Heroin, addiction and free will

The death of Phillip Seymour Hoffman has sparked some strong and seemingly contradictory responses. What these reactions show is that many people find it hard to think of addiction as being anything except either a choice or a loss of free will.

The fact that addiction could involve an active choice to take drugs but still be utterly irresistible seems difficult for most people to fathom.

Let’s take some reactions from the media. Over at Time, David Sheff wrote that “it wasn’t Hoffman’s fault that he relapsed. It was the fault of a disease”. On the other hand, at Deadspin, Tim Grierson wrote that the drug taking was “thoughtless and irresponsible, leaving behind three children and a partner”.

So does addiction trap people within its claws or do drug users die from their own actions? It’s worth noting that this is a politicised debate. Those who favour a focus on social factors prefer prefer the ‘trap’ idea, those who prefer to emphasise individual responsibility like the ‘your own actions’ approach.

Those who want to tread the middle ground or aim to be diplomatic suggest it’s ‘half and half’ – but actually it’s both at the same time, and these are not, as most people believe, contradictory explanations.

To start, it’s worth thinking about how heroin has its effect at all. Heroin is metabolised to morphine which then binds to opioid receptors in the brain. It seems to be the effects in the nucleus accumbens and limbic system which are associated with the pleasure and reward associated with the drug.

But in terms of motivating actions, it is a remarkably non-specific drug and it doesn’t directly cause specific behaviours.

In fact, there is no drug that makes you hassle people in Soho for a score. There’s no drug that manipulates the neural pathways to make you take the last 40 quid out of your account to buy a bag of gear. No chemical exists that compels your hands to prepare a needle and shoot up.

You are not forced to inject heroin by your brain or by the drug. You do not become an H-zombie or a mindless smack-taking robot. You remain in control of your actions.

But that does not mean that it’s a simple ‘choice’ to do something different, as if it was like choosing one brand of soft drink over another, or like deciding between going to the cinema or staying at home.

Addiction has a massive effect on people’s choices but not so much by altering the control of actions but by changing the value and consequences of those actions.

If that’s not clear, try thinking of it like this. You probably have full mechanical control over your speech: you can talk when you want and you can stay silent when you want. Most people would say you have free will to speak or to not speak.

But try not speaking for a month and see what the consequences are. Strained relationship? Lost job maybe? Friends who ditch you? You are free to choose your actions but you are not free to choose your outcomes.

For heroin addicts, the situation is similar. As well as the pleasurable effects of taking it, not taking heroin has strong, negative and painful effects.

This is usually thought of as the effects of physical withdrawal but these are not the whole story. These are certainly important, but withdrawing from junk is like suffering a bad case of flu. Hardly something that would prevent most people from saving their lives from falling apart.

For many addicts, the physical withdrawal is painful, but it’s the emotional effects of not taking drugs that are worse.

Most smack addicts have a frightening pre-drug history of trauma, anxiety and mood disorders. Drugs can be a way of coping with those emotional problems in the short-term.

Unfortunately, in the longer-term, persistent drug use maintains the conditions that keep the problems going. Even for those few that don’t have a difficult past or unstable emotions, life quickly become difficult after regular heroin use sets in.

If you can stay high, you’ll be less affected by the consequences of both long-standing problems and your chaotic lifestyle. If you stop, you feel the full massive force of that emotional distress.

It’s vicious circle that is often set in motion by past trauma but requires a meeting with a drug and the right social circumstances. Just taking the drug until you develop tolerance and withdrawal is unlikely to addict most people.

For example, a Vietnam War study found that just under half of soldiers reported trying heroin, 1 in 5 developed full blown dependency while in Vietnam but only about 5-10% of the dependent soldiers continued using when they arrived home. Most said they gave up without any help and only a small minority had ongoing addiction problems.

In fact, some of you reading this may have been addicted to heroin and not known it. Heroin, under its medical name diamorphine, is commonly used as a painkiller after major surgery. It’s not uncommon that patients develop tolerance and go into withdrawal after they leave hospital but just put it down to ‘feeling poorly’ or ‘recovering’.

But for persistent addicts, the ‘short-term solution that maintains the long-term problem’ cycle is not the whole story and it’s important to remember the neurological effects of the drug and how it interacts with, and changes, the brain.

Addiction is associated with difficulties in resisting cravings and making flexible decisions. This is likely to be caused by a combination of genetics, earlier experience and the ongoing impact of the drug and the drug-focused lifestyle – all of which affect brain function.

A recently popular approach is the ‘disease model’ of addiction which says that the brains of those who become addicted are more susceptible to compulsive drug use because of genetic susceptibility and / or brain changes due to early experience that ‘prime’ the brain for addiction.

