Giving addiction its due*Giving addiction its due*

Addiction what is the added value of the concept today?Addiction what is the added value of the concept today?

The University of Helsinki Centre for Research on The University of Helsinki Centre for Research on AddictionsAddictions

Gene M. HeymanGene M. Heyman

Dept. of Psychology, Boston CollegeDept. of Psychology, Boston College

October 15, 2012October 15, 2012

* This is actually my 2* This is actually my 2ndnd talk talk

First talk: Some basic findings on drug use (among DSM First talk: Some basic findings on drug use (among DSM “addicts”)“addicts”)

Outline of topicsOutline of topics

Context: What experts and addicts say about addiction, policy, Context: What experts and addicts say about addiction, policy, individual responsibilityindividual responsibility

Two questions:Two questions:– Is addiction a chronic disorderIs addiction a chronic disorder– Does drug use become involuntaryDoes drug use become involuntary

Approach: Approach: – Use DSM to distinguish addicts from drug usersUse DSM to distinguish addicts from drug users– Look at the dataLook at the data

Why don’t they just quit?*Why don’t they just quit?*

Is addiction like other psychiatric disorders?**Is addiction like other psychiatric disorders?**

Views on addiction from experts: Alan Leshner & Nora Views on addiction from experts: Alan Leshner & Nora Volkow, past and present directors of US National Institute Volkow, past and present directors of US National Institute

on Drug Abuse (NIDA)on Drug Abuse (NIDA)

““Addiction is a brain disease . . . For most people, it Addiction is a brain disease . . . For most people, it [addiction] is a chronic relapsing disorder . . . . addiction must [addiction] is a chronic relapsing disorder . . . . addiction must be approached more like other chronic illnesses.”be approached more like other chronic illnesses.”

““A metaphorical switch in the brain [is] thrown as a result of A metaphorical switch in the brain [is] thrown as a result of prolonged drug use. Initially, drug use is a voluntary behavior, prolonged drug use. Initially, drug use is a voluntary behavior, but when that switch is thrown, the individual moves into a but when that switch is thrown, the individual moves into a state of addiction, characterized by compulsive drug seeking state of addiction, characterized by compulsive drug seeking and use.” and use.” Leshner, Science, 1997Leshner, Science, 1997..

““The key symptoms of addiction...are The key symptoms of addiction...are compulsive compulsive drug intake drug intake and intense drive to take the drug....” “at the expense of life-and intense drive to take the drug....” “at the expense of life-preserving activities.”preserving activities.”Volkow, 1992, 2000Volkow, 1992, 2000

Views on Addiction: William Burroughs (1914-Views on Addiction: William Burroughs (1914-1998), author, counter culture hero, opiate addict1998), author, counter culture hero, opiate addict

Junk yields a basic formula of “evil” virus: . . . A dope fiend Junk yields a basic formula of “evil” virus: . . . A dope fiend is a man in total need of dope. . . Dope fiends are sick is a man in total need of dope. . . Dope fiends are sick people who cannot act other than they do. people who cannot act other than they do. A rabid dog A rabid dog cannot choose but bitecannot choose but bite. . Naked Lunch (1959)Naked Lunch (1959)

Policy recommendations regarding insurance coverage and Policy recommendations regarding insurance coverage and individual responsibility for addiction individual responsibility for addiction

““. . . . effects of drug dependence treatment are optimized when patients effects of drug dependence treatment are optimized when patients remain in continuing care and monitoring without limits or restrictions on the remain in continuing care and monitoring without limits or restrictions on the number of days or visits coverednumber of days or visits covered.”.”

