Author: Alex Thompson

Are addictions diseases or choices?

His view is based to a considerable extent on the case histories presented in Chapter 3, and it is that, “…whether addicts keep using drugs or quit depends to a great extent on their alternatives.” (p.84). The biographical descriptions from recovered addicts frequently point to the role of financial and family concerns, that is, contingencies other than those directly related to procuring and taking drugs, as being major factors in their cessation of drug abuse. That is, the change from abuse to recovery is based on choice alternatives.

The correlates of quitting include many of the factors that influence voluntary acts, but not, according to Figure 1, drug exposure once drug use meets the criteria for dependence. Thus, we can say that addiction is ambivalent drug use, which eventually involves more costs than benefits (otherwise why quit?). Behavioral choice principles predict ambivalent preferences, semi-stable suboptimal behavior patterns, and the capacity to shift from one option to another. To be sure “compulsion” and “choice” can be seen as points on a continuum, but Figure 1 and research on quitting make it clear that addiction is not a borderline case. Based on these definitions, then, it is proposed that addictions should indeed be considered diseases. They are clinically relevant negative states (“signs and symptoms”) following from vulnerability traits that intersect with diverse factors (“etiologic agents”) to yield replicable neurobiological changes (“anatomical alterations”).

The Correlates of Quitting and the Role of Treatment

However large that population may be, research reliably confirms that only a relatively small percentage, 25% or less, of those meeting criteria for drug abuse or dependence ever seek and receive treatment. Put in more personal terms, addicts often say that they quit drugs because they wanted to be a better parent, make their own parents proud of them, and not further embarrass their families (e.g., Premack, 1970; Jorquez, 1983). In short, the correlates of quitting are the practical and moral concerns that affect all major decisions. They are not the correlates of recovery from the diseases addiction is said to be like, such as Alzheimer’s, schizophrenia, diabetes, heart disease, cancer, and so on (e.g., Leshner, 1999; McLellan et al., 2000; Volkow and Li, 2004). Indeed, the theoretical lines so closely approximated the observations that the simplest account is that each year a constant proportion of those who had not yet remitted did so regardless of how long they had been addicted.

1. There is also no dispute, in principle, that these physiological changes may themselves change with repeated doses, nor that these changes may be correlated with subjective mental states like reward or enjoyment.
2. For example, even in the most desperate, chronic cases, alcoholics never drink all the alcohol they can.
3. To answer this question, Heyman analyzes the available epidemiological data on addicts in general, and comes to the conclusion that the majority of all drug addicts eventually cease their addiction according to accepted criteria.
4. Scores of studies support this analysis (e.g., Waldorf, 1983; Biernacki, 1986; Mariezcurrena, 1994; Klingemann et al., 2010).
5. On the y-axis is the cumulative frequency of remission, which is the proportion of individuals who met the criteria for lifetime dependence but for the past year or more had been in remission.

But There is a Genetic Predisposition for Addiction

When it comes to the rainbow of experiences in trauma therapy, there are many common themes.

A Non-Disease Etiology for Persistent Self-Destructive Drug Use

Addictive drugs change the brain, genetic studies show that alcoholism has a substantial heritability, and addiction is a persistent, destructive pattern of drug use (e.g., Cloninger, 1987; American Psychiatric Association, 1994; Robinson et al., 2001). In scientific journals and popular media outlets, these observations are cited as proof that “addiction is a chronic, relapsing brain disease, involving compulsive drug use” (e.g., Miller and Chappel, 1991; Leshner, 1999; Lubman et al., 2004; Quenqua, 2011). However, addiction is “disease-like” in the sense that it persists even though on balance its costs outweigh the benefits (e.g., most addicts eventually quit). Thus, in order to explain addiction, we need an account of voluntary behavior that predicts the persistence of activities that from a global bookkeeping perspective (e.g., long-term) are irrational. That is, addiction is not compulsive drug use, but it also is not rational drug use.

Is Addiction a Disease?

This is relevant because a common feature of addictive drugs is that they provide immediate benefits but delayed costs. Thus, it is possible that the drug is the best choice when the frame of reference is restricted to the current values of the immediately available options but the worst choice when the frame of reference expands to include future costs and other people’s needs. According to this account, persistent drug use reflects the workings of a local optimum, whereas controlled drug use or abstinence reflects the workings of a global optimum. Scores of studies support this analysis (e.g., Waldorf, 1983; Biernacki, 1986; Mariezcurrena, 1994; Klingemann et al., 2010). In estimating current rates of drug addiction Heyman appears to overstate the case.

A properly functioning reward system motivates a person to repeat behaviors needed to thrive, such as eating and spending time with loved ones. Surges of dopamine in the reward circuit cause the reinforcement of pleasurable but unhealthy behaviors like taking drugs, leading people to repeat the behavior again and again. On the y-axis is the cumulative frequency of remission, which is the proportion of individuals who met the criteria for lifetime dependence but for the past year or more had been in remission. The fitted curves are negative exponentials, based on the assumption that each year the likelihood of remitting remained constant, independent of the onset of dependence (Heyman, 2013).

There is no dispute that various substances cause physiological changes in the bodies of people who ingest them. There is also no dispute, in principle, that these physiological changes may themselves change with repeated doses, nor that these changes may be correlated with subjective mental states like reward or enjoyment. Scientifically, the contention that addiction is a disease is empirically unsupported. Addiction is a behavior and thus clearly intended by the individual person. What is obvious to common sense has been corroborated by pertinent research for years (Table 1). But while no one forced an addicted person to begin misusing a substance, it’s hard to imagine someone would willingly ruin their health, relationships, and other major areas of their lives.

Biological Risk Factors for Addiction

Research shows that dopamine rises proportionally as the goal gets closer and closer at hand, driving motivation with it. Now, if that’s the case for marshmallows and other normal rewards, imagine how powerful the dopamine surge is in response to addictive substances or acts! That swelling wave of dopamine, announcing the availability of a supremely attractive reward, thoroughly recasts the balance between present and future appeal. To choose future gain, over immediate reward or relief, becomes incredibly difficult when every synapse in the striatum and frontal cortex is resonating to the “neural now”.

This new generation of addicts included individuals who were employed, married, and well-educated (e.g., Waldorf et al., 1991). With these demographic changes, the natural history of addiction changed. More often than not, the pressures of family, employment, and the hassles of an illegal life style eventually trumped getting high.