Bryan Caplan  

Aging Out of Addiction

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Ron McKinnon, RIP... Still no free lunch...
I've known about "aging out" for ages, but former addict and neuroscience journalist Maia Szalavitz eloquently boils down the evidence:
According to the American Society of Addiction Medicine, addiction is "a primary, chronic disease of brain reward, motivation, memory, and related circuitry." However, that's not what the epidemiology of the disorder suggests. By age 35, half of all people who qualified for active alcoholism or addiction diagnoses during their teens and 20s no longer do, according to a study of over 42,000 Americans in a sample designed to represent the adult population.

The average cocaine addiction lasts four years, the average marijuana addiction lasts six years, and the average alcohol addiction is resolved within 15 years. Heroin addictions tend to last as long as alcoholism, but prescription opioid problems, on average, last five years. In these large samples, which are drawn from the general population, only a quarter of people who recover have ever sought assistance in doing so (including via 12-step programs). This actually makes addictions the psychiatric disorder with the highest odds of recovery.

While some addictions clearly do take a chronic course, this data, which replicates earlier research, suggests that many do not. And this remains true even for people like me, who have used drugs in such high, frequent doses and in such a compulsive fashion that it is hard to argue that we "weren't really addicted." I don't know many non-addicts who shoot up 40 times a day, get suspended from college for dealing, and spend several months in a methadone program.

She continues:

Moreover, if addiction were truly a progressive disease, the data should show that the odds of quitting get worse over time. In fact, they remain the same on an annual basis, which means that as people get older, a higher and higher percentage wind up in recovery. If your addiction really is "doing push-ups" while you sit in AA meetings, it should get harder, not easier, to quit over time. (This is not an argument in favor of relapsing; it simply means that your odds of recovery actually get better with age!)

So why do so many people still see addiction as hopeless? One reason is a phenomenon known as "the clinician's error," which could also be known as the "journalist's error" because it is so frequently replicated in reporting on drugs. That is, journalists and rehabs tend to see the extremes: Given the expensive and often harsh nature of treatment, if you can quit on your own you probably will. And it will be hard for journalists or treatment providers to find you.

Similarly, if your only knowledge of alcohol came from working in an ER on Saturday nights, you might start thinking that prohibition is a good idea. All you would see are overdoses, DTs (delirium tremens), or car crash, rape, or assault victims. You wouldn't be aware of the patients whose alcohol use wasn't causing problems. And so, although the overwhelming majority of alcohol users drink responsibly, your "clinical" picture of what the drug does would be distorted by the source of your sample of drinkers.

Treatment providers get a similarly skewed view of addicts: The people who keep coming back aren't typical--they're simply the ones who need the most help. Basing your concept of addiction only on people who chronically relapse creates an overly pessimistic picture.

Szalavitz does not discuss the equally fascinating "contingency management" literature that documents the strong effect of incentives on substance abuse.  But both bodies of evidence point in the same Szaszian direction: despite addicts' self-serving excuses, addiction is a choice - a choice to be immature.




COMMENTS (16 to date)
LemmusLemmus writes:

The analytical problem here is that definitions of addiction currently in common use are much too inclusive. We shouldn't be surprised that people who merely drink much more than is healthy (but don't get the shakes when they don't) age out of doing that, just like they might age out of shoplifting and driving too fast. Szalavitz tries to address this concern, but when doing so switches from systematic to anecdotal mode.

My claim, lest I be misunderstood, is that you'll see less aging out when looking at real addicts. That's not to say there's no element of choice in addiction.

NZ writes:

I've started seeing substance addiction more as akin to OCD. It can be learned, but with an ease that is not evenly, or evenly randomly, distributed amongst the population.

Aging out of addiction also depends on which drug we're talking about. I'd guess there's less aging out of prescription drug addiction (excepting Adderall, et al.) than there is cocaine or meth addiction, for instance.

Prescription drugs like Vicodin and Oxycontin aren't associated with youth/rebellion (helped by the fact that many of the addicts are older) and so there isn't necessarily that time when the addict looks in the mirror, sees fine lines in his skin and gray hairs on his head and says "This is ridiculous, I'm getting too old to be hooked on Xanax."

Ivan writes:

I generally agree with linking addiction to immature behavior. Addiction is an extreme form of selfishness to a point where an individual not only disregards the interests of others close to him/her but also the interests of the future self. This behavior is strongly associated with being childish/immature.

