Prohibitions: Mind drugs & addiction

Mind drugs

I will focus on mind drugs. David Friedman provides a useful classification:

“consider four different classes of mind drugs: pleasure, performance, personality, control. Some drugs will fit into more than one category, reflecting multiple reasons why they are used. Consider the familiar case of alcohol. Some people drink it because they like how it makes them feel – pleasure. Some drink it because they believe that it improves their performance […]. Some drink it because it provides a temporary change in their personality that they sometimes desire. And some people feed alcohol to others, sometimes without their knowledge, as a crude way of controlling them.”

Friedman explains that pleasure can be insidious:

“The more we know about how the human mind functions, the better we will become at creating drugs that give pleasure without serious negative side effects. Unless, of course, it is pleasure itself that is the problem. Arguably it might be. Evolution is an extraordinary biochemist, much better than we are at producing compounds that affect living creatures in useful ways. If we can create a chemical that gives us pleasure, and if pleasure is a good thing, why don’t we come already equipped for pleasure on demand? The obvious answer is that we are designed by evolution not for happiness but for reproductive success. [… .] If pleasure drugs are too good, they might interfere not merely with reproductive success but with physical survival. Larry Niven provides a fictional example in the form not of a drug but of direct electrical stimulation of the pleasure center of the brain. His ‘wireheads’ are capable of plugging in and starving to death, because one more minute of intense pleasure is worth more to them than food or drink. If we accept this argument, the implication is not that pleasure drugs are bad but only that they should be used in moderation. It does not follow that they always will be.”

Cocaine may serve as an illustration. Andean peasants, who chew coca leaves when they toil at altitude, don’t thereby suffer harm. The practice ‘delivers’ low doses of the stimulant gradually to the brain. This ‘natural’ delivery process ‘fits’ the evolved human biology, inherited from hunters-gatherers. By contrast, new technologies—chemical isolation of pure cocaine, hypodermic needles, and so on—produce intense pleasure by instantaneous delivery of high doses. Mismatch of biology and technology creates risk of harm.

The insidious risk, then, is addiction. Let’s consider in turn the nature & scope of addiction; exit from addiction; relations between addiction & prohibition; and efforts to debunk addiction.

The nature & scope of addiction

There are fundamental disagreements about the nature and scope of addiction. Some construe addiction as a disease ; others—for example, Gene Heyman—as a a disorder of choice. And some economists, following Gary Becker and Kevin Murphy, model addiction as a causal process of rational choice.

Faruk Gul & Wolfgang Pesendorfer propose a precise definition of addiction:

“Consumption is compulsive if it differs from what the individual would have chosen had commitment been available. A good is addictive if its consumption leads to more compulsive consumption of the same good.” (p. 1)

Jon Elster provides a clear outline of causal models of addiction:

“In the causal model, addiction is characterized in terms of habit formation and negative internalities. [… .] The first feature, habit formation, implies […] that past consumption increases the instantaneous marginal utility from current consumption. The second feature, negative internalities, implies that past consumption decreases the instantaneous total utility from current consumption. Intuitively, the first feature reflects the production of withdrawal symptoms and the second the emergence of tolerance phenomena.” (p. xi)

Helge Waal & Jorg Morland offer a profound insight into addiction as need of punctuation in everyday life :

“Often, the cigarette smoker has a ritual of using his smoking habit to punctuate his daily routines.”

A cigarette (or a drink, or a snack) to steel oneself for a difficult task; to reward oneself for completing a task; to occupy oneself while on hold on the phone; etc. etc. etc.

One may draw a conceptual distinction between addiction and captivation. An addict will crave the absent drug, whereas ‘a captive’ won’t desist the present behavior. The two phenomena may interact and overlap. Thomas Schelling writes (before mobile phones, social media, and video-game apps!):

“[Captivation] is being glued to TV, absorbed in a novel, caught in a mathematical puzzle, engrossed in a symphony, or absorbed in frustration trying to fix a recalcitrant piece of equipment. This may be where to include fantasy; some of us are as readily captivated by daydreams as by that late movie or unfinished novel. A simple interruption will sometimes rescue the captive; other times he can still hear the siren song and may be as sneaky as an addict in getting back to that puzzle, story, or daydream.” (p. 53)

Cocaine use can be doubly insidious, insofar as the drug can cause both occurrent captivation and addiction over time.

