Hi all. I’ve been low on energy for a couple of weeks, which is why I haven’t posted anything. Actually, depressed is the word. I have this whole world of opportunity waiting for me — a visit with the Dalai Lama! And yet I’m completely nonfunctional. I’ve been trying to start Book 2 for over a month, and it just seems like too much effort. At the same time, Isabel is highly stressed at work, and she brings it home with her (of course), so we argue more, which depletes my energy further.
The working title for my new book is: The Biology of Desire: Why Addiction is Not a Disease. You probably know my stance on that one. But the problem is: how to frame it in the current debate? The way I see it, most of the medical community, most if not all of the psychiatric community, most of the treatment community, and most of the scientists who study addiction (either behaviorally or neurally) do in fact see addiction as a disease. Nora Volkow, the head of NIDA (one of the nine branches of NIH) describes addiction as a disease every chance she gets. A chronic brain disease. So it’s important to refute that definition — if in fact it’s wrong. But the trouble is, you then get bogged down in this dichotomy: that if addiction is not a disease, it must be a choice.
The current spokesperson for that position is Carl Hart. Here’s the latest: a write-up and video, care of the New York Times.
Hart brings crack addicts into the clinic, they stay there for awhile, and they are offered crack to smoke on a regular basis. But they are also offered a certain amount of money each time they forego the crack. And often they make that choice: they take the money instead. Sometimes for as little as $5, and almost 
always when offered $20. In other words, addicts can choose not to partake of a highly addictive substance if they have alternative choices that are attractive. Hart deserves the credit he’s been getting for this research. He is showing that addiction is not a result of some property of a drug; it is the result of some property of the environment, namely the absence of opportunities to get rewards elsewhere. Hart compares his crack addicts to the poor, young, black, marginalized men he grew up with. He argues, very convincingly, that there were no other rewards (e.g., financial stability, steady interpersonal relationships, respectable jobs) available to them. So they chose to get high. According to Hart, it was a rational choice, given the available options.
And by the way, Hart talks about the impact of environmental impoverishment on rats too. He reviews the famous “Rat Park” studies by Bruce Alexander, which I have written about elsewhere. Here is Alexander’s own commentary on what he found out about addiction and environment.
But I don’t agree that addiction is a rational choice. Just yesterday I got an email from a meth addict who’s in big trouble. Someone I don’t know. I had answered a desperate query from this person a couple of months ago, then again a couple of days ago, saying there wasn’t much I could do to help. Then I got this email yesterday:
I am unsure of what to do or where to turn next. I tried rehab once for a few days before my body became toxic and I ended up in the hospital for a week. It was only after I tried quitting that i fell ill close to death with a high fever,failing kidneys and toxemia. Now three years later I am that much more addicted and afraid that this is what will kill me ,and it wont be long. I dont know what I am more afraid of, being sick physically and dying or staying high, falling apart mentally ,and for things to never change. Maybe this is how it was meant to be? In which case life isnt worth living and my children might be better off without me. I wish there was an antidote.
That doesn’t sound like rational choice. And I get emails like that, more or less, once every week or two.
I want to get into this debate, but where? The problem with the “choice” approach is that it completely ignores the brain. It relies on economic reasoning, not biological reasoning. But we are our biology, Our brains are not computers. They are inscribed with biases, attractions, associations, and habitual pathways of thought. Their fundamental modality is emotion — attraction and repulsion — not logic. And they really do change with addiction (as with other forms of learning). The evidence is indisputable. So, do we have to ignore the brain to oppose the disease model?
I don’t think so. I want to talk about “choice” as a highly irrational mechanism. And there’s lots of research to back that up. See Kahneman’s recent book, for example. In fact, research shows that people think that they’ve made a deliberate choice after their brains have already decided what to do. Much of this literature is quite technical, but here’s an example. I want to model addiction as a biased choice, a choice that is not inevitable but is highly probable, given the attractions that are already engraved in our synapses.
I’ve got the book mapped out, of course. I just need the momentum to get over the hump of page one. But writing this post helps. Maybe today’s the day.
Informed by unparalleled neuroscientific insight and written with his usual flare, Marc Lewis’s The Biology of Desire effectively refutes the medical view of addiction as a brain disease. A bracing and informative corrective to the muddle that now characterizes public and professional discourse on this topic.” —Gabor Maté, M.D., author of In The Realm of Hungry Ghosts: Close Encounters With Addiction
OK I don`t think Hart is correct .I don`t think crack is as addictive as say meth,herion or the big one alcohol.Before I quit drinking almost 2yrs ago,if I were in that place when I was wanting/needing booze he could have said a case of beer or $ 10.000 I would been broke but drunk.Crack I feel people start with until they see meth last longer,they get hooked and it goes from want to need.I think addiction is a disease not a choice and I pray it gets treated as just that Thank you looking forward to your next book
Thanks for your comment, and your experience sounds very familiar to me. But I still don’t see addiction as a disease. There has to be a definition somewhere between “choice” and “disease”.
I agree it’s not a disease. It’s a behavior, a bad behavior based on the rewards, chemical or mental, one is getting from the drug. A term like “diseased choice” might be a copout, but it sort of fits the addict. And to say crack isn’t as addicting as meth or alcohol is to discount the entire communities it destroyed during the ’80s, no?
Keep up the good fight. The theory of lifelong disease and overall helplessness of addicts are killing people.
I challenged Dr. Volkow to send me the proof she has addiction is a disease. The response from her staff was filled with the type of mumbo jumbo that would make a freshman science student embarrassed.
Hey Elliott, that’s great that you challenged the great lady and her team. I mentioned previously (I think) that she’s one of the seven of us who are going to talk addiction with the Dalai Lama next month. Although I’ve considered her some kind of arch-enemy in theory, she actually seems like a sweet person when you’re in the same room. I hope I get the chance to draw her into a debate when we’re in Dharamsala.
Meanwhile, I agree that the disease label is destructive for many people. But, as argued by others, here and elsewhere, it can also be helpful, especially when it comes to using health-care money to fight addiction.
Message for Marc. Get off your lazy ass and start writing . YOur fans are eagerly watining !! LOL
Disease vs choice who cares
Jack Trimpey the founder of Rational Recovery ( later to become Smart Recovery ) said it well
Who cares if its a disease or not
If its a disease , dont drink
If its not a diasease, dont drink
That being said I think its a bit whimsical for a neuroscientist to ignore the brain and the documented changes in it in the addicted person.
Of course its a disease of the brain but thats not the whole picture – as in the 3 part model of bio-psycho-socio ( and maybe spiritual ) description.
Of course choice is involved but the underlying problem in my opinion is a motivational one. Harts study shows this .
Maybe the best book Ive read on the choice thing is by Gene Heymann ” Addiction: a disease of choice ”
But then there is a huge practical problem . The disease idea is , in the US at least, finally getting the problem out of the justice system and thereby getting scads of money for research and treatment . If you turn it into a choice problem, bye bye all that lovely $$$.
Looking forward to more on this but dont expect an easy convert here .
Really interesting Marc. I am also grappling with similar questions. Where my thinking is at the moment is: While almost all the people we treat meet the criteria for moderate to severe substance use disorders, are they all addicted? Probably not. I am trying to find Hart’s original research, but not managing. I suspect that many of his test subjects meet the criteria for “Dependence” (in old DSM IV parlance), but do they meet the criteria for what I call addiction?
I know that I would only have delayed my immediate hit if there was enough money to afford a bigger hit in the future. But only if there was a chance of that future event actually occurring. Hence the whole “just one more time” battle most with addictive orders go though.
The majority of people who use drugs “self-cure” at some stage of their life because of consequences, decisional balance, other distractions and the like. These are the people who, in my opinion, are the people Hart is talking about. These are the people who are using in our underprivileged communities. These are what I call “circumstantial addicts” for lack of a better term. The problem is real, needs treatment, but is certainly, in my mind not a disease, although it looks like it at times.
Then we get the patients that will use no matter what. They can delay using depending on dose vs future dose, but if faced with no future use they will use no matter what the cost or consequence. Even when their mind screams “don’t”, their brain overrides this. Even when using is unbearable. Most people in this stage have something that looks remarkably like a disease, and may even be a disease.
I believe that there is some sort of switch that occurs along this continuum – something maybe to do with DeltaFosB levels or DA toxicity, the way memories are laid or something similar (I am not sure and neither is anyone else!) and when this switch occurs, we may be dealing with a disease and not just a behaviour at the extreme end of the bell-curve. But I am still undecided!
This two stage model makes sense to me from a treatment point of view – many treatment modalities only deal with one of the conditions described above, but seldom both.