– ((A. T. McLellan, Recent Deputy Director of Drug Control Policy, Obama Administration)A. T. McLellan, Recent Deputy Director of Drug Control Policy, Obama Administration)

““Ten percent of [the] population [are] unknowingly vulnerable to alcoholism Ten percent of [the] population [are] unknowingly vulnerable to alcoholism when they drink. They can’t be held responsible for developing that illness.” when they drink. They can’t be held responsible for developing that illness.” – Dr. David Gastfriend, Recent Director of the Addiction Research Center at Massachusetts Dr. David Gastfriend, Recent Director of the Addiction Research Center at Massachusetts

GeneralGeneral

“ “ I find it useful to conceptualize addiction as the cancer of behavior. How I find it useful to conceptualize addiction as the cancer of behavior. How else could one fathom the mother who buys cocaine for herself instead of else could one fathom the mother who buys cocaine for herself instead of food for her children …” food for her children …” – Dr. P. Martin Dr. P. Martin in New England Journal of Medicinein New England Journal of Medicine

One more account: Patty: Mother of two girls, One more account: Patty: Mother of two girls, heavy cocaine user for 15 years, drug dealer heavy cocaine user for 15 years, drug dealer

Oh, for a time my nose opened up when I went out Oh, for a time my nose opened up when I went out partying and drinking, but I learned how to handle it. You partying and drinking, but I learned how to handle it. You know, I never really decided to quit using. I just quit know, I never really decided to quit using. I just quit selling. selling.

Once I stopped selling I didn’t have the money to buy it Once I stopped selling I didn’t have the money to buy it anymore. anymore.

I would have literally had to say, “ Sorry, girls, you don’t I would have literally had to say, “ Sorry, girls, you don’t eat this week” to buy some. I would have exactly $80 for eat this week” to buy some. I would have exactly $80 for two weeks of food. Waldorf et al. (1991)two weeks of food. Waldorf et al. (1991)Cocaine Cocaine

changes: The experience of using and quitting changes: The experience of using and quitting ..

Some context, an example of human decision making: What to Some context, an example of human decision making: What to eat when you have a severe food allergyeat when you have a severe food allergy

Ira Glass: “Barbara Ira Glass: “Barbara said . . .she got incredibly sick, throwing up, rushing to the said . . .she got incredibly sick, throwing up, rushing to the emergency room, getting an IV, an anti-nausea medication . . .”. emergency room, getting an IV, an anti-nausea medication . . .”.

Barbara: “Barbara: “And being on vacation now, I've got a room full of popcorn and trail mix.”And being on vacation now, I've got a room full of popcorn and trail mix.”

Ira Glass: “Ira Glass: “You do? Right now? Wait, don't you think you're playing with fire?”You do? Right now? Wait, don't you think you're playing with fire?”

Barbara: “Barbara: “Well, you know, it's not going to kill me. And if it does, I won't know.”Well, you know, it's not going to kill me. And if it does, I won't know.”

Ira Glass: “Ira Glass: “Just a quick trip to the hospital, an IV, some medication.”Just a quick trip to the hospital, an IV, some medication.”

Ira Glass: Ira Glass: This is This is Michelle DeVito,Michelle DeVito, an emergency room doctor . . . she says that nearly an emergency room doctor . . . she says that nearly every day, she sees somebody with a food allergy who has eaten the food that they're every day, she sees somebody with a food allergy who has eaten the food that they're not supposed and ended up in her ER.not supposed and ended up in her ER.

Michelle DeVito:Michelle DeVito: “The ER is a virtual laboratory of dysfunctional behaviors and bad “The ER is a virtual laboratory of dysfunctional behaviors and bad choices. . . . much of the pathology we see in the ER is a result of bad choices. And choices. . . . much of the pathology we see in the ER is a result of bad choices. And some of them, decades of bad choices.”some of them, decades of bad choices.”

Some initial conclusions Some initial conclusions

The understanding of addiction has consequences for The understanding of addiction has consequences for public policy and tax dollarspublic policy and tax dollars

Many cases (e.g., Burroughs) are consistent with the Many cases (e.g., Burroughs) are consistent with the disease/compulsive model disease/compulsive model (“rabid dogs”) ---but not all– Real addicts vs. apparent addicts– No “real” addicts?– Food allergies (and addiction): human nature/decision making

revealed?

How to proceed

Find a tool for identifying “addicts” then test if they are chronic, compulsive (involuntary) drug users.

