If it wasn’t rational, they wouldn’t be doing it

mencken-complex-problem

Ugh.

The NY Times has another column promoting a rational addiction model.

“When they were given an alternative to crack, they made rational economic decisions.”

When methamphetamine replaced crack as the great drug scourge in the United States, Dr. Hart brought meth addicts into his laboratory for similar experiments — and the results showed similarly rational decisions.

“If you’re living in a poor neighborhood deprived of options, there’s a certain rationality to keep taking a drug that will give you some temporary pleasure,”

Here we go again. Their drug use by addicts is rational. A rational choice. If you had their lives, you’d be an addict too.

I’m not even clear that there’s a causal relationship from poverty to addiction. If so, how strong is that relationship?

In an article titled, “Taking Absurd Theories Seriously“, Ole Rogeberg walks through an extensive takedown of rational addiction theories. This video is great.

Why do people insist on framing addiction as rational?

For others, it’s assimilation into the monoculture:

To begin with, in the economic story, you are an individual.

The economic story also says that as a human being, you’re rational. In economic thought, being rational doesn’t mean that you’re sensible or that you’re a clear thinker. Being rational means that when you’re faced with a decision, you move through a three-stage process to decide what to do. Assuming you know what your goals are, you first lay out all the ways you could reach each goal and identify the costs and benefits of each possibility. Next, you analyze which option is most efficient — the one that most directly lets you get the most of what you want while costing you the least of your resources. Finally, you choose that most efficient option, because in the economic story, your best choice is always the most efficient choice.

In the economic story, you’re someone who is self-interested, in the most positive sense possible.

Being cast as someone who is rational and self-interested might sound relatively harmless, but that way of thinking has implications because it’s based on the assumptions that you know what condition you’re in, you know what your options are, and you know what you want, but those assumptions don’t necessarily hold. … The story says that you act as you do because you’re trying to get what you want, and the rest of us can tell what you want by watching how you act.

For others it’s philosophical:

Although addiction may be defined and operationalized in a number of different ways, the heart and core of the concept lies in its implication of the loss of the ability to choose – that is, the loss of free will.  Hence, and logically, the concept of addiction also implies the actual existence of free will.  And there lies the rub.

The addiction concept repackages one of the Big Questions – free will and determinism – into a new and seemingly more manageable form.   But should we be entirely comfortable with the tacit implication that ordinary, non-addictive conduct is freely willed?

Of course, this assumption underlies much of our day-to-day lives.  We show up at work late and we are responsible for the choices we made that caused our lateness.  Our legal system relies on the same assumption as well.  It assumes people freely do what they do and must take responsibility for their actions.

This came up again recently when Sally Satel published a book questioning neuroscience and addiction:

“Brainwashed” is nervously libertarian; Satel is a scholar at the American Enterprise Institute, and she and Lilienfeld are worried that neuroscience will shift wrongdoing from the responsible individual to his irresponsible brain, allowing crooks to cite neuroscience in order to get away with crimes.

Once it’s defined as a choice, and the rational choice theory isn’t satisfactory, we’ve got economists coming up with their own answers to the age old question of, why do they do it? [emphasis mine]

First-hand accounts of poverty generally recognize that heavy users of drugs and alcohol pay a high material cost.  Yet they rarely reach my verdict: that other factors – like low IQ, low conscientiousness, low patience, or plain irrationality – must be driving both poverty and substance abuse.  Instead, observers usually say that the poor consume drugs and alcohol to “dull the pain.”  Some even argue that the poor are being entirely rational: If your life is a living hell, narcoticizing yourself is the simplest solution.

There’s just one problem with this explanation: By almost all accounts, substance abuse eventually makes your life worse.  The long-term addict’s life is utterly wretched – even if you average in his periodic drug-induced euphorias.  Someone who has yet to start using drugs and alcohol doesn’t face a choice between “full pain” and “dulled pain.”  Instead, he chooses between two paths of pain:

Path #1: Full pain in the short-run, followed by gradual life progress.

Path #2: Dulled pain in the short-run, followed by a gradual downward spiral into abject misery.

Suppose you’re poor.  Your life is unusually painful, so the immediate effect of drugs and alcohol is especially attractive.  The long-run prognosis for a poor substance abuser, however, is especially repellent.  You hit “rock bottom” sooner because you don’t have far to fall.  And your version of “rock bottom” is extra bleak because you lack the financial resources and social connections to cushion the blow and get back on your feet.

The lesson: On net, poverty isn’t a believable root cause of substance abuse, because being poor doesn’t make substance abuse a better overall deal.  Why then would poor people be more inclined to narcoticize themselves?  Once again, we should look for root causes of poverty and pathology.  Low patience is the most obvious suspect.  If you loathe to defer gratification, you’ll tend to have low income, and eagerly use drugs and alcohol today despite their awful cost down the line.