Whatever we eventually find, even if it is choice, choice is never “simple” and “free choice” is a myth. Consider Slovik’s affect heuristic – designed to make life easier but can lead to deadly decisions in the wrong circumstances.
Complex questions, but well worth investigating!
Hi Shaun! I wanted to comment because what you said about delta-fosB as a “switch” sparked something in my mind. The delta-fosB stuff comes from the animal literature, and we are still unsure of how much such a molecular “switch” may contribute to the human condition. However, these data do hint at the possibility that there is a physical change that fundamentally alters the way rewards are processed. I know recovery is easier for some individuals compared to others, even if their outward symptoms and the number of “addiction criteria” they meet appear similar before the recovery attempt. Perhaps we simply don’t know enough about the brain to identify those that are in a “disease” state, where their brain is seemingly permanently altered, thus cannot distinguish those individuals from those that are not “diseased” and still capable of change. Regardless, I think it’s more useful, at this point, to not characterize addiction as a disease to give the hope of recovery. The more individuals that see recovery as a possibility, rather than relegating themselves to defeat by the addiction “disease,” the more we can convince addicts to keep working toward change.
Hi Liz
Thanks for the comment. I think you are making very valid points and my thinking aligns with yours. I must admit that I use the “disease” word when it suits my agenda! For example when trying to explain why public policy needs to be health orientated rather than criminal justice orientated, or when explaining to a family why CRAFT is a possibly a better intervention than Tough Love.
In most circumstances though I avoid the term “disease” and tend to stick to the terms “behaviour” and “disorder”.
I think that we needed the disease concept to bring the health/brain models into the picture, but this has, to a large degree, led to a reductionist view that often misses the broader complexities of addictive disorders, which are ultimately brought about by a confounding confluence of factors.
And as you point out, we currently have no bio-markers that conclusively prove the disease component.
Thanks you two, Shaun and Liz. You’ve brought an unusual degree of clarity to this debate. Shaun, you get the picture from your work in treatment as well as your knowledge of the brain. Liz, you are our guiding light when it comes to the most current brain research on addiction.
I don’t have much to add, except to reinforce your point, Liz, that the molecular changes in the brain need to be understood much better before we can use them as a criterion for demarcating “disease”. Are these changes “switch-like”, consistent with Shaun’s two-stage model? Or are they gradual? And especially are they reversible? And if so, how?
I still see Heyman’s recent paper as an excellent argument against the disease model: http://www.annualreviews.org/doi/abs/10.1146/annurev-clinpsy-032511-143041?journalCode=clinpsy
Shaun, this is very thoughtful, as always. You may be right that Hart’s “addicts” were not as hard-core as they might have been. Maybe that involved biased sampling, in that serious crack heads might not acquiesce to an in-residence program. And I certainly agree with the thrust of your argument. In fact, I think your two-stage model is about as good as it gets.
I’m also leery of Hart’s findings because of the issue of “delay discounting”. These people were told that they would not get the money until the end of the experiment. From what I understand of the attraction system, future rewards don’t count very much in relation to immediate rewards. And as you say, hard-core addicts will only delay a dose if they’re going to get a bigger dose later, but even that has to be predictable, it has to come soon, and it has to be certain, not just likely.
Your descriptions are very familiar to me, and we’ve all heard of (or been) addicts who would do almost anything for an immediate hit. So Hart’s subjects might indeed have been on the lower end of the addiction scale.
All I can do from here Marc is to tell you that I am sending you my very warmest wishes and empathy – and when I can’t sleep at night I include you in my list of friends I send healing Aboriginal and Tibetan chants to. I don’t know if they are of any help to you – but they do help me at least.
Maybe it will help cheer you up a bit to know that someone on the other side of the world has you in mind and is sending you his very best wishes.
Cheers,
John
John, it cheers me up quite a bit actually. How lovely. I can use good vibes in whatever form they come. So…thanks.
But my problem is that I can’t quite place you at the moment. This is terribly embarrassing. But I met quite a few people in Australia and I have no email record of our correspondence. Can you give me a hint?
I am always concerned when I encounter an “either/or” argument. I don’t think it’s a foregone conclusion that if it’s not a disease it’s a choice. Not that I know what it is instead, but I can live with two things–“a phenomenon currently in search of a definition” for one, and “a complex acquired condition” for two. There are many conditions that are critical challenges to well being even though they are not diseases, such as pregnancy and diabetes. And they are not relieved simply by choice, they have to run a course and be treated.
Whatever you conclude Marc, it may result in having to elaborate further on the conclusion of your memoir, in which you present your quitting drugs as an experience of radical choice expressed by putting the word “no” on the wall. As you said elsewhere, your life turned on this dime. The choice to quit does suggest that it was a choice to start and continue.
I am not in the field of addiction so these comments may not be subtle or sophisticated enough to help, but I don’t think you need higher brain science to start approaching this dilemma. You just need to be a human being who has struggled with any resistant change. This makes me wonder if some of the folks who work in this field see themselves as fundamentally different from addicts, which seems a dangerous stance to me.
Robin, you make excellent points. I like the term “complex acquired condition”, which aligns with the term I often use “a confluence of confounding factors”. Or in more relaxed environments ” a cluster fuck of complexities of brain and behaviour.”
a cluster fuck of complexities of brain and behaviour
BEST understandable diagnosis ever!
Great perspective, Robin. Certainly sophisticated enough for this group (I include myself!) The point about being content with ambiguity is especially refreshing. We often feel like we need to define a thing in order to get a handle on it. But many things work better the other way around. The definition may not come until much later in the process.
My own choice to quit tells me that it’s possible to exert control and willpower in the service of self-healing. But we already know that from many people’s accounts and from the statistics on recovery. So if quitting is a choice, does that mean addiction is a choice? I’m not so sure about that…
Scenario, for those who feel crack/meth is not as addictive as whatever else:
Stick ten people in two different houses apply alcohol to one to excess and crack or meth to the other to excess…
I suspect, 90 days later you’ll probably have 9.9 crack/meth addicts its the nature of the brain and the chems..i feel alcohol might be just as hard to quit or get off of BECAUSE it is advertised and in many encourgage….not the case with the latter.
But this is a very superficial argument.
Dr. Marc, I disagree with the rational choice statement. It seems highly rational-nearterm. The brain, does it not want to feel good. the quote you provide about he body being “toxic,” seems so honest and genuine…because to me i know that feeling/rational thought.
And the need for an “antidope.” It seems very unnatural and irrational to do anything else.
And again, i completely agree with the economics …. hence I think brain science will find the answers somehow…either through erasure of the connection between DOC and feeling better or/and through proper medical treatment for the natural understanding that our idea of econmics/poilitics/law/morals are simply unnatural…value ideation. We value spending time with loved ones, learning/teaching, creating…and maybe just sitting and being (lazy) meditating…putting out our begging bowl and giving …the “other” giving them the opportunity to do something loving…compassionate.
Until such time all science can do is apply the bandaids to our cognitive dissonance and the associated PTSD and depression/mania\/anxiety (bpd?).
Depression is a natural symptom for people like us people who understand at a cellular emotional level value we have be taught and propagandized into…who understand there is a quick fix and that is DOC.
Until, again, such time as we can put it all “on the table” maybe our only best non chemical cure is prayer and turning ones immense power over to a gawd du jour…
silly magic in my opinion. but i do not wish to injure.
once again disclaimer: I am a plumber helper, not a writer…mileage may vary, keep cool, handle with care….etc
Kevin, just so you know, I’ve read this about three times. I think your point about rational choice “in the moment” is pretty profound. The question for me is: yes, it’s a functional choice, it’s a predictable choice, but is it really a rational choice?
I’ll have to think about this a bit more when I’m not so tired. But I surely get your point!
Cheers,
Marc
Hi again, Kevin. I just wanted you to know that I keep on tossing around your notion that choosing to get high is “rational”. It’s a definite wrench in the spokes of the “disease vs. choice” debate, and it takes the economic (as in behavioral economics) approach to addiction to an extreme — which makes it both powerful and troubling.
Check out some of my recent replies to other readers. Like my reply to Joe, right near the bottom of this page. Your idea just won’t go away!!!
