Addiction and Responsibility

The American Society of Addiction Medicine has released a new definition of “addiction” which focuses on the disorder’s biological underpinnings in the brain. As I discuss at Stanford Medical School’s SCOPE blog today, distinguishing addiction from “a lot of substance use” is useful for many reasons, not least so that doctors will not undertreat acute pain with opioids out of fear of addicting their patients.

The biggest barrier for the public and the political class to accepting that addiction involves a fundamental, lasting and adverse biological change in the brain is that it can appear at first blush to invalidate the idea of personal responsibility for behavior. Some advocates of the “brain disease model” have exacerbated this resistance by trying to shame people who are afraid of or angry at addicts. Sometimes when the biological aspects of addiction are conveyed, the implicit message, in essence, runs “How can you be so heartless towards these victims of a brain disorder! Would you get angry at someone for having Alzheimer’s disease?”.

This debate is unproductive and unnecessary, a position I can best defend by discussing my bad hip.

I used to exercise on an elliptical machine for about an hour a day every other day. After a year or so of doing this, I began to feel some pain in my left hip. Being an educated, clinically skilled and mature health professional, I reacted by ignoring the problem and hoping it would go away. It didn’t. Indeed it got worse such that my hip began to hurt even when I wasn’t exercising. My doctor X-rayed my hip and found some bone spurs and calcification in the joint which will trouble me for the rest of my days.

I thus now have a lasting, adverse, physically based medical problem. But I got it entirely through voluntary behavior. One could add in further that I got it in part because I foolishly ignored the signs that my behavior was damaging my health. Those observations about my behavior, judgment and responsibility in no way contradict the reality that I now have a permanent biological change in my body.

Next question: Who is responsible for managing my medical condition? I am. If I am diligent about my stretching exercises each morning, my hip will not hurt, but if I slack off as I sometimes do it will get stiff and sore. I have no power to eliminate the damage to my hip through my behavior, but I can manage it if I act responsibly.

To sum up, my bad hip is a biologically-based medical problem that came about in part from my own behavior and from my own poor judgment (I say in part because another person with a different hip might have exercised just as I did and had no problems…indeed my right hip is as right as rain). My future behavior can’t eliminate the problem but it can influence how much trouble it causes. I thus have some responsibility for the origin of my medical problem and for its management as well, but no matter how responsible I am, I can’t ever eliminate it because it has an independent biological existence.

As with my hip, so with addiction. It is reasonable to say to someone who is not addicted “Please be more responsible about your substance use — you are choosing to act in a fashion that may eventually get you addicted.” It is equally reasonable to say to someone who is addicted “Are you being responsible in the management of your addiction, are you attending your AA meetings, staying out of bars, etc?.” But it is not logically reasonable to say “Why don’t you stop being addicted?”. They would if they could, but they can’t, and that should I think evoke some sympathy, which is in no way contradictory with expectations that the person will be responsible about how they manage their disorder.

[Cross-posted at The Reality-Based Community]

Keith Humphreys

Keith Humphreys is a professor of psychiatry at Stanford University. He served as a senior policy advisor at the White House Office of National Drug Control Policy from 2009 to 2010.