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Addiction: A Disorder of Choice

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This is an important, well-written and eye-opening book on the nature of addiction and voluntary choices. Don't let the title fool you. In attacking the disease model of addiction, Heyman is in no sense out to punish or stigmatize addicts. I've written a full length positive review at [...] here are the first few paragraphs:

Controversy about addiction over the last few decades has centered on the virtues and drawbacks of the disease model: Is addiction justly portrayed as akin to other mental illnesses such as depression, obsessive compulsive disorder and schizophrenia, and perhaps even physical illness? Or does the disease model conceal important dissimilarities to these conditions, and therefore compromise our efforts to treat and prevent addiction? The current consensus in the addictions establishment, for instance at the National Institute on Drug Abuse (NIDA), strongly favors the disease model. NIDA, other agencies, and addiction specialists have worked hard to promote the idea that "Addiction is a chronic disease similar to other chronic diseases such as type II diabetes, cancer, and cardiovascular disease." Since it's often seen as a moral failing, declaring addiction a disease has helped to destigmatize addicts and encourage parity for addictions treatment under medical insurance. This is all to the good, even if the conception of addiction driving these trends is contested.

Gene Heyman's well-written and persuasive book takes dead aim at the disease model, so will likely not be welcomed by its supporters. But whatever side of the debate they're on, anyone interested in the nature of addiction and choice should read it. Heyman, a psychologist with appointments at Harvard and Boston College, presents an eye-opening and empirically grounded theory of voluntary behavior that goes a long way toward explaining addiction, not as a disease, but as choice-making gone bad. His analysis adds substantially to the growing literature in behavioral economics that shows we are not optimally rational maximizers of our own self-interest. Addiction, it turns out, is simply one rather vivid manifestation of a basic feature of voluntary action: judged from the standpoint of an ideal consumer taking a long-term view of her choices, we tend to overconsume our immediate preferences, and in so doing undermine our net self-interest over the long haul. Drugs, including alcohol, are very good subverters of ideal, globally informed choice-making, so addiction properly understood is a paradigm disorder of choice, of voluntary behavior. Since diseases as commonly defined don't primarily hinge on choices, addiction doesn't qualify as a disease.

Because it presents choice-making as a function of controlling contingencies, not free will (p. 114), Heyman's theory does at least as much to destigmatize addiction as the disease model, while staying true to its actual behavioral dynamics. Those advocating for addicts need not deny the obvious: that addiction is unlike illnesses by virtue of the role voluntary behavior plays in becoming addicted, in obtaining drugs, and in ceasing to use them. As Heyman points out, even though people choose to use drugs and alcohol, no one chooses to become an addict. Moreover, he emphasizes that addicts can't simply choose to quit without a change in the circumstances, biological and environmental, that control their choices. He is not, therefore, a stern moralizer bent on punishment, but a clear-thinking, humane psychologist wanting to apply our best behavioral science to the treatment and prevention of addiction. No one should pre-judge this book based on preconceptions about what questioning the disease model might entail.

This book is short in absolute terms (well short of 200 pages) but at times it takes a sufficiently slow pace in order to present data and facts as tightly as possible, so as to convince the reader that: drug addiction is a matter of the individual making ultimately irrational and harmful deicisions based on a mode of thinking that does not take into account the importance of the harmful but delayed effects of drugs, and the inability to delay one's gratification.

Very convincing data are presented showing that the majority of drug users either never develope addiction or remit from addiction without any medical treatment. These facts suggest very strongly that voluntary decisions at least play a role in drug addiction.

The author explains (Chapter 6 - pages 115-141) very thoroughly why a decision that appears reasonable superficially can nevertheless be suboptimal and detrimental simply because the individual does not think about the bigger "global" picture of the situation, and does not consider the long term impact of the action. These are much more difficult when compared with merely considering the prospect of instant pleasure. Simple mathematical models are also presented for illustration.