Addictions often exhibit co-morbidity. Leitzel explains:

“At an individual level, co-morbidity is commonplace among vice addicts; for instance, a majority of pathological gamblers suffer from alcohol addiction, too, and it might prove impossible to curb their gambling problem without addressing their drinking problem.” (p. 4)

Diverse drugs have distinct addiction rates (capture ratios). Robert Gable reports:

“Of the people who sample a particular substance, what portion will become physiologically or psychologically dependent on the drug for some period of time? Heroin and methamphetamine are the most addictive by this measure. Cocaine, pentobarbital (a fast-acting sedative), nicotine, and alcohol are next, followed by marijuana and possibly caffeine. Some hallucinogens—notably LSD, mescaline, and psilocybin—have little or no potential for creating dependence.” (p. 208)

John Donohue reports some approximate addiction rates:

“ [… ] perhaps 10 percent for marijuana users, 15 percent for alcohol and cocaine users, and almost 25 percent for heroin users.” (p. 59)

Donohue also reports that entry into addiction occurs mainly during coming of age:

“surveys indicate that drug abuse disorders have a narrow age-of-onset range, with an interquartile range of 17-23 years. This suggests that efforts aimed at curtailing drug use among young people can play a key role in preventing drug addiction. Individuals who do not develop a disorder by their late twenties are much less likely ever to develop such a disorder.” (p. 11)

Exit from addiction

Most addicts exit from addiction by 'aging out.' Gene Heyman & Verna Mims report:

“age trends suggest that more than half of those who were ever dependent on an illicit drug remitted by age 30. [… .] Remission did not vary greatly as a function of drug type, and marijuana users were not the most likely to remit. [… .] each year 17 percent of those still dependent on cocaine remitted, whereas […] 5 percent of those still dependent on alcohol remitted each year. [… .] remission was stable.” (pp. 390-92)

James Schneider provides an interpretation of the surprising uniformity of aging out across different drugs:

“Interestingly, opioids have only slightly lower remission rates than marijuana, which is generally considered far less addictive. How could this be true? The addictiveness of heroin makes it harder to quit than marijuana; however, heroin’s destructiveness makes quitting it more imperative.”— The Deadly Sins: An Exploration of Behavioral Health Economics (MS 2016, presented at GMU Public Choice Seminar), p. 124.

Innovation has created relatively inexpensive new drugs and more efficient illicit distribution mechanisms. Synthetic opioids, such as fentanyls, produce euphoria at doses orders of magnitude lower than heroin does. Mark Kleiman describes changes in distribution wrought by fentanyls:

“the convenience of having the material delivered directly by parcel post rather than having to worry about maintaining an illegal ‘connection,’ constituted an enormous temptation. [… .] On top of that, the ‘technology’ of illicit retail drug distribution has been transformed by the introduction of mobile phones.”

Addiction can manifest itself also after prolonged abstinence (recovery), insofar as re-exposure to environmental cues (circumstances associated with prior drug use) can trigger cravings. However, Heyman & Mims establish that sampling bias overestimates relapse:

“when addicts are recruited independently of their treatment history, remission—not relapse—is most characteristic of addiction (and, as mentioned earlier, most addicts

do not seek treatment).” (p. 404)

If an addict believes that she cannot achieve moderation, she therefore might form a resolution to quit. Schelling counsels that abstinence is a focal point :

“One of the best discrete, qualitative discontinuities is between nothing and something. Not smoking at all is different from smoking any number of cigarettes. Zero is a unique quantity. It won’t work for calories, but for addictive behaviors it can. Another application of the discrete rule is no exceptions.”—Thomas C. Schelling, “Enforcing Rules on Oneself,” Journal of Law, Economics, & Organization 1:2 (Fall 1985) 357-374, at p. 367.