While I detest the blogger’s character-based explanation. He closes with a very salient question and observation:

Closing questions: If you were poor, would you turn to drugs and alcohol?  If you were a social worker, would you advise the poor to turn to drugs and alcohol?  I doubt it.  The reason, of course, is that on some level you already know what I’m telling you: Poverty is no excuse for substance abuse because substance abuse is an absurd response to poverty.

UPDATE: I’ve had several posts over the years about free will and addiction. One important thing to keep in mind is that when we say it’s a brain disease, it doesn’t mean the person always has zero control over their behavior.

Here are some excerpts that offer different ways to think about it.

On co-existing deterministic factors and free will:

A helpful metaphor is offered: If a machine has two controllers (one controller representing deterministic factors and the other representing free will), does that mean that only one controller works? Or, is it possible that they both are capable of controlling the machine?

On deterministic factors as a continuum:

There is certainly room to incorporate biological and genetic vulnerabilities in such a model. People may vary as to the reward power of drugs and alcohol: Some people get more pleasure than others from them. Social factors and personal experiences may also contribute to individual differences in such propensities. Thus, some people end up with stronger cravings than others.

Still, some freedom remains. The wine does not pour itself into a glass and thence down the alcoholic’s throat. The person thus makes a choice between competing impulses: indulging pleasure now versus abstaining for the sake of nonspecific but substantial delayed gains. Choosing the path of virtuous abstention depends on willpower, however. When willpower has been depleted (such as by other acts of self-control, or even by decision making in any context; see Vohs et al. 2008), their likelihood of choosing the immediate pleasure increases.

If a disease model for addiction is to be retained, we suggest abandoning the virus or germ models in favor of something more like Type II diabetes. One does not become infected with diabetes. Rather, a natural bodily vulnerability becomes exacerbated by experiences, many of which are based on personal choices. Many people will not become diabetics regardless of what they eat, but others will suffer diabetes to varying degrees as a function of diet and exercise. Moreover (and again unlike a virus), there is no definite boundary that separates the sick from the healthy. Diabetes, and by analogy addiction, is a continuum. Those who are constitutionally vulnerable move themselves along this continuum by virtue of the choices they make.

On will power as psychological energy:

…within the context of their metaphor of psychological energy, there might be times when a person has none and times when a person has no internal or external resources to replenish this energy.

…Acknowledging these considerations does disavow the role of choice. Even on the end of the continuum where a person’s biology and environment doom them to developing addiction, choices could influence the onset, course and severity. And, within the psychological energy metaphor, during periods of replenished energy a person may have the power to make choices that will protect or expend this energy in ways that preserve it (and initiate/maintain recovery) or diminish it (and lead to relapse).

On ditching the all or nothing mentality:

One way to partially reconcile the dilemma between the traditional and emerging views of choice is to first acknowledge that free will in addiction and recovery is not an all or none phenomena. The capacity for volitional control over AOD use and related decisions is variable across individuals (as a function of the interaction between problem severity/complexity and recovery capital) and is dynamic (shifts incrementally on a continual basis within the same individual through both addiction and recovery processes).

Intellectual conflicts of interest

DSM_5_2Allen Frances, Chair of the DSM-IV Task Force lets loose on the DSM-5. He acknowledges the noxious effects of professional interests on research and practice in a way that is rarely seen from leaders of his stature. [emphasis mine]

This is the saddest moment in my 45 year career of studying, practicing, and teaching psychiatry. The Board of Trustees of the American Psychiatric Association has given its final approval to a deeply flawed DSM 5 containing many changes that seem clearly unsafe and scientifically unsound. My best advice to clinicians, to the press, and to the general public – be skeptical and don’t follow DSM 5 blindly down a road likely to lead to massive over-diagnosis and harmful over-medication. Just ignore the ten changes that make no sense.

The motives of the people working on DSM 5 have often been questioned. They have been accused of having a financial conflict of interest because some have (minimal) drug company ties and also because so many of the DSM 5 changes will enhance Pharma profits by adding to our already existing societal overdose of carelessly prescribed psychiatric medicine. But I know the people working on DSM 5 and know this charge to be both unfair and untrue. Indeed, they have made some very bad decisions, but they did so with pure hearts and not because they wanted to help the drug companies. Their’s is an intellectual, not financial, conflict of interest that results from the natural tendency of highly specialized experts to over value their pet ideas, to want to expand their own areas of research interest, and to be oblivious to the distortions that occur in translating DSM 5 to real life clinical practice (particularly in primary care where 80% of psychiatric drugs are prescribed).

Motivational Interviewing works, but no better than other treatments

Cochrane conducts a meta-analysis of motivational interviewing (MI) and concludes that it’s no more effective than other treatments.

More than 76 million people worldwide have alcohol problems, and another 15 million have drug problems. Motivational interviewing (MI) is a psychological treatment that aims to help people cut down or stop using drugs and alcohol. The drug abuser and counsellor typically meet between one and four times for about one hour each time. The counsellor expresses that he or she understands how the clients feel about their problem and supports the clients in making their own decisions. He or she does not try to convince the client to change anything, but discusses with the client possible consequences of changing or staying the same. Finally, they discuss the clients’ goals and where they are today relative to these goals. We searched for studies that had included people with alcohol or drug problems and that had divided them by chance into MI or a control group that either received nothing or some other treatment. We included only studies that had checked video or sound recordings of the therapies in order to be certain that what was given really was MI. The results in this review are based on 59 studies. The results show that people who have received MI have reduced their use of substances more than people who have not received any treatment. However, it seems that other active treatments, treatment as usual and being assessed and receiving feedback can be as effective as motivational interviewing. There was not enough data to conclude about the effects of MI on retention in treatment, readiness to change, or repeat convictions.The quality of the research forces us to be careful about our conclusions, and new research may change them.

This is a great example of a major flaw in research. There are so many assumptions in every study. One wrong assumption can lead to bad findings. For example, that motivational interviewing is an especially effective and sufficient intervention to treat alcoholism.

MI is being integrated into treatment for all sorts of medical problems, chronic health problems in particular, where part of treatment is recruiting the patient into participating in a treatment that is known to be effective but often suffers from low rates of patient compliance.

The difference here is that researchers seem to be interested in replacing existing treatments for addiction with MI.

One big problem here is that this inserts the assumption that alcoholism is resolved be increasing motivation to quit or reduce drinking.

I believe that these assumptions may be correct for low severity alcohol problems and that MI may be an effective intervention for these problems.

I also believe that MI is probably a valuable tool for more severe alcohol problems, but, in these cases, its proper use is to get patients to accept and participate in treatments that are known to be effective when patients comply. Twelve step facilitation, for example.

Why is there this push for MI as a replacement treatment rather than a treatment inducement tool? Does this constitute a bias on the part of researchers? I don’t know, but note that I’m not the one tossing out the baby with the bath water. I’m suggesting MI might be very important but that they are just asking the wrong questions. It’s also a little ironic that the push to use MI to replace other treatments actually weakens the case for MI having an important role in treating alcoholism.

The truth is dangerous

Michele Leonhart official photo. Found at http...
Michele Leonhart  (Photo credit: Wikipedia)

How hard is it for the DEA to have an honest conversation about drugs? Below is testimony from the director. Note the incoherence.

“Is crack worse for a person than marijuana?” Polis asked Leonhart.

“I believe all illegal drugs are bad,” Leonhart answered.

Polis continued, asking whether methamphetamines and heroin were worse for a person’s health than marijuana.

“Again, all drugs, they’re illegal drugs,” Leonhart started, before being cut off by Polis.

“Yes, no, or I don’t know?” Polis said. “If you don’t know, you can look this up. You should know this as the chief administrator for the Drug Enforcement Agency. I’m asking a very straightforward question: Is heroin worse for someone’s health than marijuana?”

Leonhart ducked again, repeating, “All illegal drugs are bad.”

Since assuming the head position at the DEA, Leonhart has made controlling prescription drug abuse the top priority, a stance she had laid out so aggressively that it led one Democratic senator to block her confirmation.

I imagine she’s concerned about getting trapped, but come on! Reasonable people can disagree on drug policy, but only if we don’t respond to disagreement by being unreasonable.

Marijuana penalty reduction proposals in New York

Cannabis Sativa in a Cage
(Photo credit: Mrs Logic)

New York Governor Andrew Cuomo has proposed big changes in marijuana policy in his state:

“There’s a blatant inconsistency. If you possess marijuana privately, it’s a violation. If you show it in public, it’s a crime,” Cuomo said. “It’s incongruous. It’s inconsistent the way it’s been enforced. There have been additional complications in relation to the stop-and-frisk policy where there’s claims young people could have a small amount of marijuana in their pocket, where they’re stopped and frisked. The police officer says, `Turn out your pockets.’ The marijuana is now in public view. It just went from a violation to a crime.”

New York City prosecutors and Police Commissioner Raymond Kelly, whose offices handled almost 50,000 such criminal cases last year, endorsed the Democratic governor’s plan. Mayor Michael Bloomberg said the bill largely mirrors the city police directive issued last year for officers to issue violations, not misdemeanors, “for small amounts of marijuana that come into open view during a search.”