You’ve probably seen this before…but it is news to me:
http://www.wellcorps.com/Explaining-The-Hidden-Meaning-Of-Michelangelos-Creation-of-Adam.html
An excessive behavior becomes habitual. As the habit becomes the norm the system resets to accommodate it and the new setting (homeostasis) becomes the default mode. The laws of conservation of energy kick in: take the easy way; follow established pathways; deal with stress through sensitization or tolerance. Excessive bad habits create stress physically, psychologically, emotionally, and spiritually. CRF levels become chronically high, dopamine levels low. Energy levels and LTP plunge. What do kids who are rescued from abusive homes say when asked what they want? “I want to go home.” Why do we see so many clients relapse early on? It’s the draw of the familiar; it may suck but you know where you are; you know the rules. In foster care? Early abstinence? Terra incognito. You don’t know where you are or what to do. You want the ‘comfort’ of the familiar, to feel ‘normal.’
It turns out that dopamine responds to aversive stimuli as well as positive ones, especially to the emotionally stressful or fearful ones, and relief triggers a dopamine burst in the NAcc. Dopamine responds to the signal for pleasure, pain, or relief and motivates behavior. So, under adverse conditions of stress (disruption to homeostasis) dopamine promises escape and relief through the already established and easily accessed pathways to the default setting. And under stress the promised outcome is overvalued:’things will be different;’ ‘it wasn’t that bad.’Then the relapse is reinforced by the dopamine burst of being back on familiar ground.
Obviously there’s nothing absolute about the setting or nobody would get better. Hope provides motivation to change the setting. Short term stress and CRF enhance energy and LTP.
Hi Nicolas, I often refer to the “default” setting. The familiar operating procedure. The both neural and actual paths we take. As you say we find comfort in the familiar, even if that is uncomfortable.
I liken it to a field of long grass. We walk a path from A to what we hope is B. as we repeat that path it becomes more difficult to walk a new path even if we suddenly find we are ending up at C. Then, after much effort, once we have discovered the right path, all it takes is some distraction and we end up on the wrong path again. That is how I see it, and I think that is similar to what you are suggesting? or a useful metaphor for what you are saying?
WOW- I really like the walking in tall grass metaphor. Stowing away for future use.
What seems to me to be highly irrational is a society which caricaturizes (calls it a disease) the very natural human need to feel good and makes one to want to unnaturally feel guilt and shame for wanting to feel good, really good.
XA 12-steps and the moral/financial elite prosper while the subjugates (slaves) have to work to fall in line, bondage and such…
i know paranoia, ideation…with a liberal helping of ego.
Blech!
There is an analogous situation in physics which might serve as a metaphor.
I’m talking about the particle wave duality in Quantum Mechanics. Sometime a sub-atomic entity can be best understood as a wave other times as a particle. Insisting on one or the other simply ignores lot of the electron’s (for example) behavior.
Maybe addiction behaves sometimes (under certain circumstances) like a disease, other times as a choice. A single theoretical model has to ignore a lot of known behaviors.
Beware: This is a metaphor. There is no mathematical model comparable to Quantum Mechanics for dealing with mind/brain/addiction. I don’t expect one will emerge either
I would agree with your point 100%. It’s a great metaphor.
OMG.. I knew physics would creep in here sometime 🙂 . However I agree its a wonderful metaphor. Problem is you mention Quantum to most people and they flee in terror .
The reason for that is that people in general like certainty. When you tell them that reigning theory in theoretical physics (With a record of 100 million Victories to 0 defeats, almost all by knockout) is all about probabilities and offers zero certainty they don’t know what to think.
That is because it CAN’T (not even sort of) be resolved intuitively. I believe it was Bohr who said “There is no Quantum ‘reality’ ” Under Quantum Mechanics an electron is not a thing in the sense that a brick or a table is. It “is” a “wavicle”. And forget about “understanding” it. Just watch it’s behaviors, which in large populations are absolutely predictable.
We definitely aren’t in Kansas anymore but, understandably I think, most people don’t want to leave Wichita.
I suspect addictive behavior is similarly impenetrable under a “classical” view of the world.
Oh dont get me wrong , I talk physics all the time. Im not a physicist but love it. Fascinated by the similarities of buddhist thought and modern physics proven laws and theories.
Wasnt always this way but a few years ago got interested in consciousness and felt the answers were to be found at the quantum level so started to learn it.
May well not be there but what the heck- at least I know a few things I didnt before .
Ok, but the quantum description is simply useless at the scale at which we conduct our business. (large multicellulars lumbering around on a smallish planet). Here at home, rationality is the best approximation to truth, and prediction is its test. Not perfect, but it works fairly well, it keeps us sane, and it actually helps us to direct our lives.
So let’s not give up on trying to explain the WHY and HOW of addiction. We’re going to get there.
Good god.Who suggested Quantum Mechanics can be applied to human behavior?
It was a metaphor. What I was proposing is that arguing about choice/disease as either/or may be futile. Maybe addictive behavior is innately complex and can’t (maybe ever) be described as either disease or choice.
Jeff, I would never accuse you of using an idea from quantum mechanics in explaining human behavior !!! 🙂 !!! And I understand the point about refraining from choosing one definition over another — disease vs. choice — so that the “wave function” remains “uncollapsed”.
My deep thought was simply to wonder out loud whether an analogy borrowed from quantum physics could ever apply to our activities (including linguistic activities) here in the world of little big men. There’s such a thing as stretching a metaphor or analogy — no harm, no foul — but maybe there’s a limit. You wouldn’t want to use, say, an idea taken from cosmology to help explain U.S. politics. Maybe an analogy from waste management….
Marc, my comment comes from the me as a writer, as opposed to the me as a therapist or addict. I know this is less than profound, but my advice is just “DO IT.” Sit your butt down at the computer for a given amount of time, say an hour to start, and just sit there. Write anything. Write from this blog, as you indicated. Continue it, or not. Just write. You may write a bunch of crap but that’s OK, you’ll fix it later. Just don’t worry about it. Just do it. Whatever anxiety is stopping you, well, you’ll lose that in the act of writing which is not unfamiliar to you. As long as you give yourself the opportunity you’ll feel better. Even if you don’t write during the hour, do it again later, or tomorrow. It’ll happen… I’m sure.
Nicely said, Denise. 🙂
Thank you!
Really good advice. Thanks a lot, Denise. I have actually done everything but. I’ve done the equivalent of sharpening all my pencils and laying them in a row.
Ok, it’s Sunday night, but tomorrow morning I will write SOMETHING. I promise.
Marc, for what it’s worth I’ve often thought of the similarity between wanting to start something, e.g., writing, and wanting to stop something, e.g., a drug habit. With both, one has to “just” do something, i.e., start or stop. Both are about overcoming a habitual response to something; both are about getting oneself to do something about what one deems as “good” or “bad”; both require a strong motivation and commitment to whatever the desired outcome is. I’d venture to say that whatever it is that keeps us stuck on an undesired behavior (besides physical addiction!) is the same as what keeps us stuck on not doing a desired behavior. Perhaps thinking of it like this will help you get going, and continue going. Aren’t both about following through on what we say we want? If so, then what has helped to keep you sober might help you get writing…
HI Marc
The Grenade again. I believe the crack study is the biggest crock (purposefully punnish or is it alliterative?) and here is why. If you offer a REAL addict a lousy $20 or a hit of crack he will take the crack every time, especially when you consider that is less than it costs on the street.If it was more the study is still flawed because the addict would hold on until he could “double score” with the money earned. Ridiculous premise.
As “disease vs disorder”. My brain chemistry specialist and I have had this conversation several times and at length. I have never felt comfortable with disease” especially since it is not something you catch from the surrounding.environment, there is a voluntary aspect in early days, and I believe the term “disease” was used in the original AA (not 12 Step) “Big Book” put there by Dr Bob and Bill W for psychological purposes.
Most if not all alcoholics have a psych component of self loathing primarily due to their belief in personal moral failure. Calling it a “disease” is a big step forward because then they can blame their condition to a large extent on external circumstances.. At the same time we are taught personal responsibility for our actions (my favorite topic when discussing the geopolitical and cultural trajectory of Western Society) so hopefully the addict will not fall into the trap of habitually externalizing blame for all the woes of life..
My preference is and always will be “condition” or “disorder” because of the triage of multiple components including the voluntary, inherent tendencies, and seemingly innocuous drug combinations create a fertile environment for addictive behaviors.
i agree with basically all of this post. The choice of the crack addict is a no brainer. Interetingly, working and fighting around the equality act, as a reverse thought experiment I have been sending on line surveys to people one year plus into recovery as to whether they would prefer to stay on benefits, or earn less money net per month with a job, The responses so far have been 1000% in favour of the latter, It is a strong indicator of motivation. As regards to disease – kind of semantics – the condition if anything isurely s one of mental health, and genetics I personally believe play a part only in so far as family behaviors and circumstances can structure how we cope (or dont) with the world.There may be some crazys out there that think you can cure cancer with a positive mental attitude and hard work, addiction however I think or at least really hope you can
on reflection, the crack addict would take the 20 five times in a row. buy 100 worth, keep 20 worth for themselves and sell the rest for 140. Addiction is binary, nothing else matters. the crack addict in active addiction would not want 20 for anything else other than a means to the hit.
