Addiction: Choice vs.

Disease 1

Running Head: ADDICTION: CHOICE VS. DISEASE

Addiction: Choice vs. Disease

Danny O’Dell, CADC II

Kaplan University

CM220-14AU

Professor Pappas

January 16, 2010

 Addiction: Choice vs. Disease 2

Johnny's heart is beating at over a hundred and thirty beats per minute. He can't sleep

again and is sweating profusely. Johnny hears a voice saying "Don't do it Johnny. You know

how this will end." Then he hears another louder, more insistent voice saying to him, “Come on

Johnny, no one will know. Just one more time and then we will stop.” Johnny is disgusted with

himself as he reaches for the phone to make that call to his drug connection. How do we help

someone like Johnny? Some people would say that all Johnny needs is to make a conscious

decision to not use and to punish or threaten him until he stops. This is the crux of what is known

as the choice argument: addiction is a behavior and therefore is a choice, not a disease. To be

honest the choice argument is a strong argument and is the best reason for not calling addiction a

disease. To call addiction a disease and not a choice, evidence will need to show the flaws in

calling addiction a choice, show how drugs of abuse work, how addiction fits into the disease

model, identify what organ is primarily affected, and be able to recognize what the symptoms of

drug addiction are.

There are some very educated individuals who believe that addiction is a behavior and

that behaviors are a result of choices. According to Gene Heyman, a Harvard psychologist, drug

addiction is a choice, not a disease. In his book, Addiction: A Disorder of Choice, Heyman states

that addiction is not a disease and that it is a pattern of persistent but optional self-destructive

behaviors (Birns, 2009). He disputes Alan Leshner, former head of the National Institute on

Drug Abuse (NIDA), who has stated that "drug use starts off voluntary and becomes

involuntary" (Gillis, 2009, para 1). Heyman's argument seems to be that because of biographical

information that he has read where an addict is quoted saying, "Well, it was a question of getting

high on cocaine or putting food on the table for my kids," therefore this addict, voluntarily, chose

to not use drugs (Gillis, 2009, para 7). Heyman, and those who subscribe to this philosophy, are
 Addiction: Choice vs. Disease 3

able to drive home their argument by using the following scenario: put an addict's drug of choice

in front of him and tell him, "Go ahead, it is on the house." An addict, they say, will gladly take

the offer, however, this is when they challenge the addict's behavior by saying, "but if you do

choose to use, I will pull out a gun and shoot you" (McCauley, 2009). It should be fairly obvious

that faced with these choices, the addict will choose not to use. Choice theorists draw a line

between behaviors and symptoms. With diseases such as cancer and diabetes, the patient cannot

be coerced into not having the symptoms of his or her disease. This would appear to be a great

argument but is this all there is to addiction - simply find a big enough deterrent to force the

addict to make the right choices? If behaviors are choices and if free will exists, punishing and/or

coercing the addict is appropriate. The behaviors of addicts are revolting, frustrating, offensive,

and sometimes criminal and can easily be seen as bad behaviors or choices. While this might be

true, does this mean that because you have a bad act you necessarily have a bad actor or some

sort of intrinsic badness in a person? According to Dr. McCauley, doctors have been making this

mistake for centuries, believing that the behaviors that they are seeing in their patients are due to

a moral failing, ethnicity, race, personality disorder, or gender, only to discover that what they

are seeing is actually symptoms of a disease (2009).

Remember Johnny's situation, there are no drugs around him at the moment and yet all he

can do is think about using his drug of choice. There is no sleep for Johnny, no rest, only

craving. This is the addict's true suffering. NIDA defines addiction as a dysregulation of the

midbrain dopamine (pleasure) system due to unmanaged stress resulting in symptoms of

decreased functioning, specifically: loss of control, craving, persistent drug use despite negative

consequences (2008).While it is possible to use coercion (gun to the head theory) to keep an

addict from using at that moment, this will not prevent the addict from craving. The addict does
 Addiction: Choice vs. Disease 4

not have a choice of whether or not to crave anymore than a diabetic can choose to not have

elevated glucose levels.