Possession of less than 25 grams was reduced in state law to a violation in 1977, subject to a ticket and fine. If the pot is burning or in public view, it rises to a misdemeanor that leads to an arrest. Cuomo’s proposal differs from pending Assembly and Senate bills because it leaves public pot smoking as a criminal misdemeanor.

Cuomo acknowledged the existing approach disproportionately affects minority youths, with 94 percent of arrests in New York City, more than half of those arrested younger than 25 and 82 percent either black or Hispanic. He also defended keeping smoking pot a crime. “I believe the society does want to discourage the use of marijuana in public, on the street. Smoking a joint, I think, is a different level of activity than just being in possession of it,” he said.

According to advocates for decriminalizing it, 14 states, including Oregon and Massachusetts, have lowered penalties for possessing small amounts of marijuana to civil fines in a movement that began in the 1970s. Since 1996, 16 states, including California, have legalized its use for medical conditions, though New York has not.

To me, this policy strikes a good balance. I’m not a fan of the term decriminalization. Some articles have referred to the proposal as penalty reduction. I like this better. Though I’m not sure there is a universally accepted definition of decriminalization, but it generally refers to reducing possession from an offense generally punished by incarceration to an offense generally punished by fines.

To me, the term decriminalization implies that offenses like speeding are not crimes. (Am I missing something? If so, set me straight.) Penalty reduction just seems more accurate.

I’ve seen a lot of posts and articles commenting that this is a “good start” or “a step in the right direction.” I wish people would be a little clearer and more complete with these thoughts. What is the end they have in mind? Legalization? Legalization of what? Legalization of all quantities? Legalization of all drugs? Legalized sales? Legalized marketing? Legalized manipulation of the drug and consumption methods to intensify the effect? Is the model alcohol and tobacco?

It feels a little cheap and easy to make these pronouncements without taking responsibility to flesh out what you really mean.

Another question that these stories beg is this. It appears that, if passed, this bill would seek to get enforcement entities to follow the intent of NY’s 1977 marijuana law. Could enforcement entities come up with a way to circumvent this law too? What motivates enforcement entities to behave this way—what explains the disconnect between the apparently clear legislative intent and the law enforcement practice? Was it limited to marijuana laws, or do they take a similar approach with other laws? Was it limited to New York City, or was this practice common in NY State?

UPDATE: One more thought. What lessons can we learn from the K2 and Spice controversy? Even if you have a point of view that predisposes you to dismiss the matter, you should be interested in what kind of policy is sustainable and this appears to be an opportunity to learn something about the limits of the public’s tolerance for a legal drug.

Why we can’t agree

Official portrait of United States Director of...

The Obama administration just released their annual drug control strategy report and all the headlines say it emphasizes treatment over incarceration.

Sounds great, but the stories are short on details.

Others, from the Drug Policy Alliance are dismissing it as more of the same.

More of the same? Really? I think Obama’s safely within the herd on this, but one doesn’t have to go back very far to reach a time when it would be a certain death sentence for a national politician to say that we should incarcerate fewer people for drug crimes. Change may not be coming as quickly as the DPA would like, but to say that the current state of affairs is “same old, same old” is pretty silly.

All of this is mildly interesting. What is was much more interesting was this quote:

Is it a disease of the brain? I asked Columbia University psychology professor Carl Hart, who is also a board member of Drug Policy Alliance. Hart laughed. “A behavioral disease, therefore the brain is involved? OK, we can say that about everything.”

I admit, the addiction-is-an-illness line never worked for me. It leaves out personal will. It sanitizes destructive decision making. It suggests that people cannot get clean without a health care professional.

Art Caplan, director of the Center for Bioethics at the University of Pennsylvania, came up with the best explanation I’ve heard for the disease argument. People don’t want to see addicts jailed, he said, so they’ve come up with a scenario to spare users from incarceration. Ergo: “The whole drug establishment is invoking the disease model as an antidote to the criminal-justice model.”

I think it goes a long way toward explaining the difficulty in explaining the difficulty in finding any common ground on drug policy.

  • The question of free will is an important and under-addressed matter. Though I’m pretty confident it’s under-addressed because it’s not empirically knowable.
  • The suspicion of the disease model is a huge barrier. If there are profound disagreements about the nature of the issue, it’s very difficult to even begin to come up with solutions that address each other’s concerns.
  • The suspicion of each other’s motives is a huge barrier—”so they’ve come up with a scenario”. This paints advocates of the disease model as disingenuous. We’re manufacturing the model we need rather than describing what is.