Addiction: Choices and Cravings

This op-ed takes issue with the disease model of addiction, suggesting instead that addiction is best conceived as a bio-behavioral disorder involving voluntary behavior.  But since the voluntary is equally a function of conditions as the involuntary, this should lead to a reduction in punitive attitudes toward addicts, and renewed attention to the environmental determinants of addiction, in particular how lack of reinforcing life opportunities makes the use of drugs and alcohol more attractive.

Despite concerted efforts by treatment professionals to change public perceptions of drug addiction, stigma against addicts remains widespread. According to the National Treatment Plan Initiative recently released by the U.S. Center for Substance Abuse Treatment (CSAT), stigma can "cause ostracism, shame, and even denial of life’s necessities – such as employment and a place to live – for which the person in recovery is fully deserving."

In the fight against stigma, the primary strategy has been to portray addiction as a chronic, relapsing disease, rooted in bio-chemical changes in the brain wrought by drugs. The logic of those promoting the disease model is simple: people are not to blame for diseases; addiction is a disease; therefore, addicts do not deserve blame or stigma.

Well meaning as it is, this approach has had limited success, and CSAT’s promotion of the disease model is unlikely to have much further impact on attitudes. Why? Because addiction, although certainly a disorder, has characteristics which patently fall outside accepted definitions of disease, and no amount of rhetoric will change that fact.

Unlike most diseases, addiction can bring out the worst in people, including conduct we cannot help but judge reprehensible, and which often generates anger and avoidance. Equally important, addiction involves deliberate, decision-laden behavior, both in the initial choice to use substances and in planning how to obtain them. Asking the disease concept to accommodate such behaviors asks too much, which means the addiction-as-disease strategy against stigma simply lacks credibility.

A better approach would acknowledge that addiction is not a disease, but rather a bio-behavioral disorder involving persons who, although gripped by strong desires, remain rational for many, if not most, of their waking hours. The neural reward system in the "old brain," modified by repeated exposure to drugs, certainly drives behavior, but higher level cortical processes involved in decision making and choice still exist.

This means that addictive behavior has a significant voluntary component, and is sensitive to foreseeable consequences. Addicts anticipating the agonies of withdrawal can and will tailor their actions to suit the exigencies of the moment, including selling drugs to support a habit or hiding bottles to avoid detection. As clinicians will testify, some addicts make the best of their misery with considerable ingenuity.

Researchers in what is known as behavioral choice theory are seeking to better understand the voluntary component of addiction. How, precisely, do the ultimately self-destructive decisions involved in drug abuse arise out of biological, psychological, and social conditions?

Writing in the Brain and Behavioral Sciences, psychologist Gene Heyman at the Harvard Medical School’s Division on Addictions argues that evolution has endowed us with a normally adaptive "biology of choice" that can be victimized by highly reinforcing substances. The powerful, immediate, but short-lived pleasures of drugs take precedence over the more distant, long-term goal of building a meaningful life that avoids the disaster of dependence.

Moreover, Heyman points out, the voluntary behavior of buying and consuming substances is shaped by addicts’ expectations about the consequences of their behavior as it plays out in the social environment. Just as involuntary cravings are determined by exposure to drugs, so too the choices involved in addiction, mediated by some measure of planning and deliberation, are determined by an addict's surroundings, especially by the availability of drugs compared to rewarding drug-free alternatives.

Such an account seems to entail the ultimate destigmatization of addicts. Given their particular situations, those ensnared by addiction chose precisely as they did, and no other choice could have arisen. Even in its earliest stages, addictive behavior unfolds as a complex function of person-environment interaction, and were any of us in the same situation, with the same genetic vulnerabilities, brain chemistry, motives, and options, we would have acted similarly.

The immediate objection will be that such explanations let addicts entirely off the hook, should they behave badly. If their choices were fully determined, on what grounds can we hold them accountable?

The reply is straightforward: since addictive behavior is often responsive to the anticipation of consequences, then holding addicts accountable for their actions can help them change for the better. Just as drugs such as methadone and naltrexone block the effects of and craving for addictive substances, likewise well-designed social contingencies can help channel behavior within acceptable norms. We need not suppose that addicts choose addiction using some sort of undetermined free will to justify interventions which improve their behavior.

The crucial question, though, is what sorts of interventions are appropriate? The traditional view - that addicts have primarily themselves to blame for their fate - underwrites the punitive attitudes which favor criminal sanctions, with prison simply just deserts for willfully consuming drugs. But criminalizing addiction simply creates further shame, alienation, and dysfunction.

On the other hand, recognizing addiction as a bio-behavioral disorder involving both a person and a social context will help defuse resentment of addicts, since choices leading to dependence are seen to arise out of biological and environmental conditions, not a self separate from circumstances.

Furthermore, understanding these conditions points the way toward policies that will likely prove far more effective and less costly than incarceration for possessing drugs (although crimes that addicts commit against persons and property must obviously draw appropriate penalties). Community development, treatment, counseling, job training, and other structured programs can make addictive behavior less appealing by shifting the balance of rewards in favor of healthy alternatives.

Limited personal sanctions for failing to reduce drug use can still play a role in behavior change, but within a non-punitive framework which minimizes the suffering already central to the addict’s experience. As with the mentally ill, involuntary commitment of extremely dysfunctional addicts into treatment may sometimes be necessary, but only as a last resort and strictly for their own safety and rehabilitation, not as punishment.

Like the disease model, a bio-behavioral understanding of addiction will reduce stigma and increase support for prevention and treatment, but it has the key additional virtue of staying true to the facts about this disorder. Although the power of drugs to usurp normal priorities can hardly be overstated, most addicts retain some capacity to respond to social contingencies as well as to medications which control craving. This means that given the right sorts of opportunities and interventions, and given some leeway for mis-steps, they can regain their dignity and learn to behave responsibly.

Requiring personal accountability is part of this process, but in the light of a thorough understanding of addiction we will focus more on creating humane, supportive conditions that permit positive choices, and less on blaming those who were simply in the wrong place, at the wrong time.