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Is Addiction Really 'Voluntary?'.

This book continues discussions about addiction that focus on the nature vs. nurture debate. The author, a research psychologist affiliated with McLean Hospital and Harvard Medical School, Boston, leans toward the role of nurture/environmental influences in explaining addiction.

In doing so, Gene M. Heyman, Ph.D., discounts addiction as a disease. This emphasis is not the book's key strength, however. Instead, it is Dr. Heyman's rich discussion about the voluntary vs. involuntary aspects of addiction that makes the book a significant contribution to the field.

In addition, this is a timely discussion in light of proposals to put an end to separate diagnoses for substance "abuse" and "dependence" in the DSM-5 ("'Substance Use Disorder' Diagnosis Gains Favor," July 2010, p. 17). However, Dr. Heyman does not specifically address those controversies.

The opening paragraph of Chapter 5 has a wonderfully amusing commentary about how classifications can reflect different understandings of basic terms and lead to radically different (even scientifically wrong) conclusions. Of important note, Dr. Heyman clarifies that his use of the word "addiction" is synonymous with the DSM-IV definition of dependence rather than abuse. Indeed, most of his data are presented from the dependence perspective.

Dr. Heyman begins with a fascinating historical perspective showing different social responses to addiction phenomena. He begins with 17th and 18th century opium eaters--well-to-do people, drinking laudanum, medically related and often medically prescribed. What follows in the mid-19th century is a historical progression to opium smokers, including Chinese immigrants, opium dens, and smoking concentrated opium introduced by tobacco smoking (the true gateway drug in history).

History then progresses to the sniffers of the heroin synthesized in 1898 by the Bayer Co. What started as medicinal and curative for centuries became addictive, with the opium smokers and heroin sniffers leading--in the United States--to the Harrison Narcotics Tax Act of 1914, which essentially criminalized addiction.

The presentation in Chapter 3 of some personal accounts of mostly opiate and cocaine dependence helps build the case for his argument that "quitting drugs becomes part of the story of addiction" and that the claim that "addiction is a chronic disease may not be true" (p. 64).

Dr. Heyman presents very valid data, such as the Epidemiologic Catchment Area studies, from a "glass half-full" perspective that does not support addiction as a chronic disease. He highlights that most users do not become addicted and that, by age 24 years, 50% of addicts achieve remission. That percentage climbs to 75% by age 37 years, he writes, and only 16% enter treatment (p. 70). His perspective describes addiction as a limited self-correcting disorder rather than a chronic, relapsing disease. What explains the discrepancy between his conclusions and current thinking on addiction? Dr. Heyman points to research showing that addicts do worse in treatment than those who do not enter treatment. Most people who enter treatment programs have an addiction complicated by comorbid psychiatric disorders--which might account for this.

He emphasizes that epidemiologic research suggests that most addicts quit because of financial and family concerns as they mature out of it (p. 84). This leads to his message that whether addicts keep using drugs or quit depends to a great extent on their alternatives, implying that drug use is voluntary. These theories lead to his conclusion that addiction is not a disease.

At this point, he takes what I would call an unnecessarily antagonistic position and equates "disease" as being involuntary and nondisease as voluntary. In many ways, his real issue is not that addiction is not a disease but that addiction is voluntary This leads to some unnecessary forays into the relationship of "self-destructive behaviors" defining addiction rather than DSM-IV "loss of control" defining addiction, and a somewhat confusing description of genetics being related to either voluntary or involuntary behaviors, rather than to both, depending on the genetic variance.

As with many books about addiction, subtleties in language and simplification of relationships often lead to seemingly opposite conclusions. This book is no exception and is sure to be controversial in some settings. However, I hope that the novelty of Dr. Heyman's ideas about addiction occurring as a choice and his detailed elaborations will be fodder for further research--and integration toward more effective prevention and treatment protocols.


DR. CHATLOS is a psychiatrist certified by the American Board of Addiction Medicine. He also serves as associate clinical professor of psychiatry at the University of Medicine and Dentistry of New Jersey, New Brunswick.
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Author:Chatlos, J. Calvin
Publication:Clinical Psychiatry News
Date:Oct 1, 2010
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