16

Addiction, Compulsion, and Choice

The Greeks gave full recognition to pleasures in themselves. We, on the other hand, are tending more and more to ascribe lack of self-control over appetites to some agent of compulsion within the object consumed, or to some disguised psychical damage sustained in childhood, babyhood or even in the womb. The Greek notion of addiction may have been too innocent, but by denying that people consume too much of something because they enjoy it, we are also making a mistake.

—JAMES DAVIDSON, COURTESANSAND FISHCAKES:
THE CONSUMING PASSIONSOF CLASSICAL ATHENS

It’s really not that difficult to overcome these seemingly ghastly problems . . .What’s hard is to decide.

—ROBERT DOWNEY JR.

Diseases come and go. In the decades following the Civil War, all the best people had neurasthenia, a vague nervous disorder said to afflict sensitive souls in the face of modernity. For a while homosexuality was considered a disease, until it wasn’t. It’s also worth noting that diseases can be quite profitable; Geritol lucratively promised to alleviate “iron-poor blood,” and more recently such newfangled ailments as social anxiety disorder and attention deficit disorder have been quite rewarding for drug companies who publicize these illnesses and their treatments.

Perhaps the most egregious of today’s socially constructed diseases is the burgeoning category of addiction. For the notion that at least one type of addiction is a disease, we mainly have to thank not a physician or scientist but a public relations man by the name of Dwight Anderson. A recovered alcoholic himself, Anderson was recruited during World War II by a medical group called the Research Council on Problems of Alcohol in its quest to claim jurisdiction over the problem of chronic excessive drinking.

Anderson’s canny advice, published in a seminal article in 1942, was to recast the alcoholic as a sick man. “Sickness implies the possibility of treatment. It also implies that, to some extent at least, the individual is not responsible for his condition . . . it follows from all this that the problem is a responsibility of the medical profession, of the constituted health authorities, and of the public in general.”

Of course, Anderson didn’t invent the disease of alcoholism, although he did popularize it. As long ago as the seventeenth century, British clergymen warned their parishioners about the “disease” of alcoholism, which one called “so epidemical” that “all the Physicians in England know not how to stop it.” In the eighteenth century, the great Philadelphian Benjamin Rush, a signer of the Declaration of Independence, was among the physicians who took up the issue, writing that “drunkenness resembles certain hereditary, family, and contagious diseases.”

But the concept never fully took hold until Anderson came along. By now the disease model is well established, and a whole range of self-destructive behaviors that were once considered self-control problems have been medicalized. Nor does addiction any longer require a substance. People are now considered to be helpless against a panoply of “impulse disorders” routinely treated by health care professionals and in popular culture. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) sanctifies several, including pathological gambling and kleptomania. The larger culture has invented countless others, including addictions to shopping, sex, food, work, video games, TV, the Internet, and your no-good ex. Whether to include any of these in the next edition of the manual has been the subject of debate, but it’s hard to see how they can all be kept out, for when you read the diagnostic criteria for pathological gambling in the current edition, it’s easy to imagine drawing up very similar standards for any of the others.

There is an important reason why it’s so difficult to draw a bright line between addictions involving substances that act chemically on the body and the more recent kind, which involve activities such as shopping or sex. The reason is that, as the philosopher Gary Watson has put it, “addictions are continuous with ordinary appetites.” Seen in this way, addictions can help us understand the problem of self-control, for there is no more stark illustration of the conflict between short-term and long-term preferences—a conflict often present when our appetites are engaged.

There are good grounds for regarding an addiction as just an unusually durable form of desire. All humans seek pleasure; whether these pleasures are from drugs or behaviors, they act on us in similar biochemical ways. And people who are vulnerable to one kind of addiction often are vulnerable to others as well, suggesting the issue is desire rather than any particular addictive item.

What do we mean by addiction? A repetitive harmful action that persists even though you know it’s bad for you. It typically involves spending a lot of time using, using more than intended, trying to cut back without success, sacrificing social or professional activities to the abused substance, and suffering withdrawal symptoms upon stopping.

In polite company, nobody doubts that this syndrome is an illness, but I will confess to agnosticism as to whether addiction is a disease. An addict’s behavior, it seems clear, can be influenced by incentives, while the symptoms of cystic fibrosis cannot. And what we call addiction is just an unhealthy pattern of behavior rather than something apparent on an X-ray or a blood test. So how can addiction be a disease?

On the other hand, lots of diseases are socially constructed. And lots of problems that are indisputably diseases arise from a pattern of behavior. Lung cancer results largely from smoking, as smokers well know. Heart disease, diabetes, cirrhosis, hypertension, HIV, and many other ailments could mostly be prevented by different behavior, just like drug or alcohol abuse, yet nobody doubts that they are genuine diseases.