In the documentary, Pleasure Unwoven, Dr. McCauley explains that until over a hundred

years ago, doctors would usually try and treat the symptoms of a disease. This resulted in poor

outcomes and most diabetics dying in early childhood (2009). It was not until the famous work

of Louis Pasteur and Robert Koch that doctors formulated what is known as the disease model

(Lynch & Henifin, 1998). The disease model is a causal model and works as follows:

Organ

Cause

Defect

Symptoms

By using this model we can see that if the organ was the pancreas, the defect, Islet cell death (no

insulin), and the symptoms were elevated blood glucose, blurred vision, and coma, treating the

symptoms would get you nowhere. If, however, doctors were to treat the defect (no insulin) by

using insulin replacement therapy then the symptoms would recede and the disease would enter

remission. For many years, doctors did not understand how to put addiction into this model and

so left the problem of addiction outside their doors. If addiction is a choice and not a disease,

then an addict is not a patient and is not afforded the same privileges and rights that all patients

receive, therefore it becomes the legal systems problem to deal with addicts. And how does the

criminal justice system deal with addicts? They build prisons, lots of prisons. There are currently
 Addiction: Choice vs. Disease 5

2.3 million people incarcerated in the United States (Washington Times, 2008). That is more

than any other country in the world. Approximately eighty percent of the people currently

incarcerated in the U.S. are there because they have, either directly or non-directly, committed a

non-violent, drug and/or alcohol related offense (Williams, 2008). Is it the addict's intent to be

bad, to be frustrating, and to be criminal? The obvious answer seems to be no. The law says that

there must be criminal intent to prosecute and yet addicts are being incarcerated by the hundreds

of thousands. It is preposterous to believe that people who struggle with an addiction today, at

one time, sat in elementary school thinking, "I can't wait until I lie to my mom or steal from an

old lady or commit a crime that will put me in prison for the rest of my life."

The way society is treating addiction, and those who suffer from it, does seem to be

changing. This is due, to a great extent, because of what science is now discovering about how

addiction works and more important yet, where they work. What about the disease model? If

science can now fit addiction into the disease model, it is time for society to start treating addicts

as patients instead of treating them like criminals. Let us re-visit the disease model. Is it possible

to use this causal model for addiction? Yes, it is.

Midbrain

Stress-induced hedonic
dysregulation

Loss of control, craving, persistent

use despite negative consequence,
frustrating behaviors
 Addiction: Choice vs. Disease 6

As shown in the diagram, the organ that is affected is the midbrain, the defect or cause is a

stress-induced hedonic dysregualation, and the symptoms are loss of control, craving, persistent

use despite negative consequences, and frustrating behaviors (McCauley, 2009).

Until recently, there was not much we knew or understood about the brain. This could be

the reason doctors were unable to consider addiction as a disease. Because of what we do know

now, we are able to fit addiction into the disease model. There is an area of the brain responsible

for vision, hearing, memory, and motor functions to name just a few. The areas of the brain that

are important when investigating how drugs of abuse work and why some people become

addicted, however, is the frontal cortex and the midbrain. The frontal cortex is the area of the

brain that handles judgment. The frontal cortex basically handles us, our reality, where we confer

meaning onto things. It is where a mother loves her baby and where a baby loves her back (Levin

et al., 1987). It is where a person chooses what church to go to and where we choose our friends.

When something enters our world, say a hammer, it is our frontal cortex that gives it meaning

and purpose. It is a hammer, it can be used to drive a nail, to hang a picture, or tap an object into

alignment.

The midbrain or survival brain is not concerned with morals, laws, or good judgments.

The midbrain focuses on surviving the next fifteen minutes and considers all that enters into its

world a matter of life or death (McCauley, 2009). When an object such as a hammer enters the

midbrain's world, it is not interested in what it can be used for in the future. The midbrain is

calculating whether or not to; kill the hammer, eat the hammer, or procreate with the hammer.

