SEEING DRUGS AS A CHOICE OR AS A BRAIN ANOMALY

Dr. Alan I. 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
policymakers -- 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.

Lacing his presentation with jokes and Yiddish expressions -- as a
youth, Dr. Leshner summered at a Catskills hotel owned by his
grandparents, and he has a bit of Alan King in him -- he tries to
translate the science into plain English.

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

Initially, when a person uses hard drugs like 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, Dr. Leshner
says, persist long after addicts stop using drugs, which is why, he
continues, relapse is so common. Addiction, Dr. Leshner declares,
should be approached more like other chronic illnesses, like diabetes
and hypertension. Going further, he says that drugs so alter the brain
that addiction can be compared to mental disorders like Alzheimer's
disease and schizophrenia. It is, he says, a "brain disease."

In promoting this concept, Dr. Leshner has stepped forthrightly into a
debate that has smoldered for decades: are drug addicts responsible
for their behavior?

Should they be treated as sick people in need of help, or as bad
people in need of punishment? Dr. Leshner has come down squarely on
the side of illness.

And he is winning many people over. Today the brain-disease model is
widely accepted in the addiction field, and Barry R. 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," says Dr. Sally L. Satel, a senior associate at the
Ethics and Public Policy Center in Washington and a practicing
psychiatrist at a methadone clinic.

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 1960's
Alcoholics Anonymous began speaking of alcoholism as a disease.

But, initially at least, A.A. used the term figuratively to suggest
the tenacious hold drinking has on alcoholics. Over the last decade or
so, however, 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
like 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 on Long Island, 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.

Dr. Volkow says that "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." Other researchers have
found a physiological basis for the craving so many addicts
experience, but it is not yet clear how long such physiological
changes remain.

Dr. Herbert D. Kleber, the medical director of the National Center on
Addiction and Substance Abuse in New York, says that the brain-disease
concept fits with his experience with thousands of addicts over the
years. "No one wants to be an addict," he says. "All anyone wants to
be able to do is knock back a few drinks with the guys on Friday or
have a cigarette with coffee or take a toke on a crack pipe. But very
few addicts can do this. When someone goes from being able to control
their habit to mugging their grandmother to get money for their next
fix, that convinces me that something has changed in their brain."

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, 'Ah hah, addiction is a brain disease,' " he remarks. "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." While acknowledging that addiction does induce
compulsive behavior, Dr. Heyman says that 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, Dr. Heyman says, "information about schizophrenia hasn't
reduced the frequency of that illness." Dr. 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,
Dr. 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 two-and-a-half-day meeting without once hearing
such words as 'responsibility,' 'choice,' 'character' -- the
vocabulary of personhood," Dr. Satel wrote in a paper called "Is Drug
Addiction a Brain Disease?"

Written with Dr. Frederick K. 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.
"Dramatic visuals are seductive and lend scientific credibility to
NIDA's position," the paper states, but politicians "should resist
this medicalized portrait for at least two reasons.

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, Dr. 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,"
Dr. Satel said.

At the mention of Dr. Satel, Dr. Leshner bristles. "Simplistic and
polarizing," he says of her writing.

More generally, Dr. Leshner maintains that his views have been
distorted and misinterpreted. Still, he says, he has lately modified
his message, giving more recognition to the role of volition in
addiction. "Today's version," he says, is that addiction is "a brain
disease expressed as compulsive behavior; both its development and the
recovery from it depend on the individual's behavior."

But where does choice end and compulsion begin?

The slide showing that has not yet appeared.