Addiction, Choice, and Antisocial Personality Disorder

To speak of choice in the context of addiction is not blaming.

Posted Oct 24, 2019

“Shallow” and “naïve” were terms applied by some readers with respect to my October 3, 2019 blog post regarding the role of choice in addiction. One person suggested that the tone of the post was blaming in the sense of faulting addicts for “their own misery” because they became “hooked” on opioids.

The post was not about blame. The focus was on facts. Not only is there a critical dimension of choice in becoming addicted to a substance, but for more than 30 years the professional literature has also documented a link between risk of drug addiction and antisocial personality disorder.  An article in the February 1990 “APA Monitor” cited “antisocial personality” as a “major potential risk factor for becoming a substance abuser.”

Fifteen years later, Dr. Wilson Compton of the National Institute of Drug Abuse cited what was then the largest study of the co-occurrence of psychiatric disorders among U.S. adults,  He stated, “This is the first time in which we see that virtually every single drug abuse disorder is associated with an antisocial personality disorder.”*

To maintain that the individual must take responsibility for the choices he makes, including those that result in addiction, has nothing to do with blaming or being unsympathetic. It is critically important to prevention and treatment not to deny the person’s own role in becoming addicted.  Dr. Michael Kuhar in his 2015 book, The Addicted Brain, stated, “Individuals might have to work hard to take care of themselves.  If they have risk factors for becoming a drug user, then they need to pay attention to them.  If there are some that they can’t avoid, like genetic factors or drugs in the environment, then they have to work doubly hard at controlling the risk factors that they can.”  Dr. Kuhar pointed out that people at risk must avoid places where drugs are sold and “practicing the ability to say no is important.”

The major point is that the addict makes choices critical to developing an addiction.  He must also make choices to defeat addiction. Writing in the “Living Resources Newsletter” in 2014, psychologist Dr. Michael Hurd noted that 75 percent of people with the “disease” of alcoholism “cure themselves.”  He commented, “You’ll never find that sort of self-cure with real diseases.” Writing two decades ago in The New York Times, psychiatrist Dr. Sally Satel emphasized that it is the individual who “is the instigator of his relapse and the agent of his recovery.”** A group of physicians, in a guide regarding the use of opioids to manage chronic care, emphasized that a “key component of a patient medication agreement” is that “patients agree to comply fully with all aspects of the treatment program, including behavioral therapy and physical therapy if recommended.***

Dr. Scott Fishman, in his guide to physicians titled “Responsible Opiate Prescribing,”cautioned doctors that “in focusing narrowly on a disease or symptom, physicians can lose the `big picture’ of the whole person and miss important diagnostic clues.” He advised “focusing on the patient, not the pain.”  Underscoring the role of choice, he said, “The patient can choose to accept or reject physician recommendations.”   Although Dr. Fishman was not using psychiatric nomenclature, he listed antisocial behaviors linked with the obtaining of drugs such as stealing, prostitution, forgery, and selling prescriptions.  It is unlikely that a person who does not have an antisocial personality disorder will resort to such behavior to obtain drugs.****

This brings one back to the question of who becomes addicted.  Tens of thousands of patients take prescribed opioids to cope with intense pain.  How a person chooses to deal with pain, whether post-surgery or otherwise, varies with his personality.  On the one extreme is the person who refuses to take pain killers or will do so only briefly because he fears becoming dependent.  He may suffer because of that choice.  At the other extreme is the person who incessantly clamors for more medication and seeks ever higher doses.  He rejects non-pharmacological treatment to coping with pain (e.g., physical therapy, mindfulness, cognitive-behavioral therapy).  Clearly, the personalities of such individuals have some relationship to how they dealt with their condition.

Consider the following narrative written by a gentleman who copes daily with chronic pain.  “I developed arthritis of the spine and that began causing significant, then substantial pain.  They put me on a Fentanyl patch at first.  But it seemed too much.  So I asked for something lighter and got a prescription for hydrocodone. They gave me a prescription for 3 or 4 a day and I got a 120 tablet bottle each month but never needed all those. I have not once taken one pill more than prescribed and most often have taken one to three per day, fewer than prescribed.  My goal: knock down shrill pain, do not become a junkie.  I am so grateful for pain relief that I do not abuse the relief in any way.”  

Returning to the theme of the October 3 post, as one opioid patient said, “From my experience, these drugs do not reach out and grab you and hold you in a bear hug.”  Choices are made while becoming addicted, then in coping with the addiction.


*”MacArthur Research Network on Mental Health and the Law,” September 2005 update of the Executive Summary

**Satel, Sally. “Don’t Forget the Addict’s Role in Addiction,” The New York Times, 4/4/98.

***Zacharoff, Kevin et al. “Managing Chronic Pain with Opioids in Primary Care,” 2010.

****Fishman, Scott M. “Responsible Opioid Prescribing,” Federation of State Medical Boards, 2007.