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Addiction Is a Disease of Free Will

June 12, 2015

When I was five or six years old, my grandfather—my mother’s father—died of what I was always told was complications of heart disease. It was not until much later, after I had completed my medical training in psychiatry, and had already been working for a long time using neuroimaging to study the addicted brain, that I learned the real reason for his death. My mother called me one day, near the end of her life, and said, “Nora, I need to tell you something I have never spoken to you about.” She revealed me that my grandfather had been an alcoholic, and that he had killed himself in his distress at not being able to control his strong urges to drink.

This came as a shock. My mother had kept the real reason for my grandfather’s death a secret from me, even though she knew that my whole professional life was devoted to trying to understand what drugs do to the brain. She had heard me speak of addiction as a disease of the brain. So I wondered how I had miscommunicated—how I had not made her realize that it was okay to speak about addiction, that there should be no shame in it.

I’ve thought about this many times, and I realize that describing addiction as a “chronic brain disease” is a very theoretical and abstract concept. If you were a parent with a very sick child, and you went to the hospital and the doctor said, “Your child is in a coma because he has diabetes,” and the doctor went on to explain that diabetes is a chronic disease of the pancreas, would it help you understand why your child was so severely ill? No it wouldn’t. What explains it is the further understanding that the cells in the pancreas can no longer produce insulin, and we need insulin in order to be able to use glucose as an energy source—so without it, the cells in our body are energy-deprived. That explains why your child is so sick.

To explain the devastating changes in behavior of a person who is addicted, such that even the most severe threat of punishment is insufficient to keep them from taking drugs—where they are willing to give up everything they care for in order to take a drug—it is not enough to say that addiction is a chronic brain disease. What we mean by that is something very specific and profound: that because of drug use, a person’s brain is no longer able to produce something needed for our functioning and that healthy people take for granted, free will

All drugs of abuse, whether legal or illegal, cause large surges of dopamine in brain areas crucial for motivating our behavior—both the reward regions (such as the nucleus accumbens) as well as prefrontal regions that control our higher functions like judgment, decision making, and self-control over our actions. These brain circuits adapt to these surges by becoming much less sensitive to dopamine, a process called receptor downregulation. The result is that ordinary healthy things in our lives—all the pleasurable social and physical behaviors necessary for our survival (which are rewarded by small bursts of dopamine throughout the day)—no longer are enough to motivate a person; the person needs the big surge of dopamine from the drug just to feel temporarily okay … and they must continually repeat this, in an endless vicious cycle.

I go back a lot to that conversation with my mother. I realize that her shame was not just because her father had been an alcoholic, but because he had committed suicide, out of hopelessness and helplessness at his inability to control the strong urges to drink. He would try to quit, but then he would relapse, and this cycle would repeat again and again and again … until there was one last moment of self-hatred.

We can do much to reduce the shame and the stigma of drug addiction, once medical professionals, and we as a society, understand that addiction is not just “a disease of the brain,” but one in which the circuits that enable us to exert free will no longer function as they should. Drugs disrupt these circuits. The person who is addicted does not choose to be addicted; it’s no longer a choice to take the drug. Addicted people in my laboratory often say it’s not even pleasurable. “I just cannot control it.” Or they’ll say, “I have to take the drug because the distress of not taking the drug is too difficult to bear.”

If we embrace the concept of addiction as a chronic disease in which drugs have disrupted the most fundamental brain circuits that enable us to do something that we take for granted—make a decision and follow it through—we will be able to decrease the stigma, not just in families and workplaces but also in the healthcare system, among providers and insurers.

Once people understand the underlying pathology of addiction, people with the disease will not have to go through obstacles to obtain evidence-based treatments (such as buprenorphine or methadone for opioid addiction) but will simply, nonjudgmentally, receive the help they need, like a child with diabetes or a person with heart disease or cancer. They won’t have to feel that shame, or feel inferior, because people understand that they are suffering from a disease that should be treated like any other.

This page was last updated June 2015

Comments

Free Will & Dependence

I know that there are still many detractors of the "addiction as disease" position. The explanation of the loss of free will, and your own personal and tragic experience with your grandfather, are certainly points that should be taken into consideration in this debate. Thanks for the clarification.

Free Will

Does this analysis not fall apart when studies prove that when other options are provided to manage dopamine that replace alcohol/drugs that substance abuser's often choose the alternative. And if they it is a disease and not a behavior how do you account for the large number of people who experience spontaneous remission?

Drug addiction

I appreciate this discription of the addicition! It is still, as a mother of 4 girls + adopting a grandchild at age 14, very hard to deal with! I could never get enough help when they were younger & it's still the same - no one can afford it financially nor emotionally!

