choiceWhen the conversation turns to addiction, “Why don’t they just quit?” is often the first question asked. New research is indicating that addicts and alcoholics may be able to do just that: choose their way out of their addictive behaviors, with the right set of incentives and consequences.

The understanding of addiction and best treatment practices has come along way in the last 80 years. In the ’30s and ’40s alcoholics and drug misusers were thought of as moral derelicts. Treatment consisted of long visits to the sanitarium where little help was offered other than an atmosphere of abstinence.

It was in that culture that Bill W. pioneered the concept of a drunk helping a drunk and created Alcoholics Anonymous. The mental health professionals of the day thought it best left there and had little interest in solutions or providing treatment.

Fast forward to the ’90s when the ability to look inside the brain via MRI was developed, revealing just how the mind functioned. The belief emerged that addiction was a dopamine (or other feel-good neurotransmitter) problem. Somehow in addictions, the desire for pleasure hijacked the will, and addicts lost the ability to choose.

Mental health professionals became interested and scrambled for treatment solutions that would restore willpower and choice. Interestingly, self-help groups (Alcoholics Anonymous, Narcotics Anonymous, Sexaholics Anonymous and their hybrid cousins) have remained a mainstay for many in the recovery process and are an integral part of many “best practices” treatment regimens.

Recently,Carl Hart, a neuroscientist at Columbia University, conducted research that furthers understanding of addiction and presents a new refinement in the body of knowledge. Hart outlines his findings in a new book, “High Price: A Neuroscientist’s Journey of Self-Discovery That Challenges Everything You know About Drugs and Society.”

Hart doesn’t disagree that neural changes occur in the brains of addicts, that decision-making is compromised, but he maintains that addicts do not lose their ability respond to rewards. On the surface that may not sound like a very important point, but it should be a game changer for treatment professionals and those designing recovery curriculum.

Hart begins by referencing a Texan charged with public intoxication. His defense hinged on the fact that he was a chronic alcoholic and that drinking was really not a matter of choice, therefore the intoxicant should not be held accountable. The defense, however, fell apart when the prosecutor realized that the defendant had taken a single drink the morning of the trial to ward off the “shakes,” but chose not to drink further that day because he needed to be in court and sober.

The research project involved active cocaine and meth addicts with no interest in sobriety. They were sequestered in a hospital setting for two weeks. In the mornings the subjects were offered their drug of choice. In the afternoon they were offered a dose of their drug of choice or a $5 voucher or cash. The rewards would be dispensed upon discharge. The majority of the time, the addicts choose the reward over the dose. However, if the subject was offered a higher dose of drug, the drug was chosen.

When Hart raised the stakes to $20 or a dose, the addicts chose the money every time.

Hart’s arguments are supported by the success of drug courts, which are built on the concept of taking advantage of the addict’s ability to choose between using their drug of choice and receiving sanctions and rewards. Defendants must accept responsibility for their crimes, agree to attend treatment and drug testing, and meet weekly with the judge to monitor progress. As participants are successful in choosing not to use, they avoid jail time. Those who choose to use find themselves incarcerated. Drug courts, relying on the power of offenders to chose abstinence over using, have established a track record of successfully keeping people out of jail and providing an avenue for addiction recovery.

Severe addiction may narrow people’s focus and reduce their ability to take pleasure in non- drug experiences, but it does not turn them into people who cannot react to a variety of incentives.

–Carl Hart, a neuroscientist at Columbia University

Both sticks and carrots can help addicts find the ability to make better choices. Addicted physicians are a good example: When facing the loss of their license and the ability to practice, they have surprising recovery rates. Their recovery path is not easy; in addition to required addiction treatment, they must submit to random drug tests, unannounced workplace visits and employer evaluations. After five years, three out of four have been able to maintain their license to practice. In the world of addiction treatment, 75 percent recovery rates are stellar.

Hart puts it this way: “Severe addiction may narrow people’s focus and reduce their ability to take pleasure in non-drug experiences, but it does not turn them into people who cannot react to a variety of incentives.”

The addict’s compromised ability of choice takes the form of compulsion. By definition, compulsion occurs when the urge to use is greater than the will to say no. It follows that recovery is the reversing of that equation so that the will is greater than the urge to act out. What Hart is advocating is the use of incentives and deterrents to make that change in the equation.

The addict’s quest for recovery centers on finding those things that lower the urge to use (incentives, treatment, etc.) and raise the will to say no (accountability, consequences, etc.). article published 12/31/2013