The disturbing consequences of treating addiction as a disease-and every bad habit as an addiction.
Recently, the New York Times assessed the value of the Helmsley real estate empire at about $50 billion. Why, then, did Leona Helmsley steal a piddling million dollars or so by casting personal expenditures as business expenses? The crime was certainly an act of irrationality on Leona's part, like a millionaire's shoplifting.
It should be obvious to any trained clinician that Leona Helmsley is suffering from addiction to the acquisition of money, a compulsion to extract financial advantage in the most trivial ways, even when the potential gain could have no impact on her well-being. This would probably have been the most successful defense her lawyers could have presented at her tax-evasion trial. Indeed, Leona's failure to claim she was addicted could have been used as proof that she was, since one of the primary traits of addictive diseases is "denial" that one has the disease.
America is clearly moving into the 21st century in addictionology—the identification and explication of new addictions, defined as diseases. In addition to the standard drug and alcohol habits, these addictions include shopping and debt, sex and love, gambling, smoking, overeating, and just about anything people can do to excess. There are now A.A.-type support groups organized around several hundred types of activities. The crucial first step of the 12-step program that Alcoholics Anonymous and its derivatives have made famous is the obligation for the alcoholic or addict to admit he or she is "powerless over alcohol," or whatever the person's habit happens to be. This symptom is central to the disease, and A.A. focuses on loss of control as the definition, the etiology, and the excuse for addiction and addictive misbehavior.
It is not science that is fueling the movement to label so many activities as addictions. The tendency to see all addictions as cut from the same cloth returns us to 19th-century (and earlier) usage, in which to be addicted meant to be given over to a vice or activity in some unwholesome and morally reprehensible or weak-willed way. The observation that alcoholism (called inebriation and drunkenness in the last century) and drug addiction are items in a much larger class of human behavior is a fundamental realization that has been accepted throughout most of human history, but which American addictionologists have recently been rediscovering.
What is new in the 20th century is the claim that these compulsive activities somehow represent codifiable diseases. In the case of alcoholism, the inability to control one's drinking is today described as an inherited trait. This is wrong. In fact, even biologically-oriented research has shown that loss of control is not an inheritable trait, as A.A. originally claimed.
Rather, to the extent that genetic transmission of drinking patterns is indicated (and the scientific underpinnings for even this minimal proposition are far weaker than most lay readers suspect), researchers see alcoholism as the cumulative result of a long history of drinking. Some genetic theorists claim people continue drinking heavily for long periods of time to resolve neuro-psychological deficiencies or because they lack the inherited mechanism to determine when they have drunk enough. These theories nonetheless leave room for any number of environmental and personal factors to influence the development of alcoholism.
Research has shown decisively that alcoholics, even while drinking, are crucially influenced by value choices and environmental considerations. Alcoholics who seem to be out of control on the street are actually pursuing deliberate drinking strategies designed to achieve specific levels of drunkenness. Street alcoholics allowed to earn credit for booze in a laboratory will work until they accumulate enough chits to attain the exact level of intoxication they seek. Or, allowed to drink freely in an isolation booth, they will voluntarily cut down their drinking to spend more time in a comfortable, abstinent environment with other alcoholics watching television. Such alcoholics do get drunk a lot, and they prefer drinking to most other options available to them in their natural environments. Nonetheless, alcoholic drinking is a largely purposive behavior, even if alcoholics' purposes are quite alien to most people and even though alcoholics frequently regret their choices after they become sober (at least, until they become drunk again).
Much of the work on alcoholics' intentions while drinking has been conducted at the Baltimore City Hospital, part of the federally supported Addiction Research Center. But many of these same investigators are now giving their work with cocaine addicts a very different slant from the one they gave their alcohol research. This research group is often shown on television working with addicts attached to electrodes or giving responses recorded on a computer as they take or come down from their cocaine doses. A researcher then explains to the interviewer how cocaine provides a tremendous uplift, followed by an enervating down.
Actually, this process is a standard one observed in human beings engaged in activities ranging from eating carbohydrates to sexual intercourse (hence the readiness with which these activities are equated with drug addictions). Often, the researchers observe how the anticipation of the cocaine high or the need to reintroduce cocaine to alleviate the low will drive the addict to do anything. Sometimes reference is made to laboratory studies in which animals continue to inject cocaine through an implanted catheter until they kill themselves.