How to identify addictsHow to identify addicts

Use the American Psychiatric Association (DSM) criteria for Use the American Psychiatric Association (DSM) criteria for “substance dependence” to distinguish addicts from drug users“substance dependence” to distinguish addicts from drug users

Rationale: Rationale: – Official criteria for clinics, courts, & researchersOfficial criteria for clinics, courts, & researchers– Reliable/research basedReliable/research based– Divides drug users into meaningful categoriesDivides drug users into meaningful categories

Key feature: persistence of drug use despite aversive Key feature: persistence of drug use despite aversive consequencesconsequences– High levels of drug useHigh levels of drug use– Use despite health & job risksUse despite health & job risks– Relapse & takes more than initially intendedRelapse & takes more than initially intended

Questions regarding DSM “addicts”Questions regarding DSM “addicts”

Are they chronic cases?Are they chronic cases?

Do they become involuntary (compulsive) drug Do they become involuntary (compulsive) drug users?users?

Lifetime Use and Lifetime Dependence for Specific Drugs

Cigare

ttes

Alcoho

l

Other

Dru

gs

Mar

ijuan

a

Cocain

e

Amph

etam

ine

Heroin

% o

f US

Po

pu

latio

n,

Na

tion

al C

om

orb

idity

Stu

dy*

0%

20%

40%

60%

80%

100%

Ever UsedEver Dependent

* Anthony et al., 1994NCS Replication

2D Graph 1

6 7 8

Y D

ata

Heroin

Overall prevalence of use and dependence

Remission in Representative Samples of Dependent (Addicted) Drug Users (N approx. 2700)

% in

Rem

issi

on

0%

20%

40%

60%

80%

100%

Is addiction a chronic disorder, as so often claimed?

Rem% = (LT-C)/LT

Community Studies

paraphrasing O’Brien and McLellan: “cure is an unrealistic hope, addiction requires lifelong treatment as does “arthritis, diabetes, asthma”’

Textbook of Clinical Psychiatry: “for addiction patients recovery is a never-ending process, the term cure is avoided.

Type Drug

% R

em

issio

n

15%

30%

45%

60%

75%

90% ECA Survey, 1981-198NESARC Survey, 2001-2002

High remission rates for different drugs

Did type of drug matter?

Cumulative Remission From Drug Dependence & Their Best Fitting Curves

Years Since Dependence Onset

0 10 20 30 40 50 60 70

Cu

mul

ativ

e P

roba

bilit

y o

f Re

mis

sio

n

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Coc Rem = 0.98(1 - e-0.17Yr)

Mj Rem = 0.94(1 - e-0.13Yr)

Alc Rem = 0.95(1 - e-0.05Yr)

Cig Rem = "1.38"(1 - e-0.015Yr)

Fixed Asymtote = "1.38"(1 - e-0.024Yr)

Increasing functions suggest that once addicts quit, they usually do not resume heavy drug use

Yrs to 50% quit:Cocaine: 4Marijuana: 6Alcohol: 16Cigarettes: 31

Lopez-Quintero, 2010

How long does substance dependence persist?

Other methodological issuesOther methodological issues

Missing addicts? Missing addicts?

Do high remission rates persist when self-report Do high remission rates persist when self-report is validated?is validated?

Why do we say that addiction is a “chronic” Why do we say that addiction is a “chronic” disorder, when the data say otherwise?disorder, when the data say otherwise?

Clinics as basis for understanding of addictionClinics as basis for understanding of addiction

But most addicts do not seek treatmentBut most addicts do not seek treatment

Berkson’s bias: those in clinic have more than one Berkson’s bias: those in clinic have more than one disorderdisorder

Predictions:Predictions:– Drug use persists longer in clinic populationsDrug use persists longer in clinic populations– Clinic populations have more disorders (Berkson’s bias)Clinic populations have more disorders (Berkson’s bias)

Relapse Following Treatment(Resumption of Drug Use)

Months

0 2 4 6 8 10 12

% R

elap

se

15%

30%

45%

60%

75%

AlcoholSmokingHeroin

Hunt et al., 1971

Clinic results support received wisdom: “Addiction is a chronic disorder”

