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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 50-60% of the tendency toward SUD (substance addiction) is 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 2 more factors, stress and peer group or 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 changed? Think also of the stigma that surrounded HIV sufferers in the early decades of our awareness of that disease; do you still feel that way? (Look further back to the stigma applied to sufferers of Hanson’s Disease, leprosy, were treated, shunned and ostracized - how does that strike you today? Is it possible that our initial feelings about these conditions personally, societally, historically do not reflect our opinions upon reflection after thinking? 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-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 in exquisite detail, and more is being learned steadily, (please see the resource page). A sufferer of SUD can no longer make decisions we think 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, in summary, and 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 collecting and sharing the stories from families of the many other Joels struck by this wicked, most evil of diseases, SUD, is the path to opening hearts to receive the science that undermines societal stigma. In short, open hearts to open minds to reduce stigma 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.


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