The Science of Choice in Addiction

In December 1966, Leroy Powell of Austin, Texas, was convicted of public intoxication and fined $20 in a municipal court. Powell appealed his conviction to Travis County court, where his lawyer argued that he suffered from “the disease of chronic alcoholism.” Powell’s public display of inebriation therefore was “not of his own volition,” his lawyer argued, making the fine a form of cruel and unusual punishment. A psychiatrist concurred, testifying that Powell was “powerless not to drink.”

Then Powell took the stand. On the morning of his trial, his lawyer handed him a drink, presumably to stave off morning tremors. The prosecutor asked him about that drink:

The judge let stand Powell’s conviction for public intoxication.

Two years later, the Supreme Court affirmed the constitutionality of punishment for public intoxication, rejecting the idea “that chronic alcoholics … suffer from such an irresistible compulsion to drink and to get drunk in public that they are utterly unable to control their performance.”

Now, fast-forward almost half a century to the laboratory of Carl Hart, a neuroscientist at Columbia University, who has been showing that cocaine and methamphetamine addicts have a lot in common with Powell. When Hart’s subjects are given a good enough reason to refuse drugs—in this case, cash—they do so too.

The basic experiment goes like this. Hart recruits addicts who have no interest in quitting but who are willing to stay in a hospital research ward for two weeks for testing. Each day, Hart offers them a sample dose of either crack cocaine or methamphetamine, depending upon the drug they use regularly. Later in the day, they are given a choice between the same amount of drugs, a voucher for $5 of store merchandise, or $5 cash. They collect their reward when they’re discharged two weeks later.

More often than not, subjects choose the $5 voucher or cash over the drug, except that, when offered a higher dose, they go for the drug. But when Hart ups the value of the reward to $20, addicts chose the money every time.

In his new book, High Price—A Neuroscientist’s Journey of Self-Discovery That Challenges Everything You Know About Drugs and Society, Hart reports that he was surprised by his findings. Wasn’t addiction a dopamine-driven compulsion “that ’hijacked’ the brain and took control of the will?” he asks. As a graduate student Hart was taught that. It's understood that recovered addicts eschew substances for fear that even a small amount could set off an irresistible craving for more.

Indeed, this has been conventional wisdom in research circles for at least the past two decades. Many of Hart’s colleagues who teach this support their claim with brain scans showing the addicts’ reward pathways ablaze with neural activation. But studies going back to the 1960’s show that many people addicted to all kinds of drugs— nicotine, alcohol, cocaine, heroin, methamphetamines— can stop or modify their use in response to rewards or sanctions.

This means that the neural changes that occur in the brains of addicts do not necessarily disable their capacity to respond to rewards. Leroy Powell had surely experienced alcohol-induced brain changes over years of drinking, but they did not keep him from making a choice on the morning of his trial. Hart’s subjects loved cocaine, but they loved cash even more.

It is certainly true that when people have an intense urge to use, resisting is very, very hard. Yet there’s room for deliberate action in the form of “self-binding,” a practice by which addicts can erect obstacles between themselves and their drugs. Examples include avoiding people, places, or things associated with drug use; directly depositing paychecks or tearing up ATM cards to keep ready (drug) cash out of one’s pockets; or avoiding boredom, a common source of vulnerability to drug use.

The decision to self-bind is made during calmer moments when addicts are not in withdrawal or experiencing strong desire to use. And addicts have many of these moments; as a rule, they do not spend all their time nodding out or in a frenzy to obtain more drugs.

No one would choose the misery that comes with excessive use. “I’ve never come across a single person that was addicted that wanted to be addicted,” says neuroscientist Nora Volkow, director of the National Institute on Drug Abuse and an enthusiastic booster of the brain-driven model of addiction. It is true, drug users don’t choose to become addicted any more than consumers of high calorie foods choose to become overweight. But addiction and poundage is not what they are choosing: what they seek is momentary gratification or relief—a decision that is rational in the short-term but irrational in the long-term.

A typical trajectory goes something like this. In the early phase of addiction, using drugs and alcohol can simply be fun; or it can be a form of self-medication that quells persistent self-loathing, anxiety, alienation, and loneliness. Meanwhile once-rewarding activities, such as relationships, work, or family, decline in value. The attraction of the drug starts to fade as the troubles accrue—but the drug retains its allure because it blunts mental pain, suppresses withdrawal symptoms, and douses craving.

Eventually, addicts find themselves torn between reasons to use and reasons not to. Sometimes a spasm of self-reproach (“this is not who I am;” “I’m hurting my family,” “my reputation is at risk”) tips the balance toward quitting. Novelist and junkie William S. Burroughs calls this the “naked lunch” experience, “a frozen moment when everyone sees what is on the end of every fork.”

In short, every addict has reasons to begin using, reasons to continue, and reasons to quit. To act on a reason is to choose. To make good choices requires the presence of meaningful alternatives. And making a series of good choices leads to achievements—jobs, relationships, reputations. These give a person something meaningful to lose, another reason in itself to steer away from bad choices.

In his book, Hart uses his own story to breathe life into what may sound like a sterile lesson in behavioral economics. He grew up in the 70’s in the benighted Carol City in south Florida, facing poverty, racism, domestic violence, bad schools, guns, and drugs. Hart himself stole and used drugs (though he was never addicted) and peddled marijuana. Yet he ended up thriving due to the many alternatives to drugs in his life. He calls these “competing reinforcers”—high school sports, educational opportunities, and mentors. Hart wants all young people raised in despairing circumstances to have those too.

Combating social ills on such a grand stage may be a pipe dream. But, in the realm of recovery from alcohol and drugs, the principle of competing reinforcers has been scaled down to size and is being replicated across the country. Take HOPE (Hawaii Opportunity for Probation Enforcement), a jail diversion program in which addict-offenders are subject to short periods of detention if they fail drug tests., but receive a clean corrections record if they complete the year-long program. One year after enrollment, HOPE participants were 55 percent less likely to be arrested for a new crime and 53 percent less likely to have had their probation revoked than those in a control group.

Hart draws attention to how progressive rehab programs use rewards to encourage completion of job training and attendance at treatment or Alcoholics Anonymous or Narcotics Anonymous meetings, and so on. Consequences, rather than rewards, or sticks, rather than carrots, can work too. When at risk of losing their licenses, addicted physicians show impressive rates of recovery. When they come under the surveillance of their state medical boards and are subject to random urine testing, unannounced workplace visits, and frequent employer evaluations, 70 to 90 percent are employed with their licenses intact five years later.

Hart believes that both carrots and sticks, when necessary, should be used far more frequently and creatively in the management of addiction.

As Hart says in his book, “Severe addiction may narrow people’s focus and reduce their ability to take pleasure in non-drug experiences, but it does not turn them into people who cannot react to a variety of incentives.” Although addictions are hard to break, it is most useful to view the potential for overcoming them through the lens of choice. It’s not a matter of just saying no—recovery requires far more grit and conviction than that—but it is very much a matter of regarding addicts as people who can rationally choose to use opportunities to their advantage, and working to provide those opportunities.