Why Drug Addiction Is Not A Disease

In a recent interview regarding his deranged son Charlie, Martin Sheen urged people to pray for Charlie and said that he has an illness and should be pitied, just like someone with cancer.

Harvard psychologist Gene Heyman would disagree.

Heyman believes that addiction is first and foremost governed by personal choice and therefore cannot fit traditional conceptions of a behavioural illness. In a 2009 interview with Maclean’s, Heyman lays out a model of decision making that he thinks explains how addicts can voluntarily engage in activities that can lead to terrible misery.

Here are some excerpts from the interview:

Q: So why does that preclude it from being a disease?

A: At the heart of the notion of behavioural disease is the idea of compulsivity, by which people mean it’s beyond the influence of reward, punishment, expectations, cultural values, personal values. Alan Leshner [the former head of the National Institute on Drug Abuse] says drug use starts off as voluntary and becomes involuntary. But the epidemiological evidence suggests otherwise. When you read the biographical information, you see individual drug addicts [who’ve quit] saying, “Well, it was a question of getting high on cocaine or putting food on the table for my kids.” Or, “My life was getting out of control.” Or, in the case of William S. Burroughs, “The cheques from my parents stopped coming.” 

Q: How, then, did the idea that addiction is a disease governed by uncontrollable compulsion take root?

A: The first people to call addiction a disease were members of the 17th-century clergy. They were looking at alcoholism and they didn’t describe it as sin or as crime. I have a theory as to why they thought this—and why we think it even today. It’s this problem we have with the idea that individuals can voluntarily do themselves harm. It just doesn’t make sense to us. Why wouldn’t you stop? In the medical world, in economics, in psychology and in the clergy, they really have no category for this, no way of explaining behaviour that is self-destructive and also voluntary. The two categories available to them are “sick” or “bad.”

….

Q: At the centre of your argument is that much of the research on addiction to date is based on people who wound up in treatment clinics. Why is that problematic?

A: It’s problematic because 60 to 70 per cent of the time, those people have additional psychiatric disorders. And those disorders interfere with their capacity to engage in activities that would compete with the drugs—jobs, family, other activities. So the people the clinicians see, and the people the researchers study, are those who keep using drugs and don’t stop right into their 40s. That’s maybe 15 to 20 per cent of [addicts], and they have greatly skewed our picture of the natural history of addiction. From the data I’ve seen, it looks like most people who meet the criteria for addiction actually stop using by age 30.

Q: Let’s talk about the role of choice in addiction. Your argument depends on the idea that a person can voluntarily engage in a behaviour that is self-destructive. Can you explain this phenomenon?

A: My analysis is based on the fact that there are always two “best” ways to make choices. We can take into consideration the value it has at the moment—the immediate rewards. Or we can consider this kind of circle of expanding consequences that each of our choices has. Your pattern of choices can be much different depending on whether you take into consideration this broader circle. A workaholic, for example, starts out taking into account only the immediate demands of working, dropping every other consideration. But he ends up, according to himself and everybody around him, working too much. The model just tries to formalize that idea, and it’s really just common sense.

So when people are choosing the drug, they’re thinking that moment, or that particular day, would be better if they did. A chronic smoker will think that the next three minutes would be better with a cigarette than without. But after a year of smoking 20 cigarettes per day, adding up to 60 minutes each day, you might think, ‘I’d rather have the 60 minutes of not smoking each day.’ Unfortunately, you don’t choose 60 minutes at a time. You decide one cigarette—or three minutes—at a time, and that’s what makes this so difficult.

Q: So as we get older, we learn to recognize those consequences, and weigh them against other things we might spend our time on.

A: Right. Your preferences in the moment are different from what I’d call a global perspective, and they can undermine that global perspective. That’s why I’m actually in favour of drug and alcohol treatment. Many of these programs help get people through the very difficult periods of choosing things in the moment, one at a time.

Q: Your tone is even and your argument seems rational. But there are implications to all this. You’re upending ideas that have had scientific currency since the First World War. Our governments spend billions each year treating and trying to prevent drug abuse on the belief it is a disease. Are we going about it all wrong?

A: My sense is that we could be going about it a lot better. It’s possible that the reason we’re not making much progress is that we’re not treating decision-making directly. There are programs that have had considerable success, and they are based on the idea that the consequences of drug use are what’s important. There is one for airline pilots and physicians where the success rates are 80 or 90 per cent abstinence, because the negative consequences are so serious [if they fail to abstain, the addicts lose their jobs].

It’s harder where the subjects are unemployed, but again it points out the fact that this is a question of alternatives. If programs focused on alternatives, consequences and rewards in a very direct way, maybe they’d be much more efficacious and less expensive.