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Alternative Models of Addiction

DOI:10.3389/fpsyt.2015.00020
Authors:
Hanna Pickard at Johns Hopkins University
Hanna Pickard
Serge H Ahmed at French National Centre for Scientific Research
Serge H Ahmed
Bennett Foddy at New York University
Bennett Foddy
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PSYCHIATRY
EDITORIAL
published: 13 February 2015
doi: 10.3389/fpsyt.2015.00020
Alternative models of addiction
Hanna Pickard1*, Serge H. Ahmed 2and Bennett Foddy 3
1University of Birmingham, Birmingham, UK
2University of Bordeaux: IMN CNRS UMR 5293, Bordeaux, France
3NewYork University, NewYork, NY, USA
*Correspondence: h.pickard@gmail.com
Edited and reviewed by:
Giovanni Addolorato, Catholic University of Rome, Italy
Keywords: drugs, addiction, disease, choice, compulsion, self-control, substance abuse, substance dependence
For much of the twentieth century, theories of addictive behav-
ior and motivation were polarized between two models. The first
model viewed addiction as a moral failure for which addicts
are rightly held responsible and judged accordingly. The second
model, in contrast, viewed addiction as a specific brain disease
caused by neurobiological adaptations occurring in response to
chronic drug or alcohol use, and over which addicts have no
choice or control. As our capacity to observe neurobiological phe-
nomena improved, the second model became scientific orthodoxy,
increasingly dominating addiction research and informing public
understandings of addiction. The articles in this research topic aim
to move beyond the polarization between the competing moral
and disease models of addiction.
In the opening article of this e-book “Addiction and Choice:
Theory and New Data,” Heyman (1) examines new data on the
ways that addicts recover, and argues that recovery from addic-
tion is better predicted by a model in which addicts choose to use
drugs, rather than one in which they are compelled to do so by
a disease. This theme is echoed in other papers in this collection.
Satel and Lilienfeld (2) in “Addiction and the Brain-Disease Fal-
lacy” directly challenge the disease model, drawing on historical
and clinical data to argue that addicts respond to incentives and
use drugs for reasons, and so addictive behavior must be under-
stood as a choice. In “Intertemporal Bargaining in Addiction,”
Ainslie (3) reprises his large body of work on the inherent weak-
nesses of the human capacity for choice, exploring its relevance
to questions of the nature of responsibility and our justifica-
tion in holding addicts accountable for addictive behavior and its
consequences.
Other authors in this volume seek to understand the ways
in which these choices can be pathologically impaired by addic-
tion. For example, Dill and Holton’s (4) article “The Addict In Us
All” contrasts ordinary choices with what they call the “incentive
salience”choices, which are typical in addictive consumption, and
involve extreme cravings for drugs and strong motivation to con-
sume, even when consumption is neither experienced nor judged
as desirable. Henden et al. (5) in “Addiction: Choice or Compul-
sion?” chart a course between the moral and disease model by
arguing that addictive behavior can be labeled both voluntary and
compulsive, if this is understood as involving repeated decisions,
which can lead to maladaptive and self-destructive behavioral
outcomes.
The importance of negative outcomes to understanding addic-
tion is emphasized by both Levy (6) and Wakefield and Schmitz (7).
In “Addiction is Not a Brain Disease (And it Matters),” Levy argues
that while addiction does produce neurological dysfunction, this
is not enough to make it a disease. In Levy’s eyes, disease neces-
sarily involves impairment, and impairment must be understood
relative to the social and practical context in which addicts live. In
contrast, Wakefield and Shmitz’s article “How Many People Have
Alcohol Use Disorders?”points out that by focusing too heavily on
the negative health correlates of chronic alcohol use, DSM-IV and
DSM-V diagnostic criteria risk diagnosing non-addicts suffering
the ill-effects of long-term use with an addictive “disease.”
The social and practical context of addiction is also emphasized
by other authors. It has long been known that cocaine-addicted
rats will forego cocaine if offered alternative goods, such as sugar
or saccharin. Zernig et al.’s (8) article “Dyadic Social Interaction
as an Alternative Reward to Cocaine” presents data demonstrat-
ing that, in certain experimental conditions, rats will also forego
cocaine for the opportunity of same-sex snuggling. Overall, these
findings further show that drug choices are not determined by the
ability of a drug to directly activate and/or sensitize the reinforcing
and incentive salience neuronal pathways in the brain. This con-
clusion is consistent with the general evolutionary view of drug
use advanced by Hagen et al. (9). Their article notes that the most
currently widely used drugs, like cannabis, cocaine, and nicotine,
are originally plant chemical defenses that evolved to deter con-
sumption. To adapt, animals are likely to have evolved internal
protective mechanisms allowing them to use drugs in a controlled
manner.
