Disease vs. Choice: A False Dichotomy
By Kenneth Anderson, MA
NOTE FROM PRACTICAL RECOVERY: How to understand addiction (or addictive problems) is a long-standing question, and that question is addressed by several blogs on this website. Practical Recovery is pleased to publish the most recent thoughts of esteemed author, historian, advocate, and founder of the HAMS mutual help group, Kenneth Anderson, MA.
Neither the disease model of addiction nor the choice model of addiction properly accounts for the facts, because strictly speaking, addiction is neither a disease nor a choice. Trying to decide whether addiction is a disease or a choice is a bit like trying to decide whether a cat is a reptile or a bird. But if addiction is neither a disease nor a choice, then what is it? Addiction is a conditioned response, specifically, it is a form of operant conditioning. In other words, addiction is a habit. Addiction differs from other habits not in kind, but in degree: addiction is a stronger habit than other habits.
What is operant conditioning? Operant conditioning occurs when a volitional behavior results in a reward. In the case of substance addiction, ingesting the substance is the volitional behavior, which results in the release of lots of dopamine, the reward chemical. Some substances, such as LSD or psilocybin, result in very little dopamine release and have a very low addiction potential. Other substances, such as alcohol, tobacco, opioids, cannabis, cocaine, etc. result in the release of large amounts of dopamine and are highly addictive. Operant conditioning is very important for survival because it helps us form habits such as obtaining food or reproducing the species, but it becomes problematic when it results in addiction. Operant conditioning differs from classical conditioning because classical conditioning involves involuntary behaviors, like Pavlov’s dogs salivating when they hear a bell.
So where did the disease and choice theories of addiction come from? One version of choice theory is the idea that drunkenness is a sin which can be traced back to Biblical times and before. The idea of drunkenness as a disease can be found in the writings of Dr. Benjamin Rush in the late 1700s. However, the disease theory really took hold when the American Association for the Cure of Inebriates (AACI) was established in 1870. In 1874, Dr. Robert P. Harris, physician to the Franklin Reformatory Home in Philadelphia, was kicked out of the AACI for having the temerity to say that inebriety was a habit and a sin to be reformed, not a disease to be cured. This 19th century disease theory could be called the first-generation disease theory.
The second-generation disease theory had its genesis after the repeal of prohibition and the advent of AA. Although AA founder Bill Wilson used the words “malady” and “illness” rather than “disease,” AA member Marty Mann founded the National Committee for Education on Alcoholism (later known as the National Council on Alcoholism) to promote AA and spread the second-generation disease theory far and wide. This version of the disease theory promoted the idea that “alcoholics” had a mysterious metabolic defect which caused them to develop “alcoholism,” whereas social drinkers lacked the mysterious X-factor. Under this theory, “alcoholics” were all innocent victims of their metabolism and were totally unlike the evil drug fiends who chose to become drug addicts; recreational opiate use was not even a possibility under this theory, all non-medical opiate users were deemed to be drug addicts.
The second-generation disease theory fell apart under the scrutiny of modern science and led to the third-generation disease theory as stated in Alan Leshner’s article “Addiction Is a Brain Disease, and It Matters.” This version of the disease theory at least recognized that addictions to alcohol, drugs, and cigarettes all had the same underlying mechanism, but what it got wrong was the idea that addiction is a chronic, relapsing disease that inevitably ends in death unless treated.
The epidemiological data revealed by the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) showed us that the normal outcome of addiction is so-called spontaneous remission, i.e., people recover without treatment and without going to groups like AA. Lopez-Quintero et al. (2011) reported that the lifetime recovery rates were 83.7% for nicotine dependence, 90.6% for alcohol, 97.2% for cannabis, and 99.2% for cocaine. Blanco et al. (2013) found that the lifetime recovery rates were 98.7% for sedatives, 98.3% for tranquilizers, 96.1% for opioids and 99.0% for stimulants. So why do people get the idea that addiction lasts a lifetime? Because addiction usually lasts a fairly long time: alcohol dependence lasts an average of 14 years, cocaine dependence lasts an average of five years, and so on.
