DEBATE OVER DRUG ADDICTION FOCUSING ON VOLUNTARY BEHAVIOR

Dr. Alan Leshner, the director of the National Institute on Drug Abuse, a
division of the National Institutes of Health, is known for his slide shows.
Two or three times a week he gives a speech -- to treatment counselors and
prevention specialists, physicians and policy-makers -- and almost all
feature slides culled from the work of the 1,200 researchers supported by
his institute.

The slides are of brain scans, and they usually come in pairs. The
``before'' slides show the activity of a normal brain; the ``after'' ones
depict a brain that has had prolonged exposure to drugs.

What the science shows, he says, is that the brain of an addict is
fundamentally different from that of a non-addict.

Initially, when a person uses hard drugs such as heroin or cocaine, the
chemistry of the brain is not much affected, and the decision to take the
drugs remains voluntary. But at a certain point, he says, a ``metaphorical
switch in the brain'' gets thrown, and the individual moves into a state of
addiction characterized by compulsive drug use. These brain changes, Leshner
says, persist long after addicts stop using drugs, which is why, he
continues, relapse is so common.

Addiction, Leshner declares, should be approached more like other chronic
illnesses such as diabetes and hypertension. Going further, he says that
drugs so alter the brain that addiction can be compared to mental disorders
such as Alzheimer's disease and schizophrenia. It is, he says, a ``brain
disease.''

Decades-old debate

In promoting this concept, Leshner has stepped forthrightly into a debate
that has smoldered for decades: Should drug addicts be treated as sick
people in need of help, or as bad people in need of punishment? Leshner has
come down squarely on the side of illness. And he is winning over many
people. Today the brain-disease model is widely accepted in the addiction
field, and Barry McCaffrey, the White House drug adviser, routinely invokes
it.

Others are not convinced. ``I reject the notion that addicts fall under the
spell of drugs and become a zombie and so are not responsible for anything
they do,'' said Dr. Sally L. Satel, a senior associate at the Ethics and
Public Policy Center in Washington and a practicing psychiatrist at a
methadone clinic.

New orthodoxy

To her and other critics, the brain-disease model is a new orthodoxy based
less on science than on a desire to soften the stigma attached to addiction.

The idea that addiction is a disease is not new. In the 1960s Alcoholics
Anonymous began speaking of alcoholism as a disease.

Over the past decade or so, advances in brain-imaging technology have
allowed researchers to measure the impact of psychoactive substances on the
brain with increasing precision. Investigators have found that drugs such as
cocaine, heroin and alcohol increase the brain's production of dopamine, the
neurotransmitter that regulates pleasure, among other things. This helps
account for the euphoric high drug users feel. But these drugs deplete the
dopamine pathway, disrupting the individual's ability to function.

At the Brookhaven National Laboratory in New York, for instance, Dr. Nora D.
Volkow has found that even 100 days after a cocaine addict's last dose,
there is significant disruption in the brain's frontal cortical area, which
governs such attributes as impulse, motivation and drive. Volkow says ``the
disruption of the dopamine pathways leads to a decrease in the reinforcing
value of normal things, and this pushes the individual to take drugs to
compensate.''

But does causing changes in the brain qualify addiction as a brain disease?
Not according to Dr. Gene M. Heyman, a lecturer at the Harvard Medical
School and a research psychologist at McLean Hospital in Boston.

``Since we can visualize the brain of someone who's craving, people say,
`Aha, addiction is a brain disease,' '' he said. ``But when someone sees a
McDonald's hamburger, things are going on in the brain, too, but that
doesn't tell you whether their behavior is involuntary or not.''

Understanding behavior

While acknowledging that addiction does induce compulsive behavior, Heyman
says addicts still retain a degree of volition, as evidenced by the many who
stop using drugs.

``Smoking meets the criteria for addiction, but 50 percent of smokers have
quit,'' he says. This change, he goes on, is ``demonstrably related'' to the
data about the hazards of smoking that have emerged since the surgeon
general's report on the subject in 1964. By contrast, Heyman says,
``information about schizophrenia hasn't reduced the frequency of that
illness.''

Heyman also cites a well-known study of Vietnam veterans who were dependent
on heroin while overseas. Within three years of their return to the United
States, the study found, nearly 90 percent were no longer using it -- strong
evidence, Heyman says, that the addictive state is not permanent.

Sally Satel first became skeptical about the brain-disease model in 1997,
when she attended a conference of the drug-abuse institute on the medical
treatment of heroin addiction.

``So pervasive was the idea that a dysfunctional brain is the root of
addiction that I was able to sit through the entire 2 1/2-day meeting
without once hearing such words as `responsibility,' `choice,'
`character' -- the vocabulary of personhood,'' Satel wrote in a paper called
``Is Drug Addiction a Brain Disease?''

Written with Dr. Frederick Goodwin and published as a booklet by the Ethics
and Public Policy Center, the paper offers a blistering attack on the
drug-abuse institute and its brain-disease terminology.

``First, it appears to reduce a complex human activity to a slice of damaged
brain tissue. Second, and most important, it vastly underplays the reality
that much of addictive behavior is voluntary.''

To support that claim, Satel cited the results of the Epidemiologic
Catchment Area study, paid for by the National Institute of Mental Health,
which asked 20,300 adults about their psychological history. Of the 1,300
people who were found to have been dependent on or abusing drugs, 59 percent
said they had not been users for at least a year before the interview; the
average time of remission was 2.7 years.

``The fact that many, perhaps most, addicts are in control of their actions
and appetites for circumscribed periods of time shows that they are not
perpetually helpless victims of a chronic disease,'' Satel said.

Leshner says he has lately modified his message, giving more recognition to
the role of volition in addiction.

Where does choice end and compulsion begin? The slide showing that has not
yet appeared.