Addiction is a choice, not a disease

Since the 1900s, much of the treatment and public policy for addiction has been based on the idea that addiction is a disease. Psychologist Gene Heyman has done research on choice, cognition and drug use. He found that addiction is a matter of choice, therefore it doesn't fit the clinical definition of behavioural illness. By definition, a behavioural disease is compulsive; it’s beyond the influence of reward, punishment, expectations, cultural values, personal values. It was thought that drug use starts as voluntary, and then becomes involuntary.

In most research literature, addiction is described as a “chronic, relapsing disease.” Originally, Heyman's goal was to discover how drug use turned from a voluntary behaviour to an involuntary one. However, his research showed different results than what he expected. Heyman read biographies, histories and ethnographies about addiction. These showed that addicts stopped using the drugs; they stopped because of family issues, or they were in a place where it was disapproved of.

People who were heavy drug users were influenced to stop using; they were influenced by the same things that influence all of us in our everyday decisions. Addicts who've quit said things like “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, “The cheques from my parents stopped coming.” These kinds of statements were consistent throughout all the reports.

When Heyman looked at the large surveys that have formed the basis for a lot of important psychiatric research in the last 20 years, he found that they showed the same thing. Many people (varying from 60 to 80%) who once met the criteria for lifetime substance dependence no longer did so by the time they were in their 30s.

The idea that addiction is a disease governed by uncontrollable compulsion started in the 17th century. Addiction was first called a disease by the clergy. They didn’t describe alcoholism as a sin or a crime. Heyman's theory about their reasoning is that people have a problem with the idea that individuals can voluntarily do themselves harm. There was no way of explaining behaviour that is self-destructive and also voluntary; it doesn’t make sense. The two available terms were “sick” or “bad.” The idea that addiction is a sickness seemed a more humane thing to say.

At the centre of Heyman's argument is that most of the research on addiction is based on people in treatment clinics. This is problematic, since most of the time those people have additional psychiatric disorders which interfere with their ability to participate in activities that compete with drug use (like jobs, family, sports and other activities). So the studies only see the people who keep using drugs and don’t stop right into their 40s. That’s probably only 15 to 20% of addicts, which shows a distorted picture of addiction.

Heyman's argument that addiction is a choice depends on the idea that a person can voluntarily engage in self-destructive behaviour. This might seem strange, but it makes sense when you consider that there are two ways to make choices. We can look at the immediate rewards, or we can consider the circle of expanding consequences of our choices. A person's choices can be very different depending on whether or not they consider these consequences.

When someone chooses to take a drug, they’re thinking that at that time it would be better if they did. While Heyman calls addiction a “disorder of choice,” he also says that no one chooses to be an addict. That is, an addict makes these choices one day at a time. They choose to take a drug that day, they're not choosing to have a miserable life. But then they get stuck, they want the immediate rewards, so they keep taking the drug each day, even though they wish it didn’t lead to a miserable life.

There are some very successful programs against addiction, which emphasize consequences. The programs for airline pilots and physicians have success rates of 80 or 90% abstinence, because the consequences are so serious; they lose their jobs if they fail to abstain. It’s harder when someone is unemployed, but it's still a question of alternatives. These programs are more effective when they focus on alternatives, consequences and rewards in a direct way.

Some successful programs reward abstinence with vouchers for small rewards. These allow addicts to do everyday things like take a cooking class, participate in outdoor activities, or buy household goods. These are neutral, healthy activities that most people do on their own; addicts don’t seem able to do these things on their own, but when they have these options, they get engaged. Abstinence rates often continue to rise even after the voucher program ends, which means that the addicts have found these activities a better alternative than drugs.

AA and other 12-step programs are usually oriented around creating alternatives in life that compete with the rewards of drug use. For example, AA rewards sobriety: when someone says, ‘I haven’t had a drink for three weeks,’ everybody claps. AA also creates an alcohol-free social life. One of alcoholics' biggest fears is that they won’t have a social life; they think that they need alcohol to have a social life. AA creates a social alternative that involves role models and sponsors.

The other approach is to prosecute drug use and possession; most people fear going to jail. Making something illegal can make a big difference, but going to jail for drug use is probably a more severe consequence than it has to be. What the legal consequences should be is debatable. If you relax the consequences, experimentation would go up, and experimentation and dependence usually rise hand-in-hand.

Having safe injection sites for intravenous drug users is also a controversial topic. These sites try to reduce associated harms, like the spread of HIV or hepatitis. Critics of the concept say that it sends the message that drug use is okay. There is no evidence that free needles will encourage addiction, but it's possible that an addict might think that if they can inject safely they don’t need to quit.

Genetic theory also complicates the question of whether addiction is voluntary or not. According to genetic theory, behaviours like drug dependence are determined by biology. Genetics does play a big role in voluntary behaviour, but our brains are wired so that certain activities can be influenced by rewards and punishments. So even if someone is genetically inclined to addiction, they can still be influenced by consequences and rewards; they can decide to quit.

SOURCE: Gillis, Charlie. "Addiction: New research suggests it’s a choice." Macleans. 26 May 2009.