Good intentions aside, is the “brain disease” of addiction really beyond the control of the addict in the same that way that the symptoms of Alzheimer’s disease or multiple sclerosis are beyond the control of the afflicted? Showing how the two differ is an important theme of the book. If, as Heyman says, “drug-induced brain change is not sufficient evidence that addiction is an involuntary disease state,” then how are we to distinguish between voluntary and involuntary behavior?
Heyman’s answer is that "voluntary activities vary systematically as a function of their consequences, where the consequences include benefits, costs, and values.” Take, for example, the case of addicted physicians and pilots. When they are reported to their oversight boards they are monitored closely for several long years; if they don’t fly right, they have a lot to lose (jobs, income, status). It is no coincidence that their recovery rates are high. Via entities called drug courts, the criminal justice system applies swift and certain sanctions to drug offenders who fail drug tests—the threat of jail time if tests are repeatedly failed is the stick—while the carrot is that charges are expunged if the program is completed. Participants in drug courts tend to fare significantly better than their counterparts who have been adjudicated as usual. In so-called contingency management experiments, subjects addicted to cocaine or heroin are rewarded with vouchers redeemable for cash, household goods, or clothes. Those randomized to the voucher arm routinely enjoy better results than those receiving treatment as usual.
Contingencies are the key to voluntariness. No amount of reinforcement or punishment can alter the course of an entirely autonomous biological condition. Imagine bribing an Alzheimer’s patient to keep her dementia from worsening, or threatening to impose a penalty on her if it did. This is where choice comes in: choosing an alternative to drug use. Heyman realizes how odd this might seem. How can otherwise rational people choose self-destruction unless they are diseased? This question was raised in colonial America. Dr. Benjamin Rush, also known as the father of American psychiatry, was among the first to promote the notion that alcoholism was a disease. And he did so not on the basis of medical evidence, Heyman reminds us, “but rather [upon] the assumption that voluntary behavior is not self-destructive.”
It may strike some as insensitive to insist that addiction is a disorder of choice. “I have never come across a single drug-addicted person who told me [he or she] wanted to be addicted," Nora Volkow, the current director of NIDA says. Exactly so. How many of us have ever come across a person who wanted to be fat? So many undesirable outcomes in life are achieved incrementally. In a choice model, full-blown addiction is the triumph of feel-good local decisions (“I’ll use today”) over punishing global anxieties (“I don’t want to be an addict tomorrow”). Let’s follow a typical trajectory. At the start of an episode of addiction, the drug increases in hedonic value while once-rewarding activities such as relationships, job, or family recede in value. Although the appeal of using starts to fade as consequences pile up—spending too much money, disappointing loved ones, attracting suspicion at work—the drug still retains value because it salves psychic pain, suppresses withdrawal symptoms, and douses intense craving.