Addiction: Brain disease or bad habit?

That President Trump has declared the opioid crisis a national public health emergency does not address the underlying question: Is drug addiction a mental health problem or a behavioral problem?

The Massachusetts Supreme Judicial Court will soon decide.

Less than two weeks after a court ordered Julie Eldred not to use drugs while on probation, she tested positive for the opioid fentanyl.  Consequently, Ms. Eldred, a chronic substance abuser, spent almost two weeks in jail until an inpatient treatment bed was available.

On appeal, her lawyer argues that incarceration was unconstitutional cruel and unusual punishment because drug use was beyond her client's control.  In sum, Ms. Eldred had no choice.

A decision by the court in her favor may radically alter how America confronts the demand side of its metastasizing opioid epidemic.

Although the medical community generally accepts the view that addiction is a "chronic and relapsing brain disease," a learned group of scientific, medical, and legal professionals fervently dissent.

In their amici brief, Sally Satel, a psychiatrist and scholar at the American Enterprise Institute, and Stephen J. Morse, a law and psychiatry professor at the University of Pennsylvania, persuasively argue that addiction is behavior: "the persistent seeking and using of drugs despite negative consequences."

In essence, substance abuse is akin more to bad behavior than to mental illness.

They maintain that while Alzheimer's sufferers have no control over the progression of their condition, addiction is the result of repeated negative choices.  Addicts are made, not born.

Behaviorists contend further that there is little empirical evidence to support the "brain disease" theory.

For example, a plausible argument may be made that purported symptoms of the brain disease model (uncontrollable cravings; depression; anxiety; diminished impulse control; serious physical, mental, and emotional health problems) are the result of chronic substance abuse, not its cause.

Of greater concern is the risk that the majority opinion has unintentionally exacerbated the drug scourge by shielding addicts from the consequences of negative behavior.  As the prosecution argues in Eldred, "brain disease" rewards people like Ms. Eldred with the ready-made excuse that they have no choice but to use.

But just as touching a hot stove teaches a child to avoid hot stoves, the truth is that many addicts get clean and sober of their own volition or when the cumulative consequences of negative behavior become the catalyst for change.

Many former users credit a stint in jail with jump-starting their recovery.  For others, the mere threat of jail is incentive enough to seek help.

Personal responsibility is the sine qua non of a functioning member of society.  Adoption of the brain disease theory by the court will effectively remove this cornerstone of recovery.  Ironically, Ms. Eldred may too late discover that by prevailing, she will have sentenced herself to a lifetime of supervised care, treatment facilities, and the prospect of early death.

The grant of her petition will inevitably lead to more drug deaths, more and longer prison sentences without the possibility of probation or parole, increased recidivism, fewer options like drug courts to incentivize recovery, thousands of wasted lives, millions of wasted dollars, and the prolongation of the opioid epidemic.

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