Addiction debate: Is it a disease or a choice? Experts weigh in

Reminder, this is a Premium article and requires a subscription to read.
Scientific communities have been rethinking the idea that those who use drugs are themselves at fault. Photo / 123RF
Some researchers argue that the roles of social environment and personal choice have to be considered in order to make progress in treating people addicted to drugs.

The message emblazoned on a walkway
window at the airport in Burlington, Vermont, is a startling departure from the usual tourism posters and welcome banners: “Addiction is not a choice. It’s a disease that can happen to anyone”.

The statement, part of a public service campaign in a United States community assailed by drug use, is intended to reduce stigma and encourage treatment.
For decades, medical science has classified addiction as a chronic brain disease, but the concept has always been something of a hard sell to a sceptical public.
That is because, unlike diseases such as Alzheimer’s, bone cancer, or Covid, personal choice does play a role, both in starting and ending drug use.
The idea that those who use drugs are themselves at fault has recently been gaining fresh traction, driving efforts to toughen criminal penalties for drug possession and to cut funding for syringe-exchange programmes.
But now, even some in the treatment and scientific communities have been rethinking the label of chronic brain disease.
In July, behaviour researchers published a critique of the classification, which they said could be counterproductive for patients and families.
“I don’t think it helps to tell people they are chronically diseased and therefore incapable of change,” said Kirsten Smith, an assistant professor of psychiatry and behavioural sciences at Johns Hopkins School of Medicine and a co-author of the paper, published in the journal Psychopharmacology.
“Then what hope do we have? The brain is highly dynamic, as is our environment.”
The recent scientific criticisms are driven by an ominous urgency: despite addiction’s long-standing classification as a disease, the deadly public health disaster has only worsened.
Almost no one is calling for entirely scrapping the disease model. Few dispute that constant use of stimulants such as methamphetamine and opioids such as fentanyl have a detrimental effect on the brain.
But some scientists argue that brain-centric disease characterisations of addiction do not sufficiently incorporate factors such as social environment and genetics.
In the recent critique, researchers contended that, rather than emphasising the brain’s brokenness in perpetuity, an addiction definition should include the motivation or context in which the person chose to use drugs.
That choice, they said, is often about seeking an escape from intractable conditions such as a fraught home, undiagnosed mental health and learning disorders, bullying, or loneliness. Generations of family addiction further tip the scales towards substance use.
And in many environments, they added, drugs are simply more readily available than healthier, rewarding options, including education and jobs.
Choosing drugs could then be understood not as a moral failing but as a form of decision-making, with its own bleak logic.
In combination with medications that subdue opioid cravings, therapists could help patients identify the reasons that led them to use drugs and then encourage them to make choices that result in meaningful, sustained rewards.
In a 2021 paper in the journal Neuropsychopharmacology, Markus Heilig, a former research director at the National Institute on Alcohol Abuse and Alcoholism, defended the brain disease diagnosis, saying evidence has been amply documented.
But, his paper acknowledges: “Brain-centric accounts of addiction have for a long time failed to pay enough attention to the inputs that social factors provide to neural processing behind drug-seeking and taking”.
In clinical practice, the term “addiction” is becoming increasingly nuanced. John Kelly, a psychologist and professor of addiction psychiatry at Harvard Medical School, defines addiction as “a severe substance use disorder that is at the point where there are lots of changes in the prefrontal cortex as well as deeper areas of the brain” that regulate emotion and behaviour.
But only a small minority of people meet that criteria, he said.
“Even within that severe range, there’s a lot of different degrees of impairment that can occur,” Kelly added.
Genetics can exacerbate the severity of the response.
He offered the analogy of boarding a speeding train.
“It starts off being an exhilarating ride, but at some point it gets out of control and becomes derailed. It’s a matter of when you can pull the emergency cord and get off,” he said, noting that some drug users never get the chance to do so before it’s too late.
That moment, Kelly said, differs for everyone: “People will only change when there are negative consequences, but also when there is hope and optimism that change is possible, likely, and sustainable.”
In disputing the characterisation of addiction as a disease marked by compulsive or relapsing use, a few experts have argued that some drug and alcohol users can quit without treatment and even return to occasional safe use.
Smith began using drugs in adolescence and became addicted to heroin. During her darkest stretch, when she was 23, she was injecting four times daily.
