The Science of Choice in Addiction

Research has shown that beating addiction is ultimately about regarding addicts as people who can rationally choose.
(jayhem/flickr)

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:

Q: You took that one [drink] at eight o’clock [a.m.] because you wanted to drink?...And you knew that if you drank it, you could keep on drinking and get drunk?

A: Well, I was supposed to be here on trial, and I didn’t take but that one drink.

Q: You knew you had to be here this afternoon, but this morning

you took one drink and then you knew that you couldn’t afford

to drink anymore and come to court; is that right?

A: Yes, sir, that’s right.

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 PriceA 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. 

Presented by

Sally Satel is a psychiatrist, a resident scholar at the American Enterprise Institute, and the co-author of Brainwashed: The Seductive Appeal of Mindless Neuroscience. She works part-time at a methadone clinic in Washington, D.C.

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