Studies (page 164-166) have shown that social values do have an impact on the incidence of drug addiction. This should be of no surprise because values expectedly have an impact on how individual think, evaluate and make decisions.

The author does admit (page 152) that it is still not entirely certain whether drug usuage may reduce a person's ability to consider one's actions rationally. So it is not possible to exclude the possibility that there may exist a tiny number of addicts who indeed have a disease rather than a "disorder of choice".

In summary: a most rewarding and important book - particularly for health professionals who have to look after drug addicts, and to health policy makers as well.

The study of addiction is complicated by a number of problems. Like sociology, it tends to be dominated by people with strong personal or political positions that ultimately prevent it from being as objective as it should be. For instance, it is not uncommon for addicts to go straight from recovery to working in rehab clinics or doing social work. While this is great for them, it inherently alters the lens with which they look at the subject, making many reluctant to accept findings from outside their own experience.

This book is important to read because it goes an entirely different route. Starting with census data, Heyman looked at people who fit the diagnosis of addiction and tracked what happened to each addiction as the person aged. What he found was shocking. Without treatment, the majority of all "addicts" quit by the time they turn 40. As part of these findings, he noticed that drug abuse responds to economic and personal incentives. Having responsibilities, getting pregnant, the threat of being fired: these were extremely effective motivators in driving people to immediately cease drug use. The author's point is obvious: How can addiction be a chronic brain disease if most people kick it without the help of medicine or programs? More importantly, we know nothing about these people because no one studies them. Instead, our knowledge of addiction is limited to people who are in treatment, likely a heavily distorted representation of the population.

Tyler Cowen's criticism of this book is that Heyman often overstates his claims, and he's right. The book is written in the style of a self-justifying academic paper and this is probably the reason you haven't heard of it. It's the second book I've read on addiction (the other being The End of My Addiction) where the author's attitude hurt the impact of what should have otherwise been a landmark book. That being said, it's important to read books that are critical of the status quo in a given field. It's an easy way to play devil's advocate in conversation and sound more educated on a topic than you might actually be.

This is a landmark book. It gives a clear, research-based understanding of a basic cause of addiction, one that we can actually do something about.

The first couple of chapters, which include first person accounts by addicts, are page-turners. I stayed up too late reading them! I'm not a professional, but I followed the research in the later chapters and simply skipped some of the more technical stuff.

I think that addicts and even people like me who just eat too much dessert for their waistlines will find the scientific results revelatory. For researchers, this book could be a game-changer.

Dr. Heyman shows that, according to the research, "Once an addict, always an addict," doesn't hold water. It's not just a matter of a few addicts who beat the odds. Most addicts go clean on their own by their 30s. Unfortunately, by that time, they may have wreaked all around havoc.

Dr. Heyman reveals a key that addicts who go clean appear to tap into. This key can open the door to prevention and effective treatments. Despite years of failure within many treatment programs, it turns out that there are programs that are scientifically proven and a few that are proven to work amazingly well.

These research results also suggest changes needed in our childrearing and educational systems to help kids stay off drugs and to make better decisions in general.

Every once in a while I read a book that changes my understanding of people and life. This book has changed not only my understanding of addiction but also a key aspect of how people make decisions in many areas of their lives.

A book such as this one will generate two types of reviews: those who will evaluate it based on what it presents and those who simply dislike its thesis irrespective of the evidence proffered for it. I'm not saying that Heyman's thesis is ironclad, but this book amasses a substantial amount of evidence, in a well presented, thoughtful, and, dare I say, balanced, manner. Anyone who is seriously interested in the issue of addiction should at least read this book. You might disagree with the thesis, but the thesis as presented deserves serious consideration. Simply put, Heyman challenges the prevailing orthodoxy that additions are brain diseases akin to Parkinson's disease using a robust set of historical, sociological, and empirical approaches.

