Like Bad Drug Laws, the Disease Theory of Addiction Ruins Lives: We Must Target Both

Disease Theory of Addiction

The disease theory of addiction underpins punitive and abhorrent drug policies—but in fact, its negative impact is evenworse than this.

Recently, two notables on an addiction theory list to which I used to belong debated the relationship between the disease theory of addiction and drug policy.

One, my fellow Influence contributor Carl Hart, of Columbia University, expressed the view that it was a misdirected focus to argue about whether addiction is a disease rather than to prioritize dealing with drug policies that impose damaging criminal sanctions, drive racial and other inequalities, and increase drug users’ risks.

The other distinguished theorist, Nick Heather, of Northumbria University in England, instead argued that the disease model is central to our misguided drug policy and must be discarded in order to reform our drug policies in sensible ways.

I admire the work of both men, and both have spoken clearly against the brain disease model of addiction (Carl in his book, High Price, Nick in his co-edited volume, Addiction and Choice). And I really see no disagreement between them.

Why is it that certain drugs are banned as a special category of substances? Why don’t we ban fattening desserts, since obesity, many argue, is America’s number one public health problem? Why don’t we imprison obese people, while we’re at it? Of course, we banned alcohol, and then changed our mind. And we aren’t about to outlaw cigarettes, even as we make it harder for people to find places to smoke.

But we do make it illegal for people to purchase most non-prescribed drugs. Why these societal and existential inconsistencies?

Our societal racism is, sadly, a major reason that most drugs were made illegal in the first place.

But their illegal status has been bolstered in the modern era by our belief that some drugs, starting with the narcotics, embodied by heroin, have a special property of addiction, caused by an inescapable chemical-neurological interaction.The belief in the inherent “evil” of drugs is thus, nowadays, justified under the banner of  the chronic brain disease of addiction. American science declares this is just the way drugs and our brains work and there’s no escaping it.

Although we Americans are relentlessly convincing the rest of the world to view addiction in this way, the evidence is that this model is disastrous.

The perception that a link between certain drugs and addiction is inexorable allows policymakers to justify banning these substances and dealing with users as criminals—or else as patients who need to be forced to undergo treatment with no clinical justification other than that they use the drugs.

Who else uses heroin, most Americans think, but incorrigible heroin addicts?

But that isn’t true. As I have pointed out in The Influence, in 2014, 1.8 percent of Americans had used heroin in their lifetimes. In the past month, 0.2 percent had done so. In other words, a little over a 10th of lifetime heroin users have used the drug in the past month. And even that doesn’t prove that the remaining 0.2 percent are addicted by simply using the drug at least monthly (between 10 and 20 percent of those users are, per Carl Hart).

And what about painkillers, which a majority of Americans have taken, and which are considered to be as addictive as street narcotics? Although these are legally available if prescribed, fear of their addictive properties has prompted a national crackdown on access to painkillers.

Who was it who argued, to a bipartisan cast of governors, that they were misguided in urging draconian limits on prescribing these drugs?

“If we go to doctors right now and say ‘Don’t overprescribe’ without providing some mechanisms for people in these communities to deal with the pain that they have or the issues that they have, then we’re not going to solve the problem, because the pain is real, the mental illness is real,” Obama said during his meeting with the governors. “In some cases, addiction is already there.”

(God, I miss him already.)

Meanwhile, as I have also pointed out in The Influence, The New York Times made every effort to sell the scare story in reference to Prince that people are universally becoming addicted to, and as a result dying from, prescribed painkillers.  Yet, according data in the Times article itself, we could calculate “that fewer than a half of a percent of nonmedical opioid users, including heroin users, died, in a record year for both heroin and opioid painkiller deaths.”

But, [it was claimed] Prince had been using painkillers medically prescribed for pain relief. So Prince falls within a much larger denominator of opioid users—including tens of millions of Americans—meaning that he, as a supposed medical user, represents a tiny fraction of the tiny fraction of opioid users who die.

As long as we demonize narcotics, we’ll never allow people to use heroin legally in the United States. This despite positive experiences with decriminalization in several countries, including Portugal, and despite research at heroin maintenance sites in countries like Switzerland at which virtually no accidental deaths occur, users achieve better lives through better work and health outcomes, and those with addictive problems more often recover because of their access to caring providers.

In other words, treating drug users like normal people pays monumental dividends.

I first argued against narcotics as being the paragon of addiction in 1985 in The Meaning of Addiction:

The view that addiction is the result of a specific biological mechanism that locks the body into an invariant pattern of behavior—one marked by superordinate craving and traumatic withdrawal when a given drug is not available … has never provided a good description either of drug-related behavior or of the behavior of the addicted individual.