You have a fine insight into the addict’s brain. But at the heart of the issue is delay discounting again. Your hypothetical addict is saving up a present reward for a future payoff. That’s not easy, whether the currency is money or drugs.
I disagree – or perhaps I am not understanding your point. The addict is clever in their addiction. They will know exactly who to sell to, and how long it will take, the ratio of what to sell v what to keep ensures that they have all they want until they have finished selling. And if it goes wrong and they do not sell it all in time, they will take the rest themselves.
Yes, addicts do develop formulas for keeping the supply coming in. So if that’s the plan for the remaining 140, then yes, it makes sense.
Hi JLK. Excellent points. Also see Shaun’s comment, above. As someone on the front line, he also questions whether Hart’s users really were addicts, because, if they were, a small payoff days later would simply not register on the radar.
As far as I know, the “disease” label started to get used by AA in the 50s, once Hazelden got into the act and NA was using it to refer to heroin addiction. But let me know if I’m wrong.
And yes, the disease label had a valuable function in reducing overwhelming levels of shame, so that alcoholics could actually function psychologically well enough to start to take control of their lives.
I question whether we can limit the shame but also limit damage caused by the disease concept itself.
Hi Marc,
Can you quantify, at all your statement “the disease model had a valuable function in reducing overwhelming levels of shame,”
Seems to me that if that were true, labeling other physical-psycho-social conditions such as sexual abuse as a disease would do the same- or no? If I was diagnosed with “Molestationism” and to label myself as a “Molested”, would that produce the pre-requisite shame reduction for me to take control of my life and in reference to JLK’s statement, hone my ability to take responsibility for my actions and cease habitual blaming of others?
Seems to me that you may not know the Disease theory as well as you thought.
Not to be rude because I think you’re very insightful and reasonable on the subject of addiction, but Kevin’s right you underestimate the ego and it’s equal if not more powerful force and complexity than neuroscience. Freedom from ego seems an impossibility- an idea too extravagant to even be able to allow for private thought on the matter, let alone speak publically.
But enlightenment is absolutely possible and available to every human being alive if we could only turn our attention towards it. Ego is, by its very nature, not a “rational” choice maker- this is what we sentients need information, guidance and nurturance with first and foremost.
Just sayin,
Kristin
Hi Kristin. Many many people — including anti-disease-model crusaders (like Gene Heyman, Stanton Peele, and Satel and Lilienfeld in their recent book) acknowledge that calling something a disease, or simply a biological fact, can reduce the sense of personal responsibility and shame. And yes, addicts can feel less shame about their addiction when they see it as a disease. I’ve come to accept that by reading authors like those I just mentioned, but also by reading many of the commenters in this blog. I suggest you do the same.
I don’t see the shame thing as a moral issue one way or the other. It can be very helpful if it serves as a conduit toward recovery. And yes, it can also interfere with recovery by eroding the sense of personal responsibility.
That doesn’t mean that I think that abusers should forgive and forget their crimes because they claim to have a disease. That’s a whole different can of worms. Abuse (or accidents caused by drunk driving, for example) involves harming others. Addiction involves harming oneself (arguably). When it comes to crimes, especially those involving violence or cruelty, I go more with Thomas Szasz, who says that it’s impossible to determine “not guilty by reason of insanity” since the evaluation of insanity is unclear, subjective, and often conflated with moral issues.
I have no idea what any of this has to do with ego and enlightenment. If by “ego” you mean investment in oneself and one’s goals, then yes, it is a paramount target for shame-inducing judgements. But it is also the force behind trying to get off the hook.
I’ve read a fair bit of neuroscience and have followed Sapolsky’s work around stress quite carefully and it strikes me that addicts are really outliers on a bell curve of reaction to drugs. The majority of people (68%, that is 1 standard deviation from the norm) can ‘handle’ drugs like alcohol, nicotine, heroine, etc. without getting obsessive about it (addicted) while outliers cannot. Last night on the CBC there was an item on whether or not one can get addicted to food or exercise. Well, some people definitely get obsessive about these things but like the drug issue, I don’t see it simply as failed brain chemistry or moral turpitude. It’s complicated, as you well know. In whatever case, ‘society’ doesn’t easily tolerate outliers in any field of human activity. Their individuality threatens the cohesion of the group. I’m thinking here even of people with physical disabilities, Down’s Syndrome or other obviously non-moral conditions. If outliers can be ‘cured’ of their individuality with treatment, fine. if not a little social distance is required. No doubt there are people with scrambled brain chemistry who can’t function in any real sense. It may be that increased and sustained drug use alters brain chemistry irrevocably or maybe not. I’m no neuroscientist. But I am a sociologist and I do understand the social dimensions of obsessive behaviour. Otto Rank wrote a book called Art and Artist in which he compares artists to neurotics, neurotics being failed artists [that’s a complete oversimplification, but for now, it’s ok]. People who display obsessive behaviour may be expressing a sort of individuality that is part visceral, part biological and part moral. A radical individuality, so to speak that rejects for many reasons the people and their ‘normal’ preoccupations occupying that magical 1 standard deviation from the norm. So, yeah, it’s complicated.
I really like that one standard deviation idea and imagine that 2 standard deviations would identify those who would fall into the old catefory of dependent
– But who falls on the other side of that curve
Outliers, perhaps. But not just a scatter at the edge of a bell curve. Rather, addicts form a real group — which is to say there is a category (called “addiction”) that is naturally occurring, has certain features, and which shows up in many societies and groups. People within this category have a lot of things in common — outliers don’t, necessarily. Some of that commonality might be what got them there in the first place. There are certain conditions that give rise to forest fires, and forest fires have a typical profile. But I’m pretty sure that some of that commonality does have to do with brain changes. And that’s probably also the case for exercise nuts and concert pianists as well. Experience does change the brain, and common experience can change the brain in a predictable, common way.
Yes, I can imagine it might be difficult to start a book refuting the notion that addiction is a disease state. 😉 As you know I’m with Nora Volkow on this one. It’s the best metaphor we’ve got. I understand the middle ground you are trying to stake out between desire and disease, and we have in fact discussed this over dinner. Going to be a tough job but I know you have been giving this dilemma a lot of thought. I didn’t take away much that was useful from Carl Hart’s book, so I’m looking forward to your next take on it all.
Thanks, Dirk. I wondered if you’d chime in. Yes, I remember our conversation well. In fact I’ve been back to that twice. Great decor, love the Art Deco, but the food is typical Dutch, i.e., it kinda sucks.
Yes, Dutch cuisine nothing to write home about, it must be said. Pretty place to eat, though, like you say. Sorry to miss you this year.
Dirk
PS: I think a lot of the problem stems from diagnostic confusion, seen most easily with alcohol. Thanks to muddled thinking by the NIAAA, there’s an ongoing tendency to conflate alcoholics with problem drinkers. Alcoholics have a disease and problem drinkers don’t. So once you mix them together, you can say just about anything you want, since you’re analyzing a basket full of apples and oranges….
Dirk, I agree with your summation that much of the problem stems from diagnostic confusion. In my setting there is a huge amount of past trauma and the legacy of apartheid. Unemployment is high and there is a black market economy centred around drugs. Many people use drugs. The majority of them possibly. The majority would meet the old dependence criteria. Having said that, the majority of these people would simply stop using in different circumstances. Solve the socio-economic (and Alexander would say spiritual) dilemma and most of the substance use would die a natural death. But there would still be an addict population for whom the improved circumstances would make zero difference.
Interesting, Dirk and Shaun. Dirk, I do get your point. And I get Shaun’s emphasis on environmental factors. In previous comments, Shaun has proposed a two-stage model that I think works really well.
If life were a stats problem, we’d just partial (factor) out the environmental causation, and see what’s left. The trouble is, stats are no good at problems that change over time, and people start building their environments through their actions. Not only that, but in a sense the environment starts with the memories you’ve already laid down, the echoes in your brain directly following that first flare of desire.
Having run a gamut of addictive behaviours from less-healthy to arguably more healthy, and a wide range of definitions, ‘treatments’ and therapies, and lifestyle ‘choices’, my personal perspective now gives a good deal of weight for the theory of Alice Miller, and the application of that work as described by Jean Jenson in her book “Reclaiming Your Life”. Whatever gets us to actually understanding, processing, and healing the underlying emotions that create the fear and angst is more important than the label we put on our dysfunctional behaviour.
