Margaret Wente

Globe and Mail, Tuesday May 17, 2011

I’ve known a lot of addicts in my life – some of them all too well. Some were hooked on booze, some on cigarettes, a few on pot and one or two on harder stuff. Sometimes, their destructive behaviour wrecked marriages and careers, and occasionally it killed them. Some have died of lung cancer and cirrhosis of the liver, one of an overdose, and one from falling down the stairs dead drunk.

But most of these people eventually recovered – usually when they became totally disgusted with themselves, or when they realized that the alternative (losing their spouse, going broke, social ostracism or winding up dead) was even worse. Tough love often helped.

And so I’ve always doubted that addiction is best described as a “disease.” A disease is a condition that’s beyond your power to control. There’s a fundamental difference between kicking your nicotine habit (which millions of us have managed to do, at the urging of the state ) and kicking your lung cancer.

The disease metaphor has been crucial – and very welcome – in the struggle to destigmatize mental illness. Now it also dominates enlightened public discussion of addiction. Redefining addiction as a disease and not a vice has powerful effects. It encourages compassion toward the sufferers (and that’s a good thing). It also suggests that punishing, or even criticizing, them for their dependency is cruel and unjust.

The medicalization of addiction is fundamental to the case for Insite, the supervised-injection site in Vancouver that may become a precedent for other sites elsewhere. Insite’s advocates argue that by reducing overdoses, it saves lives and minimizes the impacts of the disease – just as cancer drugs do – and should therefore be provided as a medically necessary service under the Canada Health Act.

Advocates for the disease model of addiction say their arguments are evidence-based, and that their opponents are driven by ideology. But the closer you look, the shakier is the evidence for the disease model of addiction. The most cogent critique comes from Gene Heyman, a research psychologist and lecturer at Harvard Medical School. His book Addiction: A Disorder of Choice makes a convincing case that choice plays a much more important role in addiction than in other psychiatric disorders. And it demolishes the current “enlightened” picture of addiction as a chronic, relapsing illness with a bleak prognosis for recovery.

In fact, a mountain of research shows just the opposite. Most people – even hard-core addicts – successfully quit by themselves. In one study of U.S. soldiers who became addicted to heroin in Vietnam, no more than 12 per cent stayed hooked after they got home. Doctors and airline pilots who get addicted to drugs (and there are lots) have recovery rates of 85 per cent or more. Even in the roughest neighbourhoods, most people with a drug habit manage to kick it by the time they’re 30. “Whether addicts keep using drugs or quit depends to a great extent on their alternatives,” Mr. Heyman writes.

The trouble is that experts have based their views on an unrepresentative sample of addicts – that is, the kind of people you tend to find at Insite. These are the hardest of the hard cases. Most have additional psychiatric disorders, and few have meaningful alternatives. They are poor candidates for treatment (which doesn’t mean we shouldn’t try). But does that make their addiction a disease? No. Drug addiction is a set of self-destructive impulses that are out of control – just like all the other impulses that lead us to choose short-term pleasure at the price of long-term pain. Drug addiction isn’t measles, and Insite is not a hospital, and we should stop pretending that it is.