She was involved in two bank robberies and then served almost four years in federal prison, where she attended a modest treatment programme. Upon release, she finished college and completed graduate and postdoctoral studies.
It has been more than six years since she used opioids and more than 15 since she was addicted to them. Smith is quick to credit the benefits of her middle-class background and family support.
She rejects the idea that she will always be shackled to a chronic brain condition.
“I am not in recovery,” she said. “I have recovered.”
Theories of addiction have been debated for centuries.
In the 1780s, Dr Benjamin Rush, a signer of the Declaration of Independence, began calling alcoholism “that odious disease”. (“The different preparations of opium are a thousand times more safe and innocent than spiritous liquors,” he wrote.)
Compounding the modern confusion about the nature of addiction, psychiatry keeps refining criteria for what it labels “substance use disorder”. In the current edition of its diagnostic manual, the DSM-V, a person has a mild disorder if they meet at least two of 11 symptoms. The more the symptoms, the greater the severity of the disorder.
Research on drug use gained momentum in the 1970s. By 1997, Alan Leshner, then the head of the National Institute on Drug Abuse, published a foundational position paper, Addiction Is a Brain Disease, and It Matters.
To the public, policymakers, and even healthcare workers, he wrote: “Addiction as a chronic, relapsing disease of the brain is a totally new concept”.
But he did not overlook contributing factors. “Not only must the underlying brain disease be treated, but the behavioural and social cue components must also be addressed,” he wrote.
His much-cited research summary, which appeared a year after Purdue Pharma introduced the highly addictive prescription opioid OxyContin, had a powerful, positive effect.
The brain-disease designation would stimulate funding for research, be used to expand insurance coverage for treatment and prompt changes in public policy and criminal law, where newly minted drug courts – now increasingly called “recovery courts” – urged defendants into treatment. The brain-disease framework would eventually be adopted by mainstream medicine, including the US surgeon-general.
And it offered patients and families a building block towards compassion as well as ways to counter ubiquitous scorn.
The model continues to hold value, said Dr Nora Volkow, who now leads the institute. She refers to addiction as “a chronic, treatable medical condition”.
In a statement, she added: “Acknowledging that addiction involves changes to the brain does not discount the many genetic, social, environmental, and other factors that also play an important role”.
Whether the brain will ever sufficiently recover after long abstinence, however, needs further studying, argued a 2022 review of the research, though the authors suggested that evidence is promising.
But as academics wrestle with how to frame addiction, patients and loved ones struggle painfully with the lack of certainty.
Nadia, whose father fatally overdosed on fentanyl in 2023, said defining addiction as a disease lets users off the hook of responsibility.
“It’s difficult to hear people call addiction a disease, like cancer or progressive illnesses,” wrote Nadia, who lives in Minneapolis and whose last name was withheld to protect her family’s privacy.
“My father chose drugs, time and time again. He missed all three of my graduations, my wedding, and the birth of my child, as well as all the milestones of my sister. It’s hard to be told that he can’t control it. That we weren’t important enough for him to overcome it.”
Nadia was among the hundreds of readers who responded to questions from the New York Times about their families’ struggles with substance use.
Many said that they agonised: they were furious with the person using drugs or alcohol. Yet many also felt guilty for bitterly resenting a parent, sibling, child, or spouse who, they also accepted, was sick with a disease.
“People want to relieve themselves of the burden of the mixed emotions they feel towards their loved one, but that’s the burden inherent in the condition,” said Keith Humphreys, a psychologist and an addiction expert at Stanford University.
That is in part why, he said, it’s easier for people to see addiction in absolutist terms – as a choice or a disease.
Overwhelmingly, family members described their burnout.
“When a loved one is addicted to drugs it’s like they’ve been bitten by a vampire,” wrote Robin Pratt, whose sister used opioids for a dozen years.
“They never stop plotting what they can take from you to support their habit. The same person who, before drugs, you would have trusted with your life, becomes someone you wouldn’t even trust with your purse.”
Almost 30 years ago, when Leshner argued for the brain-disease designation, he did so in part to break through what he called the long-simmering “imprecision and misconception” around addiction.
He then added: “In fact, if it were possible, it would be best to start all over with some new, more neutral term”.
This article originally appeared in The New York Times.
Written by: Jan Hoffman
Photographs by: Medar De La Cruz, Hailey Sadler
©2024 THE NEW YORK TIMES
Reminder, this is a Premium article and requires a subscription to read.