The idea that addiction is a disease is an article of faith in the study of drug and alcohol dependence, providing the foundation for much of the treatment and public policy related to addiction since the early 1900s. In a forthcoming book, psychologist Gene Heyman dismantles this time-honoured assumption, arguing that addiction is first and foremost governed by personal choice, and does not therefore fit clinical conceptions of behavioural illness. Heyman has done research on choice, cognition and drug use. He has done volunteer work at a methadone clinic and he currently teaches courses on addiction at Harvard University. In conversation with Maclean’s correspondent Charlie Gillis, he offers a model of decision-making that he says explains how addicts—from smokers to opiate users—can voluntarily engage in activities that lead to long-term misery.
Q: The title of your new book, Addiction: A Disorder of Choice, is more or less self-explanatory. What led you to think that addiction may not be, as most research literature describes it, a “chronic, relapsing disease?”
A: Like everybody else, my initial goal was to find out how drug use turned from a voluntary behaviour to an involuntary one—that’s what I put down on my grant applications. But when I was teaching, I wanted to give my students at least some feeling for what addiction is like. So I began reading biographies, histories and ethnographies of addiction. This data gave a very different picture than the one I expected. The literature on how addicted people behave showed they stopped using the drugs, and that they did so because of family issues, or there was a choice between their children and continued drug use, or they were moving on to an environment where it was disapproved of.
In other words, the kinds of things that influence all of our everyday decisions were influencing people who are heavy, heavy drug users to stop using. And it was so consistent. Each report supported the other.
Then I began looking at the epidemiological data—these large surveys that have formed the basis for a lot of important psychiatric research in the last 20 years—and they showed the same thing. A huge percentage of people who had at some point met the criteria for lifetime substance dependence no longer did so by the time they were in their 30s. It varied from 60 to 80 per cent.
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: With the scientific community behind it, the idea that addiction is a sickness has also become the more enlightened position.
A: Yes, it seems a more humane thing to say, and people like to be humane.
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: Why would respected and established scientists make generalizations about drug dependence based on such a small subset?
A: I’ve thought a lot about that, and my sense is that this subset fit what people believed before they started studying. It squares nicely with this notion that addiction was either bad behaviour or sick behaviour. I don’t push this too hard. I mean, everybody knows that clinical populations can be biased. There’s even a name for it—Berkson’s bias. People who come to clinics for a certain disorder are likely to suffer from additional disorders.
Q: Still, the broader epidemiological surveys you cite have been available for anyone who cared to look. Why do you think they were ignored?
A: Well, I only looked at this data because I was teaching this course. I felt I had to. If you’re doing research looking at, say, calcium channels in individual neurons, you have so much to do that you’re not going to start reading the epidemiological literature. You don’t start making your world more difficult. But in the end, I do think it’s inexcusable, and one of the goals of my book is to bring the research world’s attention to data that has been sitting there for 20 years. In some cases, the data didn’t fit in with what the people who sponsored the surveys say addiction is. The National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism funded all the studies I cite. But NIDA and NIAAA have not taken the message of those studies to heart.
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.
Q: How might such a program work?
A: There are successful programs that reward abstinence with vouchers redeemable for modest rewards. In some cases the vouchers allow addicted people to do everyday things like take a cooking class or participate in buying household goods—any neutral, healthy, non-drug activity that most people do on their own. Remember, this is a population of people who don’t seem able to do these things on their own. Yet when these options are placed in front of them, they get engaged. In at least one of these studies, the abstinence rate continued to rise even after the voucher program stopped. That suggests the programs the addicts have gotten involved with—outdoor activities, and programs to help them get along better with their families—begin to take on a life of their own. Just as there can be a downward spiral, there can be an upward spiral.
Q: What about AA and other 12-step programs? They seem oriented around creating alternatives in life that compete with the rewards of use.
A: AA has been notorious in research circles for two reasons. One is because of the emphasis in its language on faith—‘God grant me the power’ and so on. The other is that they have not been at all interested in tracking how well they do. I don’t know whether they’re anti-research, but they’ve done nothing to measure their record. In the last few years, people have been able to get some data, and it shows they’re as successful as any other program. Personally, I think AA has intuitively developed a program that does exactly what we’ve discussed. It rewards sobriety. You know: somebody gets up and says, ‘My name is Ralph, I haven’t had a drink for three weeks,’ and everybody claps. It also creates a social life that is alcohol-free.