However, I don't agree with Bryan that this is a choice. I especially find this claim dubious given Bryan's assertions (which I agree with) that biology trumps parenting.

The way to view it is that some individuals are biologically inclined not to reach full intellectual maturity until much later in life. To say that this is a choice is akin to saying a physical disability is a choice.

Given the obvious and disastrous consequences of addiction, why would any individual rationally choose to go down this path? The only answer is that they are not choosing but are biologically inclined towards this option.

Tom West writes:

addiction is a choice

Yes, but so what? The evidence seem pretty overwhelming that self-control is a limited resource.

Sending my kids to a nice private school is a choice, too. And it seems a no-brainer as long as I don't think about the opportunity cost of the money.

Perhaps the opportunity cost of using up all one's will-power to resist addiction is simply too high (if indeed you have enough will-power to quit at all).

As for the aging out of addiction - just about every biological drive becomes less imperative (and thus needs less self-control) as we grow older. It's no surprise to me that the amount of will-power requires grows less (and perhaps within more people's reach).

RPLong writes:

"LemmusLemmus"'s point about how we define addiction is an important one. If the research described in the blog post uses consumption metrics, then that would not be a reliable indicator of addiction. However, if standard psychological assessments are used, then I think they are reliable for diagnosing addiction.

Ivan's point about Caplan's selective application of behavioral genetics is very important. This crops up often when Caplan writes posts about morality and acceptable behavior.

I think we would all benefit from a Caplanian post dedicated to how he demarcates these concepts.

D writes:

Bryan, you've written about Social security disability before (SSI/SSDI).

Well get this: the program is written in such a way that drug addicts - who and when their symtoms mirror, as they often do, those of severe depression, anxiety, or schizophrenia - are considered disabled by Social Security. I know of what I speak.

This is true whether there is some underlying real disorder or not. There will always be a diagnosis of something (depression, psychosis, etc) for billing a medical offices purposes. They can't bill for an addiction diagnosis, by itself, so they always add one. The intellectual cover used is, "They're self-medicating with the drugs." To which the reply ought to be, "then why arent they gettting better?" But I digress...

The only exception is when there is a period of sobriety showed in their medical records proving that they function well when not addicted. Otherwise, we give the addict a monthly disability check, FOR THE REST OF THEIR LIVES, generally.

Now combine your post with Maia Szalavitz', and and the situation is even uglier.

Ivan writes:

Just to clarify my earlier comment further, consider the below statements:

1.Negative consequences of addiction almost always outweigh the benefits

2.Negative consequences are frequently catastrophic e.g. disease, isolation, destitution, death, etc

3.These consequences are visible and obvious for all society to see

Given these points, I fail to see how an individual with even a modicum of rationality would “choose” to become an addict. Additionally, findings in personality psychology and evidence of strong genetic influence on behavior seem to suggest that while the addict may not be fully predetermined to go down this path, his/her options are extremely biased towards it.

However we describe the behavior of addiction, it seems that “choice” is not exactly a good word choice for what is happening.

NZ writes:

@Ivan:

Most, or surprisingly many, individuals simply don't have a "modicum" of rationality, at least in the sense you mean "modicum".

(A common libertarian fallacy is believing that rationality is a basic human characteristic.)

I think people call addiction a choice mostly for conceptual reasons: if we don't call it a choice, then we can't blame the addict for his own destructive behavior. Besides, there are plenty of examples of people who we would expect to succumb to addiction who instead don't let it start, or who eventually overcome their addiction through force of will. If they were able to do this while their peers were not, it is reasonable to presume that their choices had something to do with it.

Doug writes:

@Ivan,

Everything you list can equally be said about being sedentary, i.e. not exercising. Negative consequences of being sedentary are large and catastrophic, death, disability, depression, etc. Nearly all adults are aware of how unhealthy not exercising is. And a person's tendency to exercise are highly determined by genetics and personality.

Yet nearly half of all Americans don't participate in any vigorous physical activity whatsoever. Would you say these people aren't "choosing" to remain inactive? That their sedentary lifestyle is a disease, rather than laziness?

The failure of self-control that leads the drug addict to get high too much, is not any different than the failure in self-control that leads someone to eat a bag of potato chips and watch five hours of TV. If you're going to label substance addiction as a disease, then you pretty much have to be willing to concede that nearly all self-control failures are diseases. Including sleeping through your alarm, not cleaning your house frequently enough, browsing Reddit while you're supposed to be working, etc.

