Book review: Addiction: A Disorder of Choice by Gene Heyman

I was apprehensive about reading this book. I was worried that it was going to be a hyper-conservative and moralizing tome. What I found instead was a provocative and well-researched book that I highly recommend to anyone interested in addiction, public policy or psychiatry.

As is clear from the book’s title, Heyman asserts that the dominant paradigm of drug addiction (that it is a “chronic and relapsing brain disease”) is not correct, and that by viewing addiction as the result of a series of willful actions, we have a better understanding of the course of drug addiction and its treatment.

Why is this view controversial? It strikes at the heart of the paradoxical way that we view drugs and drug addiction in the modern US. Heyman explains: “The reasoning behind this view is that if addiction is a disease, then science will soon find an effective treatment for it, as had been the case for many other diseases, but if that addiction is a matter of choice, then the appropriate response is punishment… The core assumption of this viewpoint is that there are but two possible responses to addiction: treatment or punishment”. As a good liberal, I was uncomfortable starting the book because I was worried that Heyman would be blaming the victims of addiction, and potentially creating policy that would take away treatment options, leaving them worse off.

Heyman remains unfortunately agnostic on what ought to be done about drug abuse, but focuses instead on the science and history of drug abuse and drug policy. Here are his central arguments for addiction being a choice:

The same drugs have different effects on people that depend on cultural context
Across time, culture and place, the reactions to the same drug are markedly different. If drug abuse were a biological reflex, this would not be the case. Of course, some of the “cultural contexts” listed by Heyman (smoking versus injecting heroin, for example) can dramatically influence the metabolism of the drug, which is a biological context that can influence receptor binding, etc.

The more interesting piece of this argument was that studying only those in treatment for drug addiction biases many studies of drug addicts. These people have higher co-morbidity with other mental illnesses and are more likely to relapse. For most people, a drug habit runs a natural course, beginning in a person’s late teens to early twenties and ending by age 30. Heyman profiles the majority population of invisible “successful addicts” who start and end drug-taking behavior as free choices.

The right motivations get just about anyone to quit
When people are given enough motivation, nearly all can quit taking drugs. 85% of drug addicted doctors and airline pilots faced with the possibility of passing all future random drug tests or losing their jobs will quit taking drugs. “Change your incentives, change your behavior, change your brain”.

The genetic basis for addiction is not compelling.
Heyman uses religiosity and twin studies to prove this point. Religion is a learned and voluntary behavior, and twins tend to have similar degrees of religiosity. However, the religiosity data only show a 0.3-0.4 correlation between even identical twins, so I agree with Heyman that the argument is a little weak.

The book misses a great opportunity to go into the neuroscience of addiction, as strengthening neural circuits associated with habit, and down-regulating neurotransmitter systems affected by the drugs could be very potent reasons why drug taking is so difficult to stop.

Near the end of the book is an argument of choice behavior, largely based on the very cool research of Drazen Prelec and colleagues. While it takes Heyman a while to set up the background, it is worth following as it has a lot of explanatory power for habitual behavior of all kinds, not just drug addictions. In brief, as the negative consequences of taking drugs accumulate slowly while the positive feeling of taking drugs is immediate (albeit diminishing over time), it takes a long-term perspective to see that drug-taking is a losing prospect in the long-term. The same goes with any bad habit: while just one cupcake will not cause you to gain 20 pounds, the habit of eating cupcakes over time will accumulate those 20 pounds. It takes a strong future orientation to see that the immediate deliciousness of the cupcake is not worth the long-term metabolic cost of the cupcake. Heyman refines his argument here by pointing out that while it is silly to say that someone would choose to be an addict, one becomes an addict from the accumulation of choices. “The point is that one day of heroin does not mean addiction, just as eating desert once does not make one fat. Of course as the days accumulate, the characteristics of addiction emerge, and as the deserts accumulate, fat cells get bigger”

One disappointment is the frequent straw-man argument along the lines of “It is not likely that anyone ever referred to recovery from obsessive compulsive disorder or schizophrenia as ‘going cold turkey’”.  These arguments seem to appeal to the emotions behind addiction rather than the science. Also, cognitive behavioral therapy, which involves the willful changing of one’s beliefs and behaviors, is an effective strategy for combatting other mental illnesses such as OCD, only showing how nuanced the idea of will in mental illness really is.