These are the basic survival imperatives that the midbrain recognizes as life or death. These basic

survival imperatives are known as the feed and breed and fight or flight imperatives. It is a
 Addiction: Choice vs. Disease 7

probable conclusion that the only reason human beings have such a highly developed frontal

cortex is because the mid-brain has kept them alive long enough to develop one.

Because of studies that were performed in the 1950's, scientists found that drugs of abuse

do not work in the thinking, moral, law abiding part of the brain (frontal cortex). They actually

work in a much more primitive, scarier part of the brain (midbrain), "a part of the brain that

regulates autonomic functions such as breathing and appetite" (Henderson, 2000, para 2). One

famous study was the Peter Milner and Dr. James Olds rodent study. By inserting probes into the

animal's midbrain and providing a small shock, they were able to control the animal's behavior.

Not only would the animal perform any behavior that would be rewarded with a pleasurable

shock, it would remember, upon waking, where to go to be stimulated by the pleasurable

sensation. By stimulating specific areas of the rodents brain, Dr. Olds was also able give salience

to the pleasurable experience that would trump the other survival imperatives (Thompson, 2009).

These were important discoveries in understanding the reward system and in what part of the

brain this system resides in. This study seems to show that it is possible for pleasurable stimuli to

not only affect the survival part of the brain but to actually trump survival imperatives. When

these same probes were inserted in areas other than the midbrain there was no change in behavior

and the rodents would not push a lever for more (Thompson, 2009).

Today, science does not just have information based on rodent studies, it has modern

technology. There are tools such as rational magnetic resonance imaging (MRI) and Single

Photon Emission Computerized Tomography's (SPECTS) that use computer images to show how

different areas of the brain are activated when stimulated (Amen, 2004). What scientists are

learning about the human brain and how drugs of abuse can alter the brain are both exciting and

promising. Scientists know that drugs of abuse work in specific areas of the midbrain. These
 Addiction: Choice vs. Disease 8

areas are known as the nucleus accumbens (NAcc), the ventral tegmental area (VTA), and the

medial forebrain bundle (MFB) (NIDA, 2008). These are the areas known to be involved in

pleasure and reward. There are millions of neurons that send signals back in forth from the body

to the brain. These signals are like electrical surges driven by chemicals known as

neurotransmitters which are chemical messengers that balance the brain. The neurotransmitter

dopamine seems to play the biggest and more important role in the reward system (Tomkins &

Sellers, 2001). It is important to understand that it is this very system that insures the survival of

humans by making certain behaviors pleasurable.

Whether a person is addicted to alcohol, methamphetamine, cocaine, marijuana, heroin,

or sex, they all interact in the same area of the brain and they all create a surge of dopamine in

the midbrain (Henderson, 2000, para 2). Some drugs such as alcohol and heroin do this by

affecting the body's own natural dopamine inhibitor known as GABA, while others prevent the

neuron cell's natural recycling process resulting in an abundance of available dopamine at the

receptor sites. Another important neurotransmitter is glutamate which is believed to play a role in

the way an addict remembers how important the reward is when they use drugs (McCauley,

2009). Dopamine is not released just when something is good, it is released when something is

better than expected. That is like putting a quarter in a poker machine and hitting a royal flush.

The pay-off is huge and something you will remember.

What the choice theory does not account for is the addict's true suffering. This is known

as the craving cycle (Tyler, 2005). People often talk about craving as wanting something really

bad. But in addiction, this is not what is meant by the term craving. Craving, or the addiction

craving cycle, is broken up into four parts: obsession, compulsion, physical craving, and drug-

seeking behavior (Tyler, 2005). Obsession is an inability to think about anything else. Where
 Addiction: Choice vs. Disease 9

obsession is about thinking, compulsion is about being tied to it emotionally, not just cognitively.

