Dr. Alan I. Leshner, the director of the National Institute on Drug Abuse, a division of the National Institutes of Health, is known for his slide shows. Two or three times a week he gives a speech -- to treatment counselors and prevention specialists, physicians and policymakers -- and almost all feature slides culled from the work of the 1,200 researchers supported by his institute. The slides are of brain scans, and they usually come in pairs. The "before" slides show the activity of a normal brain; the "after" ones depict a brain that has had prolonged exposure to drugs. Lacing his presentation with jokes and Yiddish expressions -- as a youth, Dr. Leshner summered at a Catskills hotel owned by his grandparents, and he has a bit of Alan King in him -- he tries to translate the science into plain English.
What the science shows, he says, is that the brain of an addict is fundamentally different from that of a nonaddict. Initially, when a person uses hard drugs like heroin or cocaine, the chemistry of the brain is not much affected, and the decision to take the drugs remains voluntary. But at a certain point, he says, a "metaphorical switch in the brain" gets thrown, and the individual moves into a state of addiction characterized by compulsive drug use. These brain changes, Dr. Leshner says, persist long after addicts stop using drugs, which is why, he continues, relapse is so common. Addiction, Dr. Leshner declares, should be approached more like other chronic illnesses, like diabetes and hypertension. Going further, he says that drugs so alter the brain that addiction can be compared to mental disorders like Alzheimer's disease and schizophrenia. It is, he says, a "brain disease."
In promoting this concept, Dr. Leshner has stepped forthrightly into a debate that has smoldered for decades: are drug addicts responsible for their behavior? Should they be treated as sick people in need of help, or as bad people in need of punishment? Dr. Leshner has come down squarely on the side of illness. And he is winning many people over. Today the brain-disease model is widely accepted in the addiction field, and Barry R. McCaffrey, the White House drug adviser, routinely invokes it.
Others are not convinced. "I reject the notion that addicts fall under the spell of drugs and become a zombie and so are not responsible for anything they do," says Dr. Sally L. Satel, a senior associate at the Ethics and Public Policy Center in Washington and a practicing psychiatrist at a methadone clinic. To her and other critics, the brain-disease model is a new orthodoxy based less on science than on a desire to soften the stigma attached to addiction.
The idea that addiction is a disease is not new. In the 1960's Alcoholics Anonymous began speaking of alcoholism as a disease. But, initially at least, A.A. used the term figuratively to suggest the tenacious hold drinking has on alcoholics. Over the last decade or so, however, advances in brain-imaging technology have allowed researchers to measure the impact of psychoactive substances on the brain with increasing precision. Investigators have found that drugs like cocaine, heroin and alcohol increase the brain's production of dopamine, the neurotransmitter that regulates pleasure, among other things. This helps account for the euphoric high drug users feel. But these drugs deplete the dopamine pathway, disrupting the individual's ability to function.
At the Brookhaven National Laboratory on Long Island, for instance, Dr. Nora D. Volkow has found that even 100 days after a cocaine addict's last dose, there is significant disruption in the brain's frontal cortical area, which governs such attributes as impulse, motivation and drive. Dr. Volkow says that "the disruption of the dopamine pathways leads to a decrease in the reinforcing value of normal things, and this pushes the individual to take drugs to compensate." Other researchers have found a physiological basis for the craving so many addicts experience, but it is not yet clear how long such physiological changes remain.
Dr. Herbert D. Kleber, the medical director of the National Center on Addiction and Substance Abuse in New York, says that the brain-disease concept fits with his experience with thousands of addicts over the years. "No one wants to be an addict," he says. "All anyone wants to be able to do is knock back a few drinks with the guys on Friday or have a cigarette with coffee or take a toke on a crack pipe. But very few addicts can do this. When someone goes from being able to control their habit to mugging their grandmother to get money for their next fix, that convinces me that something has changed in their brain."
But does causing changes in the brain qualify addiction as a brain disease? Not according to Dr. Gene M. Heyman, a lecturer at the Harvard Medical School and a research psychologist at McLean Hospital in Boston. "Since we can visualize the brain of someone who's craving, people say, 'Ah hah, addiction is a brain disease,' " he remarks. "But when someone sees a McDonald's hamburger, things are going on in the brain, too, but that doesn't tell you whether their behavior is involuntary or not." While acknowledging that addiction does induce compulsive behavior, Dr. Heyman says that addicts still retain a degree of volition, as evidenced by the many who stop using drugs.
