Is Addiction a Disease or a Choice?
The debate about whether addiction is an inheritable disease passed down from parent to child versus a series of decisions with increasingly negative outcomes is as old as the field of addiction medicine. While this debate continues, current research suggests that the answer is not either/or, but rather a complex interaction between genetic vulnerability and lived experience.
The Disease Model of Addiction
The “disease” model of addiction says that substance use disorders (SUDs) are genetic. In this model, substance use disorder is viewed as a medically recognized brain disease that alters a person’s perception and judgment regarding their substance use and its impact on the world around them. There are camps, such as many 12-step fellowships, that acknowledge that addiction is a disease as a foundational tenet to their philosophy.
According to the disease model of addiction, when an individual is actively using, the person is helpless in their decision-making because their brain has been rewired to adopt behaviors that they would not do when sober. The solution to this issue is to adopt a complete abstinence lifestyle so the brain has a chance to heal itself. Some people in recovery will compare this to having an “allergy” to substances, where avoiding use will not trigger the “allergic reaction” known as addiction.
The Choice Model of Addiction
Alternatively, the choice model of addiction states that SUDs come from a series of maladaptive choices that can be corrected if the individual is able to make changes to their overall decision-making process.
The “choice” model is meant to empower the individual to look at their thought process and behaviors and identify where their decision-making is problematic. Life experiences, relational influences, and other factors outside of the individual shape their outlook and decisions to use. New insights into previous patterns help the individual make newer, more positive choices, leading to better outcomes.
Total abstinence is not required if a person is able to remain mindful of their maladaptive patterns and make better choices with substances each time. Cognitive-behavioral therapy (CBT) strategies and other skills-based programs are used in these situations to help individuals learn new ways to explore their relationship with substances.
Disease or Choice: Which is Correct?
So, who is right? Which side is on the correct side of history? The answer is more complex than simply choosing one side or the other. Addiction is often a synthesis of elements from both models, creating a larger model of SUD and interventions used to treat it.
Most evidence-based treatment programs acknowledge that SUD is a legitimate brain disease. Research has demonstrated that the brains of people living with SUD have significant structural differences from those of people without SUD. In some cases, these differences have existed from birth, and in others, the brain is predisposed to changes when exposed to substances. These structural differences directly impact mood, cognition, and behavior. Successful treatment involves abstinence so the brain can return to a healthier version of itself, and often, medication-assisted treatment (MAT) is used to treat the receptors that produce powerful cravings that can lead to relapse.
Where Choice Still Plays a Role
The story does not end here, however. Generally, most people who develop SUD do not become addicted their very first time using. Before dependence and, eventually, addiction take root, the individual still has the power to choose to use – or not. It is often after repeated use that the brain becomes compromised and the ability to independently choose is lost.
Furthermore, relapses may quickly return the brain to its compromised state, and the cycle will repeat until interventions separate the person from use. Human beings are complex and are exposed to situations daily that can impact the likelihood of relapse. When we experience physical and emotional stressors or pain, we have social connections that can introduce substances back into our lives, and our environments may contain relapse triggers despite our best efforts.
This is where learning new skills to resist the people, places, and things that trigger relapse comes into play. Remaining mindful of triggers and actively making decisions that promote health are the best ways to avoid relapse and the hijacking of the brain that substances cause. CBT and other skills help individuals break behavioral patterns that lead to relapse and teach them alternative strategies to meet their needs
An Integrated Approach to Recovery
As the field of addiction medicine continues to expand its knowledge to treat individuals with SUD, the combination of addressing patients’ medical needs along with their behavioral needs remains relevant.As with many other cases, opposing fields actually have more in common than they appear and, working together, create optimal conditions for patient recovery.
The best outcomes rely on science-based interventions such as medically supervised detoxification, along with prescribing MAT in concert with mindfulness and behavioral strategies to set a person up for success. Active participation in residential or outpatient programs that teach these skills and provide sober support networks is the aftercare element needed to maintain a positive sober lifestyle.