En español
NIDA

Menu

Addiction and Free Choice

February 18, 2014

Glucose metabolism in orbitofrontal cortex (OFC) in healthy and cocaine-addicted subject.Glucose metabolism in orbitofrontal cortex (OFC) in healthy (left) and cocaine-addicted (right) subject.

The recent death of Phillip Seymour Hoffman as a result of drug addiction has provoked many thoughtful, sympathetic responses in the media, from people in recovery who understand how hard it is to wrestle with addiction, as well as from scientifically informed journalists who understand that addiction is a disease. But it has also prompted others to express the age-old notion than drug use is a choice, and that those who die as a consequence of their drug use are just reaping the consequences of their freely chosen actions. It is unfortunate that that view persists in our society, despite the decades of scientific research soundly disproving it.

Choices do not happen without a brain—it is the mechanism of choice. The quality of a person’s choices depends on the health of that mechanism. However much we may wish that a person’s choices were free in all instances, it is simply a fact that an addicted person’s failures in the realm of choice are the product of a brain that has become greatly compromised—it is readily apparent when we scan their brains. Even if taking a drug for the first time is a “free” choice, the progression of brain changes that occurs after that involves the weakening of circuits in the prefrontal cortex and elsewhere that are necessary for exerting self-control and resisting the temptations of drug use. Once addiction takes hold, there is greatly diminished capacity, on one’s own, to stop using. This is why psychiatry recognizes addiction as a disease of the brain, and why professional intervention is needed to treat it in most instances.

Moreover, even the “freely willed” first choice to take a drug cannot be the basis for judgment and stigma against people suffering from addictions. Matters of choice and lifestyle—what you eat, how active you are, where you live—may contribute to the risk for, or even directly cause, a wide range of medical conditions, including chronic diseases like heart disease, type 2 diabetes, and several cancers. We do not withhold or impede treatment of people suffering from those conditions, even if their health may have turned out differently had they made different choices at various points in their lives.

There is no way of precisely predicting which freely chosen adolescent drink, or cigarette, or experimentation with an illegal substance, opened the door to a later loss of free-choice capacity in a person who has become addicted. But once addiction is established, the sufferer from this disease cannot will themselves to be healthy and avoid drugs any more than a person with heart disease can will their heart back to perfect functioning, or a person with diabetes can will their body’s insulin response to return to normal.

Thus, those who say “it was their own choice” after a person dies of an overdose fail to grasp that an addicted person’s brain has a disrupted choice mechanism. And as revealed by Hoffman’s tragic, ultimately fatal relapse into drug taking, the neuronal disruptions in the brain of an addicted person can persist even after decades of sobriety. Speaking of “free choice” is simply not useful when trying to understand an individual’s addiction or its consequences, as addiction is precisely a disease that disrupts the neuronal circuits that enable us to exert free choice.

This page was last updated February 2014

Comments

Cure?

So what is the cure for for such a brain?

There is no “cure” (yet), but

There is no “cure” (yet), but the brain can attain a more healthy functional state with long-term drug abstinence. And, we know that at least some of the changes that drugs produce can be reversed. Moreover, treatment can help people acquire the skills to manage their disease by, for example, finding better strategies to cope with stressors when they arise and learning to avoid situations that are likely to trigger relapse. Also, for some addictions, there are medications to help prevent cravings or to reduce withdrawal symptoms. It can be a long and difficult struggle, but it can be won!

Free Will

Dear Nora,
As a psychiatrist with some philosophical training I would like to direct your attention to the non sequitur on your text about free will in which you intend to show that drug addicts have a diminished or severely compromised capacity to choose (due to biological reasons).
One thing is to present scientific data and quite another thing is to draw philosophical consequences and conclusions from these findings. From the scarce data you show us, a possible conclusion is that, in making their choices, some drug addicts use their brains in a different manner from the way control people do. It is like concluding that someone with a deformed hand cannot write instead of presuming that she will write using the hands in a different way.
As the philosopher Paul Ricouer puts it "It is not my brain who thinks, I think using my brain".
Your position is contradictory with your own answer about medical treatment as you admit that it is possible to win the fight against addiction with the proper treatment. Isn't the choice to commit to a treatment an exercise of free will?

regueira

Yo soy adicto con 9 años de recuperación. la enfermedad es crónica, por tanto no se cura; pero yo doy fe de que se puede estabilizar y hacer una vida plena, igual o mejor, debido a que la terapia grupal ayuda al crecimiento personal, a la de una persona que no padeciese esta enfermedad.