"Smoking meets the criteria for addiction, but 50 percent of smokers have quit," he says. This change, he goes on, is "demonstrably related" to the data about the hazards of smoking that have emerged since the surgeon general's report on the subject in 1964. By contrast, Dr. Heyman says, "information about schizophrenia hasn't reduced the frequency of that illness." Dr. Heyman also cites a well-known study of Vietnam veterans who were dependent on heroin while overseas. Within three years of their return to the United States, the study found, nearly 90 percent were no longer using it -- strong evidence, Dr. Heyman says, that the addictive state is not permanent.
Sally Satel first became skeptical about the brain-disease model in 1997, when she attended a conference of the drug-abuse institute on the medical treatment of heroin addiction. "So pervasive was the idea that a dysfunctional brain is the root of addiction that I was able to sit through the entire two-and-a-half-day meeting without once hearing such words as 'responsibility,' 'choice,' 'character' -- the vocabulary of personhood," Dr. Satel wrote in a paper called "Is Drug Addiction a Brain Disease?"
Written with Dr. Frederick K. Goodwin and published as a booklet by the Ethics and Public Policy Center, the paper offers a blistering attack on the drug-abuse institute and its brain-disease terminology. "Dramatic visuals are seductive and lend scientific credibility to NIDA's position," the paper states, but politicians "should resist this medicalized portrait for at least two reasons. First, it appears to reduce a complex human activity to a slice of damaged brain tissue. Second, and most important, it vastly underplays the reality that much of addictive behavior is voluntary."
To support that claim, Dr. Satel cited the results of the Epidemiologic Catchment Area study, paid for by the National Institute of Mental Health, which asked 20,300 adults about their psychological history. Of the 1,300 people who were found to have been dependent on or abusing drugs, 59 percent said they had not been users for at least a year before the interview; the average time of remission was 2.7 years. "The fact that many, perhaps most addicts are in control of their actions and appetites for circumscribed periods of time shows that they are not perpetually helpless victims of a chronic disease," Dr. Satel said.
At the mention of Dr. Satel, Dr. Leshner bristles. "Simplistic and polarizing," he says of her writing. More generally, Dr. Leshner maintains that his views have been distorted and misinterpreted. Still, he says, he has lately modified his message, giving more recognition to the role of volition in addiction. "Today's version," he says, is that addiction is "a brain disease expressed as compulsive behavior; both its development and the recovery from it depend on the individual's behavior."
But where does choice end and compulsion begin? The slide showing that has not yet appeared.
Deciphering Addiction (letter to the Times)
by Mary M. Cleveland, research director for the Partnership for Responsible Drug Information
A June 24 Arts and Ideas pages article describes the debate between two camps of anti-drug crusaders: those who say drug addiction is an immoral choice and others who see it as a "brain disease." But it is also possible to see addiction as an obsessive-compulsive behavioral disorder, akin to compulsive gambling or repetitive hand-washing. Treatment for such disorders emphasizes helping people understand and manage their behavior. That includes identifying false assumptions ("I just have no self-control") and avoiding circumstances that set off compulsive behavior (hanging out with the guys).
Treating addicts as immoral or diseased makes them view themselves as bad or helpless, and makes it harder for them to gain self-knowledge or self control.
Editor's Reply to Massing
Editorial Note: This letter pretty much nails it, as long as we understand "self-control" to mean behaving in a responsible, socially sanctioned manner, not some sort of magical control exerted by a self independent in some respect of environment or heredity. Heyman's work in behavioral choice theory is all about how the voluntary aspects of addictive behavior - what gets talked about as self-control (or its absence) - are determined by the addict's social environment. For more on this see my reply to Massing below, and also see the Addiction page.
Dear Mr. Massing,
I read with great interest your June 24 New York Times piece, "Seeing Drugs as a Choice or as a Brain Anomaly." Underlying this debate, but not usually made explicit, are assumptions about volition and free will. Until these assumptions themselves are openly debated I don’t think we’re going to make much headway in resolving the controversy over the disease model of addiction.
For instance, you quote Gene Heyman as saying that "addicts still retain a degree of volition." "Volition" suggests to many people a free choice independent of environment and heredity, but what Heyman actually means by volition is quite different. It’s the voluntary component of addictive behavior, that which is sensitive to consequences, as exemplified by the higher quit rate of smokers exposed to information about the risks of cancer. Heyman believes (as do I) that voluntary behavior is just as caused, or determined, as involuntary behavior, but that its causes lie in transactions between persons and their environments; it’s not driven directly by brain anomalies (personal communication). There is no role for free will here, understood as some sort of self-originated choice that’s independent, in some respect, of a person’s biology or social circumstances.
