ADDICTION DOESN'T DISCRIMINATE? WRONG

We've heard it before. "Drug abuse is an equal opportunity
destroyer." "Drug addiction is a bipartisan illness." "Addiction does
not discriminate; it doesn't care if you are rich or poor, famous or
unknown, a man or woman, or even a child."

The phrase "addiction doesn't care" is not meant to remind us that
addiction casts a long shadow -- everyone knows that. Rather, it is
supposed to suggest that any individual, no matter who, is vulnerable
to the ravages of drugs and alcohol.

The same rhetoric has been applied to other problems, including child
abuse, domestic violence, alcoholism -- even suicide. Don't
stigmatize the afflicted, it cautions; you could be next. Be kind, don't judge.

The democratization of addiction may be an appealing message, but it
does not reflect reality. Teenagers with drug problems are not like
those who never develop them. Adults whose problems persist for
decades manifest different traits from those who get clean.

So while anyone can theoretically become an addict, it is more likely
the fate of some, among them women sexually abused as children;
truant and aggressive young men; children of addicts; people with
diagnosed depression and bipolar illness; and groups including
American Indians and poor people.

Attitudes, values and behaviors play a potent role as well.

Imagine two people trying cocaine, just to see what it is like. Both
are 32-year-old men with jobs and families. One snorts a line, loves
it and asks for more. The other also loves it but pushes it away,
leaves the party and never touches it again. Different values?
Different tolerance for risk? Many factors may distinguish the two
cocaine lovers, but only one is at risk for a problem.

Asking for more drug is no guarantee of being seduced into routine
use. But what if it happens? Jacob Sullum, a senior editor at Reason
magazine, has interviewed many users who became aware that they were
sliding down the path to addiction.

"It undermined their sense of themselves as individuals in control of
their own destinies," Mr. Sullum wrote in his 2003 book, "Saying Yes:
In Defense of Drug Use." "And so they stopped."

I only read about these people. Patients who come to our methadone
clinic are there, obviously, because they're using. The typical
patient is someone who has been off heroin for a while (maybe because
life was good for while, maybe because there was no access to drugs,
maybe because the boss did urine testing) and then resumed.

But the road to resumption was not unmarked. There were signs and
exit ramps all along the way. Instead of heeding them, our patients
made small, deliberate choices many times a day -- to be with other
users, to cop drugs for friends, to allow themselves to become bored
- -- and soon there was no turning back.

Addiction does indeed discriminate. It "selects" for people who are
bad at delaying gratification and gauging consequences, who are
impulsive, who think they have little to lose, have few competing
interests, or are willing to lie to a spouse.

Though the National Institute on Drug Abuse describes addiction as a
"chronic and relapsing disease," my patients, seeking help, are
actually the exception. Addiction is not an equal opportunity
destroyer even among addicts because, thankfully, most eventually
extricate themselves from the worst of it.

Gene Heyman, a lecturer and research psychologist at Harvard Medical
School and McLean Hospital, said in an interview that "between 60 and
80 percent of people who meet criteria for addiction in their teens
and 20s are no longer heavy, problem users by their 30s." His
analysis of large national surveys revealed that those who kept using
were almost twice as likely to have a concurrent psychiatric illness.

None of this is to deny that brain physiology plays a meaningful role
in becoming and staying addicted, but that is not the whole story.

"The culture of drink endures because it offers so many rewards:
confidence for the shy, clarity for the uncertain, solace to the
wounded and lonely," wrote Pete Hamill in his memoir, "A Drinking
Life." Heroin and speed helped the screenwriter Jerry Stahl, author
of "Permanent Midnight," attain the "the soothing hiss of oblivion."

If addiction were a random event, there would be no logic to it, no
desperate reason to keep going back to the bottle or needle, no
reason to avoid treatment.

The idea that addiction doesn't discriminate may be a useful story
line for the public -- if we are all under threat then we all should
urge our politicians to support more research and treatment for
addiction. There are good reasons to campaign for those things, but
not on the basis of a comforting fiction.

Sally Satel is a psychiatrist and a resident scholar at the American
Enterprise Institute.