The murder of Rob Reiner and his wife by their son late last year raised an agonizing question: How is it that loving parents with all the resources in the world cannot save a child (or themselves) from the ravages of addiction? And, if they cannot, how can anyone else?
Understanding what addiction is, and what it is not, is the first step. In her new book, What Would You Do Alone in a Cage with Nothing but Cocaine?, Hanna Pickard lays out what she calls a “philosophy of addiction.” A professor of philosophy and bioethics at Johns Hopkins, Picard shows extraordinary precision in presenting the case against the “brain disease” model of addiction that has become prevalent among medical professionals, social work specialists, and the public in recent years.
Her title is a reference to the famous 1985 study of rats housed in a cage with food, water, and cocaine. Within a month, 90 percent of the subjects had died of exhaustion, dehydration, or starvation because they just kept pressing the lever to access more cocaine. The results of the experiment helped cement the brain-disease model. Clearly, something “hijacked” the brain of the rats, causing them to make a choice that was obviously self-destructive.
But Pickard notes that, in 2005, researchers conducted another rat experiment, this time a “forced choice” study, in which the rats could choose either cocaine or an alternative reward—saccharine-infused water. In this case, 90 percent of the rats chose the sweetened water. Finally, in 2018, another study allowed the rats to choose between the cocaine and a minute of playtime with another rat, and almost 100 percent chose playtime. Pickard looks at these studies and asks readers to answer the question of why the rats in the first study took so much cocaine. She answers, “Presumably, because they were alone in a cage with nothing but cocaine.” The implication, and what Pickard argues in the remainder of the book, is basically this: You would, too.
Yes, it’s possible that there is something “broken” about the brains of drug addicts, but we don’t really have the brain scans or other medical evidence to prove it. Meanwhile, there are also very good, even rational, explanations for why people use drugs. Pickard begins by stipulating that there is “nothing intrinsically morally wrong with using drugs.” Whether drinking alcohol, smoking cigarettes, or taking prescription medication, “most of us use drugs.” Which drugs are considered good or bad depends on the cultural and legal context. Similarly, there are some situations in which drugs are morally wrong—using them when they impair driving or when they “compromise your ability to care for your children.”
The question of addiction is not whether a person’s drug use is good or bad in the abstract, but whether the costs to the individual and those around him outweigh the positives. At least part of the answer depends on the conception of what is good in the eyes of the user himself. The thing is, as Pickard details, there are clear benefits. And they are not only the obvious ones, such as the immediate pleasure a user experiences from the effects of drugs or alcohol. Pickard argues that relief from pain—physical but especially psychological—is also a rational motivation for drug use. She asks readers who don’t come from adverse backgrounds or who don’t suffer from mental illness to “imagine what it would be like if you did.” She writes: “Imagine you see no realistic hope that anything in your life will change, that anyone will help, that you will get any treatment. But drugs you can get. And they will take away the misery and the suffering—they will give you some comfort, some ease, perhaps even a moment, however brief, of joy.” This, Pickard reiterates, “is the human analog of being alone in a cage with nothing but cocaine.”
Pickard is clear-eyed enough to understand that such people might be driven by what Freud called the “death instinct.” The desire to harm oneself, even the desire to kill oneself, might be at work. But she also describes how being an addict can hold a different type of appeal for some. Hard as it is to imagine, addiction can provide both structure and meaning to someone’s life. “Drugs define what addicts think about, plan to do, and actually do with their day,” she writes. “Indeed, the loss of this structure and purpose can be part of what is so difficult about quitting.” Though she is not a clinician, Pickard draws extensively from an array of addiction memoirs as well as from interviews with addicts that she and others have conducted. “It’s hard, you know,” one says. “You’ve just got to replace it and get in another routine sort of thing.… It’s a way of life since I was…you know, before I was a teenager so if you’re doing something all your life and then suddenly you got to change everything about it, it’s really hard.”
But it is not just that addiction gives life a schedule—wake up, think about how to procure drugs, use drugs, etc.—it also gives some addicts a sense of identity, according to Pickard. This involves, most obviously, their social circle. If your life is defined by addiction, you will probably be spending time with other addicts. But Pickard suggests there is something deeper. As one patient explains cocaine to Canadian physician and author Gabor Maté, “I don’t know who to be without it. I don’t know how to live everyday [sic] without it. You take it away, I don’t know what I’m going to do.… If you were to change me and put in a regular-style life, I wouldn’t know how to retain it. I was there once in my life, but it feels like I don’t know how to go back.… I don’t have the…It’s not the will I don’t have; I just don’t know how.”
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Pickard argues that there are many explanations for why someone would want to use drugs, which is why she believes we need more heterogeneity in our discussions of the “philosophy of addiction.” But ultimately she comes back to her central thesis: The idea that it is a disease or that drugs have “hijacked the brain” or that they are simply “impossible to resist” for some people is neither true nor helpful. So what is? If addiction is a choice, then can we use a moral framework to discuss drug use and addiction? For Pickard, the answer is no. The language of sin or immorality is not an option, both because she doesn’t believe it (given the long human history of substance use), but also because it won’t help addicts.
If addiction, in her words, is the point at which the costs of drug use to an individual outweigh the benefits, then one often has to persuade the individual addict of that. It is true that some addicts are “in denial” about the costs to themselves and others. And others are mentally impaired or ill in a way that prevents them from seeing the truth about their addiction. But Pickard tries to help friends and families think about how to approach the individual. Instead of “blame” she offers “accountability” or “responsibility.”
The difference may seem semantic, but Pickard offers some important distinctions, ones that in her view can influence the likelihood of success: “The bottom line is that we have reason to treat people with addiction we care about and who experience a loss of control—defined simply as acting against their better judgment or sincere intention to abstain—as capable of exercising behavioral control and as wanting to do so.”
Pickard’s is a sensible book. Which is why it is disappointing to find that she offers some offhanded lines about public policy at the end, platitudes that contradict the fact-based and worldly quality of the rest of the volume. For example, she recommends “socioeconomic initiatives that guarantee housing, education, and employment for all; and—although the issues here are highly complex—the decriminalization of drug possession, which crucially, must proceed hand in hand with robust state regulation of drug markets and enforcement of crimes that are or can be drug associated, for example, driving under the influence or public disorder.”
If addiction is something that people have control over and that is informed by rational choices, then why would guaranteed employment and housing for drug users be a solution to their specific problems? Wouldn’t it be more helpful to place some conditions on these bounties rather than hand them out freely to people who are not trying to change? How is her proposal of decriminalization different from what is being tried all over the country? Are we not enforcing laws against public disorder enough? Why does disorder seem to go hand in hand with decriminalization? And if we spend enough resources enforcing such laws, won’t many offenders (particularly the so-called marginalized who can’t use drugs in their suburban mansions) be caught up in the criminal-justice system anyway? The questions raised by the solutions Pickard offers could fill an entire second book.
Photo: Spencer Platt/Getty Images
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