Just how addictive are cocaine and crack? Cocaine in any form is less addictive than cigarettes by the two key behavioral measures of addiction. Five times as many regular cigarette as crack smokers become addicted, according to Jack Henningfield, a researcher at the National Institute on Drug Abuse, and addicts indicate it is easier to give up crack than cigarettes. In fact, if we go by the NIDA survey to which George Bush alluded in his nationally televised speech last September, very few cocaine users become addicted. The survey found that 21 million Americans had used cocaine, 8 million had used it in the last year, and 3 million were current users, but only 300,000 used cocaine daily or nearly so. Government statistics thus show that 10 percent of current users and 1.5 percent of all users take the drug close to every day.
What are we to make, then, of the addict who explains that he needed to steal or kill to get more of his drug, or the woman who sells sex—one notorious addict prostituted her teenage daughter—to get money for crack? Aren't these behaviors drug effects? No, they are not, and it is a mark of naiveté—not science—to mistake the behavior of some drug users with the pharmacological effects of the drug, as though addictive loss of control and criminal behavior were somehow chemical properties of a substance.
Notwithstanding all the pseudoscience associated with it, addiction engages age-old questions about will power, self-control, personal responsibility, and values. How are some people able to turn down a fattening dessert or an after-dinner cigar which they might enjoy consuming, but which they have decided is bad for them? Do those who instead indulge themselves have a disease? Or do they have less self-control or think it is less important to be healthy?
In fact, science, like law, cannot accurately proceed without taking into account individual responsibility and values. For example, given that cigarettes are harder to quit than crack, what should we learn from the fact that William Bennett gave up smoking to take his post as drug czar? The only possible answer is that he was wise enough to recognize that he couldn't hold an antidrug post and be a cigarette addict, and that he wanted the drug post more than he wanted to continue smoking.
Of course, self-control and sound values are not immutable, Platonic ideals either. After all, Bennett inappropriately maintained his cigarette addiction throughout his tenure as secretary of education. Smokers and fat people demonstrate similarly weak self-control for years, until they successfully stop smoking or lose weight, after which we all envy them for their superior will power. People do refocus their values as their lives progress and they have different opportunities and options and become better prepared or more willing to change long-term habits. This is the nature of the beast, and nothing we learn about the chemistry of one drug versus another can change it. Try to say something sensible about nicotine's addictive properties as a way of explaining Bennett's newfound ability to abstain from smoking.
Why do we think crack/cocaine is so much more addictive than cigarettes, or heroin, or alcohol (all of which addicts with multiple addictions say are harder to quit than cocaine, whether smoked, injected, or snorted)? The drug's current reputation seems strange when we consider that cocaine was an ingredient in Coca-Cola and other soft drinks into the 20th century, and that research on cocaine's effects was conducted for 50 years before cocaine was announced to be addictive in the mid-1980s, coinciding with the explosion of recreational cocaine use in this country. Cocaine came to be addictive among some inner-city users and among a very small percentage of middle-class users who tried the drug.
Why didn't most of these people become cocaine addicts? The answer is so simple that we are left wondering why scientists can't figure it out: Most people have better things to do than to become addicted to cocaine. This is an example of a scientific concept—addiction—developing a symbolic meaning which is contradicted by the data. Nothing about drug use or any other addiction rules out choices and individual values. Without taking these facts of life into account, we cannot understand who becomes addicted and who does not, and why.
A study of middle-class users of cocaine by the Addiction Research Foundation of Toronto found not only that most regular users do not become addicted, but also that most of those who develop a steady craving for cocaine eventually cut back or quit the drug on their own. In other words, cocaine use resembles just about every other compelling experience in its potential to upset people's equilibrium, but this is not a permanent or inexorable condition for most people.
Counterpoised with these data are reports by the few who despair of kicking their cocaine habits on their own and enter private treatment centers, or by the addict-criminals who testify on television that you would kill and prostitute your children—as they did—if only you took crack. These claims are preposterous, the scientists and clinicians who encourage them are misrepresenting the facts, and we have reached a strange impasse in our civilization when we rely for information and moral guidance about habits on the most debilitated segments of our population—groups who attribute to addiction and drugs what are actually their personal problems. What, really, are we to learn from people who stand up and testify that they couldn't control their shopping sprees, that they spent all their money and went bankrupt to get material possessions we were smart enough to resist, and that they now want us to forgive them and their debts?