It’s probably true to say that the extreme version of the ‘disease model’ – which says addiction is entirely explained by these changes and is best characterised as a ‘brain disease’ – is an exaggeration of what we know about the neuroscience of addiction, but this is not to say that neuroscience is not important.

But either way, there is no clear relationship between an aspect of behaviour being best explained in neurobiological terms and not having any control over that behaviour. For example, most genuine addicts usually give up, on their own, without any assistance and don’t relapse. They still have brains, of course.

Unfortunately though, the ‘disease model’ approach is often used precisely because some think it implies addicts have less control, possibly because they feel (probably wrongly) that it is less ‘stigmatising’ to think of heroin users in this way.

Instead, we know that self-efficacy is one of the best predictors of recovery, so denying people’s role in their own decisions just undermines one of their most important tools for recovery – alongside medication, social support and other forms of therapy.

So to say an addict has ‘no choice’ over their actions is just to misunderstand addiction but to pretend these choices are like any others just misses the fact that they can sometimes be impossibly hard decisions.

Unfortunately though, people find it hard to separate any admission of addicts being able to choose their actions from blame and moral accusation.

Blaming someone for their addiction is like shaming someone for being wounded by an abusive partner. Whatever the circumstances that caused the problem, they deserve respect and treatment, and working with them to help them regain control of their circumstances and promote their own autonomy is an important and valuable way forward.

18 Comments

  1. Posted February 6, 2014 at 11:38 pm | Permalink

    I highly recommend Marc Lewis’s book, Memoirs of an Addicted Brain for a look at drug use from the inside by a former addict turned neuroscience professor at the University of Toronto. Basically, being a drug addict is physically, and neurologically exhausting work. Those of us whose systems are sufficiently integrated to be able to handle it … don’t become addicted. And then there’s the rest of us.

  2. Mark Ettinger
    Posted February 7, 2014 at 2:07 am | Permalink

    Well written but do these two really hold up under scrutiny?

    “You remain in control of your actions.”

    or this:

    “You probably have full mechanical control over your speech: you can talk when you want and you can stay silent when you want.”

    It seems to me that this just seems to be.

  3. Posted February 7, 2014 at 2:11 am | Permalink

    You said: “Most people would say you have free will to speak or to not speak.

    But try not speaking for a month and see what the consequences are.”

    It’s more like trying not to speak but having Tourette Syndrome (the type with Coprolalia).

  4. Bill
    Posted February 7, 2014 at 5:22 am | Permalink

    Thank you for a very thoughtful presentation of these issues, exactly the sort of writing that makes Mind Hacks so valuable.
    As a doctor who works with people who have addictions, one of the most difficult questions I hear is, “do I have an addictive personality?”. For a long time I struggled with the implied biological determinism of this question.
    My response to this question reflects a similar perspective to what you have eloquently described in the article.
    Addiction is like a love affair, you are at a time in your life when you meet someone (the drug), and you just fit, they understand you and make you a better person (enjoyment, reduced pain or improved initial function). They allow you to feel and do things you’d forgotten were possible and they make you feel safe. You’re in love and you’ll do anything to protect and maintain that. However, over time, you realize that they (the drug) are just using you or even harming you. You attempt to leave (quitting attempts) but they harm you (withdrawal) and you go back (resolution of withdrawal) even though you know they are no good for you.
    I have found this narrative (adapted to the person’s circumstance) to be well received by patients (and medical students) while also highlighting the struggle of will which it takes to free themselves from the drug. It also allows them to grieve the loss of that part of themselves in a way that is not belittling or determined by quaint pseudo-neurological explanations.
    The personification of the drug here is metaphorical but some authors have argued this point more literally (for instance in Dale Pendell’s Pharmako/poeia)

  5. Andrew
    Posted February 7, 2014 at 10:51 am | Permalink

    There’s no such thing as free will though. If you rewind the tape and leave everything exactly the same, people will always make the same decisions.

  6. Rebecca Wimer
    Posted February 7, 2014 at 12:27 pm | Permalink

    Excellent.

    • elizabeth
      Posted February 7, 2014 at 2:41 pm | Permalink

      If any substance known to be addictive yields approximately the same number of addicts, then wouldn’t that leave one wondering about “free will”. It’s like a train wreck in slo-mo, it’s part of our genetic make-up. Dealing with addiction involves some free will — but the creation of addiction does not. It’s an important distinction to make. The individual who has to find free-will to make decisions is doing so while under the influence of addiction. Another important distinction. So if a person decides to remain sober, he can do it only one day at a time, because the struggle remains constant. The addict does not use “free will” to choose addiction.

