addicts typically beat addiction, then non-addicts can learn to control their natural tendency to take too much.
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Addiction is no joke. Once you are hooked, you are messed up until you choose to get away. This book defends all the ideas of why we should not have any pity on those drug addicts, because they will either die or find their way out before 30. Really scary.
Addicts have made a choice
The US Congress voted this week to let the Food and Drug Administration regulate tobacco almost out of existence, but could not work up the nerve to ban it. The latest of America’s periodic bouts of prohibitionism is thus coming to an end in a typically ambivalent fashion. Authorities are split over whether people are moral agents, competent to make their own decisions about drugs, or helpless victims; and whether drug abuse is a choice or a disease.
In recent decades, the internal contradictions in US drug policy have been sharper than at any time since alcohol was banned after the first world war. Urban kids are sent to jail for drug possession while celebrities talk cheerily on television about beating their cocaine habits through rehab and self-help groups. We have a justice system that treats drug use as a malevolent act of will (to be punished) and a medical profession that treats it as an unfortunate disease (to be cured). Who is right? In a magnificent new book, Addiction: A Disorder of Choice, Gene M. Heyman, a lecturer in psychology at Harvard Medical School, argues that it is not his fellow medical professionals.
Addiction is voluntary. The idea that addiction is a “chronic, relapsing brain disease” may be well-meaning but it is false. “Everyone,” Mr Heyman writes, “including those who are called addicts, stops using drugs when the costs of continuing become too great.” We need to make clear, though, what Mr Heyman means by “voluntary”. He does not deny that addiction is an enormous problem that can wreck a life, or several. If you drive drunk or embezzle money to pay for your coke habit when you ought to be studying, the consequences can be permanent and devastating.
But addiction is not the kind of problem that most people think it is. It is not so very far from setting interest rates, devising depreciation schedules and other economic problems of “intertemporal choice”. It involves weighing the value of a current good (intoxication) against the value of various future ones that are shrouded in uncertainty. Mr Heyman shows that the ordinary dynamics of human decision-making are sufficient to bring addiction into line with what we know about other, non-addictive behaviours.
The best epidemiological evidence is that most people choose to give up addictive behaviour sometime around their late twenties or early thirties, and for perfectly rational reasons – concerns about family and career, encounters with law enforcement, etc. One episode in the recent history of US drug abuse is particularly illustrative. A lot of GIs in Vietnam turned to heroin. About 45 per cent of those who did became addicted to it, and so seriously that they would continue shooting up even when it imperilled their chances of getting home. The Nixon administration, worrying that this army of addicts would unleash a crime wave on their return, monitored them closely. But, back in the US, only 12 per cent continued their addiction. This is not typical of a “chronic disease”, Mr Heyman argues; it is typical of a shifting calculation of opportunity cost. Where the costs and benefits of addiction become easily calculable, recovery rates are excellent. Heavily addicted physicians and airline pilots, subjected to testing and told their jobs are on the line, have recovery rates well above 80 per cent.
There seem to be good prima facie reasons for viewing addiction as a disease. Mr Heyman rebuts them patiently. Repeated drug use alters the structure of the brain. Well, yes, he writes, but so does learning. Another pillar of the disease theory is that there is a genetic component to alcoholism. Certainly, Mr Heyman grants, but what genes mostly do is “affect the relative value of alcohol” – they do not remove the power of choice. Separated-twin studies have shown that there is a genetic component to the embrace of religious fundamentalism, and no one calls that involuntary.
The centrepiece of the disease theory of