The idea that addiction is a disease is an article of faith in the study of drug and alcohol dependence, providing the foundation for much of the treatment and public policy related to addiction since the early 1900s. In a forthcoming book, psychologist Gene Heyman dismantles this time-honoured assumption, arguing that addiction is first and foremost governed by personal choice, and does not therefore fit clinical conceptions of behavioural illness. Heyman has done research on choice, cognition and drug use. He has done volunteer work at a methadone clinic and he currently teaches courses on addiction at Harvard University. In conversation with Maclean’s correspondent Charlie Gillis, he offers a model of decision-making that he says explains how addicts—from smokers to opiate users—can voluntarily engage in activities that lead to long-term misery.
Q: The title of your new book, Addiction: A Disorder of Choice, is more or less self-explanatory. What led you to think that addiction may not be, as most research literature describes it, a “chronic, relapsing disease?”
A: Like everybody else, my initial goal was to find out how drug use turned from a voluntary behaviour to an involuntary one—that’s what I put down on my grant applications. But when I was teaching, I wanted to give my students at least some feeling for what addiction is like. So I began reading biographies, histories and ethnographies of addiction. This data gave a very different picture than the one I expected. The literature on how addicted people behave showed they stopped using the drugs, and that they did so because of family issues, or there was a choice between their children and continued drug use, or they were moving on to an environment where it was disapproved of.
In other words, the kinds of things that influence all of our everyday decisions were influencing people who are heavy, heavy drug users to stop using. And it was so consistent. Each report supported the other.
Then I began looking at the epidemiological data—these large surveys that have formed the basis for a lot of important psychiatric research in the last 20 years—and they showed the same thing. A huge percentage of people who had at some point met the criteria for lifetime substance dependence no longer did so by the time they were in their 30s. It varied from 60 to 80 per cent.
Q: So why does that preclude it from being a disease?
A: At the heart of the notion of behavioural disease is the idea of compulsivity, by which people mean it’s beyond the influence of reward, punishment, expectations, cultural values, personal values. Alan Leshner [the former head of the National Institute on Drug Abuse] says drug use starts off as voluntary and becomes involuntary. But the epidemiological evidence suggests otherwise. When you read the biographical information, you see individual drug addicts [who’ve quit] saying, “Well, it was a question of getting high on cocaine or putting food on the table for my kids.” Or, “My life was getting out of control.” Or, in the case of William S. Burroughs, “The cheques from my parents stopped coming.”
Q: How, then, did the idea that addiction is a disease governed by uncontrollable compulsion take root?
A: The first people to call addiction a disease were members of the 17th-century clergy. They were looking at alcoholism and they didn’t describe it as sin or as crime. I have a theory as to why they thought this—and why we think it even today. It’s this problem we have with the idea that individuals can voluntarily do themselves harm. It just doesn’t make sense to us. Why wouldn’t you stop? In the medical world, in economics, in psychology and in the clergy, they really have no category for this, no way of explaining behaviour that is self-destructive and also voluntary. The two categories available to them are “sick” or “bad.”
Q: With the scientific community behind it, the idea that addiction is a sickness has also become the more enlightened position.
A: Yes, it seems a more humane thing to say, and people like to be humane.
Q: At the centre of your argument is that much of the research on addiction to date is based on people who wound up in treatment clinics. Why is that problematic?
A: It’s problematic because 60 to 70 per cent of the time, those people have additional psychiatric disorders. And those disorders interfere with their capacity to engage in activities that would compete with the drugs—jobs, family, other activities. So the people the clinicians see, and the people the researchers study, are those who keep using drugs and don’t stop right into their 40s. That’s maybe 15 to 20 per cent of [addicts], and they have greatly skewed our picture of the natural history of addiction. From the data I’ve seen, it looks like most people who meet the criteria for addiction actually stop using by age 30.
Q: Why would respected and established scientists make generalizations about drug dependence based on such a small subset?
A: I’ve thought a lot about that, and my sense is that this subset fit what people believed before they started studying. It squares nicely with this notion that addiction was either bad behaviour or sick behaviour. I don’t push this too hard. I mean, everybody knows that clinical populations can be biased. There’s even a name for it—Berkson’s bias. People who come to clinics for a certain disorder are likely to suffer from additional disorders.
Q: Still, the broader epidemiological surveys you cite have been available for anyone who cared to look. Why do you think they were ignored?
A: Well, I only looked at this data because I was teaching this course. I felt I had to. If you’re doing research looking at, say, calcium channels in individual neurons, you have so much to do that you’re not going to start reading the epidemiological literature. You don’t start making your world more difficult. But in the end, I do think it’s inexcusable, and one of the goals of my book is to bring the research world’s attention to data that has been sitting there for 20 years. In some cases, the data didn’t fit in with what the people who sponsored the surveys say addiction is. The National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism funded all the studies I cite. But NIDA and NIAAA have not taken the message of those studies to heart.
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