Thanks for sharing honestly, Marc. I am working to resolve writer’s block myself at the moment.
I so often feel such a fraud by retyping my own writing on here but thus post really hits home. I too have run the whole gamut – and spent twenty years chasing seeking it out. I had not connection with anything else, as I think i have bored you way to much with already, but Maureen me too – from anorexia to something far far worse, . this was the first thing i wrote after a whole year in rehab. “Recovery is not an issue of substance misuse, it is the attempt to grapple with something more fundamental and terrifying – it is about coming to terms with the fact that starving cutting drinking using abusing, is not normal. Recovery is about addressing why I have accepted these patterns of behaviour into my life, why I have indulged them to the extent that they became the only thing that made sense to me; why they became the only thing that felt real.”
ps re writers block – it has taken me nine hours to write 300 words today. An American friend of mine used to talk about lake droop -she lived Rochester New York and would go home after every term at university and sleep the entire break come back and write 10,000 polished words in a weak. I call them duvet days. The days you have nothing in you, nothing to say, nothing to give nothing to think. I guess we ride them out.
In terms of my addictions, dealing with the non excited stimulated over enthusastic brain is the big test – addiction at the end of the day I think all around is about trying to control and change mental states, And much as I recoil from it, sometimes three days under the duvet listening to radio 4 you just need.
There’s nothing wrong with repeating words that are relevant, and these certainly are. It sounds like you’ve been on an amazing roller coaster. I was too. And now we sit looking back on it and trying to figure out what to write.
I agree that the underlying hurts and hurdles are crucial to understand. But addiction is a dynamic thing, a developmental process, and it creates its own currents of trauma, some of which can be so devastating. So I don’t think we always start by looking at what’s in the basement. Sometimes you have to start on the main floor.
Good luck to both of us, Maureen. I actually squeezed out three paragraphs yesterday…
Hi Marc,
Sorry to hear of your difficulty getting started. It’s because you’re grappling with fundamental issues.
//The working title for my new book is: The Biology of Desire: Why Addiction is Not a Disease. You probably know my stance on that one. But the problem is: how to frame it in the current debate? The way I see it, most of the medical community, most if not all of the psychiatric community, most of the treatment community, and most of the scientists who study addiction (either behaviorally or neurally) do in fact see addiction as a disease.//
There is the saying, “To the man with a hammer, everything looks like a nail.”
I think you have to start with the ‘disorders’ of DSM IV. Are they diseases? The psychiatrists decided on ‘disorders’ because of the connotations of ‘mental disease.’
What is your basic concept? Is it ‘healthy functioning’? Then the DSM entities, from crippling ‘generalized anxiety’ to ‘substance use’ (or whatever the current label is) are departures from that. Even ‘disorders’ may not be general enough. “Engrained Patterns of malfunctioning”?
The reason the ‘addicts’ prefer ‘disease,’ (and I hear it in 12 step groups though it’s not exactly based in the Blue Book) is that the basic concept is *something that befalls one.* The basic culturally endorsed dichotomy is between “getting measles” which befalls you, and “staying in bed late to watch movies,” which you choose. Even there, the line gets blurred, for, say, the disease of gonorrhea, which one choices play a role in getting.
Further, many diseases require new choices as part of cure, E.g. heart disease may require you to give up fatty foods. Make better choices. They do affect the disease and its cure.
The doctors or therapist are fine with “Look what’s befallen you,” because with the ‘disease’ label comes the drs’. access to being paid for his ‘curative’ treatments.
As several writers above has said, one needs a term for these ‘conditions’ which one slides into, and which are often hard to get out of, by simple ‘good choice’ (like, say, ‘get out of bed.’) There is always the mega choice of “See a therapist or doctor.”
The good side of AA and most therapies is that they do, for all the ‘disease’ talk, say, “You made a lot of choices along the way, which worsened and ‘fixed’ (set in concrete) some behavior patterns.” I think that approach is needed by all helpers and ‘addicts.’
The problem is you can’t ‘choose’ your way out of some conditions, including using drugs. You can choose a re hab, or choose to move neigborhoods, or to get a new therapist or dr. The basic choice mechanism is damaged and scaffolds are required while that power is hopefully restored as much as possible.
If I understand you correctly, Marc, you want to say a learning mechanism has gone awry. It’s set up its own little world of rewards, and they don’t accord with those of the ‘outside world.’ (As in the ‘crack addict’ choices, scenarios). Your problem, of course, is that other ‘disorders’ are learned, e.g. any of the compulsions did not exist at one time; their anxiety relieving properties had to be learned.
(There are biochemical events that exacerbate or relieve anxiety, of course.)
I suppose you want some residual category for real physical impairments, like those caused by syphilis or alzheimers. But the problem remains that even ‘personality disorders’ –e.g. narcissistic disorder– is obviously learned.
Really, you are dealing with unproductive or self destructive ways of living. You want to say they don’t just befall one, like measles, but you can’t quite say, “Make these and these choices, and you’ll be recovered.” Nor can you say, “Given your condition, ‘choices,’ or what you think are choices, don’t matter.”
The thing is that doctors ( and I am one) are taught to think in terms of disease ( and their “cures” .(.coming from the time of Hippocrates..think oath that most graduating medical students take during graduation ceremonies )
Fortunately the focus is shifting to wellness just like psychology to positve and neuroscience to normal functioning .
And debates like this, and Marc’s to be started book will continue to foster that discussion to the benefit of all
The final chapters are yet to be written.. So get cracking Marc
It is a very nice synopsis, Bill. A good final paragraph for the introductory chapter.
So far you’ve been very helpful. Do you think you could just write it for me?
Here’s the deal Marc
Ill write the final chapter– but only after I see the near final draft of the rest ot the manuscript LOL
Poke Poke
This is an excellent summary of the issues and very much in accord with how I see it.
Marc, I’m so excited about your new book! I’ll be one of the first to buy it. Can’t wait.
It seems to me you have the beginnings of your new book right here in this blog post. Just lay out the two opposing sides (disease vs. choice), as you’ve done here, and state you’re asking the question, where is the middle ground? Yes, addiction is a choice, but one that’s very skewed depending on how each individual brain is wired.
You’re off to an excellent start here. I wish you much success in getting out of your funk. I work with authors every day, and my experiences with them tell me how hard it is to get down to writing. I’m willing to bet that once you do sit down and tackle it, the words will pour onto the screen. Best of luck with it!
Thanks very much, Charlie. For your understanding and your confidence in me. Indeed I have learned a great deal from this blog community, especially about the hidden complexities of making choices. In fact, I will be using quite a lot of narrative writing, taken from interviews or chats I’ve had with many of you. I want the book to be alive with the anxiety, turbulence, and drama of addiction and recovery — not just a dry scientific treatise. And that format has been endorsed by my publishers, so I’m set.
I actually wrote the first three paragraphs yesterday, and that felt like a home run. Let’s hope the rest goes as you predict!
Hello Dear Marc,
I imagine well that you are exhausted. This is all so BIG. It makes my
brain hurt. And writing…
as David Foster Wallace said, “Writing is like trying to carry a large sheet of plywood
in a very strong wind.”
Be ever so kind to yourself, Marc.
We are with you. Such a big subject. Such a giant sheet of plywood.
I am well. My son “Martin” is well. He is on the path of well-ness.
November will be our time of reunion. And all I know is that out of the helpless, horrific years of suffering … the love survived.
Thank you, Marc for taking this very difficult walk with all of us.
We believe in you. Thank you for believing in all of us and sharing this journey
and being the voice of compassion and healing.
Sometimes I think we just don’t, and never will have the words or the formula to
describe addiction. Words fail me. But I do believe in the human spirit. It never
ceases to amaze me.
Peace. Joy. One word at a time. from Janet
Well, on the one side of the mean are those people who the closer you get to the 3rd standard deviation the easier they become ‘addicted’ because of physiological, psychological and social reasons. On the other side of them mean are those people who, the closer they get to the 3rd deviation, the less they are affected by drugs or the less they are susceptible to obsessive behaviour. Some people will never get addicted, no matter what they do. The 68% in the middle of the distribution will have a ‘normal’ relationship with drugs, etc. There is no easy answer to the issue of addiction. The concept itself must be up for discussion in my mind just as Szasz questions to concepts of schizophrenia and mental illness.
Hi Roger. I remember Szasz very well, from my days of studying “antipsychiatry”. Yes the definition is truly important, because so much else rests on it. At least that’s how it seems to me.
