Heyman, G. M. (2009). Addiction: A disorder of choice. Harvard University Press.
Preface
Chapter 1 – Responses to Addiction
- 19th century opium users were categorized into three groups: “opium-eaters”, who drank tinctures made from opium and alcohol (aka, laudanum); opium smokers, who smoked opium as one would a cigarette; and, heroin sniffers, who sniffed powdered forms of the drug through their nostrils.
- Opium-eaters were usually wealthy and well-to-do people who would typically get their fix from a doctor. They consumed their drugs in private and usually tried to keep their habit secret. In contrast, opium smokers and heroin sniffers were typically social outsiders, e.g., gamblers, prostitutes, delinquents and unemployed. Unlike the opium-eaters, both opium smokers and heroin sniffers engaged in their habit socially, in the company of other users.
- With time, a divide emerged in how society treated the different categories of opium use. Because opium smoking and heroin sniffing was done in the open and attracted social outsiders, it fell under the domain of law enforcement. On the other hand, opium-eating became more strongly associated with the medical profession. In other words, opium-eaters were seen as people who needed help, while other categories were seen as the scum of the earth.
- When the Harrison Narcotics Tax Act of 1914 was passed in the US, opiate and cocaine use were deemed illegal activities. Consequently, opium-eating and opium smoking all but disappeared there. The same fate didn’t befall heroin, though. Instead, criminal gangs took over the distribution of the drug causing its price to increase. With more money needed to get less heroin, users stopped sniffing and started injecting the drug directly into their veins to get high. [As a side note, reading this reminded me of Claude Brown’s autobiographical novel, ‘Manchild in the Promised Land’ where he describes how heroin decimated the Black community in Harlem, New York from the 1940s-50s].
- Some view addiction as a disease and that scientific research would eventually provide effective treatments for it. An unspoken assumption of this view, however, is that if an addiction is not a disease, then it must be the result of deliberate actions which must be appropriately punished (usually by law enforcement).
Chapter 2 – The First Drug Epidemic
- The behavioral effects of a drug vary as a function of the environmental setting and the individual.
- It is interesting that Ancient Egypt, Greek or Roman writers did not see opium as something that could be harmful to the individual or society. Instead, they praised its medicinal benefits.
- Europeans were introduced to tobacco smoking during the Columbian Exchange. When smoking got to the Chinese, they took the act a step further by mixing in opium. This is significant because smoking opium allows its active agent, morphine, get to the brain quickly. It is therefore no surprise that more people started consuming opium in this manner. For the first time, a large group of people started taking opium for its intoxicating effects, rather than its medicinal benefits. Even when the Chinese emperor banned the sale of opium in 1725, the decree was impossible to enforce due to how deeply ingrained it was in the Chinese society at the time.
- Numerous factors may have contributed to China, rather than Europe or South America, being the site of the first drug epidemic: (1) Maybe the Chinese had many people with disposable income and leisure time, as well as many people able to do trade with Europeans; (2) Perhaps cultural beliefs and norms were at play, for instance, Middle Age Europe saw opiates as medicine, while Middle Age China saw opiates as both medicine and aphrodisiacs; (3) Many Chinese cannot consume alcohol due to genetic factors that make them unable to process acetaldehyde. Perhaps smoked opium served as substitute for alcohol for attaining intoxication.
- During the Vietnam War, opium addiction rates among US soldiers was 7 times higher than marijuana addiction rates. This suggests that opiates are more addictive than marijuana. The biggest contributor to this observation seems to be how cheap and easy it was for the soldiers to access opium in Vietnam. Compared to being the US, there were also no stigma or sanctions associated with consuming it. There is the added fact that soldiers were surrounded by peers who also used opium.
Chapter 3 – Addiction in the First Person
- The appeal of addictive drugs is found in the uniqueness of the subjective experiences it can provide to the user.
- There is a category of addicts who fly under society’s radar because they act as functional members of society while regularly abusing opiates.
Chapter 4 – Once an Addict, Always an Addict?
- Studies aggregating nationwide survey data from the US appear to suggest that people are likely to stop consuming drugs at clinically significant levels in their late 20s – early 30s.