One of the biggest fears for alcoholics is that they won’t have a social life, that their social life is embedded in the consumption of alcohol. AA creates a social alternative that involves role models and sponsors, and there are people who get up and talk who are like them and have stopped drinking.
Q: The other approach, of course, is to prosecute drug use and possession, and I could see your argument being used to justify tightened drug laws or harsher penalties against users. I mean, if we’re talking about consequences, jail time is a fairly persuasive one.
A: I think it’s a matter of degree. I mean, how serious do the consequences need to be? For most people the idea of going to jail is chilling, and while I haven’t studied sentencing laws for drug use, my hunch is they’re much more severe than they need to be. That said, consequences matter and having something illegal can make a big difference.
Q: So this isn’t a licence to get tough.
A: No, but that’s going to be another book: what should the consequences be? There’s atrade-off. I think everybody would have to agree that if you relax the consequences—let’s say we regulated heroin and cocaine the way we do tobacco and alcohol—experimentation would go up, and the prices would probably go down. We don’t know what the exact consequences of that would be, but usually experimentation and dependence rise hand-in-hand.
Q: We should probably make an important distinction here. While you call addiction a “disorder of choice,” you also stress that no one chooses to be an addict. What do you mean by that?
A: That you’re making these choices one day at a time. What you’re choosing is to take heroin that day. You’re not choosing to have a miserable life. Eventually, you become stuck, though, where you don’t know what else to do but choose heroin each day, even though you wish it didn’t lead to a miserable life. You know, I’ve always thought it strange that people would think we should not have sympathy for those kinds of situations. In modern society, it is so easy to do things that you will later regret, whether we’re talking about something you do on the computer or something that you put in your body. A lot of people have trouble not making the sel?sh decision—the one that ruins their lives and the lives of those around them—and some of these treatment programs can help them figure that out. I also think that’s a reasonable thing for a clinician to want to do: to help people make better decisions about their lives.
Q: The concept of safe injection sites for intravenous drug users has been a hot topic here in Canada. We had a pilot project in Vancouver, which aimed to reduce associated harms, like the spread of HIV or hepatitis. Critics of the concept say it sends the message that drug use is okay. What do you think?
A: I don’t know that free needles will make someone a heroin addict. But would somebody say to themselves, “I don’t need to quit if I can find a place to inject safely”? Yeah, they might.
Q: There’s also the matter of putting the imprimatur of government on something it supposedly disapproves of.
A: Yes, and I think those things can be pretty important. In the U.S., when the surgeon general’s report came out in 1964 saying smoking was bad for your health, it had an impact. Everybody knew it couldn’t begood for you. But when it became official, people actually began to stop smoking. So those are the sorts of things you would have to consider [regarding safe injection sites]; you would have to weigh them against the public health advantages, and I think it would be a very hard decision. It would take a long time to get enough data, and I’m not sure the data would ever be good enough to provide the right answer. That would leave people a moral judgment to make.
Q: You explore issues in this book that are philosophical, almost philological, in nature. The research community, you point out, doesn’t apply words like “involuntary” or “compulsive” with much consistency. Is it time for some common understanding of these ideas?
A: I hope my book teaches my colleagues in research, as well as the public, that we can talk about things like “voluntary” and “involuntary” behaviour in ways that are testable. We can test whether behaviour is modified by its consequences.
Q: How has genetic theory—the idea that behaviours like drug dependence are determined by biology—influenced this debate?
A: There was an initial dark period. The initial impulse was to say that nothing that is disordered in our behaviour is voluntary—that everything is a disease. But we’re gradually discovering that things which are clearly voluntary, like religious beliefs, have a heritability. So people are going to say, aha, it’s not that voluntary behaviours are non-biological and involuntary ones are biological. It’s just that they have a different wiring, and the wiring for voluntary ones are more complicated. The neurons are influenced by consequences as well as by preceding biological conditions. Genetics plays a big role in voluntary behaviour, but our brains are wired so that certain activities can be influenced by rewards and punishments.
Q: You must be expecting some pushback from other addiction researchers.
A: I worry about that immensely. A lot of these are people I know and they’re my friends, so I don’t know how that’s going to play out. But I’ve written some articles that have been published that are very much along this line, and there are behavioural economists and some people who run addiction programs who are very supportive. I think the rest of the addiction world has just ignored it; in academia and science, people just tend to ignore that which they disagree with, unless they’re forced to confront it.