Typical clinic study results

Fre

q o

f A

dditio

nal

Psych D

isord

ers

10%

20%

30%

40%

50%

60%

70%

80%

Treatment Seeking is Corrrelated With Higher Comorbidity*

Drug Depend & Tx Seeking

Drug Depend & Not Tx Seeking

NotDrug Dependent

* Regier et al., 1990; Rounsaville et al., 1991

Berkson’s bias

Is addiction a chronic disorder, according to the Is addiction a chronic disorder, according to the data? data? SummarySummary

Yes, for some (perhaps most) clinic populationsYes, for some (perhaps most) clinic populations

But most addicts do not seek/end up in treatmentBut most addicts do not seek/end up in treatment

Illicit drug addicts not in treatment tend to quit by age 30 Illicit drug addicts not in treatment tend to quit by age 30 (alcohol and cigarettes quit at lower rates)(alcohol and cigarettes quit at lower rates)

One difference in the two groups: Additional medical One difference in the two groups: Additional medical disorders disorders

Is addiction a disease (meaning involuntary Is addiction a disease (meaning involuntary drug use)?drug use)?

In 1619, Robert Harris described habitual In 1619, Robert Harris described habitual drunkenness as this “Dropsilike disease.” drunkenness as this “Dropsilike disease.”

In 1628, William Prynne notes that drunkenness is a In 1628, William Prynne notes that drunkenness is a “dangerous dropsie and disease.”“dangerous dropsie and disease.”

John Bury (1677) writes: “drunkenness is a disease John Bury (1677) writes: “drunkenness is a disease so epidemical that all the Physicians in so epidemical that all the Physicians in EnglandEngland know not how to stop it.”know not how to stop it.”

Who are these early commentators and Who are these early commentators and what were they thinking?what were they thinking?

British clergymenBritish clergymen

Basis of diagnosis (1609): those who addict Basis of diagnosis (1609): those who addict themselves . . . turn delight into necessitie . . . themselves . . . turn delight into necessitie . . . yet against all rules of reason yet against all rules of reason . . . they will not . . . they will not leave their drunkennessleave their drunkenness

Drinking seemed irrational therefore it was a Drinking seemed irrational therefore it was a disease (assumption: voluntary behavior is disease (assumption: voluntary behavior is rational)rational)

Additional, more recent explanations: addiction is a Additional, more recent explanations: addiction is a disease because it has a biological basis: genes disease because it has a biological basis: genes

and drug-induced changes in the brainand drug-induced changes in the brain

Genetic etiology:Genetic etiology: “the evidence of this physical basis “the evidence of this physical basis (genes) has significantly advanced the acceptance of (genes) has significantly advanced the acceptance of alcoholism (addiction) as a disease.” Miller & Chappel alcoholism (addiction) as a disease.” Miller & Chappel (1991)(1991)

Drugs change the brainDrugs change the brain: “That addiction is tied to : “That addiction is tied to changes in brain structure and function is what makes it, changes in brain structure and function is what makes it, fundamentally, a disease.” Alan Leshner, fundamentally, a disease.” Alan Leshner, Science (1997)Science (1997)

Fig. 5. Photographs of three examples ofapparently anomalous apical dendrites on Cg3 pyramidal cells in rats that self-administered cocaine (see text). Robinson et al., 2001, Synapse…

Changes in nucleus accumbens and cortex produce a “recipe for addiction.”

Given Access to Saccharin, Preference Shifts toSaccharin Following

Escalated Cocaine Intake

Days

1 2 3 4 5 6 7 8 9 10%

Pre

fere

nce

for

Sacc

harin

0

20

40

60

80

100

Cocaine Intake EscalatesWhen It Is Only Option

Days

Day 1 Day 21

mg C

oca

ine/D

ay

5

10

15

20

25

Perhaps as much as 15 g/day for humans (or about 1-2 wk supply for heavy user).

Motor sensitization (3x a much cocaine as in Robinson study); saccharin linked to lower DA release) Recall Volkow : “at expense of life preserving activities”)

The proper questionThe proper question

All psychological phenomena vary as a function of All psychological phenomena vary as a function of variation in genes and brain structure/functionvariation in genes and brain structure/function

Thus, we can ask: do genes and drug- induced Thus, we can ask: do genes and drug- induced neural adaptations insulate drug use in addicts neural adaptations insulate drug use in addicts from the determinants of choice?from the determinants of choice?

