In an interview on Drugs

Which leads us to Addiction: A Disorder of Choice by Gene Heyman. 

This is an attack on the ‘brain disease’ model of drug use. I mean, yes, if a disease is something abnormal, involuntary, and unwanted, then a bad habit is a disease and drug abuse is a bad habit. And the disorder obviously lodges in the brain and not in the elbow, so in that sense I don’t have a problem with saying that it is a brain disease. But imagining that brain imaging will tell us all about it is wrong. What Heyman is really attacking is the notion that drug consumption by people with bad drug habits is involuntary in the same way as the tic of Tourette’s or the tremor of Parkinson’s. 

Whose theory is that? 

The brain disease idea is actually the theory of Alan Leshner, who was director of the National Institute on Drug Abuse, and it is now pretty much dogma. Nora Volkow is the current director and has the same view. The theory is also that it is a particularly chronic and relapsing disorder, and Heyman produces the data to show that that is false. Drug abuse is one of the least chronic of the psychiatric disorders. The group of people today who meet diagnostic criteria for substance abuse or dependence is about eight per cent of the adult population. Three years from now two-thirds of those will not meet diagnostic criteria. The most typical course of drug abuse is a single incident that can last months or years and it resolves when that person decides to stop or someone else tells them they have to stop. Mostly they do recover, and not necessarily to abstinence. For alcohol it is often a return to normal drinking. 

The idea of a chronic relapsing disorder comes from drug treatment programmes – if you are running a programme then the people who come to it are those with a chronic relapsing disorder, those people who didn’t recover on their own. Even then, the ones who recover after a single treatment episode don’t come back, so the clinic population winds up being dominated by people who keep trying and failing to get a grip on their drug-taking. So if you look at any drug-treatment programme you are going to see the people with the chronic relapsing disorders, but they are a minority of a minority. Most people who use drugs don’t get in trouble and most people who do get in trouble using drugs don’t have a chronic relapsing disorder. 

Is there a class element to this? 

There’s a class elements in several ways. People with more to go back to are more likely to recover. So physicians who get caught dipping into the medicine cabinet and are told that if they keep using they’ll lose their licence have about a 75 per cent chance of being OK. They’ve got a lot to lose and also they got through medical school internship so they have some self-command. But there’s class all the way through it. Drug abuse is one good way to move down the SES spectrum. 

The what?

Socio-economic status. Sorry, American academic jargon. We’re American so we can’t have class – it’s SES. If you look at the skid-row population, a lot of them weren’t poor growing up but they wound up on skid row through their drug abuse. Also, poor users are more likely to commit crimes they’ll get caught for to support their habits. And poor people have less privacy and live more of their lives in public spaces, meaning that their drug problem is more likely to become somebody else’s problem. There is also the opposite end – people who don’t have work to go to or anything to lose because they are too rich.