To take an alternative view, I just went to a very nifty lecture. This Dutch researchers looks at huge networks of psychiatric symptoms and cluster-analyzes them. Then he uses the symptom clusters as the diagnostic categories. There is no need for an underlying, global disorder, like depression or anxiety disorder, in his view. A lot of things just correlate. And by that logic, feeling isolated, helpless, needy, and compelled to return to a source of available relief is just a cluster of things that go together. For most people.
Hmmm, could the universe really be this orderly?
Does the perception of patterns in random data through statistics imply order? I have always thought of statistics as a filter allowing chaos to be processed in an orderly fashion; it is a way to separate data relevant to the problem under study from the ocean of random and irrelevant data that obscures it.
But doesn’t that imply order? There’s a lot besides beauty that’s in the eye of the beholder.
Bill, I agree with everything you said. But you didn’t read my post carefully. I DON’T ignore the brain. Just the opposite. And I want to model brain changes — which I’m well aware of — as an instance of learning, a deeply embedded habit, rather than a disease. This habit becomes a pivot point in decision making…because it IS motivational. That’s the problem.
Oh Sorry Marc
I DID read it carefully and was poking you a little to get you going 🙂
I would have to be very dense to even for a millisecond think youd ignore your baby
xoxoxox
Ok, pokes are fine. Actually pokes are great.
PS. Too bad we didn’t meet up in Boston. You seem, um, swell!
I don’t believe their is any one diagnoses for addiction and with harts study, sure people will take an alternative to their drug of choice like crack only… and I say only at a certain stage of their cravings. During the Jonesing stage of graving from crack form most, the alternatives are endless only to use that alternative to getting more crack.
Hi Richard. A very similar view was expressed by others, including Shaun and Mimesis. Check out their comments. I definitely get the point.
Through my reading and participation in this forum I have come to see addiction as a maladaptive response to pain–physical, mental, or social. It is a positive feedback loop; it cycles faster and faster until it proceeds to destruction. The drive to find relief from the unbearable stress must have at some point in our evolution as a species have resulted in increased chance of survival. In the absence of an environmental or cultural outlet for that drive and in the presence of substances, behaviors, or activities that provide relief, however temporary or ultimately destructive, comes addiction.
It may be a layman’s misunderstanding, but what I have gleaned from the discussion is that the potential to get caught in the destructive feedback loop is a feature of our cranial terrain and chemistry. The potential to perceive that the pain of remaining stuck in the loop is greater than the pain and effort required to escape it, is there as well. Some people perceive the benefit of escaping the feedback loop so easily they never become stuck. Others will be jarred out of the loop along a spectrum of pain and difficulty ranging from mild to severe. Some people will never escape.
What we seek is the mechanism to turn the positive feedback loop of addiction into a negative feedback loop so people can return to a state of equilibrium. I don’t know how we get there. I remember being stuck at the point where neither of the choices before me, continuing to feed my addiction or quitting, seemed like a very good choice. Both roads looked equally impossible. Time and practice have changed my perspective … one road leads no where; the other leads to a future. There were people along the way who said it would get easier. Despite how painful it was at the time, I chose to believe them. They were right.
Great comment, Chris! I agree with almost everything. I especially agree that addiction is a positive feedback loop. Each time we relieve the stress with an addictive substance or behaviour, it rebounds with greater intensity a little bit later. So we continue to learn to get relief in a way that increases the need for relief. That’s a key explanatory platform. What the brain offers is a way to conceptualize the changes in behavioural compulsions, associations, value attribution, expectancy, all that, which get laid down over time — developmentally. Feedback loops need to keep track of themselves, so to speak.
I also agree that there is a meta-perspective that makes all the difference and that can initiate an opposing feedback process. But that may also be positive feedback, not negative, when you look closely. Because… the relief also builds on itself. As you said, it gets easier. Each success reduces the intensity of the anxiety, disappointment, sense of betrayal, etc, making it easier to abstain the next time around.
The only thing I disagree with: you say– “The drive to find relief from the unbearable stress must have at some point in our evolution as a species have resulted in increased chance of survival” — well, I think you’re putting in an extra step. Stress relief was always adaptive — it allowed us to function more effectively. In fact the whole emotion system evolved (after we sloughed off “fixed action patterns” around the post-amphibian level) to move us toward psychological equilibrium; even rodents want to “feel ok” (because it feels ok to feel ok, that in itself is the goal) Well that’s enough, and of course that’s already a product of evolution.
Anyway, that’s a minor quibble. Thanks for your input!
Well Marc you have certainly stirred up the pot of debate on this one. I too could write a book on this subject, and like you said getting started is the tough part. Their is just so much to consider around this subject. When mothers came out with M.A.D.D Mothers Against Drunk Drivers I came out with my own called S.A.D.D Substance Abuse Defiant Disorder. I too have been fighting against the single diagnoses for recovery in that the disease model state does not cover all. More importantly it was not something I could except as part of my recovery. For some this is enough and they except this as a disease and never drink again, for me if it’s a disease then it can be cured. So my journey of recovery was a long journey of understanding and knowledge which has led me to change up my opinion many times. Today I think of the Disease over Choice model both apart, and in the same, as to the brain, which is diseased by the drugs or the alcohol and the choice as separate and of the mind. I’m trying to keep my reply short but it’s hard Marc… hahaha.. It’s like your mind knows what’s right and what’s wrong but your brain bombards the mind in all the choices for the mind to figure out, and some times it’s easier to just give into the brain, to shut it up for awhile.
You make me laugh, Richard! Which is a nice feeling. I think I was following you until you started going in circles. But yes, I remember that you’ve previously expressed some defiance and a sense of unquenchable individuality — wanting to do it your own way, without submitting to expert opinion and all that goes with it. And yes, the disease model is the major hub of expert opinion these days — and it doesn’t leave much room to be an individual and figure it out as you go along.
I have observed that whenever an issue comes down to a dualism – such as disease vs choice – the answer seems to not only fall somewhere in the middle, but also outside of the dichotomy itself. I am starting to see addiction more as a systemic problem: you can’t make an automobile microwave your leftovers.. the nagging intuition I have points towards *evolution.* We were not designed for the environments we currently must navigate to make the choices we must make, to adapt as quickly as we must to function well during our elongated life spans. We were not designed to override our biology (neuro or otherwise), yet nowadays it is becoming imperative. I think the answer lies outside of the limited spectrum of disease vs choice – all the way down to the infrastructure that framed it in the first place. You can’t make a school of fish elect a representative governing body to create a system of laws and intentions for the benefit of their offspring’s offspring’s offspring in the current oceanic environment. How were we designed to react to certain stimuli? How/why have those systems gone awry in our current world? Would we consider the automobile to have MDD, microwave-deficiency disorder?
Another hunch is that those of us who seem to be more “hard-wired” than others might have a trait that was actually adaptive under certain circumstances in our past, but that may have outlived its usefulness. Food for thought.
Really thoughtful stuff, Joe. Seriously. You’re right about looking outside the dichotomy. In fact, I think that’s what we mean by “false” dichotomy. And I totally agree that we need to shoot for a functional explanation — seeing addiction in terms of how we work, how we learn, how we feel in response to incoming stimuli. AND all that needs to be grounded in a hard-nosed biological account that recognizes our evolutionary trail. What’s actually I think a bit brilliant is your analogy with cars and microwaves. In fact, if we’re doing what we were made to do (no more, no less) then the concept of a disease just doesn’t work. I strongly agree with that perspective, but you’ve framed it more neatly than I ever have.
I guess what I disagree with is the idea that we never had to (in our evolution) override our biology. Many parts of the cortex (lateral prefrontal, anterior cingulate) evolved precisely because animals had to make choices and NOT just follow some unitary “gut instinct”. The dog who is torn between approaching an object (food or sex, for example) because it’s attractive and going the other way because it’s dangerous. Everything above a reptile, approximately, has some cortical resources for countering urges because they are too dangerous to pursue (in other words, because of opposing urges to stay safe). I guess it’s just “inhibitory control” — and we study that a lot in laboratory animals, like rats. For example, google the “stop signal paradigm”.
Yet I do agree that our present societal environment is so whacked, in relation to our ancestral environment, that there are novel and sometimes very unfortunate consequences — coming out of our “natural” capacities to choose one kind of opportunity (e.g., trusting a substance because you can’t trust another member of your species). As another reader said, I think Kevin Cody, there is something very rational about choosing relief by plunging ahead with our addictive behaviour — even though it can kill us in the long run. I interpret him as saying, simply, it’s natural. But it’s taking place in an environment that isn’t.
My thought is, when addiction is accompanied with a mental disorder, such as depression, it becomes a disease, a new disease (addiction-depression). If addiction stands alone, no complication, it may be a choice.
