The Purpose in Chronic Addiction

Abstract

I argue that addiction is not a chronic, relapsing, neurobiological disease characterized by compulsive use of drugs or alcohol. Large-scale national survey data demonstrate that rates of substance dependence peak in adolescence and early adulthood and then decline steeply; addicts tend to “mature out” in their late twenties or early thirties. The exceptions are addicts who suffer from additional psychiatric disorders. I hypothesize that this difference in patterns of use and relapse between the general and psychiatric populations can be explained by the purpose served by drugs and alcohol for patients. Drugs and alcohol alleviate the severe psychological distress typically experienced by patients with comorbid psychiatric disorders and associated problems. On this hypothesis, consumption is a chosen means to ends that are rational to desire: Use is not compulsive. The upshot of this explanation is that the orthodox view of addiction as a chronic, relapsing neurobiological disease is misguided. I delineate five folk psychological factors that together explain addiction as purposive action: strong and habitual desire; willpower; motivation; functional role; and decision and resolve. I conclude by drawing lessons for research and effective treatment.

Keywords:

• action
• addiction
• compulsion
• disease
• folk psychology
• psychiatry
• treatment

Acknowledgments

This research is funded by a Wellcome Trust Biomedical Ethics Clinical Research Fellowship. I am grateful to Louis Charland, Bennett Foddy, Neil Levy, Andrew Mcbride, Julian Savulescu, Gonzalo Urcelay, Steve Pearce, Walter Sinnott-Armstrong, and especially Ian Phillips for discussion of the ideas contained in this article. I am also grateful to the AJOB Neuroscience anonymous referees for their criticisms and suggestions, and to editor John Banja for his professionalism and encouragement.

Notes

1. For a critical discussion of this aspect of AA from an addict's perspective, see Flanagan (forthcoming).

2. These findings cohere with the longitudinal study of male drinking patterns in Vaillant (1995).

Note that Charland's ultimate target in the quoted paper is the claim that heroin addicts have sufficient decision-making capacity to consent to treatment. Charland's argument for this claim has two strands. The first strand argues directly from the fact that addicts “can't say no” to heroin and so, according to Charland, have no voluntary choice over consumption: The irresistible compulsion to use impairs their decision-making capacity about heroin (2002, 37 ff.). The second strand argues that long-term patterns of abstinence and relapse demonstrate that heroin addicts lack a sufficiently stable set of values and preferences with respect to heroin over time for their decisions at any one time to manifest sufficient decision-making capacity for consent to treatment (Charland 2002, 41 ff.); Charland develops this second strand of argument and relates instability of values and preferences to what he calls “pathological affect” in recent work (Charland 2011). I believe there are good reasons to reject this second strand of argument. But it is important to be clear that, unlike the first strand, it does not depend on Charland's claim that addicts “can't say no” to heroin. This leaves open the possibility that Charland could abandon his claim that addiction is a form of irresistible compulsion while yet pursuing his target claim that addicts do not have sufficient decision-making capacity to consent to treatment.

Note that although Leshner's claim about the effect of addiction on choice is equally as strong as Charland's, he nonetheless emphasizes the importance of embedding a disease model of addiction within a wider context, where multiple factors, including genetics and social environment, contribute to the development and maintenance of the disease.

For a good example of research that emphasizes the graded nature of control in addiction, see the articles collected in Addiction and Responsibility (2011) edited by Jeffrey Poland and George Graham. See also Pickard and Pearce (forthcoming) and Sinnott-Armstrong and Pickard (forthcoming).

Steward (2009) defends this concept of action and argues that it is found throughout the history of philosophical writing on action and free will, for example, in Aristotle (1984), Hobbes (1999), Hume (1975), Reid (1994), and Kant (1960). See too Williams (1995) and Alvarez (2009) for detailed exposition and defence of the claim.

For an important discussion of this possibility, see Yaffe (2011); for an objection to the details although not the spirit of Yaffe's account, see Pickard (2011).

Note that, contra Levy, from a clinical perspective there is no absurdity in the claim that an agoraphobic can leave the house. Effective treatment for agoraphobia is likely to include a form of exposure therapy that involves nothing other than the patient leaving the house, with increasing duration and regularity, and decreasing support from the therapist. Repeated exposure to anxiety-provoking stimuli reduces anxiety. The more you do it, the easier it gets, but you have to do it for exposure therapy to work. The clinical presumption in exposure therapy is that agoraphobics can leave the house, however much they desire not to. This of course is perfectly compatible with clinical recognition of the degree of the agoraphobic's anxiety, and the consequent difficulty for them in facing it.

For a balanced, reflective account of a personal struggle with addiction that is broadly in keeping with the theory and evidence presented here, see Flanagan (2011; forthcoming).

“Rough-and-ready” signals that there is no commitment to these factors carving human psychology at its joints. They may not prove to be the most accurate classification of folk psychological states; rather, they represent a natural and pragmatic grouping of the kinds of considerations relevant to a psychological understanding of addiction.

For development of this view in relation to questions of responsibility within addiction, see Levy (2011b).

For further discussion of this point, see Pickard and Pearce (forthcoming).

Philosophers debate the nature and strength of the connection between intentional and belief; the connection suggested here is very modest, claiming only that one cannot rationally form an intention to do something if one believes that one cannot do it. Of course, one can rationally form an intention to try to do something, if one is unsure but believes that one might be able to do it. For discussion of the philosophical debate see Holton (2009).

Note that there may of course yet be similarities between addiction and various chronic diseases with respect to factors like degree of genetic predisposition, environmental impact, anticipated course, and treatability. For discussion see McLellan et al. (2000).

This replacement also reduces the risk of overdose, infection, and disease due to self-injection; provides the opportunity for a more stable, and less marginalized and criminal, lifestyle to develop where recovery and abstinence may be more realistic possibilities; and allows reduction in dosage to be gradually implemented and medically monitored, minimizing risk to the patient.

Interestingly, self-image may be correlated with self-efficacy. Robert West reports a study finding that within one week of quitting, half of all participating smokers thought of themselves as ex-smokers. This self-image is optimistic: On average 75% will be smoking again within the year. However, 50% of those who thought of themselves as ex-smokers were still abstinent at 6 months, as compared with 0% of those who did not immediately embrace the label (West 2006, 163; West expects to publish these and related findings more fully in the near future [personal communication]).