Is addiction a choice? The controversy continues. One reader writes in to DrHurd.com the following:
“I have done more than average investigation into the concept of addiction. I believe there can be multiple causes, both biological and psychological. This is true for many psychiatric conditions. It is true that taking a drug is a choice, but craving it and the degree to which one craves it is what I call the addiction. The craving may be completely involuntary as a result of biological conditions. I think it is very safe to say there is a strong biological component as one of the causes of addiction, but there is more than one way to have an addiction. There is also a strong interplay between the biology of the brain and psychology of course.”
Dr. Hurd replies:
At least you’re conceding
that putting substances into one’s body is a choice. But then you speak of conditions — psychiatric and otherwise. There’s danger in applying the concept “condition” to errors in reasoning, errors in behavior or even problems in functioning. To call your emotional or behavioral problems a “condition” is to put them into the same category as the common cold, the flu, heart disease or cancer. These are all conditions too. What brought these conditions on — poor choices or simply bad genes — is not the point here. The point is that once you call something a condition, you are referring to it as a process outside of your control (absent effective medical, entirely external interventions.)
Clearly, heart disease and the flu qualify as conditions. Regardless of how you got them, the conditions have a biological life of their own until or unless you cure them with medical intervention (or wait for them to pass, often the case with the flu.)
Not so with substance abuse. If a substance abuser views his problem as a condition, it’s entirely reasonable for him to think, “I have to wait for this condition to pass.” As in the flu. Or, “I have to wait until proper external/medical intervention is administered; then hopefully I will be cured.” What is the nature of the external, medical intervention? The “treatment” of choice are Twelve Steps programs, or rehab programs administratively run by physicians, but essentially Twelve Steps programs. Twelve Steps programs are support groups grounded in a non-denominational faith-based approach to life, with many kernels of rational wisdom thrown in, as well. Whatever you think of the ideology of Twelve Steps, it’s not a medical intervention and there’s nothing external about it. It’s up to the Twelve Steps member to apply the principles of that philosophy to his life and addiction; nobody is doing this for him. He might choose to believe that his God or Higher Power is doing it all for him, or at least guiding him; this is his supernatural belief, but it’s still his own body and mind that are submitting to any of the “treatment.”
The reader is essentially arguing here, “Addiction starts out as a choice. But once the choice to take the drug is made, it becomes an illness.” If it’s an illness, then why is the only cure for the substance abusing individual to stop — and (more importantly) to STAY stopped? With or without “treatment,” with or without AA, with or without counseling, religion, peer/family support or anything else — it’s only the individual who can stop. And it’s only the fact of the individual stopping that defines a cure. This is not a medical condition, not even in a metaphorical sense!
The reader continues,
“There are many medications which can cause imbalances of the neurotransmitters [in the brain]. There is an acne medication which interferes with serotonin and ADD medications can cause imbalances after stopping them that last for years. After taking these medications for a number of years and then removing them can create conditions of hypomania and bipolar and cravings for drugs, food, elevated energy and extremely high libido. These symptoms can eventually resolve without any choice on the part of the individual after several years when the system completely corrects itself. Psychological factors can perpetuate the imbalance if drugs are used further or other traumatic psychological events occur since the biology of the brain clearly reacts to the inputs of the life of the person.”
Dr. Hurd replies:
You’re asserting that the brain creates cravings. This isn’t necessarily the case. It is true that the brain is required for craving to occur. In other words, craving is partly a physiological process. When you crave something, there’s a physiological process going on, including in your brain, involving the neurotransmitters and other brain receptors, as you say. But there are other things going on simultaneously. The person with that brain is thinking, or evading; is using reason or is doing his best not to reason things out at all. These involve choices. The person is weighing the pro’s and con’s of drinking, or is mindlessly giving in to them. Or, the person isn’t giving in, but he’s not reasoning things out, either. He’s simply forcing himself not to drink, choosing to exercise sheer will instead of any introspection at all. Each of these are choices. All of these are different choices that people with more or less the same brain make-up are exercising. Even the same person, with the same chemical brain make-up, will make different choices at different times in his life. At age twenty-five, he’s evading the consequences of drug abuse and refusing to think or reason at all. Five or ten years later, he’s not only thinking about the consequences but is three years sober. Every time he passes a drug-selling corner or a bar, he resists any urges created by those neurotransmitters of which you speak.
What happened in this “cured” person? Did some kind of medical or other external intervention cause his faulty neurotransmitter wiring to change? If the nature of his “condition” was an “illness,” then this must be so. But where’s the evidence that this occurred? I’m not aware of any medication or any other externally imposed mechanism that forces a person’s brain to change in such a way that he no longer abuses drugs or alcohol. I’m unaware of it, because there isn’t one. It’s the person who’s effecting the cure. It’s the person who chose to change, and to stay changed.
Addiction specialists and researchers flatter themselves when they claim that alcoholism and addiction are diseases. This allows them to claim credit for any progress a person makes, or any changes a person employs in his daily life with respect to drug abuse. Addiction theorists use the factual existence of a brain, and the chemical/neurotransmitter make-up of the brain (about which very little is understood) to not only explain all of addiction, but to wipe out the existence of personality traits, choices, conscious thinking and other psychological processes of the mind exercised by the individual’s volitional will to think (or to evade the effort).
Their claim is, “The brain made them do it” — while they offer no evidence whatsoever of what is being done to the brain to effect the change in behavior, attitudes and beliefs that only the addict him- or herself can influence.