Disease or Choice: Why Does It Matter?

No definition will change the fact that people are suffering. (napocska/Shutterstock)

Every once in a while, we witness heated debates on social media regarding the disease model of addiction. Despite widespread acceptance within the medical community, many view the disease model with absolute disdain. They feel that addiction is a choice, plain and simple.

Regardless of the stance they take, many people tend to feel very strongly on this issue. On at least a few occasions, we’ve seen people insult each other’s intelligence for holding opposing views on the matter. And every so often, someone arguing that addiction is based entirely on choice will suggest that the best solution to the drug crisis is to simply let them die. The discussion becomes emotionally charged before long, and most participants walk away with some feelings of resentment toward the others. But could there be some truth to the claims that addiction is a choice? How did it come to be defined as a disease in the first place?

Both sides of the debate warrant discussion. However, as we intend to show, the answer ultimately bears little relevance to the more important topic of discussion. For whether we define addiction as a choice or a disease, it should have little bearing on our treatment of those in need of help.

The Disease Model of Addiction

Addiction is often classified as a chronic brain disease due to its effects on our brain chemistry. (Ahuli Labutin/Shutterstock)

Many factors influence the disease model of addiction, but it all comes down to the effects of drugs on a person’s brain. Drugs and alcohol flood the brain’s reward centers with dopamine, creating an effect that the user finds pleasurable. Over time, the brain adapts, leading to increased tolerance—and consequently, a greater rate of substance use.

As tolerance to dopamine goes up, it even affects other things that a person might usually enjoy, such as entertainment, food, sex and time with family. After long enough, the addict or alcoholic may find it difficult to enjoy their substance abuse as they once did. Addicts who reach this point often say that they don’t like using anymore, but don’t feel normal if they stop.

Substance use can affect far more than just the brain’s reward centers. After a long period of addiction, the brain’s ability to learn and make decisions may be impacted as well. Long-term use can also affect memory, behavior and stress management.

While addiction often develops over long periods of substance use, biology and environmental factors sometimes play a role as well. Exposure to drugs at an early age, or certain genetic factors inherited from a family member may increase the likelihood of becoming addicted. Even so, predicting the development of addiction proves quite difficult. One factor may be the age at which a person first uses. As noted by the National Institute on Drug Abuse:

“Although taking drugs at any age can lead to addiction, the earlier that drug use begins, the more likely it will progress to addiction. This is particularly problematic for teens. Because areas in their brains that control decision-making, judgment, and self-control are still developing, teens may be especially prone to risky behaviors, including trying drugs.”

Due to the range of factors that influence a person’s addiction, there remains no cookie-cutter cure. Individualized treatment at a dual diagnosis facility remains the preferred recovery method for many, as it allows the addict or alcoholic to simultaneously address co-occurring disorders such as depression or PTSD. Even following treatment, relapse remains a potential threat. Continued use of recovery tools such as meetings and a solid support system will help to mitigate the dangers of relapsing, but addicts and alcoholics must remain aware that it only takes one use to fall back into old habits.

Is Addiction Just a Choice?

While accepted by many experts in the medical community, not everyone agrees with the disease concept. In fact, the disease model itself is relatively new. And while many aspects of the disease model make sense in the light of what happens in the brain, some criticize the chronic brain disease label as failing to acknowledge the absence of shared qualities between addiction and “real” diseases. Dr. Lance Dodes writes for Psychology Today:

“In addiction there is no infectious agent (as in tuberculosis), no pathological biological process (as in diabetes), and no biologically degenerative condition (as in Alzheimer’s disease).”

The choice model suggests greater control over our minds, with potentially promising implications depending on your viewpoint. (Sergey Nivens/Shutterstock)

We should note that Dodes does not necessarily characterize addiction as a choice, but rather as a psychological condition. The closest he comes to the word “choice” is “compulsive behavior,” and he does not agree with stigmatizing those who suffer. By contrast, many who believe in the choice concept take very harsh views against addicts and alcoholics.

Regardless of how addiction develops psychologically, many would agree that it at least begins with a choice. However, even this statement takes us down a slippery slope. At which point does a developing addict cross the point of no return? Even if we agree that their brain becomes hijacked over time, could they know precisely when to stop before it’s too late? Saying that addiction begins with a choice will not be enough to appease those who believe that it is a choice. After all, smoking is a choice, whereas cancer is very clearly not. And the primary argument made by those who argue the choice model is that addicts should simply stop.

