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Painful Choices

In response to:

Opioid Nation from the December 6, 2018 issue

To the Editors:

In her comprehensive and thoughtful essay about the opioid (and other drug) problems afflicting Americans [“Opioid Nation,” NYR, December 6, 2018], Marcia Angell seems unable to avoid blaming the victim. In the context of addiction as a disease, Dr. Angell writes that “for most users there was a moment of choice in becoming addicted,” this as a way of separating addicts from those suffering from cancer or diabetes. This throwaway line suggests that one makes a choice to be an addict, yet among the myriad reasons that lead any individual to first ingest a psychoactive substance, becoming an addict is not one. Dr. Angell otherwise expresses the appropriate empathy that must be the starting point in responding to addiction, but in this instance she unfortunately perpetuates the uninformed and simplistic view shared by so many of those who lack that requisite empathy.

William Brigham
Palo Alto University
Palo Alto, California

To the Editors:

Marcia Angell argues that addiction is not a disease like diabetes because it involves “a moment of choice in becoming addicted.” Addiction is not a choice and does not arise in a moment. Like type II diabetes, addiction comes about through a complex interplay of behavior, environment, genetics, and physiology. Most individuals with type II diabetes would not have this condition if they ate a healthy diet, exercised more, and lost weight; these are all “choices.” Many of us choose to drink alcohol, but most do not become addicted; those who do become addicted did not decide in a moment to become afflicted with this difficult problem. Moreover, as Angell points out in her article, many individuals who have become addicted to opioids were exposed to these drugs through a physician’s prescription. The notion that addiction is a choice is a dangerous one and suggests that it can be avoided simply through willpower alone (or “just saying no”), which unfortunately is not the case.

Darius Rastegar
Johns Hopkins University
School of Medicine
Johns Hopkins Bayview Medical Center
Baltimore, Maryland

Marcia Angell replies:

When I referred to “a moment of choice in becoming addicted,” I did not mean users choose to become addicted. The author of one of the books I reviewed, Ryan Hampton, described very well the transition from first using an opioid, which was a choice, to progressively losing that choice as he became addicted. Addiction is a process, and no one can become addicted unless he or she takes the drug in the first place. Nevertheless, I believe I made it clear in my discussion of “deaths of despair” and the social, economic, and psychological hardships that many users face that I would not “blame the victim” at any point in the process. Perhaps my greatest concern now is that we will return to the earlier days of inadequate pain relief in an indiscriminate zeal to fight the opioid epidemic. That would double the tragedy.