In particular, the early twentieth-century concept of addiction [is] disproven both by the phenomenon of controlled opiate use even by regular and heavy users and by the appearance of addictive symptomatology for users of nonnarcotic substances.

A large body of user research, most notably Lee Robins’ exploration of heroin use by Vietnam vets when they returned home, concludes “contrary to conventional belief, the occasional use of narcotics without becoming addicted appears possible even for men who have previously been dependent on narcotics.”

I summarized in Meaning: “heroin does not appear to differ significantly in the potential range of its use from other types of involvements, and even compulsive users cannot be distinguished from those given to other habitual involvements in the ease with which they desist or shift their patterns of use.”

Since I made the assertion, much else has occurred to reinforce the idea that addiction is not a special property of narcotics—including the medical establishment’s declarations that cocaine and smoking were addictive alongside of narcotics. Thus the illegality of the former has been bolstered, while the latter has been made ever more difficult (and expensive) to consume.

In 2013, DSM-5 finally declared one non-drug involvement, gambling, was addictive—on the grounds that, apparently alone among all activities, “pathological gambling and substance-use disorders are very similar in the way they affect the brain and neurological reward system.”

It’s taken American psychiatry an age to get there, but they are slowly approaching the realization that any substances or activities may fall into that pigeonhole we label “addiction”—or they may not. There’s just no basis for dividing things in the universe irrevocably into bins labeled “addictive” and “non-addictive.” And it’s going to take policymakers even longer to catch up to this reality.

Of course, there’s the outlying case of marijuana. People don’t really believe marijuana is addictive, principally because they, and people they know, have used it reasonably.  Which is why a solid majority of Americans favor legalizing cannabis.

This despite a quiet but steady drumbeat showing that marijuana can, indeed be addictive—most recently in an article in the Journal of Clinical Psychiatry that found marijuana intermediate, between alcohol and nicotine, in the rate of dependence it produces. The lead investigator, Jesse Cougle, declared, based on the research results: “the addictiveness of cannabis has been underestimated” and the finding “definitely contradicts a lot of opinions on the topic.”

But we’re not going to stop the march towards legalization of marijuana no matter what such research shows. Our non-hysterical acceptance of the drug is due to a cultural shift in our view of cannabis. This acceptance has not occurred because people can’t become dependent on it. But, as I have written, we are familiar enough with marijuana, as we are with alcohol (and dare I say sex, gambling, shopping and other addictive involvements) that most of us don’t believe it causes an irresistible brain disease that human beings can’t avoid or reverse.

We just need to confront drug pitfalls the way we do the rest of the potentially dangerous involvements in our lives. Attempting to avoid such dangers by banning and penalizing any one drug is more lethal than it is protective.

Although the disease theory has not always been an essential ingredient of punitive drug policies, it today comprises the most powerful and oft-used weapon in the prohibitionists’ arsenal.

Which brings us to an argument Nick Heather emphasizes that I, personally, am possessed by—even as Carl Hart supports this argument by pointing out that we are selling drug addiction myths as part and parcel of our popular culture.

It’s not just because the disease theory of addiction underlies our irrational drug laws that it is intolerable. It’s because convincing people that their substance use is an uncontrollable, irreversible biological-neurologic-brain syndrome is, in and of itself, a horrible detriment to society.

As Nick points out:

The disease understanding deeply affects how people with problems of addiction understand their own predicament and what they should do about it. It destroys their confidence that they can recover, either on their own or with the help of friends and loved ones, which the evidence clearly shows they can.

Nick opposes the disease theory not only because it is “strongly related to the war on drugs,” but because, by itself, opposing the brain disease theory of addiction “may be, in the long run, equally important for social justice and the humane response to people’s misfortunes and unhappiness.”

Both the disease theory and our drug laws are insidious and malevolent.

Happily, although there is far to go, we are gradually recognizing the need to reverse punitive drug policies and to eliminate associated legal punishments. But, much as I wish it were so, I see no clear equivalent movement against the brain disease model.

Many people have received prison sentences which can ruin their lives.  But, equally so, if less tangibly, an identity as an addict may be inescapable and pernicious. And that identity may also lead to death, as it has recently for some of the most privileged, no matter how unnecessarily that identity was imposed on them in the first place.

Although we must confront the institutionalized racism of our drug laws, I cannot bear the idea that we simultaneously ignore an equally horrible way of ruining human lives—one that is claimed, mistakenly, to be dictated by science.