Like Heyman, Satel certainly understands the power of environmental contingencies in shaping addiction, but she consistently reinterprets this sort of causality as a matter of the addict’s self-control, suggesting to the unwary that there might be a freely willing self that chooses addiction (or not). For instance, you quoted her from her (and Fredrick Goodwin’s) booklet, "Is Drug Addiction a Brain Disease?" saying "The fact that many, perhaps most addicts are in control of their actions and appetites for circumscribed periods of time shows that they are not perpetually helpless victims of a chronic disease." But being "in control" of one’s actions and appetites is nothing over and above having one’s behavior shaped to conform to social norms by one’s social and interpersonal situation, perhaps with the help of pharmaceutical interventions. It’s not a matter of free will.
Satel is aware of this issue, since in the preface to her pamphlet she writes: "Among the questions raised by this essay is whether the traditional concept of free will can be sustained in the face of new knowledge about biological and environmental forces that shape human behavior." Curiously, however, nowhere in this booklet does free will get discussed (I hope it will be in future publications from the Ethics and Public Policy Center, Satel's organization). Instead, Satel gives plenty of examples of how addictive behavior is a function of various factors (e.g., it can be influenced by Contingency Management, is exacerbated by "boredom, depression, stress, anger, and loneliness") but always ends up ultimately blaming the addict, as in the following: "They are instigators of their addiction, just as they are agents of their own recovery…or non-recovery. The potential for self-control should allow society to endorse expectations and demands of addicts that would never be made of someone with a true involuntary illness."
Interestingly, the second sentence of this quote draws on clear the connection between self-control and reinforcement contingencies, since addicts only have *potential* for self-control, which gets *realized* by placing expectations and demands on addicts (or by having them grow up in better social circumstances in which good behavior is the norm, not the exception, thus avoiding addiction in the first place). If such is the case, then how can addicts be the "instigators" of their addiction or recovery?
Satel doesn’t seem to want to face the implications of a scientific understanding of addiction, or behavior generally: there is no originative, freely willing agent to praise or blame for choices. Perhaps this is because she supposes, as do many, that having got rid of free will there are no longer grounds for holding addicts (or the rest of us) accountable. But of course this is wrong. The same grounds exist as before: we want to conform addicts’ behavior to social norms so that they become responsible adults. Therefore we are justified in arranging social contingencies which can shape their behavior, or, to use that highly misleading expression, give them "self-control."
To the extent that punitive attitudes (some of which I detect in Satel) are based in the notion that we are the instigator of our own faults, seeing through the myth of free will constitutes the ultimate distigmatization of addicts. This means that in choosing contingencies to shape behavior, we can no longer justify punitive contingencies on the grounds that people could have done otherwise in the biological, psychological, and social conditions they were faced with growing up, and that therefore they deserve to suffer. (They might have done otherwise if conditions had been different, but they weren’t, which is why we have to change those conditions.) Knowing that choices are not willed independently of circumstances, our attitudes towards addicts might change to become more compassionate; as a result we might pay more attention to preventing the formative conditions of addiction than to after-the-fact sanctions.
However, this is not to say that "tough love" isn’t sometimes necessary. The threat of losing privileges as a result of bad behavior does work to instill "self-control". But the default position differs from Satel’s: it is to minimize the addict’s suffering in the process of recovery, and head off problems before they start with all the resources we can muster directed at the conditions which generate addiction. This is not, as you can imagine, the libertarian laissez-faire prescription I suspect Satel might endorse.
Once those championing the disease model of addiction (such as Alan Leshner) understand that voluntary behavior is just as determined as any disease process, they won’t any longer have to deny the voluntary component of addiction in order to destigmatize addicts. But they will have to face the fact that a certain number (one hopes a bare minimum) of negative contingencies may be necessary as a last resort to restore dignity and responsibility to an addict. So the anti-stigma folks have to concede something here, as well as the libertarians.
I want to thank you again for raising this issue, but I think you’ve only hit the proverbial tip of the iceberg. Whether its depths will be plumbed, given the social reticence about exploring the issue of free will, is an open question.
...and a letter to the Times, unpublished:
To the Editors:
Michael Massing usefully examines the disease model of substance abuse, pointing out that there are voluntary choices involved in drug seeking behavior, even in the late stages of addiction (Arts and Ideas, June 24). But just as physiological abnormalities in the addict’s brain can be traced to the chemical effects of drugs, so too the voluntary aspects of drug use can be traced to the addict’s social and psychological milieu.
This means that to treat and prevent addiction effectively we must pay as much attention to the environment of potential addicts as to their brains. It also suggests that in destigmatizing addiction, discovering the environmental determinants of choice is just as important as finding the genetic and physiological mechanisms of compulsive craving.
In the light of a scientific understanding of voluntary behavior, social stigma might still play a role in helping to reduce drug abuse, but it should be applied only when other, less punitive means are proved ineffective. Seeing why addicts behave as they do will force us to acknowledge that were we handed the same genetic and environmental lot in life, our choices would have been much the same.