I knew that doing this further jeopardized my life prospects and my relationships with everyone I cared about. I knew it made no sense. But I didn’t believe that I could cope in any other way. Until I finally recognized that I needed treatment and began recovery in 1988 — with the prospect of that lengthy sentence under New York’s draconian Rockefeller laws still occluding my future — I didn’t think I had any real choice.
These questions are at the heart of drug policy and the way we view and treat addiction. But simplistic answers have stymied efforts to ameliorate drug use disorders and reduce stigma.
Research now shows that addiction doesn’t mean either being completely subject to irresistible impulses, or making totally free choices. Addiction’s effects on decision-making are complex. Understanding them can help policymakers, treatment providers and family members aid recovery.
Claims that people with addiction are unable to control themselves are belied by basic facts. Few of us inject drugs in front of the police, which means that most are capable of delaying use. Addicted people often make complicated plans over days and months to obtain drugs and hide use from others, again indicating purposeful activity. Those given the option will use clean needles. Moreover, small rewards for drug-free urine tests — used in a treatment called contingency management — are quite successful at helping people quit, which couldn’t be possible if addiction obliterated choice.
However, those who contend that substance use disorder is just a series of self-centered decisions face conflicting evidence, too. The most obvious is the persistence of addiction despite dire losses like being cut off by family members or friends, getting fired, becoming homeless, contracting infectious diseases or being repeatedly incarcerated.
Most people who try drugs don’t get addicted, even to opioids or methamphetamine, which suggests that factors other than simply being exposed to a drug can contribute to addiction. The majority of people who do get hooked have other psychiatric disorders, traumatic childhoods or both — only 7 percent report no history of mental illness. Nearly 75 percent of women with heroin addiction were sexually abused as children — and most people with any type of addiction have suffered at least one and often many forms of childhood trauma. This data implies that genetic and environmental vulnerabilities influence risk.
So how does addiction affect choice? Neuroscientists and philosophers are beginning to converge on answers, which could help make policy more humane and more effective.
Brains can be seen as prediction engines, constantly calculating what is most likely to happen next and whether it will be beneficial or harmful. As children grow up, their emotions and desires get calibrated to guide them toward what their brains predict will meet their social and physical needs. Ideally, as we develop, we gain more control and optimize the ability to choose.
But there are many ways that these varied processes can go awry in addiction and alter how a person makes choices and responds to consequences.
Image: Urbazon/E+, via Getty Images
