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Addiction: Choice or Disease? Lets Just Move On

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My previous posts, the theories of addiction, parts one and two, focused heavily on the neurobiology of drug addiction. Partly, this is due to my research and training in the neuroscience of addiction, but also, the ideas about addiction have shifted from our earliest misconceptions of addiction as a moral failing to our current understanding of addiction as a medical disorder. Recently, however, a debate has started to crop up, with some researchers stating that addiction is not a disease; rather, it’s a disorder of choice.  

This “either it’s a choice or it’s a disease” debate hinders our ability to empathize and to maximize treatment benefit. We’re divided. It’s time we move on and focus on what we can learn from each other’s stories. Let’s use that knowledge for the reason most of us got into this field in the first place: to help individuals with substance-use disorders.

First, I want to briefly break down the debate. Most of the addiction researchers I’ve talked to believe addiction is a disease of the brain. One prominent researcher and director of the National Institute of Drug Abuse (NIDA), Nora Volkow, has even said that addiction is a disease of free will.

Addiction scientists call on three decades of research, stating that addiction is a brain disease, affecting particular brain regions, such as the reward system and the pre-frontal cortex. These studies have shown that the reward system is “hijacked” by drugs, and the cognitive control center deteriorates with extensive use, causing deficits of personal control. Their stance on the matter is unwavering, and I think I understand why, but the message may be confusing to some. Here’s an excerpt from an article Dr. Volkow put out last year: 

…[the death of Phillip Seymour Hoffman] has … prompted others to express the age-old notion than drug use is a choice, and that those who die as a consequence of their drug use are just reaping the consequences of their freely chosen actions. It is unfortunate that that view persists in our society, despite the decades of scientific research soundly disproving it. Choices do not happen without a brain—it is the mechanism of choice. The quality of a person’s choices depends on the health of that mechanism. However much we may wish that a person’s choices were free in all instances, it is simply a fact that an addicted person’s failures in the realm of choice are the product of a brain that has become greatly compromised—it is readily apparent when we scan their brains. Even if taking a drug for the first time is a “free” choice, the progression of brain changes that occurs after that involves the weakening of circuits in the prefrontal cortex and elsewhere that are necessary for exerting self-control and resisting the temptations of drug use. Once addiction takes hold, there is greatly diminished capacity, on one’s own, to stop using. This is why psychiatry recognizes addiction as a disease of the brain…
A vintage ad poster found at:

Basically, Dr. Volkow is stating that addiction affects the brain, which affects the person’s ability to make choices. I would say, though, the “age-old notion” is not that addiction is a matter of choice. It’s that addiction is a moral failing. Maybe that’s just splitting hairs, but I don’t think so. Researchers, such as Marc Lewis, Carl Hart and others advocate for the changes that occur in the brain that make choices difficult, but, in a sense, they are arguing for people and researchers to understand that addiction is not just about biology.

So, why is there so much push-back on these “choice” advocates? Simply put, researchers that have worked so hard to point out the disease-like qualities of addiction don’t want the public to think it’s a moral problem. That people with addiction are weak-willed. This is understandable, and I think the choice advocates need to acknowledge this issue and be more conscientious about how they might be affecting public opinion.

I also think the NIDA and other addiction scientists need to better communicate the nuance of addiction; that there are other factors than just changes in the brain. 

To illustrate, consider this research that shows when people with substance use disorders are given the choice of an alternative, non-drug reward, some people choose the non-drug reward over drugs. This idea forms the basis of Contingency Management, which I and other addiction researchers have written about and published papers on. The interpretation of these data break down into at least two basic possibilities: 

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1) Some people using drugs aren’t truly dependent upon drugs; they don’t have the disease. Otherwise, they would choose drugs, not the alternative reward. 

2) People have a compromised brain that makes not choosing drugs hard, but a more immediately available and tangible reward makes the choice to not use easier.

Either of these possibilities seems likely, so I’m going to go with all of the above. In some ways, I think everyone agrees that addiction is characterized as a pathology that involves neurobiological dysfunction, but some researchers point to it becoming problematic because of environmental embedded-ness. Drug users who commit crimes are examples of this, especially those in disadvantaged situations. They get caught in a downward spiral, in which choices become limited. Because I’ve written about this before, I’m going to rehash something I feel is really important:

To me, there is a troubling dichotomy at work. At first, people have more control over the amount they use, and [many] do so for the pleasurable effects. However, with continued use, the underlying neurobiology changes, adapts, if you will, to the extensive use of a particular drug by setting new baselines of homeostatic mechanisms (e.g. tolerance develops), continually increasing the value of a drug … and increasing wanting for a particular drug. Research makes it clear that drug use changes the brain, eventually causing dysfunctional and maladaptive behaviors, which can lead to adverse physical, mental, and social consequences. This means that drug use causes damage to the brain and does, indeed, impair the abilities of the user to make ideal choices. I think it’s important to note that some people with addiction will continue to have, at least, some agency in the decisions they make … but the difficulty of making choices will be more severe for some and impossible for others. The real challenge lies in recognizing the individual needs of each person.

