All About Addiction aims to be a place where an open conversation about issues relevant to addiction can be discussed. To that end, the following is a piece from Christopher Russell that challenges the notion that people in some way lose control over their behavior suggesting instead that their seemingly compulsive behavior is actually volitional. Look for an upcoming post featuring Dr. Jaffe’s views on some of the points made by Christopher.
The Myth of “Loss of Control” – By Christopher Russell
Popular wisdom among addiction neuroscientists states that while initial drug use is voluntary, with repeated drug consumption the consumer moves closer to a critical, tipping point separating non-addicted from addicted drug use (e.g. Leshner, 1997). At the passing of this critical point, believed to reside in drug-induced changes to one or more brain sites and gene expression, the individual is argued to lose his ability to control (experience loss of control) is use of drugs thereafter. Beyond this point, drug use is now something which happens to the individual, compelled by pharmacological causes, not something the individual does for phenomenological reasons.
This notion of a physical “loss of control” as an explanation for why some people continue to use drugs has prevailed as the core hypothesis of the view of addiction as a progressive disease for the past 200 years (Levine, 1978) and today remains largely accepted by the general public as a taken-for-granted, scientifically-proven truth of addiction. Furthermore, the primary use of the word addiction has come to describe a particular set of behaviours which have a causal basis operating irrespective of the will of the individual (Davies, 1996), with “addicts” used as the term to distinguish those who are no longer able to control their drug use from those who are still able to control their drug use.
But why has this belief become so ubiquitous among the general public when the neuroscience community has produced no evidence which is sufficient to warrant the conclusion that certain individuals are physically unable to stop using their drug? Additionally, no evidence has been provided which warrants the conclusion that a critical, tipping point exists in the brain at which a person shifts from non-addicted to addicted drug use, the point at which the “loss of control” is assumed to occur. Both beliefs remain hypotheses for which there is as yet no evidence, however, the public understanding tends to be that these arguments have been long since proven as basic truths of addiction. What we do know and can show today is that some people find quitting a drug to be easy, a bit hard, quite hard, or extremely difficult. But evidence of the difficulty to exercise control should not be confused with an inability to exercise control, no matter how much the evaluation “I can’t stop” feels like a literal truth about our capabilities. This 3-part blog describes what we can and cannot show about the nature of drug use today and why the “loss of control” myth has prevailed as a “fact” of addiction for many people.
What we can and cannot show about addiction today
What we can and cannot show about the nature of addiction today is summed up by Akers (1991), a sociologist:
“The problem is that there is no independent way to confirm that the “addict” cannot help himself and therefore the label is often used as a tautological explanation of the addiction. The habit is called an addiction because it is not under control but there is no way to distinguish a habit that is uncontrollable from one which is simply not controlled”.
In other words, we have only shown that some people do not stop using drugs, not that they cannot stop using drugs (which would show true loss of control). The belief that some people cannot control their drug use will soon be shown to be a scientific fact, which comes from the moral judgment that people who do not stop when they say they really want to stop and who continue to use even to the detriment of other important things in life like work and relationships must be doing so not of their own will, but rather, their behaviour must be being compelled by a force outside of their will. In other words, the value-laden judgment is that no person in their right mind would voluntarily pursue this life; therefore, it fits with our view of a moral society to think that a drug “addict” is not a morally reprehensible person, but rather, must be using drugs against his will. But we must remember that to say “for why else would this poor person continue to use drugs?” is a value-laden statement about how we believe morally decent humans should behave. We should not infer that people cannot stop using drugs simply because we observe them not stopping. This may be useful information in itself, but is not evidence of a loss of control.
What medications do and do not do
Of course I do not deny that the use of medications like naltrexone, acamprosate and buprenorphine make it easier to forego certain drug use by blocking parts of the brain which motivate drug use. I would encourage people to use these medications if they find it helps them to not use other drugs. However, reducing the difficulty of quitting should not be confused with restoring the individual’s ability to quit as if this ability was at any point lost. Medications can help people quit using drugs and great strides are being made to manufacture medications which make the process of quitting easier to do and tolerate. However, these medications are not necessary for controlling drug use in the way heart medicines, radiation therapy, and insulin is necessary to stave off the mortal threats of heart conditions, cancers, and diabetes respectively. These groups of people do not have agency over their conditions in the way drug users have over their behaviour.
No medication has yet been shown to restore a drug user’s free will to reject drugs. Additionally, manufacturing medications has long been considered by addiction researchers such as Bruce Alexander, Stanton Peele, and John Davies to be focusing on the thin edge of the wedge; too much focus on the uses of medication, they would argue, restricts the need for drug users and treatment providers to consider a broad social analysis of why drug use is so prevalent in our societies.
The paradox of “behaving responsibly” after loss of control
The paradox inherent to the belief that some drugs erode free will and others can restore free will is that a drug user is expected to exercise his control and his will to sign up for and attend treatment and take medication like a “responsible” person should do precisely when we believe he has been robbed of his control and will to make choices about drugs. This paradox is also seen in the myth that an “addict can only quit after he hits rock bottom” which is promulgated by the 12-step movement; we expect people to show free will to quit precisely when they are thought to be least free to make choices about drugs. In other words, we expect so much self-control from those we believe are no longer capable of self-control!
The defence of this paradox has tended to be along the line of “he has not lost his free will to control all parts of his life, only the parts which involve drugs”. In one of his early speeches in San Diego, June 6th, 1989, William Bennett, former National Drug Policy Director and drugs czar appointed by President George H. W. Bush, defined an “addict as a man or a woman whose power to exercise rational volition has been seriously eroded by drugs, and whose life is organised largely – even exclusively – around the pursuit and satisfaction of his addiction”. Bennett’s statement reflects a common logical contradiction. Organisation of one’s life around anything is a rational skill, a wilful act, often requiring complex cognitive operations to be performed such as planning for an event which is two and three moves ahead. As Schaler (1991: 237) notes, “If an addict’s power to exercise rational volition is seriously eroded, on what basis does the addict organise life?” Interestingly another curious medical-moral contradiction by Bennett was noted by Massing in his book The Fix. Massing said “Addicts were in his (Bennett’s) view irresponsible individuals lacking basic levels of self-control” (p195). If these people do lack the capacity for self-control, how can they be responsible for not showing self-control? If they were irresponsible, it is their irresponsibility which causes drug taking; self-control is irrelevant. Bennett appears to be of the view that addiction is a moral failing which the addict is helpless to prevent, which is logically impossible.
Instead, what we do observe is that drug users are actually very good at putting in place the conditions by which drugs can be obtained, and that many people who are diagnosed as drug addicts do show a great capacity for self-control of behaviours except for those involving drugs. So addiction neuroscience is not pursuing a neurobiological basis of free will, per se, just the basis of our free will to control drug use, which is an even harder premise to swallow.
Stay tuned for Dr Jaffe’s reponse and part 2 coming soon.
Akers, R. L. (1991). Addiction; the troublesome concept. The Journal of Drug Issues, 21(4). 777-793. (only available in print form at present).
Davies, J. B. (1996). Reasons and causes: Understanding substance users’ explanations for their behaviour. Human Psychopharmacology, 11, 39-48.
Leshner, A. I. (1997). Addiction is a brain disease, and it matters. Science, 278,45−47.
Levine, H. (1978). The discovery of addiction: Changing conceptions of habitual drunkenness in America. Journal of Studies on Alcohol, 39, 143−174.
Massing, M. (1998). The Fix. University of California Press Ltd; London England.
Schaler, J. A. (1991). Drugs and free will. Society, 28(6), 235-248.