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Disease or Decision: Solving the Riddle of Addiction

The concept of addiction as a disease, though familiar and widely accepted today, is still somewhat novel. When one thinks of diseases, cancer, diabetes or Alzheimer’s may come to mind; each of these is so different from addiction in their nature. Historically, addiction has often been viewed as a moral disease, if a disease at all.

Despite being based on facts and rational deductions, the disease model of addiction isn’t without its detractors. However, there are certain elements of the concept that seem almost contradictory to what we know to be true about this malady, leaving people puzzled about what addiction really is in this age of science, technology and definitive answers. So…what, exactly, isn’t explained adequately to the reasoning person concerning the disease model of addiction? Does the theory lend itself to excusing a person from any responsibility for drug abuse behavior?

Defining the Disease Model of Addiction

Brain illustrationAccording to the disease model of addiction, a person who is addicted to alcohol or other drugs suffers from a progressive, incurable brain disease that’s characterized by the brain’s altered structure and functioning. In experiments on both animals and humans, subjects that had become chemically dependent exhibited neurological anomalies that weren’t present in subjects that hadn’t been continuously exposed to addictive substances over a period of time.

The regions of the brain most noticeably affected by such substances involve impulse control and inhibition, learning the negative consequences of behaviors, and compulsive risk-taking. Despite whatever may have initiated substance use, it is clear that the underlying source of a substance abuse disorder, through continued use, turns into a brain structure and function issue – that is, a loss of control over the situation by the user.1

Addict: Perpetrator or Victim?

When one gets a feel for the disease model, it does make sense. Then again, there are schools of thought that don’t agree, and their arguments against the disease model of addiction are also compelling.

Some who are skeptical of the disease model suggest that addicts hide behind the label of disease, using it as an excuse to avoid having to be personally accountable. Indeed, calling one’s addiction a disease makes the person sound more like a victim of chance or circumstance than someone who should be held responsible for any choices made. On the other hand, it’s hard to argue with the actual, observable differences that exist between the brains of people addicted to alcohol or drugs and “clean” brains.

As background information, addictive substances affect the brain’s “reward circuit” by flooding it with dopamine, a chemical messenger. This reward system controls the body’s ability to feel pleasure and motivates a person to repeat behaviors needed to thrive, such as eating and spending time with loved ones. This overstimulation of the reward circuit causes the intensely pleasurable “high” that can lead people to take a drug again and again.2

The Disease “Dilemma”

Hand refusing a beerThat brings us to the next issue. If addiction is a disease rather than a matter of choice, why is it that people who choose not to abuse alcohol or drugs have virtually a zero percent chance of developing an addiction? This seems to be an irreconcilable difference that distinguishes addiction from most other recognized diseases.3

Granted, a person can certainly decrease the odds of developing diabetes, as an example, by making certain lifestyle choices; however, one might have to concede that genetic or environmental factors could exist to trigger the disease’s development. But in the case of addiction, it’s virtually impossible to become an addict without first being a substance user.1

Clearly, there are some discrepancies between the disease model of addiction and the way that addiction actually works. Fortunately, there is a way to reconcile these apparent discrepancies.

How Does Choice Play a Part in the Disease of Addiction?

The issue of personal accountability seems to be the area of greatest contention with the disease model of addiction. The reality of how addiction works tell us so. It is understandable why some think the disease model exonerates people from the role they play in their own addiction, and, certainly, some individuals may seek to take advantage of the label of disease in order to excuse their abandonment of responsibility.4

As far as perception of addiction is concerned, however, the disease model is a way of explaining how and why addiction occurs; it seeks to mitigate some of the stigma surrounding those with an addiction. That same stigma is a significant factor in many addicts being so afraid of demonization by others that they are not willing to admit their addiction and seek appropriate help.

In summary, addiction occurs as a culmination of continued exposure to an addictive substance over a period of time. This occurs only through personal choice. However, when the individual has developed the disease of addiction, the substance abuse is no longer merely a choice, but a compulsion due to physiological dependence and, through the lens of an altered brain, psychological dependence as well.5

Perhaps These Aren’t Totally Unrelated Concepts After All

It’s important for people to understand that, in the end, the concept of addiction as a disease and the reality that one can only become an addict by choosing to use alcohol or drugs aren’t irreconcilably contrasting. Rather, both ideas are part of a bigger picture and help to answer the riddle of addiction.6

What do you think? Do you agree that both decision and disease are involved in becoming addicted to alcohol or other drugs? Share your thoughts with us. We’re interested in hearing what you have to say.

“Addiction and Free Choice.” National Institute on Drug AbuseFebruary, 2014.

“Understanding Drug Use and Addiction.” National Institute on Drug Abuse. August, 2016.

Schaler, Jeffrey A., Ph.D. “Addiction Is a Choice.” Psychiatric Times. October 1, 2002.

4 Stossel, John. “Is Addiction Just a Matter of Choice?” ABC News. April 21, 2017.

5 Heyman, Gene M. “Addiction and Choice: Theory and New Data.” Frontiers in Psychiatry. NCBI, May 6, 2013.

6 Soper, Richard G. “Addiction: Character Defect or Chronic Disease?”American Society of Addiction Medicine. 13 March 13, 2014.

Written By Dane O’Leary