Addiction in particular can teach us something about compulsion. We call neat people compulsive, praise movies and books as compelling, and say that addicts are compelled in some way. But the behavior of most addicts shows that they are not truly compelled. For example: most people who become addicted to opiates—which are quite addictive—somehow manage to quit without professional help, usually by the age of around thirty. In one celebrated series of studies that began to appear in 1974, Lee Robins found that only 12 percent of heroin-addicted Vietnam veterans remained hooked three years after returning to the United States. When the stresses of duty in Southeast Asia ended, so did most of the heroin use—typically without professional intervention. Indeed, treatment seems to be the resort of the most intractable addicts, which is probably why it so often fails. The actor Robert Downey Jr.’s many publicized treatment lapses may give the impression that addiction is always compulsive, but what it really illustrates is that addicts who seek treatment are far from typical.

It’s worth noting as well that rates of addiction vary widely in different times and places, suggesting that drug abuse, like other appetitive behaviors, is more subject to custom than compulsion. Americans born after World War II have drug addiction rates many times higher than those of Americans born before the war, a difference that far exceeds age-cohort differences for other psychiatric disorders. The high-stress, big-money, self-absorbed culture of Hollywood seems particularly conducive to substance dependence (just ask Mel Gibson, Lindsay Lohan, Kelsey Grammer, Charlie Sheen, Liza Minnelli and countless others). When it comes to addiction, apparently, culture matters, just as it does with respect to eating, shopping, venting anger, or any other form of gratification.

History also suggests that social pressure, intelligent use of law, and other such factors can be an effective antidote. In 1790, the average American consumed about 2.5 gallons of alcohol per year—not much more than we do today. But in the first three decades of the nineteenth century, consumption rose sharply, so that by around 1830 annual average intake had reached 7 gallons of pure alcohol, leading one historian to call ours “the alcoholic republic.” It was not a pretty picture; saloons sprang up everywhere, violence flourished, and for many women and children, home life grew chaotic and brutal. Then the culture changed. A wave of Protestant revivalism, which brought self-control back into the realm of God, spawned a nationwide temperance movement. “Evangelical preachers,” the historian Jackson Lears tells us, “became a key force for popularizing a culture of control, a force that put human choice at the center of the spiritual order.” Predestination was out, in other words, and free will was in. The result was that Americans cleaned up their act. By 1845 per capita alcohol consumption had fallen to less than 2 gallons a year. (All these figures vary depending on the source, but the magnitude and direction of the change are unmistakable.) Localities slashed the number of tavern licenses and many storekeepers stopped stocking booze. Gambling, racing, and such blood sports as cockfighting, all of which went hand in hand with drinking, receded as well.

The fact that addicts respond to incentives further argues against their helplessness. For instance: it turns out that treatment for drug addiction has a relatively poor track record except with pilots and physicians, who afterward face random drug testing and potential loss of their licenses and careers. For these two groups of professionals, scared straight by the knowledge of catastrophic consequences if they relapse, treatment has a high success rate. Nor are threats of Draconian punishment the only things that work; programs that offer relatively modest rewards such as movie tickets also have had some success.

Price also affects consumption, even when the price isn’t as high as early death. The economists Philip Cook and George Tauchen found that higher liquor taxes significantly reduce the incidence of cirrhosis of the liver, a reliable proxy for chronic heavy drinking. The main argument against legalizing substances such as marijuana and cocaine—that more people will abuse them—implies that laws and penalties make a difference in whether they are abused and therefore that addiction is far from invariably compulsory.

Incentives probably matter to most addicts; it’s a fair bet that, offered $1 million to abstain for a month, most will manage to stay clean long enough to collect. Or recall the case of John Cheever, who described himself as “a weak man, a man without character” because he couldn’t stop himself from drinking. On one level, Cheever was too hard on himself, since alcoholism was considered a disease even as he wrote those words and, like many self-regulatory disorders, has a significant hereditary component. (Years later, his daughter Susan Cheever would write about her own struggles with addiction.) On the other hand, his reference to character suggests some sense of his own acquiescence when he gives in. Is it possible, at the moment when he took the drink, that he literally didn’t want to? If so, did he have a sudden bout of alien hand syndrome (an actual medical condition in which the sufferer’s hand, like Dr. Strangelove’s, seems to have a mind of its own)? Unlikely, unless he happened to have the hemispheres of his brain surgically separated.

Imagine for a moment that Cheever’s long-suffering wife held a gun to his head and said, “Don’t blink or I’ll shoot!” Because the autonomic nervous system is immune to such threats, we can predict with certainty that eventually he would blink, proving he had no choice in the matter. But imagine now a different scenario, a more realistic one in which she credibly said, “Don’t drink or I’ll shoot,” perhaps after a night of raging and tears so that she seemed persuasively distraught. The odds are that there would be no drinking—which makes us wonder if Cheever’s drinking really was compulsory, hard as it may have been for him to stop. A gun pointed at the head, after all, will not banish the symptoms of Alzheimer’s disease or multiple sclerosis.