In “The Shame of Addiction,” Flanagan (10) argues that the
first-personal experience of shame – typically a social and moral
emotion – is central to understanding human addiction and the
motivation addicts have to heal, but that shame can be distin-
guished from blame, allowing addiction to be conceived as an
aspect of personal agency without returning to the moral model.
In the final article of this e-book, Heyman et al. (11) present data
suggesting that years spent in school is a key predictor of illicit
drug use, after controlling for IQ and impulsivity, suggesting not
only a potential social cause of addiction but also, equally, a social
solution.
The e-book also contains articles exploring the classification of
addiction and its potential status as a natural kind, the role and
extent of pleasure in explanations of addiction, and various more
unusual forms of addiction, such as workaholism, which we nat-
urally characterize as involving a need for control, as opposed to
involving a loss of control.
www.frontiersin.org February 2015 | Volume 6 | Article 20 | 1
Pickard et al. Alternative models of addiction
Considered as a whole, the articles in this volume demonstrate
that we can conceptualize addiction as choice,while avoiding both
the scylla of moralization and the charybda of brain disease. By
doing so, they emphasize the need to give equal attention and
weight to the historical, contextual, and biological factors that are
significant in addiction, to move forward in understanding and
responding to the problem. Addiction as choice may thus offer a
unifying and integrative framework for future research in the field.
REFERENCES
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2. Satel S, Lilienfeld SO. Addiction and the brain-disease fallacy. Front Psychiatry
(2014) 4:141. doi:10.3389/fpsyt.2013.00141
3. Ainslie G. Intertemporal bargaining in addiction. Front Psychiatry (2013) 4:63.
doi:10.3389/fpsyt.2013.00063
4. Dill B, Holton R. The addict in us all. Front Psychiatry (2014) 5:139. doi:10.
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5. Henden E, Melberg HO, Rogeberg O. Addiction: choice or compulsion? Front
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6. Levy N. Addiction is not a brain disease (and it matters). Front Psychiatry (2013)
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7. Wakefield JC, Schmitz MF. How many people have alcohol use disorders? Using
the harmful dysfunction analysis to reconcile prevalence estimates in two com-
munity surveys. Front Psychiatry (2014) 5:10. doi:10.3389/fpsyt.2014.00010
8. Zernig G, Kummer KK, Prast JM. Dyadic social interaction as an alternative
reward to cocaine. Front Psychiatry (2013) 4:100. doi:10.3389/fpsyt.2013.00100
9. Hagen EH, Roulette CH, Sullivan RJ.Explaining human recreational use of ‘pes-
ticides’: the neurotoxin regulation model of substance use vs. the hijack model
and implications for age and sex differences in drug consumption. Front Psychi-
atry (2013) 4:142. doi:10.3389/fpsyt.2013.00142
10. Flanagan O. The shame of addiction. Front Psychiatry (2013) 4:120. doi:10.3389/
fpsyt.2013.00120
11. Heyman G, Dunn BJ, Mignone J. Disentangling the correlates of drug use in a
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Conflict of Interest Statement: The authors declare that the researchwas conducted
in the absence of any commercial or financial relationships that could be construed
as a potential conflict of interest.
Received: 09 January 2015; accepted: 31 January 2015; published online: 13 February
2015.
Citation: Pickard H, Ahmed SH and Foddy B (2015) Alternative models of addiction.
Front. Psychiatry 6:20. doi: 10.3389/fpsyt.2015.00020
This article was submitted to Addictive Disorders and Behavioral Dyscontrol, a section
of the journal Frontiers in Psychiatry.
Copyright © 2015 Pickard, Ahmed and Foddy. This is an open-access article distr ibuted
under the terms of the Creative Commons Attribution License (CC BY). The use, dis-
tribution or reproduction in other forums is permitted, provided the original author(s)
or licensor are credited and that the original publication in this journal is cited, in
accordance with accepted academic practice. No use, distribution or reproduction is
permitted which does not comply with these terms.
Frontiers in Psychiatry | Addictive Disorders and Behavioral Dyscontrol February 2015 | Volume 6 | Article 20 | 2
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The Shame of Addiction
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  • Oct 2013
Addiction is a person-level phenomenon that involves twin normative failures. A failure of normal rational effective agency or self-control with respect to the substance; and shame at both this failure, and the failure to live up to the standards for a good life that the addict himself acknowledges and aspires to. Feeling shame for addiction is not a mistake. It is part of the shape of addiction, part of the normal phenomenology of addiction, and often a source of motivation for the addict to heal. Like other recent attempts in the addiction literature to return normative concepts such as "choice" and "responsibility" to their rightful place in understanding and treating addiction, the twin normative failure model is fully compatible with investigation of genetic and neuroscientific causes of addiction. Furthermore, the model does not re-moralize addiction. There can be shame without blame.
