The choice argument and pleasure cont’d

The NY Times recently had a Room for Debate feature on addiction. They published opinions from 6 different people on addiction with one being a clear advocate for the disease model. This is a little like publishing a debate feature on climate change and having 1 of 6 experts believe that global climate change is occurring.

Two of the writers, Carl Hart (previous posts on Hart) and Gene Heyman (previous posts on Heyman), emphasized pleasure.

It’s well established that addiction is a disorder of the pleasure pathways. When other parts of the brain (related to, say, vision or movement) or other organs experience disorders, we don’t devote NY Times features to whether they really are a disease or whether choice is a factor in the illness. However, when pleasure enters the picture, we have a very difficult time surrendering the notion that we are, or should be, in full control of our behavior.

Kevin McCauley addresses the role of pleasure in advocacy for the choice argument:

Addiction is a disorder of the brain’s ability to properly perceive pleasure. I think it’s this moral loading of pleasure that makes it harder to accept that this is a disease process. It’s easier to just write addicts off as bad people who just want to feel good. In fact, that’s a corollary of the choice argument. It says exactly that, “Addicts don’t shoot gasoline into their veins, they shoot drugs into their veins! And, why? Because it feels good. Addicts do it because it feels good!”

In fact, there’s a sentence in the AA big book that says basically the same thing, “Men and women drink essentially because they like the effect produced by alcohol.” And that’s exactly right. What addiction is, is a defect in the brain’s like mechanism.  Pleasure is the capacity of the brain, and being a natural organ, the brain can break. And, addiction is, at it’s heart, a broken pleasure sense.

A chronic illness?

addiction (Photo credit: Alan Cleaver)

Bill White responds to a recent article that has gotten a lot of attention by Gene Heyman, a disease model critic. Heyman (and a couple of other recent articles) question whether it’s accurate to call addiction a chronic illness.

If there is anything that the full scope of modern research on the resolution of AOD problems is revealing, it is that the dichotomous profiles of community and clinical populations represent the ultimate apples and oranges comparison within the alcohol and other drug problems arena.

…

Conclusions drawn from studies of persons in addiction treatment cannot be indiscriminately applied to the wider pool of AOD problems in the community, nor can findings from community studies be indiscriminately applied to the population of treatment seekers.

…

Adults and adolescents entering specialized addiction treatment are distinguished by:

1) greater personal vulnerability (e.g., male gender, family history of substance use disorders, child maltreatment, early pubertal maturation, early age of onset of AOD use, personality disorder during early adolescence, less than high school education,  substance-using peers, and greater cumulative lifetime adversities),

2) greater problem severity (e.g., longer duration of use, dependence, polysubstance use, abuse symptoms co-occurring with substance dependence;  opiate dependence),

3) greater problem intensity (frequency, quantity, high-risk methods of ingestion, and high-risk contexts,

4) greater AOD-related consequences (e.g., greater AOD-related legal problems),

5) higher rates of developmental trauma and post-traumatic stress disorder,

6) higher co-occurrence of other medical/psychiatric illness,

7) more significant personal and environmental obstacles to recovery, and

8) lower levels of recovery capital–internal and external resources available to initiate and sustain long-term recovery.

Bill points out the real world consequences of these arguments.

This is not merely an academic question.  Are families reading the headlined summaries of such reviews to conclude that the prolonged addiction of their family member results from moral and character defects of self-control that prevent “maturing out” of such problems that most people, according to these reports, achieve?  Should such chronicity render one unworthy of family and community support?

Read the rest here.

A disorder of choice

This blog post expressing skepticism about addiction as a brain disease was recently brought to my attention.

He lays out A pro-disease argument as THE pro-disease argument:

What do gambling, sex, heroin and cocaine — and the other things that can addict us — have in common?

One strategy is to look not to the substances and activities themselves, but to the effects that they produce in addicts. And here neuroscience has delivered important insights.

If you feed an electrical wire through a rat’s skull and onto to a short dopamine release circuit that connects the VTA (ventral tegmental area) and the nucleus accumbens, and if you attach that wire to a lever-press, the rat will self-stimulate — press the lever to produce the increase in dopamine — and it will do so basically foreover, forgoing food, sex, water and exercise. Addiction, it would seem, is produced by direct action on the brain!

(See here for a useful Wikipedia review of this literature.)

And indeed, there is now a substantial body of evidence supporting the claim that all drugs or activities of abuse (as we can call them), have precisely this kind of effect on this dopamine neurochemical circuit.

“all..have precisely this kind of effect”? Who has asserted that? (This is import, he uses it against the disease model.)

These studies do, however, offer a stunning  demonstration of the power of a malfunctioning pleasure circuit. Noe’s reaction? Meh. We all have a reward pathway.

Neuroscientists refer to the system in question as the “reward-reinforcement pathway” precisely because all rewarding activities, including nonaddictive ones like reading the comics on sunday morning or fixing the leaky pipe in the basement, modulate its activity.

As an indicator of a disease, he presents the effect of a malfunctioning VTA as binary. If the addict is sometimes able to choose something else over the drug, we’re not like that rat and it must not be a disease.

So, because the drug’s domination is not total, we treat this experience described in the NYT as though it has the same basis as the experience of non-addicts?

“Cocaine reconnected my mind to my body, and I felt tremendously alive, hypersexual and hopeful once again,” he wrote. “At least I had a new God to believe in, even if I knew all along this was a false God, a deceitful God, one who always promised misery and defeat. So, I choose this God of intense extremes over the monotony of everyday life.”

