The prevailing wisdom today is that addiction is a disease. This is the main line of the medical model of mental disorders with which the National Institute on Drug Abuse (NIDA) is aligned: addiction is a chronic and relapsing brain disease in which drug use becomes involuntary despite its negative consequences.
The idea here is, roughly, that addiction is a disease because drug use changes the brain and, as a result of these changes, drug use becomes compulsive, beyond the voluntary control of the user. In other words, the addict has no choice, and his behavior is resistant to long-term change.
This way of viewing addiction has its benefits: if addiction is a disease then addicts are not to blame for their plight, and this ought to help alleviate stigma and to open the way for better treatment and more funding for research on addiction. This is the main rationale of a recent piece in the New York Times, which describes addiction as a disease that is plaguing the U.S. and stresses the importance of talking openly about addiction in order to shift people’s understanding of it. And it seems like a welcome change from the blame attributed by the moral model of addiction, according to which addiction is a choice and, thus, a moral failing—addicts are nothing more than weak people who make bad choices and stick with them.
Yet, though there are positive aspects to seeing addiction in this light, it seems unduly pessimistic and, though no one will deny that every behavior has neural correlates and that addiction changes the brain, this is not the same as saying that, therefore, addiction is pathological and irreversible.
And there are reasons to question whether this is, in fact, the case.
From everyday experience we know that not everyone who tries or uses drugs and alcohol gets addicted, that of those who do many quit their addictions and that people don’t all quit with the same ease—some manage on their first attempt and go cold turkey; for others it takes repeated attempts; and others still, so-called chippers, recalibrate their use of the substance and moderately use it without becoming re-addicted.
But there is also strong scientific evidence that most people recover from addiction on their own and that things are not as simple as the medical model implies.
In 1974 sociologist Lee Robins conducted an extensive study of U.S. servicemen addicted to heroin returning from Vietnam. While in Vietnam, 20 percent of servicemen became addicted to heroin, and one of the things Robins wanted to investigate was how many of them continued to use it upon their return to the U.S. and how many remained addicted. What she found was that the remission rate was surprisingly high: only around 7 percent used heroin after returning to the U.S., and only about 1-2 percent had a relapse, even briefly, into addiction. The vast majority of addicted soldiers stopped using on their own.
Also in the 1970s, psychologists at Simon Fraser University in Canada conducted the famous “Rat Park” experiment in which caged isolated rats administered to themselves ever increasing—and often deadly—doses of morphine when no alternatives were available. Yet, when these rats were given a mate and alternatives to drugs they stopped taking them. And in 1982 Stanley Schachter, a Columbia University sociologist, provided evidence that most smokers and obese people overcame their addiction without any help.
Although these studies were met with resistance, lately there is more evidence to support their findings.
In The Biology of Desire: Why Addiction Is Not a Disease, Marc Lewis, a neuroscientist and former drug addict, argues that addiction is "uncannily normal," and he offers what he calls the learning model of addiction, which he contrasts to both the idea that addiction is a simple choice and to the idea that addiction is a disease.* Lewis acknowledges that there are undoubtedly brain changes as a result of addiction, but he argues that these are the typical results of neuroplasticity in learning and habit formation in the face of very attractive rewards.
In reviewing a number of case studies, Lewis argues that most addicts don’t think they are sick (and this is good for their recovery) and that the stories of people who have overcome their addiction, instead of impotence and disease, speak of a journey of empowerment and of rewriting one’s life narrative. That is, addicts need to come to know themselves in order to make sense of their addiction and to find an alternative narrative for their future. In turn, like all learning, this will also “re-wire” their brain.
Taking a different line, in his book Addiction: A Disorder of Choice, Harvard University psychologist Gene Heyman also argues that addiction is not a disease but sees it, unlike Lewis, as a disorder of choice. Heyman presents powerful evidence not only that just about 10 percent of people who use drugs get addicted and only around 15 percent of regular alcohol drinkers become alcoholics but also that around 80 percent of addicts overcome their addiction on their own by the age of 30. They do so because the demands of their adult life, like keeping a job or being a parent, are incompatible with their drug use and are strong incentives for kicking a drug habit.
This might seem contrary to what we are used to thinking. And, it is true, there is substantial evidence that addicts often relapse. But most studies on addiction are conducted on patients in treatment, and this skews the population sample. Most addicts never go into treatment, and the ones who do are the ones, the minority, who have not managed to overcome their addiction on their own.
What becomes apparent is that addicts who can take advantage of alternative options do, and do so successfully, so there seems to be a choice, albeit not a simple one, involved here as there is in Lewis's learning model—the addict chooses to rewrite his life narrative and overcomes his addiction.**
However, saying that there is choice involved in addiction by no means implies that addicts are just weak people, nor does it imply that overcoming addiction is easy. It is incredibly hard, and for some people, practically impossible to undo years of habit.
The difference in these cases, between people who can and people who can’t overcome their addiction, seems to be largely about determinants of choice. Because in order to kick substance addiction there must be viable alternatives to fall back on, and often these are not available. Many addicts suffer from more than just addiction to a particular substance, and this increases their distress; they come from underprivileged or minority backgrounds that limit their opportunities, they have histories of abuse, and so on. So although choices are in principle available, viable choices for people are largely dependent on determinants of choice beyond their control, and this can mitigate their responsibility.
This is important, for if choice is involved, so is responsibility, and that invites blame and the harm it does, both in terms of stigma and shame but also for treatment and funding research for addiction.
It is for this reason that philosopher and mental health clinician Hanna Pickard of the University of Birmingham in England offers an alternative to the dilemma between the medical model that does away with blame at the expense of agency and the choice model that retains the addict’s agency but carries the baggage of shame and stigma. Both these models, Pickard claims, place the responsibility away from us: it is either the addict’s fault or the disease’s. But if we are serious about the evidence, we must look at the determinants of choice, and we must address them, taking responsibility as a society for the factors that cause suffering and that limit the options available to addicts. To do this we need to distinguish responsibility from blame: we can hold addicts responsible, thus retaining their agency, without blaming them but, instead, approaching them with an attitude of compassion, respect and concern that is required for more effective engagement and treatment. And the two, responsibility and blame, can come apart if we realize that responsibility is about the person who makes choices, but blame is about our choice of how to respond to them.
In this sense, the seriousness of addiction and the suffering it causes both to the addicts themselves but also to the people around them require that we take a hard look at all the existing evidence and at what this evidence says about choice and responsibility—both the addicts’ but also our own, as a society. We can call addiction a disease because the concept of a disease is not clearly defined, but if by “disease” we mean that there are brain changes that lead to lack of choices, then there is ample evidence to dispute this view. In the end, we cannot understand addiction merely in terms of brain changes and loss of control; we must see it in the broader context of a life and a society that make some people make bad choices.
*Editor's Note (11/21/17): This sentence was edited after posting to clarify the original.
**Editor's Note (11/21/17): This paragraph was edited after posting to correct inaccuracies in the original.