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Dyadic Social Interaction as an Alternative Reward to Cocaine
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  • Sep 2013
Individuals suffering from substance use disorders often show severely impaired social interaction, preferring drugs of abuse to the contact with others. Their impaired social interaction is doubly harmful for them as (1) therapy itself is based and dependent on social interaction and as (2) social interaction is not available to them as an "alternative", i.e., non-drug reward, decreasing their motivation to stop drug use. We therefore developed an animal experimental model to investigate the neurobiology of dyadic social interaction- vs. cocaine reward. We took care to avoid: (a) engaging sexual attraction-related aspects of such a social interaction and (b) hierarchical difference as confounding stimuli. The cocaine- or social interaction stimulus was offered - in a mutually exclusive setting - within the confines of a conditioned place preference (CPP) apparatus. In our paradigm, only four 15-min episodes of social interaction proved sufficient to (i) switch the rats' preference from cocaine-associated contextual stimuli to social interaction CPP and (ii) inhibit the subsequent reacquisition/reexpression of cocaine CPP. This behavioral effect was paralleled by a reversal of brain activation (i.e., EGR1 expression) in the nucleus accumbens, the central and basolateral amygdala, and the ventral tegmental area. Of relevance for the psychotherapy of addictive disorders, the most rewarding sensory component of the composite stimulus "social interaction" was touch. To test our hypothesis that motivation is encoded in neuron ensembles dedicated to specific reward scenarios, we are currently (1) mapping the neural circuits involved in cocaine- vs. social-interaction reward and (2) adapting our paradigm for C57BL/6 mice to make use of the plethora of transgenic models available in this species.
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Addiction: Choice or Compulsion?
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  • Aug 2013
Normative thinking about addiction has traditionally been divided between, on the one hand, a medical model which sees addiction as a disease characterized by compulsive and relapsing drug use over which the addict has little or no control and, on the other, a moral model which sees addiction as a choice characterized by voluntary behavior under the control of the addict. Proponents of the former appeal to evidence showing that regular consumption of drugs causes persistent changes in the brain structures and functions known to be involved in the motivation of behavior. On this evidence, it is often concluded that becoming addicted involves a transition from voluntary, chosen drug use to non-voluntary compulsive drug use. Against this view, proponents of the moral model provide ample evidence that addictive drug use involves voluntary chosen behavior. In this article we argue that although they are right about something, both views are mistaken. We present a third model that neither rules out the view of addictive drug use as compulsive, nor that it involves voluntary chosen behavior.
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Intertemporal Bargaining in Addiction
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  • Aug 2013
The debate between disease models of addiction and moral or voluntarist models has been endless, and often echoes the equally endless debate between determinism and free will. I suggest here that part of the problem comes from how we picture the function of motivation in self-control. Quantitative experiments in both humans and non-humans have shown that delayed reward loses its effectiveness in proportion to its delay. The resulting instability of preference is best controlled by a recursive self-prediction process, intertemporal bargaining, which is the likely mechanism of both the strength and the experienced freedom of will. In this model determinism is consistent with more elements of free will than compatibilist philosophers have heretofore proposed, and personal responsibility is an inseparable, functional component of will. Judgments of social responsibility can be described as projections of personal responsibility, but normative responsibility in addiction is elusive. The cited publications that are under the author's control can be downloaded from www.picoeconomics.org.
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Addiction and Choice: Theory and New Data
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  • May 2013
Addiction's biological basis has been the focus of much research. The findings have persuaded experts and the public that drug use in addicts is compulsive. But the word "compulsive" identifies patterns of behavior, and all behavior has a biological basis, including voluntary actions. Thus, the question is not whether addiction has a biology, which it must, but whether it is sensible to say that addicts use drugs compulsively. The relevant research shows most of those who meet the American Psychiatric Association's criteria for addiction quit using illegal drugs by about age 30, that they usually quit without professional help, and that the correlates of quitting include legal concerns, economic pressures, and the desire for respect, particularly from family members. That is, the correlates of quitting are the correlates of choice not compulsion. However, addiction is, by definition, a disorder, and thereby not beneficial in the long run. This is precisely the pattern of choices predicted by quantitative choice principles, such as the matching law, melioration, and hyperbolic discounting. Although the brain disease model of addiction is perceived by many as received knowledge it is not supported by research or logic. In contrast, well established, quantitative choice principles predict both the possibility and the details of addiction.
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