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.”

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