  7. Posted February 7, 2014 at 2:41 pm | Permalink

    Wow, common sense ! So rare nowadays it’s almost like a superpower . I guess you’re familiar with the works of Alexander and DeGrandpree after reading this? As somebody who has tried and taken a multitude of so called addictive substances I can say you have pretty much hit the nail on the head here as did DeGrandpree

  8. leslie glazer
    Posted February 8, 2014 at 4:16 am | Permalink

    excellent post that articulates the difficulty in approaching addiction in terms of the will by in essences pointing to how it encompasses the problems of will and action in general. Addiction is a limiting case, but captures how our choices are free and finite, conditioned by causes yet always with some degree of consent on our own part to go along with the pulls of craving, desire and emotion or to avoid the pressures of pain, the sense of emptiness and anxiety. The ideology of the disease model, while sensitizing us to the difficulties of choice once one is in the grip of addiction, also undermines responsibility and the sense of self-efficacy. The suboxone craze now underway in addiction treatment while helping reduce the underlying pressures the the recovering addict needs to struggle against can also make the difficult deconstruction of the addicts cognitive frame more challenging in their abdication of responsibility and dependence on a drug to get over dependence on a drug.

  9. rachel
    Posted February 8, 2014 at 8:16 pm | Permalink

    Nature abhors a vacuum, and drugs (among other forms of addiction) are excellent at filling that void.
    You might not notice the gaping hole at first, that vacuum inside you, it’s there but not there (by it’s very nature), but when you meet your drug, you’ll know the wonderful feeling of having it filled in.
    Gettin off drugs is basically admitting that there is that void, that nothing else will ever make you whole, or not as well as the drug does, and that you have to throw that wonderful little helper off the cliffs anyway. Because bad bad bad.
    So, to stay with the analogy of drug as a person: It’s not like mourning someone special who passed away. It’s like telling someone you love with all your heart to get the f**k out of your life and never call again. Because side effects. So you can be alone or with someone who will never measure up to what you once had.
    Free will and all. What a decision to make.

    • Leslie glazer
      Posted February 8, 2014 at 9:57 pm | Permalink

      I’m glad this discussion is continuing, but I have to qualify what I am hearing in Rachel’s comment. Yes, drugs sometimes are connected with some void inside us. In this regard our drug of choice seems to fil or fulfill us, and not having it can leave us empty. But there is also a significant way that some drugs can empty us and leave us void and in need perhaps a chicken and egg problem. Something’s create the need they hen purport to fill. The problem with drugs like opiates (and other drugs to some degree) is that the need actually is never filled but always searched for in the next fix. A hope always dashed. So let’s not romanticize stopping drug us as kicking out ones deepest love and soulmate only because if side effects. It’s more like pathological love for someone who lies, cheats, beats, and in countless ways fails you but yet who you can’t resist. Turning them out. Never mind that In Addition to the dynamic between void and fulfillment many substances– especially opiates but to some degree other anxiolytics, sedatives, and even alcohol– are connected with the dynamic between appearance and reality. While they can fill a void, they also can dissemble, numb, and cloud the realities, sometimes really painful but sometimes even the normative pains of living and developing and relating honestly with life and our social world. In this way the filled void is an illusion as best, and sometimes quite a narrow one.

    • Mary
      Posted February 14, 2014 at 10:01 pm | Permalink

      Perfectly said

    • Posted February 20, 2014 at 8:11 am | Permalink

      Great comment. That’s exactly what it’s like. In fact you don’t even know how empty that place is until you’ve been filling it for a while (with drugs….or love) and then try to stop.

  10. Posted February 9, 2014 at 4:45 am | Permalink

    Reblogged this on Axion NeuroTherapy and commented:
    NeuroRescue: This is a very thoughtful and balanced analysis of heroin addiction that incorporates Neuroscience and philosophy of choice.

  11. rmgw
    Posted February 9, 2014 at 5:46 pm | Permalink

    And see the recent “Nature” article/tantrum about “animal activists” using a social understanding of addiction to undermine the right of “scientists” to use nonhumans as models of addiction: how very dare they when we scientists KNOW it’s a disease requiring vivisection to sort out. Indeed, this is a political debate, you hit the nail right on the head there!

  12. inphact
    Posted February 24, 2014 at 2:25 pm | Permalink

    Excellent read on Addiction ! I will recommend this to anyone interested in this subject .

  13. Posted February 27, 2014 at 9:27 pm | Permalink

    Freewill or no freewill, ask “Why did he die? Too large a dose. Too much alcohol will kill you just the same. The heroin, if legal, would have had a strength of dose on the container like alcohol does. I don’t think the overdose was suicide do you?


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