Alas, William James observes that addicts are resourceful at making excuses for exceptions. He rehearses the genre:

“How many excuses does the drunkard find when each new temptation comes! It is a new brand of liquor which the interests of intellectual culture in such matter obliges him to test; moreover, it is poured out and it is a sin to waste it; or others are drinking and it would be churlishness to refuse; or it is but to enable him to sleep, or just to get through this job of work; or it isn’t drinking, it is because he feels so cold; or it is Christmas day; or it is a means of stimulating him to make a more powerful resolution in favor of abstinence than any he has hitherto made; or it is just this once, and once doesn’t count, etc., etc., ad libitum —it is, in fact, anything you like except being a drunkard.”

Relapse can undermine an addict’s confidence in her ability to quit. Elster identifies a predicament of self-defeating sophistication :

“if you can predict that you will deviate from your best plan, you may end up deviating even more from it or earlier than if you are unaware that you will fail.”— Explaining Social Behavior (2007), p. 237.

However, a strategy of bundling one’s choices can restore (a more cautious, humbler) determination. George Ainslie and John Monterosso explain:

“Of greatest interest is the phenomenon of choice bundling, an increase in motivation to wait for delayed rewards that can be expected to result from making choices in whole categories. [… .] the bundling effect can also be discerned in the advice of 12-step programs. [… .] While perceived helplessness might seem to promote under-confidence that future abstinence can be maintained, the 12-step method fuels expectation that abstinence can be maintained. The ambitious resolutions that have ceased to be credible (‘I’ll never drink again’) are replaced by believable building blocks: ‘one day at a time.’ The believable expectation of one day’s sobriety becomes worth more than devalued long-range expectations—and yet the effect of a series of successful single days builds that very credibility that was lost, and this rebuilding is concretized in the practice of keeping a running total of how many days abstinent the participant ‘has.’” (pp. 1 & 11)

Addiction & prohibition

Samuel Butler notes that moral criticism of intense pleasure from mind drugs essentially castigates shortcuts :

“Morality turns on whether the pleasure precedes or follows the pain. Thus, it is immoral to get drunk because the headache comes after the drinking, but if the headache came first, and the drunkenness afterwards, it would be moral to get drunk.”

However, John Stuart Mill notes that the criterion of criminality is harm to bystanders, or clear and present danger:

“No person ought to be punished simply for being drunk; but a soldier or a policeman should be punished for being drunk on duty.”

Now, many who would prohibit mind drugs condemn not intoxication per se , but addiction. More precisely, they condemn specific addictions, or addiction to any of a particular subset of mind drugs, which, they believe, present a clear and present danger of dehumanization. For example, James Q. Wilson argues that some, but not all, mind drugs can destroy the soul :

“dependency on certain mind-altering drugs is a moral issue [… .] we treat [nicotine and cocaine] differently not simply because nicotine is so widely used as to be beyond the reach of effective prohibition, but because its use does not destroy the user’s essential humanity. Tobacco shortens one’s life, cocaine debases it. Nicotine alters one’s habits, cocaine alters one’s soul. The heavy use of crack, unlike the heavy use of tobacco, corrodes those natural sentiments of sympathy and duty that constitute our human nature and make possible our social life.”

A question of consistency arises: What about alcohol? Is heavy alcoholism more like chain-smoking? Or more like heavy use of crack? Heavy alcoholism, too, ‘corrodes the natural sentiments of sympathy and duty.’ Moreover, alcohol, when abused, especially by an inwardly angry person, is the mind drug most dangerous to bystanders. Drunkenness can cause impairment of motor skills, illusion of control, and disinhibition—a peculiar, potentially combustible admixture. Think drunk driving and domestic violence. I conjecture that psychology of repugnance produces inconsistency in intuitions about prohibition of mind drugs. Cocaine, heroin, and even cigarettes are repugnant to bystanders, partly because they often involve ‘unnatural’ forms of delivery to the brain: Snorting, self-injection, smoking. By contrast, alcohol is sipped from a glass or bottle, like water. Think how a cold beer quenches thirst on a hot day.

However that may be, the general point stands: Moral criticism of addiction often is entangled with repugnance. Robert MacCoun calls this tangle moral outrage. In MacCoun’s carefully designed survey, more respondents favor prevalence reduction than favor harm reduction for addictive drug use (especially heroin). By contrast, more respondents favor harm reduction than favor prevalence reduction for other risky behaviors (teen sex and skateboarding). (p. 87). I infer that prohibition of mind drugs is motivated partly (largely?) by a composite of (a) moral outrage against drug addicts and (b) paternalistic deterrence towards the subset of citizens who refrain from drug use because of prohibition.