The other big problem I have with this is that there is no mention of the memory circuits or the frontal cortex. No one says that addiction is explained by the reward pathway. No one claims that the course, severity and treatment response of addiction are not influenced by factors outside the brain or outside the person.

A few other thoughts.

It’s worth noting that Gene Heyman repeatedly points to 2 things as primary evidence that addictive drug use is not involuntary. Narratives from addicts about hitting bottom and choosing to recover and epidemiological data showing large numbers of substance dependent people experiencing spontaneous remission or natural recovery.

Narratives from addicts demonstrate that choosing recovery is necessarily for recovery. So? Choosing to quit is necessary but not sufficient. How many addicts choose to quit and are unable to? Why is this ignored?

As for the people who experience spontaneous remission, what are the other possible explanations?

• Maybe our diagnostic tools are crude and capture false positives. Maybe those with these false positives are likely to moderate or quit on their own.
• Or, maybe there is a spectrum of severity and those with the less severe forms moderate or quit on their own.
• Or, maybe its course varies. Would this be incompatible with it being a disease?
• Or, maybe there are several neurological mechanisms (reward pathway, memory circuits, risk evaluation, self-regulation, stress responses, etc.) and some people may have 2, others may have 6.  Some factors may be associated with a more chronic form, others may be associated with a more severe loss of control and overall severity may be associated with the number of factors the person has. (Some might be primary to addiction, others secondary.)

Finally, Heyman refers to this as a “disorder of choice.” Of course it is. The defining characteristic is impaired control where drugs are concerned. It ebbs and flows. It’s not complete. Addicts live in a zone where they can influence but not control their choices related to drugs and alcohol. It is multifaceted. But, there is a neurobiological basis for and the fact that it has boundaries does not mean it’s not a disease.

Addiction in the News

From the director of a Maine OD prevention project:

Katz cited Suboxone as the latest drug to be abused.

The trend is particularly unnerving because of Suboxone’s importance in treating opiate addiction when used for its intended purpose.

“Suboxone can turn people’s lives around,” Katz said.

“Pharmaceutical companies assured everyone it couldn’t be abused. All the information came from pharmaceutical reps,” Katz said. Potential for abuse with this drug has been completely underestimated and has exploded, she said. “There seems to be an unstoppable flow on the street.”

A prestigious hospital 110 miles south describes their approach in an interview:

Larry Harmon: What is the state-of-the art treatment at McLean Hospital for
addiction to heroin and other opioids?

Kevin Hill: In most cases, we recommend buprenorphine (available as Suboxone or Subutex) medication treatment in addition to counseling.

This interview follows a lengthy article that was very critical of methadone programs in the Boston area. Of course, one of the arguments for suboxone is that it’s better than methadone:

MARIANNE TUCKER, 60, was 15 when she ran away from an abusive household in Albany and settled in Fall River, where she became addicted to heroin. She spent roughly 25 years in methadone treatment programs, including at the clinic now operated by Habit OPCO in Fall River, one of 10 methadone clinics in the state run by the Boston-based, for-profit company. She, like many addicts, describes her years on methadone as an endless cycle of daily dosing and methadone-related appointments. Tucker, who received state-subsidized treatment, said she sought to reduce her dosage, but staffers told her not to concentrate on the milligram number, just on how she felt.

“The for-profits keep you so high, you don’t know what you’re doing,’’ said Tucker.

The worst part, she said, was the daily experience of being around other addicts who weren’t committed to recovery. “This is the best place to hook up if you want to do dope,’’ she said.

About five years ago, she walked away from the clinic and sought Suboxone treatment from Dr. Claude Curran, a controversial addiction specialist in Fall River. Unlike with methadone, her Suboxone dose has gone down over time. And while methadone made her feel high, Suboxone makes her feel like the person she was before she started to use heroin — a feeling of freedom described by many addicts who switch from methadone to Suboxone.

Meanwhile, a columnist in the Canadian press uses the high recovery rates of doctors to assert that addiction is a choice without noting the disparities int he kind of treatment that doctors receive:

Doctors and airline pilots who get addicted to drugs (and there are lots) have recovery rates of 85 per cent or more….“Whether addicts keep using drugs or quit depends to a great extent on their alternatives,” Mr. Heyman writes….Drug addiction is a set of self-destructive impulses that are out of control – just like all the other impulses that lead us to choose short-term pleasure at the price of long-term pain. Drug addiction isn’t measles, and Insite is not a hospital, and we should stop pretending that it is.

Finally, Insite is seeking to create a “safe inhalation room” for crack addicts:

Proponents say the room would allow health officials to reach a fast-growing segment of drug users, a group prone to viruses because of dirty crack pipes. Critics say scientific evidence for the benefits of supervised inhalation rooms is scant, and such a facility would hurt addicts by allowing them a space to continue their habit.

The medical/public health case for an inhalation room is much weaker. What’s it about then? If it’s a desire to do outreach, what does it say about the effectiveness of outreach efforts, that, seemingly, the only way to improve them is to provide a place to get high?

Addicts have made a choice

Now Gene Heyman has become the go to guy for anyone with an ideological aversion to addiction as a disease.

What’s most troubling is that many of his fans have much more broad readership that the Journal of Substance Abuse Treatment.