by Joshua Hoe
I have several “addiction” related searches that I have Google Alerts do for me automatically every day and one of them is about “addiction research” (I like to keep up on whatever newly released studies come out etc.).
I was surprised to see one of the first results yesterday was an article from Sally Satel and Scott Lilienfield in a publication of the American Enterprise Institute.
I was surprised most because the AEI doesn’t do much writing on addiction, it is primarily known for writing about political issues from a more pro-free market and supply side economics slant.
Ms. Satel however is a practicing Psychiatrist and lecturer at Yale (certainly more of an expert on the medical side of things than me) who clearly has a economic/political slant to her work (one of her books is sub-titled “the case for compensating organ donors” for example).
So, after reading her article, I was no longer surprised. Ms. Satel clearly believes in bringing market pressures to bear on the question of addiction. I feel, to some extent, that her argument is the Tail Wagging the Dog.
The Economics Of Straw People
Ostensibly, her beef is with the disease model of addiction. She says:
“The model “continues to be questioned” not because the linkages between addiction and biological processes hadn’t always been well established. But rather because those linkages only show, as anyone would expect, that the brain is involved with drug addiction. The linkages do not, per se, make the case that addiction is best defined as a brain-based phenomenon. Indeed, we fully expect more details about the biology of addiction to be uncovered in the near future. But that won’t make it anymore a brain disease than it is now. But first, it is surely true that addiction is both associated with and leads to brain changes. So what does that mean? It means that brain alterations associated with addiction can make it more challenging for addicts to make certain choices, but those changes do not come close to eradicating the capacity to choose.”
I actually agree with much of that. I have my own issues with the Disease Model, and I think she correctly identifies (as other neuroscientists like Marc Lewis have) that correlation does not justify causation.
But then she takes another step, Dr. Satel says:
“Volumes of research show that most people who are addicted respond to incentives and consequences, such as small cash payments, opportunity to participate in work programs, threat of an overnight jail stay.”
Now we are uncovering her true agenda.
Rational Economic Choice – Building The Strawperson
Dr. Satel then, hyperlinks two of her other articles which explain her argument in more depth. In the link to her 2010 article in something called AJOB Neuroscience she says:
“The mechanical simplicity of the “brain disease” rhetoric has a seductive appeal that obscures the considerable degree of choice in addiction, as Buchman and colleagues note. Consider the daily routine of addicts. They rarely spend all of their time in the throes of an intense neurochemical siege. Most heroin addicts, for example, perform
some kind of gainful work between administrations of the drug. In the days between binges, cocaine addicts make many decisions that have nothing to do with drug-seeking. Should they try to find a different job? Kick that freeloading cousin off their couch? Attend a Narcotics Anonymous meeting, enter treatment if they have private insurance, or
register at a public clinic if they don’t? These decisions are often based on personal meaning.
This attempt to connect addiction to rational choice economic models is more than a bit misleading in several ways:
* People who believe addiction is a brain disease do not think addicts become zombies (like on the Walking Dead) incapable of anything but pushing for a fix. They believe, from what I have read, that choice is constrained not foreclosed
* This description of the process is wrong. Most experts describe addicts moving most often from normal life, to triggering events, to acting out behaviors.
This is a pretty important set of distinctions, because it proves both that the disease model is not inherently at odds with her position and also that what she is describing is a bit self-serving in terms of her larger argument.
In other words, IMHO, Ms. Satel is building a bit of a straw person argument to fit her position here.
“Many autobiographical accounts by former addicts reveal that they were startled into quitting by a spasm of self-reproach (Lawford 2008): “My God, I almost robbed someone!” or “What kind of mother am I?”
Look, what we don’t want to do is to replace one flawed model that puts too much weight on one group of contributory factors with another model that does the exact same thing.
Personal Responsibility (Tough Love)
And this is where the real agenda is uncovered.
“But incentives do work in addicted patients, as clinical trials of a strategy called “contingency management” show. The standard trial compares addicts who know they will receive a reward for submitting
drug-free urines with matched addicts not offered rewards (Silverman et al. 2001). In general, the groups that are eligible to be rewarded with, for example, cash, gift certificates, or services are about two to three times more likely to turn in drug-free urines compared with similar counterparts who were not able to work for such incentives. In drug courts (a jail-diversion treatment program for nonviolent drug offenders), offenders are sanctioned for continued drug use (perhaps a night or two in jail) and rewarded for cooperation with the program. The judge holds the person, not his or her brain, accountable for setbacks and progress.”
This is a really important argument to talk about now because virtually all of the so-called “sentencing reforms” people are considering around the subject of addiction include a combination of exactly these carrots and sticks.
The problem here is that she doesn’t have to prove that incentives can be effective tools anymore than proponents of the disease model have to prove that addicts have been turned into helpless zombies.
Addiction doesn’t make you helpless, it makes it harder to resist your behaviors or substances when you encounter emotional triggers. The disease model does not mean addicts are doomed to never saying no to their substances or behaviors anymore than saying Diabetics are incapable of modifying their relationship to sugar.
This difference is critical because the question is not can addicts resist or defy their urges (her assumptions about the disease model aside, nobody I have read believes people are helpless in the face of addiction). The problem is that a program of personal responsibility, incentives, and tough love won’t account for one huge problem.
Relapse is part of recovery.
Traditional tools of recovery, personal responsibility, economic incentives, all work at times, but no research suggests that they work 100% of the time. The point is, that personal responsibility and free will do not account for 100% of what addicts face.
Look, I totally get that the world does not operate the way we want it to at all if we start believing that people are not ultimately responsible for their decision-making. This is what most conservatives and free-marketers are really afraid of – the idea that personal responsibility can be destabilized as the essential foundation of law.
But, the point of the disease model is not to destabilize the entire basis for law and economics. The point is to say that the tables are tilted against addicts as they encounter triggers on a hourly, daily, and weekly basis throughout their lives.
The point is that addicts are not morally failing when they lose those battles. As someone who has actually gone to prison over actions related to my addiction, I have always explained it like this:
I am morally responsible for everything I have done while addicted, but my addiction itself is not a moral failing.
This does not mean addicts are incapable of moral failings when acting out, just that using itself is not a moral failing.
This may seem like splitting hairs, but I do think there is space for both novel approaches to addiction (like using economic incentives) and traditional tools within the disease model.
And, most important, a strategy of harm reduction is almost always superior to a policy of retribution unless crime beyond using a substance or engaging in a personal behavior happens.
The danger with throwing the disease baby out with the bathwater is that the novel approaches and the traditional tools combined will be unlikely to end “addiction” in any addict. Nor are they likely to prevent all relapses in any addict.
This is troubling because what society tends to do is throw up their hands whenever someone relapses (see Johnny Manziel) and say “well we sent them to rehab so it’s on him now.” Or “We gave her economic incentives, and she failed, so it’s on her now.”
My suggestion is to use every tool possible (including economic incentives), to hold everyone accountable legally for “crimes” they commit (not including using a substance or engaging in a behavior that hurts nobody else directly), and to decriminalize and use harm reduction techniques whenever possible.
At the end of the day, I disagree with Dr. Satel’s description of the disease model because it seems to start from political and not scientific assumptions and because it seems to concoct a straw person disease model to serve those political purposes.
At the same time, I fully realize that Dr. Satel is a professional and I totally respect her expertise.
What do you think about the articles by AEI and Dr. Satel? Let me know, leave a comment!