Does biology of addiction lead to involuntary drug Does biology of addiction lead to involuntary drug use?use?

Criteria for the voluntary/involuntary Criteria for the voluntary/involuntary continuumcontinuum

Not free willNot free will

Different causal relations: elicited vs. feedbackDifferent causal relations: elicited vs. feedback

Elicited: reflexes, instinctsElicited: reflexes, instincts

Feedback: Values, sanctions, opinion of others, Feedback: Values, sanctions, opinion of others, costs benefits, punishment, reward, etc.costs benefits, punishment, reward, etc.

Examples and difficult casesExamples and difficult cases

Contrasts Contrasts – Patellar reflex vs. kickPatellar reflex vs. kick– Blush vs. rougeBlush vs. rouge– Blink vs. winkBlink vs. wink– Ballistic missile vs. guided missileBallistic missile vs. guided missile– Sneezing vs. spittingSneezing vs. spitting

Difficult cases: OCD symptoms, compelled Difficult cases: OCD symptoms, compelled crimes (e.g., kidnap victim forced to rob bank)crimes (e.g., kidnap victim forced to rob bank)

Do the factors that influence choice help bring drug use to a halt in addicts (and can the same be said

for symptoms of other psychiatric disorders?)

Logical implications of high remission rates plus non-clinic recovery in community samples

Correlates of recovery:– Information: Surgeon General’s Report on smoking (1964)

– Historical events: Harrison narcotics tax act (1914) /Prohibition (alcohol)

– Biographies: values and practical concerns

Common themes in biographical accounts of Common themes in biographical accounts of quitting:quitting:

Stories are laced with explicit and implicit values:Stories are laced with explicit and implicit values:– :“I wasn’t put on earth to be an addict”:“I wasn’t put on earth to be an addict”– ““I wanted my parents to be proud of me again”I wanted my parents to be proud of me again”– ““I didn’t want to embarrass my children”I didn’t want to embarrass my children”– ““I was sick of the hassles”I was sick of the hassles”

Ordinary concernsOrdinary concerns– Fear of arrestFear of arrest– Finances and occupational concernsFinances and occupational concerns– Family pressuresFamily pressures

If drug use is voluntary, why don’t addicts just quit? Drug is the better choice from a local perspective (1)

Addictive drugs are behaviorally “toxic”---they undermine the value of competing activities

Benefits are immediate; costs are delayed

No direct self-satiating mechanisms as with most other rewarding activities

Intoxicating, whereas moderation depends on judgment

If drug use is voluntary why don’t addicts just quit? (2)

Intoxication, depression, anxiety and other emotional states reduce the frame of reference to “now”

Lifestyle associated with drug use may not include activities with long time horizons, thereby promoting local frame of reference

Is addiction like other mental disordersIs addiction like other mental disorders

Yes, e.g., analogous to OCD: symptom provides Yes, e.g., analogous to OCD: symptom provides immediate reward, resisting symptom provides delayed immediate reward, resisting symptom provides delayed larger rewardlarger reward

No:No:– Addiction’s unique idiomsAddiction’s unique idioms– Addiction’s unique correlates of recovery: legislation, Addiction’s unique correlates of recovery: legislation,

opinion of others, AAopinion of others, AA– Importance of cohortImportance of cohort

Year of Birth19

36-1

945

1946

-195

5

1956

-196

5

1966

-197

5

Pro

ba

bili

ty t

ha

t D

rug

Use

Le

ad

s to

De

pe

nd

en

ce b

y A

ge 2

0

0.00

0.04

0.08

0.12

0.16

Historical Variation in the TransitionFrom Drug Use to Drug Dependence*

*National Comorbidity Study

Psychiatric Disorder

Lik

elih

oo

d

0%

2%

4%

6%

8%

10%

12%

14%

Schizo

Abuse/

Dep

OCD

Panic

Depre

ssion

Man

iaAnx

iety

Disord

er

Affect

ive

Differences in Likelihood of Psychiatric Disorders as Function of Differences in Year of Birth (ECA)

Born 1952-1963,

Born 1917-1936

The original talk summarized:The original talk summarized:

““Addiction” is a useful labelAddiction” is a useful label

Addiction as compulsion is not in accord with the Addiction as compulsion is not in accord with the researchresearch

Addiction as a psychiatric disorder is Addiction as a psychiatric disorder is questionablequestionable

The talk that there is not time for: Why are we so The talk that there is not time for: Why are we so susceptible to the idea that addicts are compulsive susceptible to the idea that addicts are compulsive

drug users?drug users?

