Does Calling Heroin Addiction a Brain Disease Help Avoid Tragedies Like Philip Seymour Hoffman's Death?



In a recent Time essay, David Sheff says Philip Seymour Hoffman was not responsible for the decisions that led to his death because he suffered from "a brain disease that's often progressive"—i.e., drug addiction:

It wasn't Hoffman's fault that he relapsed. It was the fault of a disease that often includes relapse as a symptom and the fault of the ineffective treatment he received.

You might surmise that there is a connection between viewing addiction as a brain disease and coming up with an effective treatment for it. But you would be wrong. The dominant model for addiction treatment in the United States is the 12-step approach promoted by Alcoholics Anonymous, which describes addiction as a disease yet advocates what amounts to a spiritual cure—one that does not seem to work better than any other approach, possibly including no treatment at all.

Sheff, author of Clean: Overcoming Addiction and Ending America's Greatest Tragedy, suggests some alternatives. "Traditionally," he writes, "the only choices offered to addicts were 12-step programs, but proven treatments now include cognitive behavioral therapy, motivational interviewing and psychopharmacology." But the effectiveness of cognitive behavioral therapy and motivational interviewing hardly depends on viewing addiction as a brain disease rather than a hard-to-break habit. And although "psychopharmacology" sounds  more like a medical treatment, here is what Sheff has in mind:

We don't know if Hoffman was, upon discharge from treatment, prescribed medications like Suboxone, which prevents opiate relapse, but it's unlikely, because most treatment programs eschew them. If he had been (and if he took them as prescribed), it's almost certain that he'd be alive today. Another medication that may have saved his life is naloxone, a drug that reverses an overdose. All opiate addicts, as well as police and other first responders, should have access to this drug. 

Suboxone contains buprenorphine, an opioid used, like methadone, in "maintenance treatment," which substitutes one narcotic for another. (Although Sheff speculates that lack of proper medication may explain Hoffman's apparent overdose, the New York Daily News reports that buprenorphine was found in the apartment where he died.) There may well be advantages to substituting an orally ingested pharmaceutical-quality opioid for a snorted or injected black-market opiate. But that does not mean addiction is a brain disease, or that a heroin addict must accept that view to benefit from the substitution. It is even less plausible to suggest that naloxone will work to reverse a heroin overdose only if you adopt Sheff's view of addiction, although he is certainly right that naloxone should be more widely available.

Might there be disadvantages to viewing addiction as a brain disease? Stanton Peele, a psychologist who has been writing about addiction for nearly four decades, suggests that the "learned helplessness" inculcated by the disease model makes tragic outcomes like Hoffman's death more rather than less likely. An addict who believes complete abstinence from heroin is the only acceptable option because he is physiologically incapable of exercising control over his drug consumption may be ill-prepared for a relapse. Having adopted an all-or-nothing view, he may be disinclined to take precautions such as moderating his intake, asking friends to look in on him, having naloxone on hand in case of an overdose, and avoiding other depressants (which are involved in the vast majority of so-called heroin overdoses). In other words, the lack of responsibility that Sheff urges can have deadly consequences.