If compulsion is not interrupted, it will lead to physical craving. In his book, Enough Already!,

Bob Tyler (2005) states that this is where the body asks for the drug, a "tissue hunger for a drug

that is caused by brain chemistry imbalances" (p. 27). Lastly, if no intervention is acquired, drug-

seeking behavior is the action the addict will take to get their drug of choice such as pick-up the

phone to call their drug connection. Johnny is not choosing to obsess and experience the negative

physical reaction, is he experiencing the craving cycle.

To help Johnny, society will need to offer more than coercion and punishment. Society

needs to make treatment available and affordable. In his book, Addiction is a Choice, Jeffrey

Schaler, Ph.D. (2000) makes numerous claims such as: treatment does not work, twelve step

programs are religious cults, and that addiction is nothing more that some sort of intrinsic

badness in people. Actually, contrary to Mr. Schaler's claims, studies are proving that treatment

does work. As with any other disease, there is a high incidence of relapse. According to the

Journal of American Medical Association (JAMA), forty to sixty percent of addicts will

experience relapse (Perkinson, 2008). Do these numbers mean that treatment does not work as

Mr. Schaler would have us believe? JAMA also states that thirty to fifty percent of people with

type I diabetes will experience relapse also. Does this mean that treatment for diabetics does not

work? Or does it mean that treatment needs to be re-evaluated and readjusted to meet the

patient's needs?

In order to have optimal results a treatment center should offer trained and credentialed

substance abuse counselors, psychiatrists, nutritionists, psychologists, and other professionals

who can be combined to meet the many needs of the addict. The best treatment that is currently

available is the type of treatment offered to chemically dependent physicians and airline pilots.
 Addiction: Choice vs. Disease 10

This treatment includes ninety days inpatient treatment but is followed up by a case manager for

an additional five years. They are required to submit random urine samples, which are screened

for drugs of abuse, and attend regular support groups. The success rate with this type of

treatment is ninety to ninety-four percent (Perkinson, 2008).

There is also the argument that treatment is not cost effective. In the book, Love First,

Jeff & Debra Jay (2000) state that, "For every dollar spent on treatment, we save society four to

seven dollars" (p.21). Investing in treatment is far more cost effective than money allocated to

interdiction (patrolling the borders for drugs) or law enforcement. According to Jeff & Debra Jay

(2000) "It takes 246 million dollars in law enforcement or 366 million dollars in interdiction to

get the equivalent results of 34 million dollars in treatment" (p.21). When all the facts are

considered, not offering affordable treatment and imprisoning addicts is not only harsh but

expensive. The more we learn about addiction and those who suffer from it, the more it becomes

obvious that stigma and bias prevents us from effectively treating addictions. Based on these

facts, it appears that the addict does not fail the treatment process but that inferior treatment fails

the addict.

While it should now be obvious that because of modern science and much research, we

now know more than ever about how drugs work and the devastation they cause in the reward/

pleasure system of the human brain. There is, though, still much to be learned and discovered.

We now know that neurotransmitters in the human brain are of paramount importance in

understanding addiction. We know that not everyone comes to the table of life with the same

brain. We know that if all we do is judge the addict by his or her behaviors, we are missing the

true suffering experienced by the addict. It should also be apparent that punishing or coercing

addicts is not working and is not the solution. Addicts themselves are teaching us what works
 Addiction: Choice vs. Disease 11

and what does not work. Are we listening? I believe that many of us are. Every time an addict

gets clean and becomes a responsible productive member of society, they are showing us that

they were never really bad people; they were actually sick people who simply needed treatment.

The next time you see someone like Johnny struggling with their disease will you be able to

demonstrate empathy? Or will you just, as many people do, simply see the disgusting, amoral,

frustrating, and sometimes criminal behaviors that we should now know are all symptoms of the

disease, and continue to perpetuate the stigma that has been all too often placed on addicts in our

society?
 Addiction: Choice vs. Disease 12

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 Addiction: Choice vs. Disease 13

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