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Brain Disease? Isn’t substance use addiction just a choice? Can’t they just say ‘no’?

This is a common but flawed perception. Those that suffer from SUD frequently encounter this belief, one that attributes poor choices or weak character to their problem. This creates a social/cultural stigma upon addiction and suppresses treatment seeking and access, incarceration rather than hospitalization, employment and housing headwinds to the recovered, along with reduced acceptance back into society. Long term recovery is resisted and compromised to the detriment of all and the death by relapse of many. At its heart, this perspective frees those of us unaffected by SUD to feel self-justified and judge others freeing us from any responsibility or inclination to encourage our institutions to provide aid and reduce this crisis.

First, this perspective ignores the overwhelming evidence that @60% of the SUD population have a genetic susceptibility to the disease if they get exposed to anything that triggers those pathways, such as a legitimate prescription. The remaining 40% is composed primarily of two environmental factors, stress and social group, which affects availability. Do we judge those with heart disease or diabetes, both of which have genetic and lifestyle components? Do we restrict medical treatment and socially isolate this population? Look at how we as a culture treated different mental illnesses and conditions in the past, such as bipolar disease, or depression - was that appropriate then before our perceptions evolved? Think also of the stigma that surrounded HIV sufferers in the early decades of our awareness of that disease. And look into history to the stigma applied to sufferers of leprosy - they were shunned and ostracized. Is it possible that our initial feelings about these conditions do not reflect our opinions upon reflection? Can our thinking evolve with the science? Can we respond rather than react in order to substantively decrease the SUD crisis?


Second, the choice view also ignores the severe craving that the addicted experience. Unlike a normal strong desire, it captures the whole being of the afflicted making them certain their survival depends upon the substance. I liken it to the desperation a drowning person must feel- should we call out swimming instructions to them and judge their inability to swim or do we throw them a lifeline? What would you want for yourself? For your child, parent, or sibling? Another question might be, if you have one drink, an accepted and legal, ubiquitous substance, do you feel you must fight the desire for another with your strong self-discipline, good judgement, and fine character? If not, what did YOU DO to NOT have that desire?


Third and critically, the choice argument is fatally flawed in its assumption that an afflicted person can make choices with the same capacity they had pre-substance addiction, with the same capacity that you and I may possess free from SUD. Addiction attacks and damages the choice and decision making parts of the brain, the memory, and the neural pathways, anatomically and biochemically. There is lots of research available demonstrating this process, and more is being learned steadily. (Please see the resource page). A sufferer of SUD can no longer make decisions that we think are rational, or as they would think before their SUD or after their recovery. They are being driven by their midbrain, their Ventral Tegmental Area, Nucleus Accumbens, and Amygdala to use substances which they feel are as required for survival as their next breath. The Hypothalamic-Pituitary-Adrenal axis gets hijacked causing cortisol levels to become disordered. The dopamine, glutamate, and serotonin neurotransmitter cycles, along with many others we may not be as familiar with, are corrupted. The Hippocampus and memory are altered. And all of these break the normal functioning of the Anterior Cingulate Cortex, the Orbitofrontal Cortex, and the Ventromedial Prefrontal Cortex which coordinate our decisions, our choices, our voluntary actions and behaviors.


Forget the complicated names, essentially the brain is broken. Our free will is not really free. The SUD sufferer needs help, not judgement. This can be hard to accept because the behaviors, actions, and words of someone afflicted can be so alienating, offensive, damaging, and illegal. However, an isolating, punishment response has been shown to make the situation worse individually and societally with less likelihood of recovery, in addition to being cruel and incorrect. Stigma kills.

Addressing stigma is my main concern because it is the critical linchpin, the one commonality, to all aspects of successful treatment and successful long-term recovery. I believe that increasing awareness that SUD is a disease that breaks your brain is a key to reducing stigma. And I believe that humanizing the statistics by telling Joel’s story as he wanted to do - we had discussed a book together and he worked helping many in recovery - and by collecting and sharing the stories from families of the many other Joels struck by this wicked, most evil of diseases, is the path to opening hearts and minds to receive the science that undermines societal stigma. Societal opinions evolve - I want to leverage that. In short, open hearts to open minds to reduce stigma to improve treatment to reduce deaths and damage from SUD.


We can dramatically alter the course of SUD, freeing individuals and our society from the plague of demonizing the sufferer rather than the disease itself. Addiction and its stigma are both treatable diseases.

Then what role does choice play?

In my mind it plays at least two critical roles: one in prevention and one in recovery. Prevention is particularly important in the younger than 25 yo, the brain developing years when the brain is more susceptible to entrenched damage from SUD. This time is even harder due to the natural and healthy adolescent urge for adventure, wing stretching, and independence pursuit. Greater risk-taking accompanies this stage pairing a greater vulnerability physically with reduced resources mentally. Guidance and open discussion are fundamental to helping young people make healthy long-term choices in this arena. On reflection, I think that we did not discuss the dangers of substances sufficiently because we never imagined substances would be appealing to our kids. Have you felt that way? BE AWARE. We thought sub-consciously that we were immune to this problem. Perhaps if we had regular conversations, Joel would have been more protected from his innate vulnerability. (See Jessica Lahey’s book "Addiction Inoculation" if you have young kids.)


The second critical role of choice is choosing recovery. The cruelty of this disease can be seen in that it breaks the decision-making apparatus of brains thus disabling the volition needed to gain the desired freedom from the substance. There is a bitter irony in that while 60% of the vulnerability to SUD is genetic and totally out of an individual’s control, treatment success is dependent on their ability to behave as if they have 100% control while using their damaged reasoning and choice making. We, our individual attitudes forming the societal attitudes underlying our institutions and protocols, can help dramatically, easing the path to earlier and thus more long-term successful treatment.

Having worked in this community for more than a decade, I can state confidently that every person suffering from SUD wants to break free from the substance once they realize it controls them rather than they control it, that it is destroying rather than enhancing their lives. The substance’s effect on the brain hides this realization though. There is one tragic group exception that I have seen, that is the long-time addicted persons who have struggled mightily to become free of their addiction but have repeatedly failed, often because they cannot access the help they need, that give up and are just waiting for death to end their hell. My question to us all that are now free from SUD, do we not aspire to be members of a better society than that? Is that who we really want to be? Will you see a drowning person and walk on by with the suggestion they learn how to swim, or they should not have made the choice to get so close to the water? When YOU fall in water over your head in some other area of your life, is that how you want to be treated? How about your child? Stigma kills. Let’s stigmatize the substances of the disease, not the person who has it. We will all benefit. A more compassionate and responsible society will result.

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