Treatment Options

I have been in a buprenorphine treatment program for a year and a half and I agree with the writer of this article that treatment is very difficult to participate in and shaming. I receive my dose daily at a methadone clinic that also does buprenorphine treatment. I must go everyday, wait in line (some days for over an hour), and if i do not have enough money to pay for it, I cannot get my dose. Then when I finally was able to get a job, I would drive the 15 miles one way to the treatment place, only to have to turn around and leave because the line was too long to wait and get to work on time. What employer wants their employee to be late? Especially to get drugs?It is a never ending cycle of this day in and day out. It is like getting drugs from a legal drug dealer. I never wanted to be a drug addict and I never planned this to happen in my life. We need to fix this system drastically so that other people suffering from addiction can get and maintain the help that they need. Some days I think t would be easier just to use. It is a sad world out there for people in recovery, especially when you don't have money to pay to get a private doctor and a prescription for your treatment.
Thanks for reading this.

Addiction, free will & the brain

What are your thoughts on African Iboga root bark and it's effects on the brain? Only a small percentage of addicts who use heroin are likely to remain in recovery from traditional treatment, however ibogaine has proven to be very effective for many alcohol and opiate abusers with the proper aftercare. Have you come across this in your brain research or have plans for research on this?

NIDA did investigate ibogaine

NIDA did investigate ibogaine (a hallucinogenic shrub from West Africa) as a potential addiction treatment, but we abandoned this research as the plant was found to be toxic to the brain. We are currently funding research on a related compound that is thought to be less toxic.

Addiction

I agree totally with Addiction Is a Disease of Free Will. As an opioid user on and off for 45 years, these words ring true to me. It takes many months, if not years, for one's body and mind to recover from a bout of opiod use. During that time, the temptation to use is extremely high. One can expect fatigue, low energy and recurring depression. The longer one uses opioids, the longer the recovery lasts. The challenge is even greater for a patient using opioids to mask underlining physical and psychological issues.

The problem now is that with physicians increasingly monitored for pain medication prescribing, opioid prescriptions are more difficult to obtain - even for chronic pain patients. The new laws and regulations are pushing addicts to heroin which is cheap, strong and sometimes laced with Fentanyl. The heroin delivery systems are far more sophisticated than ever before and readily available in the suburbs.

In my view, Suboxone should be the treatment of choice. In most cases, a Suboxone certified physician is limited to 100 patients and there are far too few certified physicians. The demand far exceed the availability. Further complicating matters is that a substantial portion of Suboxone patient loads require long-term Suboxone treatment further encouraging doctors to avoid long-term treatment to enable them to open the doors to new patients.

Treating patients for addiction is not rocket science. Family care physicians know their patients far more than addiction experts. I say let Family Medicine doctors prescribe Suboxone with strict standards of practice.

Disease of the will

Thank you, Dr, Volkow. Thank you for continuing to shed light on this terrible affliction; to help us remove the stigma and the shame that accompanies full-blown addiction. Defining addiction as the loss of ability to make choice is apt and accurate.

response to Nora's "free will"

Dear Dr. Volkow-

First, thank you for your response to my call for help concerning craving. My adult children and their spouses are firmly in the grips of addiction. My involvement in recovery began in 1985 with Dr. Joe Cruse and his wife's groundbreaking work in codependency, "the other side of the coin".

I believe your line of study is heading in the right direction. Wrong-headed thinking is shown by Rand Corporation's recent studies that laud South Dakota's 24/7 program as a world-wide model for punative governmental reaction to disease behavior of craving-"random drug tests-skip or fail-return to jail." @BeauKilmer

I stand ready to assist you in any manner you devise to modify the political/social stigma that hinders true recovery of all afflicted by addiction.

Please continue your leadership role in this vital medical research and treatment.

Leslie England, JD, retired SD/Colo lawyer

No that hard to quit coke.

I was a cocaine user for 10 years. About 5 of those years I was a daily user spending $300- $800 per week. I went over a year spending $800 per week straight. One day I decided that I have to stop before I end up dead. So I just stopped cold turkey. It wasn't hard, I didn't have cravings and could care less if I ever do it again in life. I've been clean for a year and a half. I believe that people that have a hard time quitting don't really want to quit and use excuses why they can't quit. The key to quitting any addiction is you truly must want to stop. I've quit cigarettes before and eating excessively. Lost 80lbs just by eating healthy and proper portions in 9 months. Bottom live you have to want to do it.

You are very lucky that you

You are very lucky that you’ve been able to quit drugs and develop a healthy eating routine to lose weight and presumably keep it off. Unfortunately many people are not so lucky-- they want to stop using drugs, they recognize the toll its taking on their lives and they suffer grave consequences of their drug use. In fact, no one wants to be addicted to drugs—but people vary in their likelihood of becoming addicted and their ability to stop using drugs. A range of genetic and environmental factors contribute to this; and we are trying to better understand these to prevent the devastating toll of addiction.

Free will

Feed the addiction the substance. This will help for better "free will" decisions. These types of people want to maintain a life. We are all high once a day. Craving begins with a thought.