Since mental disorder is often co-occurred with addiction, I think, that may be where the “disease” theory draw from.
I just went to a talk yesterday, where a psychiatrist was reporting that nearly ALL mental disorders don’t come alone. In other words, comorbidity is the norm! And yes, you’re right, that is so very true and obvious when it comes to addiction.
But does that make it a disease?
This psychiatric researcher was saying, and I agree, that the “bunching” of disorders really means that we were wrong to characterize them as unitary disorders in the first place. He wants to get rid of the DSM labels and look at mental/emotional problems as big clusters of symptoms — things like negative mood, irritability, sleep problems, over- or undereating…whatever goes together in a cluster in many people.
With addiction, it’s clear that frightening experiences (e.g., trauma) as well as dread about the future, impulsivity, a sense of isolation or loneliness, all that stuff….just goes together. But that’s almost the opposite of a disease, which implies a very specific intrusion or shut-down or whatever: like the relation of diabetes to insulin production in the pancreas, or pneumonia to an infection of the lungs that permits fluid to build up, which further weakens the capacity to fight the infection.
In sum, I don’t see that comorbidity supports the disease concept…
Comorbidity exists for sure and I know in the addiction arena,” overdetermined”. The question I will proffer is ,” does the overdetermined roots of addiction help push it into the disease concept definition or out” . Or neither ?
Marc ,I agree with you on the comorbidity its a non issue in relation to the disease concept .
jim maguire
By that do you mean that it doesn’t advance the argument one way or the other? If so, I agree. Overdetermination is a really important concept. For those who don’t know this term, it means that many roads lead to Rome. It means that a particular outcome is a result of many causes, or any causes — it’s a highly likely outcome which is actually hard to avoid — given certain precursors or certain contexts. I was catching up on “The Wire” recently. Growing up black and poor in a Baltimore slum made it very likely that these guys would become drug dealers — or at least drug users. It’s overdetermined. And that’s pretty close to what Hart is describing in his subjects, but the way of thinking about cause and effect is really different. The outcome is more “fated” than “chosen”.
Anyway, I think certain states, like addiction, or depression, or even dyadic states such as abuse and/or co-dependency are overdetermined in the way you mean, Jim. They are holes waiting for a rolling ball to fall into. Or low-points in a terrain into which water pours when it rains, increasing the probability that they will get deeper and become pools. This image comes from the “dynamical systems” approach, which I’ve found very helpful for thinking about child/adolescent development.
If Drug Addiction is all about CHOICE, then I would have conclusion like this:
1) Addicts are over spoiled self-centered brats.
2) They are so stupid. They risk their lives, careers, families…homeless, going to prisons… all for that rush.
3) They are criminals.
4) They deserve all the bad things they got.
5) Nobody can help them. Lucky ones recover or survive, unlucky ones suffer or die.
But this conclusion does not seem right…
Yes, that’s often the set of implications that goes with the “choice” model. I hope you’re not imagining that it’s my position!
To repeat: saying that addiction is not a disease doesn’t mean (in my mind) that it’s a choice in the normal sense of that word.
Nothing new here?
http://www.theguardian.com/commentisfree/2013/sep/26/brain-scans-porn-addicts-sexual-tastes
No, but the implications for teens’ emerging sexuality are really frightening! Very useful article.
Marc, with your “choice model”, would addicts make “irrational choice” only when it comes to drugs, or they make Irrational Choices for just about everything in their lives?
In other word, can addicts make Normal Choices for other things that are not related to drugs?
It isn’t MY choice model, Jenny. The idea that addiction is a “choice” is something I usually argue against. But by that I mean it’s not a “free choice” — yes, there is some intention involved, but the pathways of alternate choices are increasingly shut down.
People make bad choices, or silly choices, or “accidental” choices all the time. In that way addiction is not exceptional. It is exceptional in that each time you do what you do, it gets harder to do anything else next time.
Marc, thanks for the clarification. I’d say, it is not easy to get a clear picture of what people are saying on this site. What I got is that, you think addiction is not a Disease, Nor a Choice, but a “Diseased Choice”?
Whatever it is, drug addiction does make people think Irrationally; and the harms to people’s health and life are still the same…
I hope to see you professionals in this field to have more discussion about “Solutions”, such as to “find healthy things to do to fill the Void” (especially for functioning adults)… Exercise and nutrition are important for recovery…
Hi Marc,
You said in part, “I want to model addiction as a biased choice, a choice that is not inevitable but is highly probable, given the attractions that are already engraved in our synapses.”
I think the kind of ‘choice’ one wants to affirm, roughly, is that the people can respond properly to stimuli, including advice and direction from others. She or he is not like a train on a track, or even one of those robotic paintsprayers for cars in automated factories.
“Highly probable” does not quite capture what’s going on. It’s highly probable if you heard your keys hit the ground (having fallen from your pocket) you’d stop and picl them up. If you were at home and smelled smoke, you might grab the kids and go out of the house.
Person’s seeming driven by inner demons qualify. Dylan Thomas was told, after a bender, “Drink another bottle and you’ll be dead.”. Soon, he did, and died. That’s the kind of ‘non responsiveness’ that leads one to say things like “He’s deranged,” or “He has a mental disease” or “…psychological disorder.’
You want to say that he learned the response, and that it was ‘corrupted learning,’
meaning several things, including that doesn’t serve him well and that the behavior is, so to say, ‘sticky,’ difficult to change (caught in an ‘attractor state’).
It’s more than the ‘bias’ of a ‘bad habit’ or of “failing to account for the baseline” stuff.
If you want to speak in terms of the brain, the person’s brain is, so to say, so deeply programmed/conditioned that it doesn’t adjust responses, or learn new ones. I guess you say it’s lost plasticity.
The other issue is that when people complain, as in your OP, of their addiction, they’re choosing in ways that frighten or embarrass them. I.e. it’s not just compulsion, as the compulsion some famous writers have reported to make them work night and day to finish a novel. The psychologist call it ‘ego dystonic,’ as you know. Balzac would not complain if he found himself writing another novel, but a gambler, headed for the track, with the family’s mortgage payment and grocery allowance in his pocket, might (if fallen low enough) feel unnerved, etc. “I can’t help myself,” as your addict, quoted, was saying.
—
You do agree that some seem not able to ‘choose’ their way out of their corruptly learned pattern and rut, just as a classic schizophrenic can’t choose his way out of hearing voices, I think. Perhaps you want to say, in the former case, that radical intervention and change of environment and its contingencies might ‘work’, i.e. break the habit. The afflicted person, perhaps you’d say, has a ‘metachoice’ as to seeking a new environment. Once that’s in place, new learning can occur, the person can repond appropriately to stimuli (signs of danger) once again, etc.
Hi NN. When I said “highly probable” I meant it in an abstract almost ironic way. It’s true that it’s not the best description, and it’s certainly not meant as a definition.
I do see addiction as a bad habit, in agreement with much of what you say above. Indeed, corrupted learning, an attractor state, etc. And indeed the brain loses plasticity. Absolutely….that’s the problem. Which amounts to “non-responsiveness” to anything outside a fairly small subset of stimuli. So Dylan Thomas is covered by that definition. Given the present attention to “neuroplasticity” (e.g., Norman Doidge’s book: http://www.normandoidge.com/normandoidge.com/MAIN.html), it’s important to stress that addiction is pretty much the opposite.
In starting to write book 2, I’m writing lot about what the brain isn’t. It isn’t a computer, it isn’t a person, it’s an organ, but it’s not like any other organ, etc. But as to what the brain is, I think “habit-forming” is completely correct. Habits are enormously important in every aspect of life. They replace much of “consciousness’ 95% of the time.
We need to understand that addiction is a particular kind of neural habit, because it is not restricted to any particular category of place, person, thing, or activity.
Hi Marc,
Re: email you received….
I used amphetamines for many years, was in a hopeless space mentally, physically, spiritually, financially, in fact in every way possible. I couldn’t see any way out but death and also believed it was possible my children were better off without me, even considered we were all better off dead.
I’ve been drug free for approximately 9 years now. Not sure how I got to my first meeting, how I even found out about them, but NA (Narcotics Anonymous) and the twelve step program they use (along with boundless support from other recovering addicts and a desire on my part to want something different) was my last hope at living. The program worked for me, the meetings were my life support for a few years. I no longer attend meetings but I do practice the principles I learnt in the program and I believe this us why I am drug free today. I do not believe I have a disease, however, I know if I use a substance to try to feel “better” I could end up in trouble therefore, I choose not to. But there was a time when I felt I had no choice. NA taught me about choice, powerlessness, faith and hope among many other things. I sincerely hope whoever emailed you gets the opportunity to find what I’ve been given by all those addicts in NA – good advice, loving suggestions, honesty, hope and identification with another human being. And of course, on going recovery.
