“Addiction is a chronic and relapsing brain disease.” Few would dispute this statement purported by the National Institute on Drug Addiction (NIDA). Those of us who work in the disciplines of clinical medicine and research pharmacology have been inculcated with its corollary: “once an addict, always an addict.”
Such claims conjure up the notion that those addicted to substances remain powerless over their pharmaceutical spells. Substances like alcohol, nicotine, cocaine, opiates and their derivatives create a physical dependence in those addicted to them. Denying the body access to such drugs triggers symptoms of physical withdrawal. Those who succeed in extricating themselves from the regular use of such drugs remain constantly at risk for relapse. Such facts are borne out by modern research and methods of treatment.
Or are they?
Now comes a work—Addiction: A Disorder of Choice—in which research psychologist Gene Heyman challenges the view that substance abuse is an irresistible act wholly beyond the control of the user. Although Heyman does not deny that addiction is independent of the brain, he does argue that it is in part voluntary behavior. He further maintains that “it is not possible to understand addiction without understanding how we make choices.”
Repeated use of drugs ultimately changes brain structure and function by altering biochemical pathways, reinforcing those that mediate the experience and memory of pleasure. Such neuronal pathways persist, producing cravings even after the addict has stopped using. If addiction itself is not a brain state, but rather a behavior, the question then arises: do neurochemical changes in the brain prevent the user from exercising voluntary control over choice and actions?
Heyman argues that “drug-induced brain change is not sufficient evidence that addiction is an involuntary disease state.” He points to a number of studies where, through the judicious use of contingencies, addicts demonstrated the ability to voluntarily change their behavior and stop using.
The more we learn about brain functioning from biochemical research, the more apt we are to regard behavior as something regulated by the action and balance of neurotransmitters in brain. Ultimately, we might decide that all behavior is involuntary, that each one of us is an automaton, dependent upon the synaptic activity of the moment. And yet—as any parent knows—behavior can be shaped by meting out consequences and contingencies. Eventually, children learn to modify their own behavior through voluntary choice.
Heyman extends his argument to include other addictive behaviors such as compulsive gambling, shopping, and sex. Each involves a craving, an intense impulse and—for Heyman—a voluntary choice.
These arguments bring to mind a passage from John Steinbeck’s epic novel East of Eden, in which he discusses sixteen verses from the book of Genesis about humankind’s ability to wrestle with the temptation of sin. For Steinbeck, “these sixteen verses are a history of humankind in any age or culture or race.” The crux of the premise centers around timshel, a Hebrew verb translated as “thou mayest.”
But the Hebrew word, the word timshel—‘Thou mayest’—that gives a choice. It might be the most important word in the world. That says the way is open. That throws it right back on a man. For if ‘Thou mayest’—it is also true that ‘Thou mayest not.’
Steinbeck goes on to develop this idea through character dialogue in the book:
‘Thou mayest’! Why, that makes a man great, that gives him stature with the gods, for in his weakness and his filth and his murder of his brother he has still the great choice. He can choose his course and fight it through and win.
Steinbeck concludes the passage with these words:
I feel that a man is a very important thing—maybe more important than a star. This is not theology. I have no bent toward gods. But I have a new love for that glittering instrument, the human soul. It is a lovely and unique thing in the universe. It is always attacked and never destroyed— because ‘Thou mayest.’
If Steinbeck and Heyman are correct, in the face of seemingly insurmountable odds, struggling addicts might be able to triumph over their addictions by an exercise of the will—one day at a time.
If they are wrong, ultimately we may be forced to confront our own pyschopharmacological demons in the form of serotonin, dopamine, norepinephrine and GABA.