Addiction is a choice – but this does not mean people with addiction are to blame.

In recent decades, we have constructed the idea that addiction, or Substance Use Disorder (SUD) is a Brain Disease. This has derived from neuroimaging research that suggests people with addiction have a brain that is fundamentally ‘different’ – their dopamine functions are blunted and therefore it is impossible for them to seek pleasure from non-substance using activities. Furthermore, studies suggest their prefrontal regions show abnormalities which means they are no longer capable of inhibiting themselves and having the capacity to not take the drug. This has been embraced by many, and the understanding has formed that addiction and free-will simply cannot co-exist.

However, evidence from behavioural observations paints a very different picture. Contingency management works as an effective intervention for people with addiction – it provides insight that choice is still very much within their cognitive control. When given the opportunity to be rewarded for not using substances, it provides an opportunity for revaluation within the decision-making process. This is similar to how a ‘healthy’ brain works, in contrast to the implications of the Brain Disease Model of Addiction (BDMA). Heyman et al (2013) states 80% of people who previously met the criteria for SUD are now in remission – this means they are not abstinent, but no longer engage in problematic substance use. This is indicative that free-will plays an important role in addiction. Therefore, it is vital to understand why there is so much variation in the outcomes of people with addiction, and what we can do to help those most vulnerable.

Furthermore, research shows the majority of people who once met the criteria for SUD, will never seek treatment. It is worth asking the question – why are so many people struggling with substance use problems refusing to seek help? The Brain Disease model inspired a way of thinking about addiction away from a moralistic high ground – it helped us medicalise the problem, pushing for research and better treatment. It encouraged society stop blaming the individual and using puritanical judgement as an excuse to marginalize those suffering. However, we have reached a time where the BDMA is no longer useful.

The model takes away empowerment of the individual, stating that their brain is flawed and unable to ever fully recover. However, the science does not back this up and it is premature to attribute a neurological dysfunction as a full explanation for addiction - scans have shown brain changes fluctuate between different individuals with addiction, showing further investigation is needed. The damaging stigma around addiction has returned with this model, although it may look different to the moralistic judgment society has historically thrown on people with addiction, it is just as damaging. To believe someone is fundamentally ‘wired’ differently because of a diagnosis with SUD, creates the illusion that there is a healthy brain and an unhealthy brain, which is not yet fully understood within the field of neuroscience. The concept of becoming the ‘other’ when receiving a SUD diagnosis can cause self-stigma amongst those with SUD’s, resulting in shame. Shame is powerful, and research shows it reduces the likelihood to seek help, and creates a belief that they may not have the power to recover.

It is time we completely reframe how we view addiction. Theories around the neuroscience of decision making can help us understand the development and treatment of addiction. Yet, currently this is massively overlooked by the media and general public. The study of decision making processes states that generally, we make decisions by weighing up the perceived value of each option. However this is obviously largely subjective, and can easily become maladaptive.

Professors at the University of Sheffield are researching how this functions in people with addiction. The Theoretical Model of Decision Making in addiction suggests that PWA do actively consider the perceived value of taking the substance or not, but this is often done very quickly and without much thought. Empirical evidence from Copeland et al (2023) reinforces this; the study concludes that ex-smokers take longer to make decisions about tobacco related cues. This suggests that once recovery has been undertaken, decision making becomes less compulsive and more thoughtful. It is therefore worthy to consider mindfulness as a useful tool in addiction recovery.

Studies also show the perceived value of taking the substance is malleable to change. Decisions can change when there are increased cost of substance use, or increased pleasure and availability of activities not involving substance use. Empirical studies have explored this, and Dora et al (2023) determined that lighter drinkers value other reinforcers such as food, more so than heavier drinkers, after a negative emotional experience. However, when heavy drinkers experienced high craving, and a negative mood, their subjective value of alcohol increased. This provides some insight that people who drink more frequently, value alternative coping mechanisms less.

The theory integrates previous models such as behavioural economic theories of addiction which proposes that addiction occurs and persists when the valuation of taking the substance is higher than non-substance reinforcers (any other activity not involving drug use), suggesting that free-will remains in people with addiction. It is true that addiction often continues even when the individual has a desire to quit, but according to this model, this happens because there is higher relative value attributed to substance use. However, this does not mean people with addiction are themselves to blame. The contextualised reinforcer pathology model can help explain this; when an individual is in an environment where they lack the opportunity to seek out other forms of fulfilment, this results in an inflated valuation of the substance. A lack of alternative reinforcers can mean being unable to find the means to pursue career or educational goals, interests and hobbies, and develop meaningful relationships. Copeland et al (2022) found moderated drinkers have more of these reinforcers than heavy drinkers, which suggests they are central mechanisms of change. Therefore it is important to consider the role of socioeconomic status and deprivation when it comes to the problem of addiction. Many people are in a situation where substance use may appear to have the most rewarding outcome, when compared to the other options they have available.

Furthermore, when individuals make the choice to continuously use the substance, it must be understood that this decision is based on a valuation process that also involves trying to curb cravings, avoiding stress and financial strain, or self-medicating for other comorbidities such as mental or physical illness. This is often overlooked, as when people view addiction as a choice, it is easy to conclude that this choice is between intoxication and sobriety, but it is undoubtedly more complex than this.

These theories don’t completely undermine the all the research conducted around the BDMA. The models highlight that substance use is valued relatively higher in people with addiction, over alternative reinforcement, because repeated drug use changes the brains reward system. Changes in the function of the ‘pleasure’ receptor in the brain, dopamine, means after long term substance use the individual becomes desensitized to normal enjoyment from other activities. Hyperbolic discounting often also appears in people with addiction, meaning after long-term substance use, immediate positive rewards become favourable over rewards that may take longer. However, these changes are not necessarily permanent, nor are they inherent to people with substance use disorder. It also does not mean that the importance of neurological changes in the brain should be emphasized over the role of environmental factors such as socioeconomic status in addiction.

It is necessary that we as a society can develop a more nuanced perspective on addiction and its causes. In order to fully irradicate the stigma around the disorder, we must commit to understanding addiction as a problem that stems not from the individuals broken brain, or twisted morals, but from the circumstances in which surround them. In order to get rid of the shame that surrounds labels such as ‘alcoholic’ or ‘drug addict’, we must understand what those terms mean, and how any one of us could one day find ourselves under its umbrella.

With these theoretical accounts which emphasize the role of free-will and environment in addiction, it improves our ability to target the mechanisms in interventions that currently work in addiction treatment. For example, AA is notoriously effective for helping people with alcohol use disorder remain sober, but with this novel understanding of addiction, treatments can be developed that provide substance-free reinforcers like social support and community, without emphasis on religion and complete abstinence that is unhelpful for many. Furthermore, by understanding addiction as a problem often rooted in inequality and poverty, it can be ensured that future developments in therapeutic or pharmacological treatments are accessible to those most vulnerable and in need of support.