Cheers, Jo.
Thanks for this Jo. A lot of people read this blog — most without commenting, of course. Something like a thousand or more per post. I truly hope that the writer of that email reads your comment.
It is also good to hear a very positive impression of a 12-step program. Many readers have had somewhat negative experiences, but a substantial number also have good things to say. I’m glad that NA gave you exactly what you needed. It sounds like you were in really serious shape.
This reminds me of a thought I had recently. As I have become involved in studying biology more in depth, one of the issues I had revolved around cancer. The current means to deal with cancer is to give harsh chemicals that make a body lose many good cells along with these cancer cells considered to be bad. Why? Because someone in leadership somewhere along the line decided to take that approach. Your friend at NIDA is probably a present day version of such a person. So if she says it is a disease, then she might be right (think monkey see monkey do). The truth is, she may be wrong, but you may also be wrong. What is cancer? Cells that can undergo rapid division to a number of divisions than what we currently consider normal. The question then about cancer is, what if our approach is wrong? What happens if we do nothing about the dividing cells, and leave it to nature? I would guess there probably are a few (or a lot) of cases where nothing gets done and nature takes care of it. We just might not know about it because in order to know, someone has to come in for help. At which point they probably are given this horrible cocktail of chemicals that are going to set off so much of their nature. Anyway, enough of this endless wall of text.
Bottom line is, I commend you for the alternate thinking and philosophy- It is enjoyable for me to read and ponder about. The whole dis-ease story gets old. But the truth still is, nobody knows for sure and so much is unknown that nobody can say they know for sure.
I appreciate your view and hopefully others start to as well.
Thanks for your encouragement. I do see how important it is to have alternative approaches, but, as you say, the “mainstream” approach (which is the disease model when it comes to addiction) may not be wrong. More precisely, there may be many valuable aspects to it, even though it is not completely right.
I think this is the case with the disease model. I wouldn’t want to squelch it, just revise and extend it.
If I had a serious cancer, I would choose the chemo cocktail over doing nothing at all. It may not be ideal, but I figure it’s a lot better than nothing.
In science, we are quite used to having competing theories and models. I don’t see why it should be different in the treatment world.
Neuroscientists like Dr. Volkow describe addiction as a disease because of the way the process of ever-deepening tolerance to drugs alters the Limbic system. It’s that process that explains why addiction is progressive and (if the drug is acutely toxic)ultimately fatal if left untreated. The brain’s drug-induced alterations skew motivation –that is, they affect choice-making. Neuroscientists say addiction is a disease of the decision-making apparatus. SO the question isn’t about choice, it’s about what the motivation behind the choice is. Choices aren’t simple. And choices differ depending on time frames. An addict’s short-term choice to use drugs to stave off withdrawal is rational in the short run while simultaneously irrational in the long run. Describing addiction as a choice is a misleading oversimplification.
Could those who assert addiction is not a disease please answer two questions: first, do you accept that the process of deepening tolerance is the central mechanism of the addictive process? and if not, how do you explain addiction’s progressivity?
I agree with much of what you say, Steve. The complexity of making choices, the importance of underlying motivation, and the time-related distinction in how rational or irrational a choice is judged to be.
But I disagree with your conclusion. Addictions are progressive whether or not they are to substances characterized by increasing tolerance. Drugs like alcohol and nicotine have little if any tolerance build-up, and even cocaine has little tolerance after a couple of days. Pot: zero. And then there are food addictions, gambling addictions and so forth. (though Doidge recently argued that porn addiction also builds up tolerance — you need more and more extreme images)
Many of these look very similar when it comes to alterations in striatal circuitry. And yet tolerance is not the underlying constant.
There can be many other reasons why addiction is progressive. Lots of things are progressive. Sexual deviancy (e.g. pedophilia), abuse, OCD rituals, and much more benign things like nail-biting and nose-picking. Even good things, like learning to sing or play in tune. What all these things have in common is simple: they all develop. My training is in developmental psychology, so this does not seem so mysterious to me.
Marc, I think you (and others) might have “forgotten” there is a body that connected to a brain. When researching the brain function and development, the professionals should include the biology of the body system into the picture. Brains do not act alone, they also respond to body’s signals.
Marc: Thank you for replying.
While your background is in developmental psychology, mine was as a criminal investigator and prosecutor. I consider myself an “evidence guy,” trained to rely on whatever the evidence proves in the end, no matter what my initial impression was. When first introduced to the disease model of addiction in rehab, I was completely disbelieving. But then I studied the science in depth, found it convincing, and was forced to change my mind.
To this evidence guy, your reply is lacking. Essentially, you say things like addiction just develop. But why? The disease model has a coherent explanation backed by experimental data: the brain reacts defensively to the long-term overstimulation of the limbic system caused by drug abuse by changing the system, making it less efficient; but users notice that inefficiency, they get less relief than they expect and counteract it by taking more drugs more often. A downward spiral results in which the brain increasingly gums up the limbic system, inducing the user to take even more, which causes further brain change, etc. This explains both why addiction is progressive and why, if the drug is acutely toxic, it’s ultimately fatal if left untreated.
I don’t mean to be flip or disrespectful (after all, you’re a neuroscientist and I’m not), but do you have a coherent model for why addiction is progressive that’s equally or more persuasive than the disease model, or is your view that stuff just happens?
You also write, “Drugs like alcohol and nicotine show little if any tolerance build-up, and even cocaine has little tolerance after a couple of days. Pot zero.” This is contrary not only to the research I’ve seen (persistently fewer dopamine D2 receptors and transporters in sober addicts compared to non-addicts; desensitization of opiate and cannabinoid receptors as well as dopamine receptors) and directly contradictory to my experience with alcohol, opiates, cocaine and pot. Just to take alcohol, I survived a BAC of .413 when non-alcoholics die in the mid-.30s, and when I relapsed (twice) a couple drinks were all I needed at first but I progressed back to a liter a day within days. Wasn’t your experience that you needed more and more drugs over time? Perhaps I don’t understand what you mean by “tolerance build-up.” Could you flesh that out?
I’ve ordered your book and hope to read it over the weekend, so if you’ve already addressed these issues and don’t want top rehash it here, kindly point me in the direction of the discussion in your book and I will read it with great interest.
Thanks.
steve
Sorry, Steve, but I think you are being “flip”. I’ve been working as a scientist for well over 20 years. I’ve authored dozens of articles in high-ranking journals. That qualifies me as an “evidence guy” too, right?
This could be a long discussion, but I’ve already written about these issues in some depth, over a few years. You could start with a post I wrote when I was a member of a PLOS blog, before I quit because I wanted more hard neuroscience and less opinion: http://blogs.plos.org/mindthebrain/2012/11/12/why-addiction-is-not-a-brain-disease/
And look at my paper in Perspectives on Psychological Science: http://pps.sagepub.com/content/6/2/150.abstract
And yes, maybe read my book.
Then we could discuss matters further. But before that, I want to make one point–
You say: “This is contrary not only to the research I’ve seen (persistently fewer dopamine D2 receptors and transporters in sober addicts compared to non-addicts; desensitization of opiate and cannabinoid receptors as well as dopamine receptors) and directly contradictory to my experience with alcohol, opiates, cocaine and pot.”
As an evidence guy, surely you can’t rely on your own or anyone else’s experience. And the reduction in D2 receptors is a controversial topic, as genetic effects and post-drug effects are usually conflated. But throwing around the names of neuromodulators doesn’t amount to evidence. Most drugs affect most neurotransmitter systems through complex interactions. I think my main point was that people also get addicted to gambling, sex, food, and other activities, behavioural addictions produce brain changes that overlap in many respects with substance addictions, and the word “tolerance” is usually reserved for a limited number of substance addictions, certainly not all, and its application to behavioural addictions (and OCD — also a compulsive disorder) is either inaccurate, meaningless, or controversial.
No, I don’t think addiction “just happens.” That would be idiotic.
Let me rephrase that last sentence. There are legitimate perspectives that see real-life phenomena as “just happening.” But scientists and criminal investigators (I assume) are interested in connecting effects to causes. Calling addiction a “disease” does absolutely nothing to uncover the complex causes of this developmental phenomenon. It’s simply a description — nothing more.
What I am trying to say is, when some people’s body can’t take any more drugs, because their heart or organs have been damaged, because they become weak and fragile, because the drugs are killing them… but their brains still want more drugs despite all the signals the body sent out… Something is terribly wrong with this brain!