In a
recent Time essay, David
Sheff says
Philip Seymour Hoffman was not responsible for the decisions that
led to his death because he suffered from “a brain disease that’s
often progressive”—i.e., drug addiction:
It wasn’t Hoffman’s fault that he relapsed. It was the fault of
a disease that often includes relapse as a symptom and the fault of
the ineffective treatment he received.
You might surmise that there is a connection between viewing
addiction as a brain disease and coming up with an effective
treatment for it. But you would be wrong. The dominant model for
addiction treatment in the United States is the 12-step approach
promoted by Alcoholic Anonymous, which describes
addiction as a disease yet advocates what amounts to a spiritual
cure—one that does not
seem to work better than any other approach, possibly including
no treatment at all.
Sheff, author of Clean: Overcoming Addiction and Ending
America’s Greatest Tragedy, suggests some alternatives.
“Traditionally,” he writes, “the only choices offered to addicts
were 12-step programs, but proven treatments now include cognitive
behavioral therapy, motivational interviewing and
psychopharmacology.” The effectiveness of cognitive behavioral
therapy and motivational interviewing hardly depends on viewing
addiction as a brain disease rather than a hard-to-break habit.
“Psychopharmacology” sounds more like a medical treatment,
but here is what Sheff has in mind:
We don’t know if Hoffman was, upon discharge from treatment,
prescribed medications like Suboxone, which prevents opiate
relapse, but it’s unlikely, because most treatment programs eschew
them. If he had been (and if he took them as prescribed), it’s
almost certain that he’d be alive today. Another medication that
may have saved his life is naloxone, a drug that reverses an
overdose. All opiate addicts, as well as police and other first
responders, should have access to this drug.
Suboxone contains buprenorphine, an opioid used, like methadone,
in “maintenance treatment,” which substitutes one narcotic for
another. (Although Sheff speculates that lack of proper medication
may explain Hoffman’s overdose, the New York Daily
News reports
that buprenorphine was found in the apartment where he died.) There
may well be advantages to
substituting an orally ingested pharmaceutical-quality opioid for a
snorted or injected black-market opiate. But that does not mean
addiction is a brain disease, or that a heroin addict must accept
that view to benefit from the substitution. It is even less
plausible to suggest that naloxone will work to reverse a heroin
overdose only if you adopt Sheff’s view of addiction, although he
is certainly right that naloxone should be more widely
available.
Might there be disadvantages to viewing addiction as a brain
disease? Stanton Peele, a psychologist who has been writing about
addiction for nearly four decades,
suggests that the “learned helplessness” inculcated by the
disease model makes tragic outcomes like Hoffman’s death more
rather than less likely. An addict who believes complete abstinence
from heroin is the only acceptable option because he is
physiologically incapable of exercising control over his drug
consumption may be ill-prepared for a relapse. Having adopted an
all-or-nothing view, he may be disinclined to take precautions such
as moderating his intake, asking friends to look in on him, having
naloxone on hand in case of an overdose, and avoiding other
depressants (which are
involved in the vast majority of so-called heroin overdoses).
In other words, the lack of responsibility that Sheff urges can
have deadly consequences.
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