Recall William BurroughsRecall William Burroughs

Junk yields a basic formula of “evil” virus: . . . A Junk yields a basic formula of “evil” virus: . . . A dope fiend is a man in total need of dope. . . dope fiend is a man in total need of dope. . . Dope fiends are sick people who cannot act Dope fiends are sick people who cannot act other than they do. other than they do. A rabid dog cannot choose A rabid dog cannot choose but bitebut bite. .

From: From: Naked Lunch Naked Lunch (1959)(1959)

Burroughs Burroughs reduxredux

His allowance from home stops (at age 40)His allowance from home stops (at age 40)

““I stood there with my last check in my hand and I stood there with my last check in my hand and realized that it was my last check. I took the next realized that it was my last check. I took the next plane to London [to enter “treatment”].”plane to London [to enter “treatment”].”

– From From Naked Lunch…(1959)Naked Lunch…(1959)

Global Frame (Drug+ NonDrug Market Baskets)

0 3 6 9 12 15 18 21 24 27 30

100V

150V

200V

250V

300V

350V

400V

Equili-brium

x Drug Days + (30 - x) Non-Drug Days

Local Frame (Drug vs. NonDrug)

0 3 6 9 12 15 18 21 24 27 30

Val

ue

0V

3V

6V

9V

12V

15VDrug (Choice DependentDecreases in Value)

Value of Non-Drug Undermined by Drug Effects

Number of Drug (e.g., heroin) Choices In Last 30 Days

Equili-brium

Equili-brium

Graph is consistent with Amer. Psych Assoc. definition of addiction: Persistence of drug use despite negative consequences

Graph is consistent with temporal pattern of addiction: alternating periods of drug use and abstinence

Week of Treatment

1 2 3 4 5 6 7 8 9 10 11 12

% C

on

tinu

ou

sly

Ab

stin

en

t

0%

20%

40%

60%

80%

100%Prosocial Incentives for Abstinence12-Step (Narcotic Anon.) Program

Retail VouchersReduceCocaine Use

Explicit test of incentives

Months Since Treatment6 9 12

% C

oca

ine

Ab

stin

en

t

0%

20%

40%

60%

80%

100%

VouchersCounseling

Higgins et al.1995

Choice-based voucher treatment: Cocaine dependent usersIncentives and

drug use in cocaine addicts

Abstinence When Positive Drug TestsCan Result in Job Loss

1a 1b 2 3 4 5 6 7 8a 8b 9 10

% A

bst

ine

nt o

r "

Do

ing

We

ll"

0%

20%

40%

60%

80%

100% No Monitoring

Remission Rates for Psychiatric DisordersNCS (1990-1992)

Subst

Use

AllDiso

rder

s

% in

Re

mis

sio

n

15%

30%

45%

60%

75%

All psychiatric disorders, not counting drug and alcohol dependence.

Do all psych disorders have high remission rates?

10 8 6 4 2 0

Ince

ntiv

e V

alue

20

40

60

80

100

120

140

160180

200

Time to Reward

15 13 11 9 7 5 3 0

Competing MotivesDelay, Incentive, and Choice

Delay to Smaller Reward

Delay to Larger Reward

Reward Value = Amount/(1 + k Delay)

Green Amount = 200Red Amount = 100

Green Delay = D + 5Red Delay = D

k = 1

Benefits of Cigarette Now vs Penalties Later

Delay

10 9 8 7 6 5 4 3 2 1 0

Va

lue

-150

-100

-50

0

50

100

150

NonDelayedChoice

Val

ue

-150

-100

-50

0

50

100

150BenefitsCosts

Overall Value of Cigarette =s (Benefits - Penalites)= (100 -150 units of value)

Moment Neg. Consq.TakeEffectDiscounted

Value of Neg. Conseq.