Regueira

Desde España, gracias Dra. Volkov por sus investigaciones sobre esta enfermedad, aún tan desconocida para mucha gente. GRACIAS.

Let my voice be heard

I been on methadone my drug tests come out clean I go take a hair follicle drug test and it comes back as morphine,and codeine I ask all doctors and they say that the methadone breaks down well they take my 5 year old daughter because of that then the judges here in lubbock Texas they don't understand methadone and as a result we get discriminate against methadone I been at my job over 5 years never have I got any government assistance that is why people have trouble looking for help our hospital here is ranked high around the world and when they know someone is on methadone were junkies methadone is not only for heroin it's also for many other opitas I was taking pain pills but I looked for help to better my life and look what happens to me please someone hear my voice I don't want any one else to go threw what I'm going threw

Free will

Interesting philosophical position that I have been thinking a lot lately.
No cure means that the biological changes as adaptation within the brain can not be undo like the fact that riding a bicycle can not be unlearned.
Why and how people reach sobriety and stay sober is poorly research and maybe there is the answer.

Although addiction changes

Although addiction changes the brain in a lasting way, it is probably not as “unlearnable” as riding a bicycle. Neuroimaging evidence from people with methamphetamine addiction, for example, show that after a year’s abstinence from the drug, significant recovery of lost dopamine transporters is seen—indicating a restoration of at least some of the prior ability to function without the drug. Every drug is different, and there is much we still do not know about the recovering brain, but with proper treatment (and ideally, support from the community, family, and loved ones), it is possible to at least partly undo the effects of addiction.

Strong Logic Here

I couldn't agree more.

Your contributions to the understanding and treatment of addiction are remarkable. Thank you.

treatment merry-go-round: craving, relapse, parole violation

my 30 ya has wrecked a dozen cars, the last rollover 2005, injuring a passenger resulted in felony, violation of suspended imp., jail, treatment, job, apartment, craving, relapse, broken neck, arms, teeth, felony imposed, jail, treatment, job, new apartment, craving, relapse, prison, treatment, half-way house 400 miles away, craving, job, relapse, kicked out of half-way house, new apartment, AA, craving, relapse, half-way house again, now waiting for the other shoe to drop....lost all self-esteem, all material things, fired over and over, brain rewired in an addictive way...what chance is there to arrest this free fall before disaster and death???

REHAB IS INEFFECTIVE IN CHRONIC CASES. JUDGES DO NOT BELIEVE CRAVING IS REAL

I’m so sorry to hear about

I’m so sorry to hear about your 30-year-old’s ongoing troubles; and of course, addiction is devastating not only to the person with the disease but also to their loved ones. But it is key that you not give up, sometimes it takes many attempts at rehab and treatment before a person is able to regain their life. For some addictions, medications may help; for others talk therapy, but also services to help a person get back on their feet (medical, employment, housing, etc). The main thing is to find a doctor or treatment center that is using evidence based practices, and that can individualize treatment to meet all of your son’s needs. SAMHSA’s treatment locator may be of help to you in this, and NIDA has also created a booklet to help you know what to look for in a treatment program. Recovery is possible, although extraordinarily difficult and often a very long and bumpy road.

Find Help Near You

The following website can help you find substance abuse or other mental health services in your area: www.samhsa.gov/Treatment. If you are in an emergency situation, people at this toll-free, 24-hour hotline can help you get through this difficult time: 1-800-273-TALK. Or click on: www.suicidepreventionlifeline.orgExternal link, please review our disclaimer.. We also have step by step guides on what to do to help yourself, a friend or a family member on our Treatment page.

Add new comment

Get this Publication

    About This Blog

    Welcome to my blog, here I highlight important work being done at NIDA and other news related to the science of drug abuse and addiction.

    Dr. Nora Volkow: Video Highlights

    NIDA Director, Dr. Nora D. Volkow Videos