- The pharmacology of a drug appears to be responsible for determining when drug use transitions into abuse; on the other hand, individual factors (e.g., presence of other psychiatric disorders) appear to influence quitting addictive behaviors
- Whether addicts quit or continue to consume drugs is largely dependent on the ability to take advantage of nondrug alternatives available to them.
- When there are immediate and salient consequences for reducing drug use, e.g., job loss or gift vouchers, addicts will comply
Chapter 5 – Voluntary Behavior, Disease, and Addiction
- “We inherit genes; we do not inherit behaviors”.
- Addicts may learn to ignore their cravings when the incentive structures in their lives are modified. When the urge to use drugs is in conflict with the urge to do better work or be a better parent or pay the bills, drug use will decrease
- To determine whether an act is voluntary or involuntary, the root is not found in their genes or brain, but in their behavior.
- 17th century English clergymen adopted the view that addiction was a disease because they could not fathom how struggling church members could continue drinking despite having drinking-related problems. Although it is not immediately apparent, this view is a formulation of the neoclassical economic assumption that humans are inherently rational beings who always make decisions that are in their best interests. Accordingly, in this view, any deviations from rational behavior have to be due to disease.
- The key defining factor determining whether an act is voluntary is whether it varies as a function of consequences (e.g., costs, benefits, the opinions of others, cultural values, self-esteem, and other factors influencing decision-making). Involuntary acts, on the other hand, are mostly elicited by the preceding stimuli (e.g., urges) and is little affected by consequences.
- In an intervention where patients could earn vouchers for producing drug-free urine tests, drug use reduced. This is called contingency management. This pattern of reduced drug use even continued after the intervention was over.
- When cues predict that there won’t be any opportunity to use a drug, cravings decrease (e.g., there is usually no urge to smoke in a plane, despite the ‘no-smoking’ sign flashed). Yet, the same cues in another context (e.g., gas station) may signal an opportunity to use the drug, and the cravings increase.
Chapter 6 – Addiction and Choice
- Addiction depends on 3 factors: (1) general principles of choice and decision making; (2) behavioral effects of addictive drugs; (3) individual and environmental factors affecting choice
- Choice Principle I: The values of outcomes influence how people make choices, and people’s choices also change the value of outcomes over time. That’s why preferences are dynamic and change with time. New activities that were exciting at first can become boring and activities that were boring at some point in the past can be perceived as interesting.
- Choice Principle II: In any given context, it is possible to choose between available items one at a time (local choice), or to organize the items into sequences and choose between different sequences (global choice). Local choice is simple but ignores the dynamics between choice and changes in value. Global choice, on the other hand, is conscious of these dynamics.
- Choice Principle III: People always choose what they consider the better option. If they are in the local frame, that means choosing the option that currently has the higher value; if they are in the global frame, this means choosing the sequence or collection of items with the higher value
- People have a natural inclination to make choices in the local frame often because the arrangement of items of choice into sequences (i.e., global frame) is more abstract and not salient. However, it is possible to arrange conditions such that people choose in a global frame
- When decisions are made continually within the local frame, it can lead to overconsumption, which is one of the conditions for an addiction.
- In the local frame, the value of drug use to the lonely addict is always higher than the value of nondrug activities (e.g., working and positive nondrug social interactions) because of the subjective pleasures of intoxication and the pain of withdrawal. However, because of a combination of tolerance to drugs (i.e., needing a larger dose to get the same high), legal consequences, and social stigma, each instance of drug use reduces the value of the next instance of drug use in the local frame.
- In the global frame, the value of a sequence of drug use pales in comparison to the value of a sequence of nondrug activities (e.g., working and positive nondrug social interactions). Hence, the decision is made to engage in the nondrug activities instead.
- When addicts are regretting past behavior or anticipating future relapses, they are in the global frame.
- One reason explaining the temptation of the local frame is that the immediate benefits (i.e., the ‘high’ gotten from the addictive substance) is immediate, while the costs (e.g., hangovers, social stigma, legal consequences, poor health) are delayed, indirect, uncertain and abstract at the time of choice.
- It is difficult for addicts to quit if they are in the local frame because: (1) the benefits of nondrug activities are not immediate; (2) the benefits of the drug use are immediate and outweigh that of nondrug activities – even in the worst days of drug use!