I found this book transformative. It is clearly a game changer. Heyman surprisingly shows that the addictions can be understood as a quirk in the psychological principles governing all human decisions. He integrates and explains an enormous set of data from economics, psychology, epidemiology, and sociology to support his thesis. His theory also accounts for the success of support groups such as AA and other treatment programs in helping addicts to recover. I found his writing clear and accessible to any intelligent non-professional. I think this book will be of interest not only to specialists but to anyone whose life has been deeply affected by decisions we make even though they destroy the very things we most cherish in life.

This book was great. I must say it was one of the first I've read that was completely able to swing me away from the "addiction as a disease" concept. The arguments are strong and relevant. They are simple to understand, obvious, and most importantly easy to describe when the debate amongst your peers inevitably comes up. Read this book, you won't regret it.

Having read the only the reviews and the authors summary, I think he truly does have something to say about addiction as a disorder of choice in the addiction model. However, it leaves the most important question unanswered. Why?

It is well known that the dopamine drive is the reinforcing trigger for behavior, including addictive behaviors so one must ask the questions: WHY do some people seem to need something to trigger dopamine stimulation? Why do some people chose short term over long term gain? Why do some people land on and learn to rely on a "fixed" trigger? Here, in my mind, is an example of biology finding a way to meet it's needs, for it's own sake, and not for the sake of the organism. By whatever means, dopamine is necessary. Exposure to the trigger, and it may only take one, provides the means. As people grow in other areas, and find healthier, more acceptable alternate means, often by the age of thirty, they become more willing to sacrifice the trigger that may have helped them through, but hurt them as well. My thoughts about this book is that it will change little if we do not understand and acknowledge how powerful the dopamine drive is, and how we teach our children to induce that drive in themselves in healthy ways early in their lives, before they have the opportunity to succumb to unhealthy means. When as parents, we fail to provide both discipline, (yes the reward is coming-learn to wait), and adequate (for the child)reward-genuine love, time attention and approval- addiction to harmful behaviors is a real possibility. Many of the children who become addicts learn instead that the reward, love, time attention, approval, is a tool to manipulate them, is not real, and never really comes-no matter what efforts they exert for it, until they have that first drink, smoke, snort, etc.....by that time, they are often already too cynical to trust that it can come in any other way. Some get lucky but many don't.

One should really stand back and consider the worth of the thesis of this book from a practical standpoint, even if proved. It may have some small value as self-justification for politicians and the legal community since both are hesitant and ill-equipped to deal with any concept of diminished responsibility. It will likely not be regarded by the therapeutic community as anything more than an improper extrapolation from the concept of motivational enhancement therapy (MET); something it already accepts may serve a useful purpose toward recovery in some cases of addiction.

We all live in an ever-changing matrix of influences that affect our everyday choices. Not often are we presented with distinct or dramatic choices like those of physicians or pilots confronted with job loss as reported (it is the approximately 10% that failed who should be studied) or war veterans returning home to vastly different surroundings. The Vermont voucher study as a validation leaves me singularly unconvinced. The definition of who is actually an addict is questionable and reaching any conclusion about addicts based largely on statistical analysis with definition an unresolved issue bears very close scrutiny. Any anecdotal report of spontaneous remission or voluntary recovery could likely be matched with as many or more well-conceived and structured interventions that have failed.

The current version of DSM 1994 is detailed as DSM-IV-TR 2002 in the American Psychiatric Publishing text noted hereafter. There could be a vast difference between the condition of a person who manifests only the three criteria required to qualify out of the seven stated within a twelve-month period and a person who has "lit up every light on the pinball machine" for say three years or more. It may work for some screening purposes but in drawing the conclusion Mr. Heyman does, it is entirely too general.

Proving addiction is not a "disease" of the brain or an involuntary behavior seems to be part of the constellation of opinion opposing legalization of currently illegal drugs, a matter concerning which I have no considered opinion.

I believe the AA approach is that alcoholism is an obsession of the mind coupled with and allergy of the body, the latter being loosely understood as a special physical vulnerability on the part of the alcoholic to the substance. Dr. Schwartz and Sharon Begley in their books have drawn attention to human brain capacity for neuroplasticity, particularly relative to cases of obsessive-compulsive disorders (OCDs). The approach developed for OCD treatment uses a 4-step program.

The Human Frontal Lobes (2nd ed.) 2007 by Bruce L. Miller and Jeffrey L. Cummings describes obsessive-compulsive disorders in the chapter on psychiatric diseases and sets forth four neurosurgical procedures used with severe, medically intractable OCD cases and four pathophysiological models (including Schwartz model). It does not appear that matters are very simple in respect of OCD or that neuroplasticity may always be an answer. The obsessive-compulsive aspect of addiction could indicate a brain circuitry issue that is somehow related to OCD or is a subtype thereof, notwithstanding the behavior which follows has immediate positive feedback instead of negative. Specific reference to the relationship between the obsessive-compulsive component of alcohol craving, neuroticism and anxiety is made in an article in 2005 Oxford Journals Press publication entitled Neter Alcoholic Typology and is available searching through Google online. A great many addicts enter treatment without requiring detoxification, not even evidencing significant withdrawal symptoms, so what part is mental and what part physical (however that dichotomy may be expressed to entwine) still remains a good question. Comorbidity would not be an issue, except on rare occasions.

Better descriptions of 12-step and other treatment programs including MET are contained in The American Psychiatric Publishing Textbook of Substance Abuse Treatment edited by Marc Galanter and Herbert D. Kleber (4th ed.) 2008. It is large and rather expensive text but does have access to large portions of its contents for perusal online without purchase. There are no records kept of individuals who became sober with the help of AA but remaining sober, no longer attend meetings. The numbers of these I believe would be very significant.

Readers should locate Mr. Heyman's book on the Canadian amazon website. They should note reference to the book In the Realm of the Hungry Ghosts by Dr. Gabor Mate which is informed and excellent.

Mr. Heyman, not too surprisingly, reaches what is essentially the same conclusion here as he had already reached in the 2001 book edited by Philip B. Heymann and William N. Brownsberger entitled Drug Addiction and Drug Policy, in his chapter entitled "Is Addiction a Chronic, Relapsing Disease", so there is no great revelation in this latest book. The introduction to that book states Mr. Heyman's opinion corresponds with those of Valliant and Stael, two other contributors, in that demands coupled with concern for the addict can be brought about in a coercive form with as great effect as voluntarily. Consider the reality, please. Coercion will continue to be employed vigorously in connection with illegal drugs and abuses of legal drugs, all with limited effect, irrespective of any definition or analysis of addiction or substance abuse in vogue. A little more open-mindedness and understanding (backed by proper research) is what could assist both results and the humanity of the process, in general.

So, what is the practical effect of the conclusion reached by Mr. Heyman? Probably just to again reinforce the coercive approach but there is at least the potential of a negative effect on research and treatment funding if anyone should, in fact, accept his conclusion. Consider that where legal addictive substances and behaviors are involved, a significant element of the coercive option now used is extracting substantial taxation revenues from them in full knowledge that a predictable fraction of the citizenry will become addicted. It becomes particularly hypocritical and irresponsible when adequate addiction funding fails or becomes subjected to general health cutbacks. Governments do not need any further assistance in deluding themselves as to their role and responsibility.

Saw the latest interview in my newsfeed, the AMA laid this to rest decades ago, as did APA, it is a disease. Now there are choices one can make to worsen or lessen the disease, but study after study on the genetics of addiction solidly come down on the side of the disease model. No serious clinician argues this point, by the 1980's there simply was so much evidence that the "Choice" people could no longer mount a serious argument. Books that intend to alter lives must be based in well conducted research, must not have a "mission" to prove a point at the expense of folks suffering from a massive issue such as addiction. Different points of view are great, but not when they are made without good sound scientific evidence.