Author and psychiatrist Sally Satel explores the choice model in an article for The Atlantic. She believes the choice model should empower addicts and alcoholics by helping them to realize that they can choose a better life. Furthermore, while she believes that addicts choose to use, she notes that this does not mean they chose addiction.

“No one would choose the misery that comes with excessive use…. It is true, drug users don’t choose to become addicted any more than consumers of high calorie foods choose to become overweight. But addiction and poundage is not what they are choosing: what they seek is momentary gratification or relief—a decision that is rational in the short-term but irrational in the long-term.”

So even the choice model does not suggest that addicts can stop easily. It still allows for both compassion and treatment, while merely refocusing the conversation on the behavioral symptoms of the malady. It’s clear that whether we define addiction as a choice or a disease, we’re still dealing with people in need of help.

Of course, there is still a model that some could use to deny the need for treatment, but it’s not one that you hear come up a whole lot in conversations like this. That’s probably because supporters of this particular belief don’t tend to focus solely on alcoholism or addiction, but rather on the whole of human nature itself. We’re talking about a belief called determinism.

Free Will vs. Determinism

Some theorize that we actually have far less control over our thoughts and actions than we prefer to believe. (Ollyy/Shutterstock)

To put it somewhat glibly, determinists believe all acts to be the result of cause and effect. In the case of human behavior, determinism would suggest a lack of free will. Human beings do not choose our behaviors, but rather react to stimuli outside of our control. For quite some time, the closest we had to scientific proof of determinism was a study from the early 1980s in which participants showed signs of movement before making the conscious decision to move. In other words, they did not choose their actions but merely reacted to background neural processes.

As one might imagine, this sparked a great deal of debate. And fortunately for those of us who like to believe in free will, more recent studies indicate that these background stimuli can be cancelled. In other words, while our brain would seem to suggest decisions before we are conscious of making them, we do not actually have to follow through with this.

But rather than argue the case for free will, let’s pretend that determinism remains uncontested. If such were the case, one might argue that there is no point in treating addicts and alcoholics. After all, determinism would suggest that addicts literally cannot control anything they do. How could we possibly treat such a condition?

The answer should actually be obvious, but allow us to use an example from best-selling author Sam Harris. In his short book Free Will, Harris illustrates the value of treatment while arguing in favor of rehabilitating criminals rather than engaging in retributive punishments.

“If we imagine that a cure for evil exists, we can see that our retributive impulse is morally flawed. Consider, for instance, the prospect of withholding the cure for evil from a murderer as part of his punishment. Would this make any sense at all? What could it possibly mean to say that a person deserves to have this treatment withheld? What if the treatment was available prior to his crime? Would he still be responsible for his actions? It seems far more likely that those who had been aware of his case would be indicted for negligence.”

It takes little effort to see a similar argument in favor of addiction treatment. And while we wouldn’t accuse those who condemn addicts as negligent, their views may at least be described as somewhat misguided. Because, like it or not, our current drug crisis affects each and every one of us. And denying addicts the help they need could hurt more people than we may initially realize.

The Common Solution

Regardless of how we define addiction, quality mental health treatment remains the best answer for those who are struggling. (Shidlovski/Shutterstock)

Disease, choice, determinism—no matter how you define it, treatment can help addicts to change their thought processes and engage in healthier behaviors. This helps not only the addicts themselves, but also their families and those who care about them. So in the end, the “let them die” argument we hear every so often makes no sense. All it does is cause unnecessary pain. Addicts and alcoholics can be helped. There is no good reason to deny them and their families the care they deserve.

We know that addiction costs our nation money in health costs, not to mention lost work hours and numerous lives. Punishing addicts rather than providing greater access to treatment takes its toll on our legal system, and ensures higher recidivism rates by denying them the help they need to rehabilitate themselves. Refusing funding for Narcan to first responders means a higher death toll, while the lack of funding provided for treatment all but promises that we will remain in a state of emergency until the opioid crisis has spun even more out of control than it already has.

No matter how you feel about the disease model of addiction, know that there is always a way out. If you know somebody who is struggling, do not give up on them. Urge them to contact us so we can provide the help they need. And if you are struggling with addiction yourself, know that we are here for you. We are more than happy to offer you the care and compassion you need to turn things around.