Moreover, Cohen et al. (2007) found that only about 15% of people with alcohol dependence ever went to AA or got treatment. In other words, almost everyone with an addiction recovered without treatment! Researchers sometimes call this “spontaneous remission,” but this is a bit of a misnomer, because unlike the common cold, addictions don’t go away on their own. When you ask someone who kicked a habit on their own, they will tell you that it was due to a lot of hard work.
As a result of these data from NESARC, some researchers, such as Gene Heyman, developed choice theory based on behavioral economics. However, the problem with this is that almost no one chooses to become addicted to a substance. People choose to enjoy substances recreationally and tend to slip into addiction without realizing it. Initially it takes more effort to use a substance than not use it. But eventually, the balance changes, and it requires more effort to abstain from the substance than to use it. This is the genesis of addiction.
It is also essential to recognize that people use substances not only to seek pleasure, but also to avoid pain. Often, people are using drugs to escape the dystopian hellscape in which they are living. For instance, they may live in a highly dysfunctional family or living situation, have major health problems, or be experiencing the impacts of insufficiently regulated capitalism.
“Robber barons” love the disease theory because it absolves them of responsibility for having created the social conditions which create addiction and instead puts the blame for addiction on the biology of the individual, blaming the victim rather than the villain. However, the only way we will see reductions in addiction is if we change the social conditions which create it.
We saw above that almost everyone will eventually recover from addiction even with no AA and treatment. However, there is one caveat. People must stay alive in order to recover. This is why harm reduction programs are of such immense importance. If we keep people alive, they will almost certainly recover. If we shove them into treatment against their will they usually do not recover because of the treatment, although they may later recover on their own.
Even though people do not choose to become addicted, the only way anyone can ever overcome an addiction is by making a choice to do so. Although some may choose to go to AA or treatment, most choose to do it on their own, and they succeed.
But what about people getting addicted to opioids prescribed by their doctors? It happens all the time on TV shows, but in real life, as Maia Szalavitz points out, people very rarely become addicted to opioids when taking them as prescribed. The problem with the massive unnecessary overprescription of opioids was that so many of them got diverted, say, for example, by junior finding grandma’s never-used pills in her medicine cabinet and taking them for kicks.
Chartier et al. (2016) used the NESARC data to investigate the reasons that people with alcohol use disorder don’t get treatment; the top five reasons were as follows:
- Thought should be strong enough to handle it alone ………… 37%
- Thought the problem would get better by itself ………………… 90%
- Thought problem was not serious enough ……………………….. 66%
- Too embarrassed to discuss it ………………………………………… 57%
- Wanted to keep drinking ………………………………………………….. 83%
The interesting thing is that those who chose not to go to treatment were essentially correct. Most people do recover on their own, and about half moderate their drinking instead of abstaining.
But aren’t things like targeted naltrexone (aka the Sinclair Method), aversion therapy, and methadone medical treatments for the disease of addiction? Actually, targeted naltrexone and aversion therapy fit in perfectly with the operant conditioning model of addiction. By blocking the reward from alcohol, targeted naltrexone results in deconditioning from the act of drinking. And aversion therapy is simply counterconditioning. As for methadone, it is best viewed as a form of harm reduction which substitutes a less harmful opioid for a more harmful one, methadone being less harmful because it is legal and because it is long acting and does not interfere with life so much as heroin which must be injected several times a day.
But doesn’t the disease theory reduce stigma? It clearly does not. When was the last time you heard a father tell his daughter, “You should marry that guy, he’s an alcoholic?” Being labelled as diseased turns people into lepers and pariahs; it only benefits those people who are trying to market an addiction treatment program or recruit members through fear to an organization like AA. Accurately describing addiction is operant conditioning, i.e., a very strong habit, is the best way to destigmatize it and help people overcome it.
What needs to change is addiction treatment itself. We need to stop telling people with addictions that they are lepers who are diseased forever and can only be saved by a lifetime of meetings and divine intervention of an omnipotent deity because these things are false. Humans are not powerless; they are powerful. Treatment needs to work with the inner strengths of each person to help them get stronger. And treatment should not take credit for people saving themselves; treatment is just an aid in this process. Going to treatment needs to be a bit like going to a gym–the goal is to get stronger. And if treatment stops being so awful by emphasizing surrender to God and the scarlet letter of a lifelong alcoholic or addict identity, people would be much more motivated to go. And treatment, when it’s done right, can greatly speed up the process of natural recovery.