Here, we come to point I want to emphasize in this post. I’m getting a little frustrated with people digging their feet into the ground on some issue and becoming immovable. Researchers are not infallible. NIDA is the funding entity for addiction research, but that doesn’t mean that they’re absolutely right about the nature of addiction; however, they have three decades of addiction research to back up their views. That’s not something we should brush aside so easily. And, we should consider the moral issue and public perception of addiction. Just because one researcher experienced addiction and says that addiction isn’t a disease, doesn’t mean he’s got the inside scoop on the nature of addiction – and is non biased. Just because another researcher grew up in a disadvantaged neighborhood and says that addiction isn’t really a problem but tends to be a problem of environment and disadvantage, doesn’t mean he’s got the correct angle on this issue – and is non biased.

To be clear, I don’t think they’re wrong. In a way, I think they’re all correct, given their particular circumstances. The neuroscientist who grew up in an impoverished neighborhood and saw the effects drugs had on his community, knowing that choices in that environment were limited provides valuable insight into the reason some people use drugs. In this particular case, some might excessively use drugs but not necessarily have addiction. If given a choice to have better alternatives, some individuals in this environment would choose to not use drugs. The key is understanding individuals on a personal level to know which people would benefit from this.

The neuroscientist that used a lot of drugs when he was young, then quit, and now says that addiction is just accelerated habit learning, and all it takes is retraining the brain to not prefer drugs may also be beneficial. I have a feeling – and he does too – that those in more privileged circumstances will be more likely to quit or change their use, hence change their brain. Here’s what he said in a recent Guardian article:

I guess there is a point where the devastation of addiction, combined with the situation of people’s lives – whether through poverty or crime and social isolation – and when those factors hook up they get really hard to stop, really, really hard to stop.
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So, what does it matter whether we call it a disorder, a disease, or a choice? Well, choice might imply more power over your situation but also brings with it a lot of shame for those who can’t quit, as well as stigma from society. To NIDA’s point and credit, disease implies long-term changes to the body and brain – which is partly true, though the brain can almost fully recover with enough abstinence. Thus, people are victims of an unfortunate medical disorder, one that is difficult to understand and hard to treat. We should always consider this to minimize the damage done by people that don’t understand addiction and never will. Too much of our perception of people using “too many drugs” is one of moral failing whether we realize it or not. If you don’t believe me, catch that first thought you have the next time a supposedly drug-addicted, homeless person asks you for money. For a long time, my first thought was, “they’re just going to buy drugs or alcohol”. Now, I think, “what do I really know about this person and their circumstances?” Often times, we have no idea or truth regarding the reason someone has become homeless. Plus, the truth is, although the rate of alcohol and drug abuse is higher in the homeless population than in the general population, the majority wouldn’t be considered dependent on drugs or alcohol.

Let’s learn from each other’s stories and use them to have greater compassion for the individuals experiencing difficult situations. Let’s understand how we might approach people with a particular backgrounds and current circumstances to better help them. What would it hurt to give up your pet theory for a second or two and acknowledge that you might be wrong, or maybe that you might not be helping anyone by furthering your own agenda? I’ve learned that many researchers have very personal reasons for getting into addiction. Not always, but many times they or friends and family have dealt with addiction or seen the negative effects of addiction. These personal reasons might drive researchers to get at the heart of addiction and to find answers, but there’s not always a simple solution. 

All of these opinions are valid and useful in shaping research and for better understanding a complex issue, like addiction. We should be working to create a more inclusive environment rather than discrediting each other. I find myself currently resonating the most with Peg O’Connor, whom in a New York Times debate said:

As a society, we look for quick fixes. There is no easy or quick fix to addiction. It takes time to develop, and it takes even more time to learn how to live without the substances…

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Paul S. Regier has a PhD in neuroscience and studies addiction at UPenn. Follow him on Twitter and on Medium.

Thank you to Erika Rood for her review and edits.

Cover photo from a vintage wallet, found at: