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Tuesday, May 6, 2014

Drug Addicts As Rational Actors

Rethinking the science of addiction

How do you justify taking away someone’s agency? The easiest way is to claim they didn’t have it in the first place.

For a long time, both popular media and information sources on the subject have depicted drug addicts as zombies incapable of making rational choices. describes drug addiction as causing “changes in your brain,” which “interfere with your ability to think clearly, exercise good judgment, [and] control your behavior.”

Drug use and addiction are a lot more complicated than what we get in most policy debates. These debates are more often driven by political incentives and personal biases than actual evidence. We’ll return to this evidence in a moment. Right now, let’s unpack this “national conversation” a little more.

According to the National Institute on Drug Abuse, “Although the initial decision to take drugs is voluntary for most people, the brain changes that occur over time challenge an addicted person’s self-control and hamper his or her ability to resist intense impulses to take drugs.”

This view is fairly representative. The focus of this accepted wisdom is often about how the brains of addicts are different from those of non-addicts, which gives rise to the idea that if you alter the addict’s brain with substances, you alter his or her behavior.

  • The National Institute on Drug Abuse claims “drugs change the brain in ways that foster compulsive drug abuse.” Its website describes addiction as “a chronic, often relapsing brain disease that causes compulsive drug seeking and use.”

  • This view is shared by the Drug Enforcement Administration. According to its Drugs of Abuse 2011 resource guide, “Addiction is defined as compulsive drug-seeking behavior where acquiring and using a drug becomes the most important activity in the user’s life. This definition implies a loss of control regarding drug use, and the addict will continue to use a drug despite serious medical and/or social consequences.”

And all these statements seem uncontroversial until you get to the fundamental question: Do drug addicts lose their agency—that is, their ability to make rational choices?

The prevailing view is that addicts simply lack free will.

But as ubiquitous as the view might be, it’s actually a pretty recent development in thinking about addiction. “Historically speaking, the idea of addiction as a brain disease is a very new one,” according to the University of Utah’s Health Sciences department. “People once saw addiction as a personality flaw and a sign of weakness. This stigma persists in society today and is a major challenge for addicts and the people who treat them.” Is it a challenge? Could there be some wisdom in the idea that one is able to find the strength to make better decisions?

In many ways, viewing addicts as victims who need help has improved outcomes and led to better addiction treatment options. However, the view that addicts lack free will no doubt contributes to wrongheaded ideas on the right and left. For those on the right, it is morally permissible to lock up drug offenders; on the left, it’s fashionable to think of addiction as a blanket public health problem requiring more State resources for more clinics and more social workers.

But what if addiction didn’t mean addicts have no choice? Maybe it really means something closer to this: The addict chooses to use drugs when others wouldn’t. In other words, that decision-making process varies from user to user and from addict to addict in nuanced ways. But it’s still a decision-making process.

For years, Dr. Carl Hart has been bringing drug addicts into the lab and giving them choices. Would you rather have some crack now or $20 later? It’s like a grimier version of the marshmallow tests for kids. And he’s been continually surprised at how rational those choices are. Addicts will often give up more doses of crack for $5 in cash or a voucher. Every meth and crack addict took $20 when offered.

Besides the implications this finding has for how to treat addiction, it also raises questions about the ethical implications and underpinnings of incarcerating addicts and casual users alike.

No doubt the view of addiction as reducing rational actors to agency-less drug-craving automata opens up several ways to evade the questions surrounding whether or not it’s ethical to lock someone for ingesting a certain substance. Put another way, the evasion comes precisely in pegging social costs like crime to that purported lack of agency. So, in some quarters, the rationale goes: They have to be locked up because they’ll just do anything to get their drugs.

On the other hand, a similar premise can justify requesting expanded budgets to finance less punitive public health measures. And neither of these justifications is always and in every case wrong. Certainly, some addicts make poor life choices, engage in criminal activity, and impose social costs due in great part to their addictions. But Hart’s work demonstrates that conventional wisdom and popular media tropes get the zombie premise wrong: People are still agents.

In addition, the no-agency view has helped policymakers sidestep the issues of how genetic, environmental, and societal factors can all influence addictive and drug-seeking behaviors. Remember the infamous studies showing drug-addicted rats pushing the button for drugs until they literally starved themselves to death? Dr. Hart’s research is exposing the full picture of that study, too, along with some startling implications for humans if said rats are suitable analogs.

“The rats that keep pressing the lever for cocaine are the ones who are stressed out because they’ve been raised in solitary conditions and have no other options,” Dr. Hart said. “But when you enrich their environment, and give them access to sweets and let them play with other rats, they stop pressing the lever.”

“The key factor is the environment, whether you’re talking about humans or rats,” he said.

If drug-addicted humans and rats have more agency than we realized, are cages and clinical complexes the most ethical response? Treating people as agents again could change the way we think about controlling the social costs of addiction. 


Find a Portuguese translation of this article here.

  • Cathy Reisenwitz is a D.C.-based writer. She is Editor-in-Chief of Sex and the State and her writing has appeared in The Week, Forbes, the Chicago Tribune, The Daily Beast, VICE Motherboard, Reason magazine, Talking Points Memo and other publications.