Psychiatric Times, February 2003, pp. 11-12

Addiction—Choice or Disease

Stanton Peele, Ph.D., J.D., Senior Fellow, Drug Policy Alliance

Both views in the “addiction is a choice/disease” point-counterpoint (Psychiatric Times October 2002, p54) leave out critical aspects of addiction, without which it is not possible to make sense of the matter.

Jeffrey A. Schaler, Ph.D.’s, view that addicts choose to use seems glib in the face of those addicts like David (son of Robert) Kennedy and Terry (daughter of George) McGovern who were children of privilege who killed themselves with chronic drug/alcohol use. These are extreme cases where the substance seemingly takes over the individual’s ability to choose.

However, I believe it is wrong to generalize their fates to all drug and alcohol misusers, including even quite compulsive users, for whom internal and environmental cues and options continue to play critical roles. John H. Halpern, M.D. appears to make the opposite error, seriously understating the variety of outcomes in addiction and the degree of choice exercised in bringing about these outcomes.

For example, Halpern cites the difficulties that people have in quitting smoking (studies of addicts regularly report nicotine among the drugs that are most difficult to quit). Yet half of all addicted smokers in the U.S. have now quit, and the large majority did so without formal treatment or self-help programs of any type. Question any table of ten or more people, and you will find multiple miracle self-cures!

In fact, surveys of drug and alcohol users, including those deeply dependent on the substances, regularly yield similar results, Consider Deborah Hasin, Ph.D., and colleague’s study of untreated heavy drinkers over time, comparing those drinkers with DSM-IV alcohol-dependence assessments at baseline with those without such diagnoses (J Stud Alcohol 2001;62[4]:509-517). This study found that dependent subjects show a significantly greater percentage of drinking reductions:

According to clinical expectation, individuals with a current diagnosis should be less likely to reduce (control) their drinking than individuals without such a diagnosis. We studied the question longitudinally among nonpatients, using different ways of measuring alcohol consumption and different statistical strategies. No strategy supported the hypothesis.

At the same time, addiction treatment on the most modern medical basis often fails to improve upon natural outcomes. In his references, Halpern cites but does not discuss the first multisite trial in alcoholism treatment in men using naltrexone (ReVia). Results showed no greater reduction in drinking from naltrexone than placebo (N Engl J Med 2001;345[24]:1734-1739).

To deny people’s regularly demonstrated ability to reduce or cease self-debilitating behaviors, no matter how powerfully embedded in their lives, is to minimize the opportunity and the fact of change in smoking, drinking, drug use and so on, even for those reckoned to be addicted by diagnostic tools. That people retain tremendous discretion in attacking addictions is critical for our public health and treatment efforts, which should both recognize and support—indeed, treatment should build on—such self-efficacy.

Dr. Schaler (Ph.D., Adjunct Professor, American University School of Public Affairs) responds:

I appreciate Drs. Peele and Rifkin’s opinions regarding my assertion that addiction is a choice, not a disease. Bodies are diseased. Behavior refers to something people do.

Dr. Peele agrees that both mindset and environment are key to comprehending addiction. Privileged and underprivileged people alike self-destruct for existential reasons—nothing causes them to do so.

Dr. Rifkin confuses theory about why a behavior occurs with a description of the behavior itself. There is no such thing as involuntary behavior, and there is nothing unscientific about the exercise of free will. Choice is what characterizes us as uniquely human, not psychiatry as a science.

Dr. Halpern (M.D., Instructor in Psychiatry, Harvard Medical School) responds:

Dr. Peele is in error in suggesting that my arguments that addiction is a disease is generalized to all users/misuers. Any substance can be used or abused, and physicians well know that medications have specific parameters for safety. That individuals diagnosed with alcoholism reduce their consumption over time versus nonproblem drinkers is also extraneous to this debate.

Although Dr. Peele reads otherwise, my article did indicate that naltrexone failed to be effective in a multisite trial to treat alcoholism. Again, this failure may be due to giving naltrexone qd as opposed to prn for increased cravings.

It would be misleading to buy into Dr. Peele’s argument that because millions of individuals stop smoking tobacco on their own, we should ignore the disease model of addiction and instead focus on the you-have-power-to-quit platitudes to our patients. While the tobacco industry might hail such assertions, this tremendous discretion proves insufficient. According to the Centers for Disease Control and Prevention, 430,000 Americans die every year now because of their addiction to tobacco. Drug education and promoting self-efficacy are part of treatment but clearly fall far short of what is needed.