Overall Value of Cigarette =s(Benefits - Penalties =s)(100 - 25 units of value)

Moment Cigarette isAvailable

-25

How can we justify interventions to aid addicts, if How can we justify interventions to aid addicts, if they so often quit on their own?they so often quit on their own?

We can shorten the period of self-destructive We can shorten the period of self-destructive drug usedrug use

Likelihood of quitting depends on alternatives Likelihood of quitting depends on alternatives and judgment.and judgment.– Drug user may have few alternativesDrug user may have few alternatives– Assuming a better alternative to drug use exists, it Assuming a better alternative to drug use exists, it

may take sober effort to achieve itmay take sober effort to achieve it

Missing Addicts?Missing Addicts?

Perhaps addicts who keep using are missing?Perhaps addicts who keep using are missing?

Assume most addicts remain addicts but go missing. Thus real % Assume most addicts remain addicts but go missing. Thus real % no longer showing symptoms is 20% not 80%. How many missing no longer showing symptoms is 20% not 80%. How many missing addicts are there?addicts are there?

Let 80% = True % of current addicts = (Current Addicts + Let 80% = True % of current addicts = (Current Addicts + XX)/()/(XX + + Lifetime Addicts), where X = number of missing addicts.Lifetime Addicts), where X = number of missing addicts.

X X = 3 x Current lifetime addicts (or about 12 % of Americans were = 3 x Current lifetime addicts (or about 12 % of Americans were addicted to an illicit drug at some time in their life---and 75% of this addicted to an illicit drug at some time in their life---and 75% of this population (>20 M) cannot be found and are still addicted or deadpopulation (>20 M) cannot be found and are still addicted or dead

% of "Cases" Who No Longer

Met Criteria for Drug Dependence

% C

ases R

em

itte

d

0%

20%

40%

60%

80%

100%

Remission % for Opiate Addiction:"Prospective, Intensive" Studies

% in

Rem

issi

on

0%

20%

40%

60%

80%

100%

Remission in studies that include repeated, face-to-face interviews, back-up validation methods

Does type of study matter?

Political Attitudes InTwins Living Apart*

Cor

rela

tion

(Sim

ilarit

y)

0

20

40

60

80

*McCourt et al., 1999

The logic behind the genetic argument:

(1)Addiction has a genetic basis.

(2) You do not choose your genes.

(3) Therefore, drug use in addicts is involuntary

(4) Sensible argument if voluntary behaviors do not have a biological basis

(5) Yet…see graphBut as this graph shows voluntary behavior has a genetic basis also

Brain plasticity is inherent to all psychological Brain plasticity is inherent to all psychological phenomena, particularly learning and voluntary acts. phenomena, particularly learning and voluntary acts.

That addiction is That addiction is tied to changes in tied to changes in brain structure and brain structure and function is what function is what makes it, makes it, fundamentally, a fundamentally, a disease. disease. Alan Leshner, Alan Leshner, Science (1997)Science (1997)

But all learning is But all learning is tied to changes in tied to changes in brain structure and brain structure and function…function…

VVVVolkow et al., Synapse, 1993, 14:169-177.

Summary:Summary:

In accordance with the idioms that distinguish addiction from In accordance with the idioms that distinguish addiction from chronic illnesses, research revealschronic illnesses, research reveals

Most addicts stop using drugs and usually do so without Most addicts stop using drugs and usually do so without professional assistanceprofessional assistance

The primary factors that bring drug use to a halt are those that The primary factors that bring drug use to a halt are those that influence decisions: familial concerns, economics, values influence decisions: familial concerns, economics, values

We cannot make a similar summary for “chronic illnesses”We cannot make a similar summary for “chronic illnesses”

Although addiction has a biological basis, these differences Although addiction has a biological basis, these differences are important and too large to overlook: Thus, addiction, is not are important and too large to overlook: Thus, addiction, is not “Really like chronic diseases”“Really like chronic diseases”