At this juncture it may be helpful to consider what we mean by compulsion, a notion that has been stretched so far in recent decades that it’s hard to recognize. If you are in your car, stopped at a light, and a tornado carries it off with you in it, this is surely compulsion—you didn’t want this to happen, yet you were powerless against the forces of nature. But does this model apply to addiction? For if the addict is compelled, how do so many manage to quit? Compulsion implies that the addict is acting against his will, but what stops him from taking steps—seeking treatment, giving away his drugs and money, turning himself over to the police—to enforce his will while desire is satiated?

Addiction, it seems, is at least to some extent voluntary—like so many other behaviors. In general, we might say with the psychologist Gene M. Heyman that “the degree to which an activity is voluntary is the degree to which it systematically varies as a function of its consequences.” And we know that addiction varies with consequences. Addiction is not good for job performance, family finances, or spousal relations. It impairs health. It can put the addict at risk of robbery or worse in the hunt for illegal drugs. These consequences carry less weight for people in their late teens or early twenties, a period of risk taking when most drug addicts start using. But by their late twenties, these same addicts stop or cut way back. (Not every addiction ends with a dish of cold turkey.) It’s possible their maturing brains can produce greater self-regulatory resources at that point. It’s also possible that in their late twenties they begin to realize that adult responsibilities aren’t going away, and keeping a family intact or holding on to a job is incentive enough.

There is a further sense in which addiction is voluntary, and that has to do with knowledge. Many users of addictive substances know from the very first hit that addiction is a risk they run. They probably also know that the longer they use, the more likely addiction becomes. And if they don’t know, it’s reasonable to think they should, just as a person who fires an arrow in a crowded city park is expected to know that someone will likely be hurt. The role of knowledge is evident when it comes to tobacco. Nicotine is highly addictive, but millions of people have quit smoking—unassisted—since word got out that tobacco kills, suggesting that they were not truly compelled to smoke in the first place.

Now, clearly something physical is at work with addiction—as it is with any appetite. Some have said that the addict’s compulsion comes from changes in the brain caused by the abused substance. Others cite heredity; genes clearly play a role in addiction and in self-control generally. Like criminals, addicts often have broader self-control problems; one researcher found that “smokers, alcoholics, drug dependent patients and pathological gamblers all suffer from abnormalities in motor impulsivity and delay discounting problems and . . . these abnormalities are associated with hypoactivity of the prefrontal cortex.” In other words, addicts have difficulties inhibiting their actions—in a game of Simon Says, for example—and they place a lower value on the future than others do. The problems of addicts in this department are not unlike those of people who have damage to the forebrain, the area where self-control functions are thought to reside. In short, addicts are worse than the average person at managing desire.

Yet neither biochemistry nor genes can fully remove addiction from the realm of voluntary behavior. Heyman has noted that just about everything changes the brain; plasticity is its essence, yet this doesn’t lead to what we consider a loss of choice. Nor do genetics imply compulsion, since all behavior is genetically influenced, yet this doesn’t make people unfree. Even the manifest self-destructiveness of addicted behavior doesn’t necessarily imply compulsion; people make bad choices all the time without anyone’s calling into question the voluntary nature of their choices.

This is not to say that behavior never comes close to being compulsive; people with anorexia nervosa and obsessive-compulsive disorder, among other such ailments, seem to suffer from a disorder of the will, almost as if alien invaders somehow abolished their autonomy and made them shun life-giving calories or check the gas for the hundredth time—as if these people were puppets on a string. Some addicts seem like this as well—people whose will has been hijacked or is otherwise defective, who often have additional psychological problems, and who will persist in drinking or shooting up even to the death.

It may be reasonable to say that these people have a disease, and perhaps we should reserve the term “addicted” for these refractory cases rather than the millions of smokers and coffee drinkers and Internet surfers and cocaine users who, when they stand up to their own cravings, can change their behavior for good. Too many behaviors, over the years, have been shifted from the voluntary part of the spectrum to the involuntary part, as if we could no more stop shopping than we could stop breathing. But every time we move something into this involuntary category, we chip away at our humanity.

Maybe it would be better to acknowledge, like the Greeks, that a lot of the behavior we call addiction is really a love of pleasure that carries the force of habit. We become addicted mostly because of the central issue in all self-control problems, which is the disproportionate value we place on short-term rewards. An addict who’s using drugs or who’s headed for the craps table is meliorating—choosing one more line of coke or throw of the dice as if each choice were made in a vacuum. Behavioral economists call this the peanuts effect, because one more of almost anything is just, well, peanuts in the grand scheme of things.

But our choices add up; each one influences others, and cumulatively a series of delightful short-term choices can leave us much worse off in the long run. This is the addict’s dilemma, and this may be why addictions of all kinds appear to be proliferating—because technology has enabled the production of vastly more seductive pleasures, such as crack cocaine and video games, and because the cultural and practical barriers to short-term pleasures are a lot lower than they used to be.