The message in all this is that one of the best antidotes to addiction is to teach children responsibility and respect for others and to insist on ethical standards for everyone—children, adults, addicts. Crosscultural data indicate, for instance, that when an experience is defined as uncontrollable, many people experience such loss of control and use it to justify their transgressions against society. For example, studies find that the "uncontrollable" consequences of alcohol consumption vary from one society to another, depending upon cultural expectations. In arctic Finland, drinking sessions regularly lead to knife fights and killings; in Mediterranean countries such as Greece, on the other hand, such violence is virtually unheard of, and people do not perceive a link between alcohol and aggression.
The modern "scientific" view of alcoholism and addiction has actually caused addictive behaviors of all kinds to grow. It excuses uncontrolled behavior and predisposes people to interpret their lack of control as the expression of a disease which they can do nothing about. Treatment advocates attack those who don't accept the disease model of addiction as being "unscientific" and "moralistic," or as practicing "denial." On the contrary, the refusal to accept the loss-of-control myth seems to inoculate people against addiction.
One of the worst consequences of the idea that addiction and alcoholism are diseases is the notion that substance abuse can be treated away, a view continuously propagated by a large and growing addiction-treatment establishment and bought by well-meaning public officials and private citizens. In fact, these treatments are exorbitantly expensive ($7,500 to $35,000 a month in a private treatment center) while being demonstrably ineffective.
One of the most remarkable works of addictionology of the 1980s was a tome by psychiatrist George Vaillant entitled The Natural History of Alcoholism. Vaillant defended throughout his book the medical model of alcoholism, but then revealed that the alcoholics he treated at Cambridge Hospital in Massachusetts with detoxification, compulsory A.A. attendance, and counseling fared no better than comparably severe alcoholics who went completely without treatment. Several times in this strange book, Vaillant warns professional readers not to interfere with "the natural healing process"—this, in a work by a psychiatrist who insists that we need to get more alcoholics into treatment.
What works in fact for alcoholism and addiction is giving people the options and values that rule out addictive drug use. Investing more in futile but expensive treatment programs simply subtracts from the resources that are available to influence people's actual environments in ways that can reduce their vulnerability to addiction. Even Dr. Herbert Kleber, Bennett's deputy in charge of "demand reduction," has indicated that addicts can only be treated by being "given a place in the family and social structures" that they may never have had before. In other words, as Kleber puts it, they require "habilitation more than rehabilitation."
The head of the NIDA, Charles Schuster, indicates that in treating drug addicts, "the best predictor of success is whether the addict has a job." Of course, the best way to avoid addiction in the first place is to have in place social structures, jobs, and values that militate against habitual intoxication. But these are hardly treatment issues, and to approach them as such is to attack the problem in a belated, piecemeal, and ultimately self-defeating way.
Thus, to the extent that Bennett and Bush's "war on drugs" focuses on external agents and supplies, it not only misses the point of addiction, it actually deprives domestic programs of the resources they need to have any impact on the conditions in inner cities that fertilize drug abuse. As for Bennett's resolve to stamp out casual drug use as a part of his attack on addiction, there really is no relation between the two. As Bush himself indicated in his nationally televised speech in September, the NIDA found that 23 million Americans had used an illicit drug during the previous month when questioned in 1985, a number that declined to 14.5 million in 1988. Yet during this same period, daily drug use—and especially cocaine addiction—climbed.
Clearly, although we convinced those with the most personal resources and responsibility to stop experimenting with drugs, those who are unable or unwilling to control their drug use grew more numerous and found themselves in a deeper hole. At the same time, as we have seen, the NIDA survey to which Bush alluded found that minuscule numbers of those who experiment with cocaine become addicts. Here we see how the administration's own statistics disprove the link between recreational drug use and addiction that Bennett seeks to claim.
In the area of addiction, what is purveyed as fact is usually wrong and simply repackages popular myths as if they were the latest scientific deductions. To be ignorant of the received opinion about addiction is to have the best chance to say something sensible and to have an impact on the problem.
Stanton Peele is a senior health researcher at Mathematica Policy Research in Princeton, New Jersey, and the author of Diseasing of America: Addiction Treatment Out of Control.
This article originally appeared in print under the headline "Control Yourself".