Addiction: A Disorder of Choice

February 23, 2010

"It seems to me,” William S. Burroughs Jr. once wrote, that “if you put something pleasant in front of someone, they’re going to take it.” But not everyone succumbs to the temptation. Why do some fall prey to addiction while others do not?

This important book by a research psychologist who works at Harvard Medical School and its affiliated psychiatric hospital challenges many common beliefs about the nature and treatment of addiction. Gene Heyman argues that addiction is best understood not as a disease, but as a “disorder of choice.” Further, he contends that people who are addicted to certain substances often cease being addicted, most often by their thirties. Both of these positions are quite controversial, but Heyman’s alternative perspective has important implications for understanding and addressing this hugely important problem.

The Diagnostic and Statistical Manual of Mental Disorders identifies substance dependence, or addiction, as a disease. Heyman himself writes that substance dependence is “a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues the use of the substance despite significant substance-related problems.” But, Heyman says, addiction to substances differs from diseases because choice plays a role that it does not play in schizophrenia, depression and other psychiatric disorders. Furthermore, although defining addiction as a disease has diminished the moral stigma attached to it, criminalization of behaviors related to addiction reveals our ambivalence about the disorder.

Heyman reviews data from two important national surveys (the Epi demiologic Catchment Area Survey and the National Comorbidity Survey) that demonstrate a much greater rate of remission from addiction disorders than from other mental illnesses. These data challenge the common conception that addiction is a lifelong condition. Heyman maintains that most addicts cease being addicts by their mid-thirties and that data showing stubborn, lifelong addiction are based on research conducted mainly among persons seeking treatment for addiction, who tend to be older and who have a much higher prevalence of other psychological disorders as well as addiction. Thus, he argues, persons in treatment for addiction are ironically less likely to experience remission of symptoms than those not in treatment. He does not argue that treatment programs are useless. Many of them do offer benefits. But, he contends, the majority of addicts who experience remission do so without formal treatment, and they do so at a relatively young age.

Heyman’s understanding of addiction is based on neuroscience and a theory of voluntary behavior, or choice. The knowledge of how dopamine binds to neural receptors to provide feelings of intense pleasure is basic. But neuroscience does not explain addiction. Most people who use alcohol or other drugs will not become addicted. Heyman cites data indicating that only 15 percent of alcohol users will become alcoholics (that is, people who meet the clinical definition of substance dependence). The figures vary for other drugs, but in every case a minority of users become addicts. Even heroin, which has a much higher rate of addiction among users than any other substance, seems to lead to addiction only in a minority of persons who have used it.

So why do certain users become addicted, while others do not? Heyman allows that there are poorly understood genetic predispositions for addiction. Identical twins, even those raised apart, are more likely to both be addicted than fraternal twins. But Heyman argues that genetic similarities do not diminish the role of choice. Identical twins, even when reared apart, are also more likely to share certain kinds of religious beliefs than fraternal twins. Thus, Heyman argues, genes play a role in our beliefs, our choices and our behavior—all of which we consider voluntary—as well as in traits (such as height) about which we have no choice. A proper understanding of addiction, Heyman writes, must therefore consider the role of choice.

Basing his very interesting discussion on Richard Herrnstein’s research on economic choices, Heyman distinguishes between what he calls local and global choices. All of us choose what we most want, but what we most want at any given moment is affected by a number of changing considerations. Choice is dynamic, not static. A local choice is one I make simply on the basis of immediate preference—for example, I prefer Chi nese food, so I will go to a Chinese restaurant. However, if I value Chinese food, I will perhaps understand that I will enjoy it more if I eat it less frequently, so I will make the global choice not to eat Chinese food too often. This basic understanding is the key to Heyman’s work. Addicts are people who, for a time or always, make local choices. Powerful substances like heroin can so flood one’s brain with dopamine that the positive effect is indescribable, and some people compulsively pursue that sensation. But for others even such a powerful experience is placed into a larger perspective by circumstances, relationships and obligations, so that if one wants to keep a job or marriage, for example, the addictive quality of heroin recedes.

Many factors contribute to the development of global choices, Heyman says. The ability to make such choices may itself be affected by genetics. None theless, Heyman argues that addiction, unlike other diseases, is a disorder of choice that can be changed when other factors become more important. Thus, the most effective treatment programs for addiction provide community, incentives and perspectives that help develop new global choices.

Addiction is a condition that affects almost everyone in our society, directly or indirectly. The historical studies of addiction that Heyman recounts, as well as the current success of nicotine reduction, indicate the important contribution of cultural as well as physiological strategies. Hey man’s argument will be controversial and disturbing to many people who experience or treat addiction because it disputes many current as sumptions. Some will fear that it minimizes the seriousness and persistence of addiction. Whether his understanding will prove accurate and useful remains to be discovered. Nonetheless, without being a theological treatise at all, Heyman’s work reminds us of the centrality and complexity of choice in human life.