- Successful quitting of an addiction requires a commitment to the global frame which only begins to accrue benefits when a pattern of engagement in nondrug activities, rather than a single instance, is established.
- In the last choice in a series of choices, the distinction between the local and global frame disappears. Thus, an addict that thinks ‘This is the last time I will take this drug’ is settling into the local frame where the value of the addictive substance outweighs nondrug activities.
- One day of drug use doesn’t render a person an addict. Rather, it is the continual treatment of all opportunities to use the drug as ‘one day’ that eventually leads to an addiction.
- Because the arrangement of items of choice into sequences (i.e., global frame) is more abstract, it usually take more deliberate effort to make them salient.
- Choices in the local frame correspond to the discrete activities we engage in from day-to-day, while choices in the global frame are usually abstractions that can only be accessed through the imagination or aids to imagination (e.g., trackers, planners, schedules) [As another side note, many of the spiritual exercises engaged in as part of religious practice, (e.g., meditation, praying, fasting, looking to qualifying for heaven or avoiding hell) all function, at a behavioral level, as a means of transitioning the individual from a local frame to the global frame].
Chapter 7 – Voluntary Behavior: An Engine for Change
- Dopamine, a neurotransmitter often invoked in addiction theories, does not distinguish between addictive substances and nonaddictive substances. Activities such as exercise and even a painful pinch of a rat’s tail (e.g., D’Angio et al., 1987) leads to the release of dopamine in the nucleus accumbens region of the brain.
- Substances that lend themselves to addiction have the following properties: (1) they have immediate benefits; (2) they have delayed or hidden costs; (3) they reduce the value of other nonaddictive activities in their lives; (4) they encourage the local frame or undermine the global frame; (5) they are still consumed, even if additional instances of consumption reduce the value of the next instance of consumption.
- Nonaddictive activities and substances are not behaviorally toxic. That is, they do not undermine the value of other activities or substances. For instance, day-to-day activities (e.g., work or physical exercise) does not undermine the value of healthy leisure activities. The converse is the case as well, healthy leisure activities do not undermine the value of work or physical exercise.
- Nonaddictive substances and activities, on the other hand, undermine the value of both the next instance of consumption, as well as the value of nonaddictive substances and activities in their lives. An addict hates the state of addiction, and may be unwilling to engage in work or other healthy alternatives
- Addictive substances or activities do not lead to easily lead to satiation or fatigue. This tendency eventually leads to tolerance where more of the addictive substance or activity is needed to provide the same level of satisfaction
- Addictive substances impair the ability to shift into the global choice frame.
- Choice depends on the context. The value of an activity or substance to a decision-maker is determined by both their intrinsic properties, as well as the properties of the competing alternatives.
- Choices that have higher value in the global frame are usually beneficial to the decision maker in the long run. However, because choices in the global frame are abstract, any physical and/or cognitive efforts made to make them more salient (e.g., planning, scheduling and tracking) are also valuable activities that will benefit the decision-maker in the long run.
- In their day-to-day lives, individuals do not weigh all the short-term or long-term consequences of each choice they make. What people typically do instead, is either adopt private rules of conduct or follow culturally transmitted norms for what constitute acceptable social behavior
- Certain religious practices also fall under the category of socially transmitted norms that govern behavior – even in private. Kendler et al. (1997) and Gartner et al. (1991) are few of the studies demonstrating the negative correlation between being engaged in religious practices and drug addiction or drug use when in stressful situations.
- When certain religious values are internalized, the individual is more likely to operate in a global frame where benefits and consequences of day-to-day choices no longer salient at the local level. Instead, the decision-making process is simplified into whether or not the religious prescriptions apply to their particular situation. That said, there are obviously instances where private rules of conduct might be beneficial for entering the global frame but are at odds with the prevailing social norms.
- One reason for relapses may be due to always expending cognitive effort on reviewing the costs and benefits of all alternatives at every point of decision making, instead of abiding by prudential rules of conduct (private or socially mediated) that make the global frame more salient.
- “[A]ddicts are not compulsive drug users. They choose to keep using drugs, and they can – and do – choose to quit”