DON'T FORGET THE ADDICT'S ROLE IN ADDICTION

WASHINGTON -- From the first installment of Bill Moyers's widely publicized
television special, "Addiction: Close to Home," on Sunday night, viewers
learned that addiction is a chronic and relapsing brain disease.

The addict's brain "is hijacked by drugs," Mr. Moyers said that morning on
"Meet the Press," adding that "relapse is normal."

These are the words of a loving father who was once at his wits' end over
his son's drug and alcohol habit. But as a public health message, they miss
the mark. First, addiction is not a brain disease. And second, relapse is
not inevitable.

The National Institute on Drug Abuse, part of the National Institutes of
Health, is waging an all-out campaign to label addiction a chronic and
relapsing brain disease. It seems a logical scientific leap.

Obviously, heavy drug use affects the brain, often to a point where
self-control is utterly lost -- for example, when a person is in the throes
of alcohol or heroin withdrawal or in the midst of a cocaine binge.
Scientists have even identified parts of the brain that "light up,"
presumably reflecting damage, after long-term exposure to drugs. Yet as
dramatic as the images of this phenomenon are, there is wide disagreement
on what they mean.

"Saying these changes predict that someone will relapse amounts to modern
phrenology," John P. Seibyl, a nuclear radiologist and psychiatrist at the
Yale School of Medicine, told me. "We don't have any data linking these
images to behavior, so how can we call addiction a disease of the brain?"

One of my colleagues puts it this way: You can examine brains all day, but
you'd never call anyone an addict unless he acted like one. That's what is
really misleading about the Moyers assertion that "addiction is primarily a
brain disease" -- it omits the voluntary aspects of an addict's behavior.

Addicts' brains are not always in a state of siege. Many addicts have
episodes of clean time that last for weeks, months or years. During these
periods it is the individual's responsibility to make himself less
vulnerable to drug craving and relapse.

Treatment can help the addict learn how to fight urges and find alternative
ways to meet emotional and spiritual needs. But will he take the advice?
Maybe. More likely, he will begin a revolving-door dance with the treatment
system. A recent study showed that only 1 in every 21 patients complete a
year in a treatment clinic. To drop out generally means to relapse.

"Addicts make decisions about use all the time," Dr. Robert L. DuPont, a
former director of the national institute, points out. Researchers have
found that the amount of alcohol consumed by alcoholics is related to its
cost and the effort required to obtain it. Two decades ago Lee Robins, a
professor of psychiatry at Washington University in St. Louis, in a classic
study of returning Vietnam veterans, found that only 14 percent of men who
were addicted to heroin in Vietnam resumed regular use back home. The
culture surrounding heroin use, the price and fear of arrest helped keep
the rest off the needle.

Thus drug addicts and alcoholics respond to rewards and consequences, not
just to physiology. Relapse should not be regarded as an inevitable,
involuntary product of a diseased brain.

Turning addiction into a medical problem serves a purpose, of course. The
idea is to reduce stigma and get better financing and more insurance
coverage for treatment.

As a psychiatrist, I'm all for treatment, but when the national institute
says that addiction is just like diabetes or asthma, it has the equation
backward. A diabetic or asthmatic who relapses because he ignores his
doctor's advice is more like an addict, as his relapses result from
forsaking the behavioral regimens that he knows can keep him clean.

True, former addicts are vulnerable to resuming use -- hence the "one day
at a time" slogan of Alcoholics Anonymous. But they are by no means
destined to do so. The message that addiction is chronic and relapse
inevitable is demoralizing to patients and gives the treatment system an
excuse if it doesn't serve them well.

Calling addiction a behavioral condition, as I prefer, emphasizes that the
person, not his autonomous brain, is the instigator of his relapse and the
agent of his recovery. The experts on Bill Moyers's program say that making
addiction more like heart disease or cancer will reduce stigma.

They're wrong. The best way to combat stigma is to expect drug users to
take advantage of treatment, harness their will to prevent relapse and
become visible symbols of hard work and responsibility.

This prescription does not deny the existence of vulnerabilities,
biological or otherwise. Instead it makes the struggle to relinquish drugs
all the more ennobling.