The intellectual conclusions simply become too absurd. At one time, some in medicine thought that there was a special physiological differentiation between substance addiction and other typical "moral failures." But there's not, modern neuroscience has proven that the same self-control mechanism is responsible for everything. If we don't hold the addict personally responsible, then we pretty much have to concede that virtually no one can be held morally responsible for any decision.

Ivan writes:

@NZ
It’s a good point and I think one of the problems is that libertarians, even thoughtful and intelligent people such as Bryan Caplan, erroneously extrapolate this intelligence onto other people. This puts them in an uncomfortable position of having to rationalize patently irrational behavior.

@Doug
I agree with you that there is a difficult grey area in debating whether general moral failings are a choice. Having said that, there is definitely a sliding scale of morally dubious behavior. For example, the near certainty of disastrous consequences of addiction makes it a really extreme case. I don’t think negative consequences of other moral failings that you have listed are nearly as extreme.

Yes, your exercise example is valid, however many, many people live healthy lives despite being sedentary. In other examples you can even make a case of a rational trade off: choosing to live in a dirty house and using the time you would have spent cleaning on something you enjoy more. None of this is remotely the case with addiction.

My point is that becoming an addict is so patently and obviously a bad choice by any reasonable standard that it can only be made by an individual suffering from some sort of cognitive impairment. If that is the case, then can it really be classified a “choice”?

Tom West writes:

I think people call addiction a choice mostly for conceptual reasons: if we don't call it a choice, then we can't blame the addict for his own destructive behavior.

I think there's the nub of the whole thing right there. To my mind, there's not really any doubt that choice is a continuum, from choices I can make without a second thought to choices that I would never have the strength to make.

For the addiction argument, ideology determines the conclusion one needs to reach. From there, its simply a matter of marshaling enough facts to prove it. Since there are plenty of facts on both sides, given the continuous nature of reality, both sides can go home happy knowing they've proved that addiction is/isn't a choice, and the other side is simply being blind because the facts it don't suit their ends.

Ak Mike writes:

Ivan - let me take Doug's side. I think your riposte to him, that "many, many people live healthy lives despite being sedentary" is weak. The predictable and obvious consequence of sitting around and eating too much, suffered by a very large fraction of our population, is that one becomes fat, weak, diabetic, and heart-diseased. It is, in your words, "patently and obviously a bad choice." People do it for the exact same reason that they take drugs - the momentary pleasure overwhelms the long-term consequences. You have not made a case that "becoming an addict" (i.e., taking illegal drugs a lot) is different in kind from a wide spectrum of other unhealthy behaviors that provide short-term benefits.

charlie writes:

People aren't good with complexity or grey areas.

Overcoming an addiction clearly requires a more radical exercise of willpower than most people experience in their everyday lives. It is qualitatively more difficult than getting to the gym, eating right, or showing up to work on time. So, Caplan is wrong to call it a "choice" in the colloquial sense.

At the same time, it is self-evidently not a "disease." Researchers continue to look for a cure to cancer; the cure to alcoholism however is well known (don't drink).

It doesn't seem necessary to force addiction into a voluntary/involuntary box.

NZ writes:

@charlie:

That's a great point. I'm always irritated when drug addiction is referred to as a disease. Journalists are guilty of this quite a lot.

Earlier I said that I liken drug addiction to OCD; a disorder is more accurate, but even there I want to be cautious not to bring my concept too close to other standard medical disorders.

Ivan writes:

@AK Mike

I think it depends on how much someone is overeating. If it is egregious and to a point of becoming morbidly obese then that would be qualified as addiction in my mind.

My point is that when someone essentially inflicts great and predictable harm on themselves, this cannot possibly be classified as a choice in the same way you were to choose between say a Honda Civic and a Toyota Corolla.

It may not necessarily be classified as a disease but to me, it's obvious that something is not right with the mental faculties of the addicted individual.

Hazel Meade writes:

Including sleeping through your alarm, not cleaning your house frequently enough, browsing Reddit while you're supposed to be working, etc.

*gulp* (Looks around) (Checks to see if anyone else is looking shifty eyed)


I suspect LemmusLemmus has it right. That there are a small number of drugs (i.e. heroin, tobacco) where addiction is more than just an immature choice. But popular definitions of addiction throw in all sorts of things that are really just metaphorical addictions.

Actually I think anyone who has never had an addiction try smoking for a while just to see how it feels. Quit before you really get addicted, but smoke enough so you can feel what it feels like.

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