Tomorrow, for my last publicity event in Toronto, I’m giving a talk at a Harm Reduction group. I don’t know that much about harm reduction as a philosophy or practice. I do know that I like the idea that there are many and varied paths to recovery, or maintenance, or whatever you want to call a relatively harm-free solution to addiction. I also recently found out that the Harm Reduction folks don’t even like the word addict. I think I get their point. The tension here seems to resolve to the ongoing debate, both in science and in clinical practice, about whether addiction is a disease or a choice. Here’s what I think.
It’s a false dichotomy. Addiction is not a disease like cancer or diabetes. No way. It’s hard to get rid of, which makes it like a disease, but that’s really just an analogy. The resemblance stops there.You can’t catch it. It’s not communicable. And you can’t cure it according to some specific formula. This idea is very much at odds with the pronouncements of the American Society of Addiction Medicine, the high church of addiction, as it were. So is addiction a choice, is it just bad behaviour, is it the result of a genetic predisposition to self-indulgence or a low tolerance to psychological pain? All of these other definitions fall short as well. Addiction has an incredibly powerful, self-propelling momentum that takes it beyond the realm of “normal” choice or “normal” bad behaviour. If addiction is neither a choice nor a disease, then the choice vs. disease dichotomy is useless. It creates havoc and argument, it’s confusing, and it takes our minds off the more important issue. Such as: What is addiction really?
The disease camp assumes that the brain is important for understanding addiction. Addiction, they claim, is a brain disease. But the choice people paint themselves into the opposite corner. They claim that the brain is not important for understanding addiction. Rather we need to understand how difficult circumstances — trauma, rejection, economic hardship, and so on — affect substance-taking behaviour. What’s that got to do with the brain?
It’s got everything to do with it! Choices are not some magical puff of our spirit selves. Choices come from the brain. And the choice to take drugs, or booze, or cigarettes, again and again, comes from a brain that has been altered by a series of similar choices in the past. It just takes a moment of reflection to realize that choices are rarely “free”. And while philosophers debate the very existence of free will, we can be much more practical about it. Choices involve an exchange between the part of your brain that wants something (the ventral striatum and related areas) and the part of your brain that thinks about consequences and directs behaviour accordingly (dorsal and lateral regions of the prefrontal cortex). That exchange takes place in the synapses (connections) that join these regions. And those connections are altered by so many aspects of experience: hardship, success, self-image, trauma, and very clearly by the spiralling of wanting and relief that results from substance-taking itself. No two people have the same brain to work with, but there are features of addicts’ brains that neuroscientists can describe in detail: high levels of dopamine continue to strengthen the feelings of craving that spring from the striatum, while the satisfaction of those pernicious goals continue to reinforce the circuits that give substances their meaning and value. And the regions responsible for self-control are themselves weakened by excessive demands for impulse control. So their connections to the regions of craving shrivel because they’ve lost their potency.
Understanding the brain is essential for making sense of the kinds of choices that addicts repeatedly make. But that doesn’t make addiction a brain disease. It makes it an aspect of the biology of being a sensitive human being in an often difficult world.
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