Addiction and Criminal Responsibility: The Law’s Rejection of the Disease Model

Ch. 22 in Evaluating the Brain Disease Model of Addiction

Perhaps such high abstinence rates reflect the individual characteristics correlated with the responsibilities and skills involved in medicine and piloting an airplane. A similar program with men and women on probation in the criminal justice system obtained similar results, however. Hawaii’s Opportunity Probation with Enforcement (HOPE) program is an innovative approach to the problem of high rates of drug use among men and women in prison (Hawken & Kleiman, 2009). The program focuses on the post-release probation period, with the aim of breaking the vicious correlation between drug use and recidivism. The terms of parole include a contract to abstain from illegal drugs. To ensure that the probationers abstained, they were subject to random drug tests. Positive tests resulted in a few days back in jail. The key finding was that drug use decreased by more than 80% within the first three months of the contingency plan, and by more than 90% at six months (Hawken & Kleiman, 2009). A control group composed of probationers who were not under threat of immediate consequences for drug use continued to use drugs at the same rate as at the start of their probation.
The intervention results tell the same story as the epidemiological research, self-reports by addicts, and the historical record: addicts can choose to stop using drugs; they retain the capacity to quit. In contrast, the interventions that help addicts to quit drugs would not alleviate the symptoms of diseases that defenders of the disease model say addiction is similar to (e.g., McLellan et al., 2000; O’Brien & McLellan, 1996). one could reasonably suppose that rewards persuade tumors to shrink. But rewards persuade addicts to reduce drug use.
Many other studies also confirm that addicts respond to incentives (e.g., Gupta, 2015; Robins et al., 1974, addressing heroin addicts returning home from Vietnam; Westbrook et al., 2011; Volkow et al., 2010, addressing the positive effects of visualizing negative consequences). These powerful findings illuminate the capacity for self-control in addicts. They also underscore the idea that addicts persist, not because of an inability to control the desire to use, but from a failure of motivation. Granted, summoning sustained motivation can be a great challenge. It takes a lot of energy and vigilance to resist persistent craving.
**
Also see Brief of Amici Curiae of 11 Addiction Experts in Support of Appellee
scholarship.law.upenn.edu/‌cgi/‌viewcontent.cgi?article=2936&context=faculty_scholarship

The subjects in the Vermont study were treatment seekers, who presumably wanted to change. Would contingencies work on drug addicts who did not volunteer to seek help? Physicians and airplane pilots who are on probation for drug use provide a handy test of this question. The physicians and pilots were compelled to enter treatment and forced to make themselves available for random testing. If they tested positive, they risked permanently losing their license to practice and the income and status associated with such prestigious professions. Given how much was at stake for the lives of these subjects, they had very strong reasons to cease using and they did. The abstinence rates were typically above 80% and averaged close to 90% (Coombs, 1997, graphs in Heyman, 2009).