Don’t Forget the Addict’s Role in Addiction

The New York Times, April 4, 1998

By Sally Satel

Sally L. Satel is a psychiatrist who works in a methadone clinic.

From the first installment of Bill Moyers’s widely publicized television special, “Addiction: Close to Home,” on Sunday night, viewers learned that addiction is a chronic and relapsing brain disease.

The addict’s brain “is hijacked by drugs,” Mr. Moyers said that morning on “Meet the Press,” adding that “relapse is normal.” These are the words of a loving father who was once at his wits’ end over his son’s drug and alcohol habit. But as a public health message, they miss the mark. First, addiction is not a brain disease. And second, relapse is not inevitable.

The National Institute on Drug Abuse, part of the National Institutes of Health, is waging an all-out campaign to label addiction a chronic and relapsing brain disease. It seems a logical scientific leap.

Obviously, heavy drug use affects the brain, often to a point where self-control is utterly lost — for example, when a person is in the throes of alcohol or heroin withdrawal or in the midst of a cocaine binge. Scientists have even identified parts of the brain that “light up,” presumably reflecting damage, after long-term exposure to drugs. Yet as dramatic as the images of this phenomenon are, there is wide disagreement on what they mean.

“Saying these changes predict that someone will relapse amounts to modern phrenology,” John P. Seibyl, a nuclear radiologist and psychiatrist at the Yale School of Medicine, told me. “We don’t have any data linking these images to behavior, so how can we call addiction a disease of the brain?”

One of my colleagues puts it this way: You can examine brains all day, but you’d never call anyone an addict unless he acted like one. That’s what is really misleading about the Moyers assertion that “addiction is primarily a brain disease” — it omits the voluntary aspects of an addict’s behavior.

Addicts’ brains are not always in a state of siege. Many addicts have episodes of clean time that last for weeks, months or years. During these periods it is the individual’s responsibility to make himself less vulnerable to drug craving and relapse.

Treatment can help the addict learn how to fight urges and find alternative ways to meet emotional and spiritual needs. But will he take the advice? Maybe. More likely, he will begin a revolving-door dance with the treatment system. A recent study showed that only 1 in every 21 patients complete a year in a treatment clinic. To drop out generally means to relapse.

“Addicts make decisions about use all the time,” Dr. Robert L. DuPont, a former director of the national institute, points out. Researchers have found that the amount of alcohol consumed by alcoholics is related to its cost and the effort required to obtain it. Two decades ago Lee Robins, a professor of psychiatry at Washington University in St. Louis, in a classic study of returning Vietnam veterans, found that only 14 percent of men who were addicted to heroin in Vietnam resumed regular use back home. The culture surrounding heroin use, the price and fear of arrest helped keep the rest off the needle.

Thus drug addicts and alcoholics respond to rewards and consequences, not just to physiology. Relapse should not be regarded as an inevitable, involuntary product of a diseased brain.

Turning addiction into a medical problem serves a purpose, of course. The idea is to reduce stigma and get better financing and more insurance coverage for treatment.

As a psychiatrist, I’m all for treatment, but when the national institute says that addiction is just like diabetes or asthma, it has the equation backward. A diabetic or asthmatic who relapses because he ignores his doctor’s advice is more like an addict, as his relapses result from forsaking the behavioral regimens that he knows can keep him clean.

True, former addicts are vulnerable to resuming use — hence the “one day at a time” slogan of Alcoholics Anonymous. But they are by no means destined to do so. The message that addiction is chronic and relapse inevitable is demoralizing to patients and gives the treatment system an excuse if it doesn’t serve them well.

Calling addiction a behavioral condition, as I prefer, emphasizes that the person, not his autonomous brain, is the instigator of his relapse and the agent of his recovery. The experts on Bill Moyers’s program say that making addiction more like heart disease or cancer will reduce stigma. They’re wrong. The best way to combat stigma is to expect drug users to take advantage of treatment, harness their will to prevent relapse and become visible symbols of hard work and responsibility.

This prescription does not deny the existence of vulnerabilities, biological or otherwise. Instead it makes the struggle to relinquish drugs all the more ennobling.