Respondents who favor heroin prohibition might be mistaken, by their own criterion. They favor prohibition because they wish to reduce prevalence of addiction, which they deem repugnant, even if prohibition increases aggregate harm to residual addicts. However, Becker & Murphy make a case that legality will reduce addiction, by a concatenation of mechanisms:

“The lower drug prices that would result from full decriminalization may well encourage greater consumption of drugs, but it would also lead to lower addiction rates and perhaps even to fewer drug addicts, since heavy drug users would find it easier to quit.”

Legality -> Increase in prevalence, Decrease in addiction rate, & Increase in recovery rate -> Indeterminate ‘sign’ of change in number of addicts.

Wireheads notwithstanding, innovation might produce safer mind drugs, too. Michael Darden & Nicholas Papageorge summarize their findings:

“Rational self-medication suggests that, when presented with a safer, more effective treatment, individuals will substitute towards it. [… .] We demonstrate an economically meaningful reduction in heavy alcohol consumption for men when SSRIs became available. […] addiction to alcohol inhibits substitution. [… .] punitive policies targeting substance abuse may backfire, leading to substitution towards even more harmful substances to self-medicate. In contrast, policies promoting medical innovation that provide safer treatment options could obviate the need to self-medicate with dangerous or addictive substances.”

Debunking addiction?

As noted above, the mainstream academic view is: “A good is addictive if its consumption leads to more compulsive consumption of the same good.” But is the ‘compulsion’ irresistible?

Benjamin Rush (1746-1813), a Founder, was also a pioneer in the theory of addiction as mental illness or disease. He reports a categorical declaration by an alcoholic:

“When strongly urged, by one of his friends, to leave off drinking, he said, ‘Were a keg of rum in one corner of a room, and were a cannon constantly discharging balls between me and it, I could not refrain from passing before that cannon, in order to get at the rum.’”

Thomas Szasz and Bryan Caplan are skeptical. Caplan argues that alcoholism and other ‘addictions’ aren’t diseases, but extreme preferences for mind drugs over other goods. ‘Extreme preferences’ are unusual preferences that create social friction. Medical illness (disease) constrains what a person can do. Addiction does not present physical constraints. Conversely, one can have a disease without changing one’s preferences.

Szasz writes:

“The business of psychiatry is to provide society with excuses disguised as diagnoses, and with coercions justified as treatments.”— The Untamed Tongue (1990), p. 178

Caplan makes a case that ‘addicts’ and the establishment alike strategically embrace the misleading disease diagnosis because it provides (a) an excuse to persons who are labelled addicts for their deviant behavior, and (b) a justification for the establishment to impose harsh measures (coercive treatments) on addicts. People with normal preferences can simultaneously ‘be themselves’ and be liked. People with abnormal preferences must balance these two goals. The disease theory enables ‘addicts’ to strike a balance, by conforming to social desirability bias. A ‘gun to the head’ test is dispositive for distinguishing between constraints and preferences. A gun to the head won’t enable a paralyzed person to walk, but will induce Benjamin Rush’s avowedly ‘powerless’ alcoholic to abstain. Indeed, psychiatric research about ‘contingency management’ finds that the majority of heavy users of mind drugs will go ‘cold turkey’ simply for a moderate price —not a gun to the head.

Heyman & Mims provide other corroborating evidence and arguments against the disease model of addiction. (pp. 403-4 and references). And Peter Arcidiacono and co-authors provide evidence that heavy drinkers and smokers make forward-looking choices:

“This study investigates whether models of forward-looking behavior explain the observed patterns of heavy drinking and smoking of men in late middle age in the Health and Retirement Study better than myopic models. [… .] Our empirical findings suggest that forward-looking models with an annual discount factor of approximately 0.78 fit the data the best.”

Scott Alexander (a pen name)—a psychiatrist and tireless, protean blogger—systematically rejects Bryan Caplan's critique.

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John Alcorn is Principal Lecturer in Formal Organizations, Shelby Cullom Davis Endowment, Trinity College, Connecticut.

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