Free Will

Free will was a consistent theme in my Catholic upbringing, defining the conditions for sin. A google search defines it as “a future not directed by fate.” So much history is associated with the concept of “free will” that I am uncomfortable thinking of the complex neurological, social, behavioral, and cultural processes of addiction defined as removing “free will”. The description of the brain processes of addiction also minimizes the other shapers of addiction.
Life trajectories of the addicted before becoming hooked on drugs are often characterized by low potential employment, chronic poverty, and a high probability of incarceration. There are multiple opportunities for prevention of drug abuse, other than drug inhibitors. Recent media visibility has shown how cities systematically and structurally target low income communities with tickets (parking, jay-walking) – becoming a pathway to warrants, parole and then prison. Inter-generational patterns of abuse offer ample opportunities prior to adolescence to break this pattern of abuse. School-based and family-based interventions again suggest a route to stop abuse, prior to the establishment of the disabled brain circuitry. These interventions should not be neglected while looking for the magic bullet that will block the highly-rewarding drug.

Hats Off

Dr. Volkow;
Hats off to you and to your life's work of researching the disease of addiction. I have been an opiate addict since I was 18 and I am now 58. I can relate to the concept of losing free will. the cycle of use, withdraw, recover is as chronic as the disease and it IS shaming. The whole treatment system we have in this country is set up to be nothing but shaming. Today I am on methadone and feel okay other than the fact that I am chained to klinic every day of my life. A klinic who does not understand the need to be on as appropriate dose of methadone......so I continue to use off and on. Do I want to? Is this what I want for my life? NO. I have gone periods of being clean long enough to obtain graduate degrees in counseling and addiction counseling, get my credentials and begin my career only to use and end up without a job, suspended credentials, and more guilt and shame. When does it stop? Please...continue doing what you are doing. We need you so much!!!

addiction and prevention

I appreciate the invitation to discuss a critical topic like the nature of addiction as well as your willingness to self discloses sensitive experiences of your own. Many of us have stories and experiences that motivate us to scientific careers in the study of addiction.

It is worth noting, however, that there is a danger in projecting our personal experiences with addiction onto a scientific agenda for reducing the prevalence and addiction in the communities and worldwide. Although there are many tragic stories of individuals who were unable to change their behavior in the face of addiction with alcohol, marijuana or other drugs, there are also stories of individuals that have made dramatic changes, or families who prevented children with a high genetic loading from developing drug or alcohol addiction. While certainly the brain is critically involved in the movement from use to addiction, it is also involved in the volition to move from addiction to sobriety, on ones own or in the context of support services and treatment.

Like diabetes and other chronic medical problems, the solution is never entirely medical, and the critical issue of prevention should remain as central to the scientific and community discussion. The IOM 2009 report is an excellent start for a scientific discussion on future directions that should be prioritized, as these recommendations are based on over two decades of carefully conducted, randomized trials. A recent book by my colleague Dr. Tony Biglan on the “Nurture Effect” (Biglan, 2015) also provides a comprehensive statement of the cumulative evidence in favor of attending to the environments in which we raise and education children.

The Irony, the Paradox and the unfolding American Tragedy

The Irony: Myriads who favor drug legalization justify their cause as one of individual freedom. In essence they are arguing for their mind's own 'free will' to engage in recreational drugs. Yet a certain, verifiable percentage of drug users will become addicted. The irony is that the addiction from their own drug abuse will eventually deprive their minds of the free will they originally argued for!

The Paradox: The addicted mind does not enjoy drugs! Their minds are perpetually driven in vain efforts just to regain dopamine normalcy. The euphoria is gone, even the simple pleasures in life most take for granted are lost.

The Tragedy: Drug addiction is truly a horrible condition to acquire! Yet unfortunately it appears America in the current political climate, is hellbent on marijuana legalization anyway. Proliferation and acceptance will guarantee our country even more addiction and the host of other associated problems that will plague those individuals and our society for decades to come.

choice vs free will

I was an addict and a drug dealer. I have been clean for over four years now and receiving my Bachelors for Chemical Dependency Counselor. After using heroin intravenously (IV) for many years, I understand where choices can get fuzzy and free will is very much absent. I will say though, before every poor and ridiculous decision I made during that time, there was always a glimpse of the right choice that came to mind. I often ignored it because I wouldn't feel good and I knew the one thing that would make it better. I had been in trouble many times and still to no avail, I would get out, be clean, and still go right back to getting high. It wasn't until I wanted to, and I mean really, very deeply wanted to be sober that I finally made the choice to not use today. I haven't taken any suboxone or methadone to "treat" my addiction. I am, and have always made my own conscious decisions. Whether my decisions were right or wrong, they were mine. I do not go to meetings, I don't take any medications, and am really upset when people say I am due for a relapse because I am not making the choices the government tells addicts to do. I would love to advocate for both, choice and disease, because I feel that people that were using drugs to mask other brain illnesses need to be taken seriously. But, for myself I have never had a mental illness and have made own choices. I would love to bring awareness that I am not mentally defective because I used drugs at one point in my life. I can make good decisions, I can hold a job, be respectful, abide by laws, be "normal", and have above average intelligence to boot. How and where do I jump on that advocacy train?

Free will-Voluntario

Los comentarios de la Dra Volkow siempre son importantes y sería bueno que también se pudieran traducir al español.

Constant Craving

Dr. Volkow - thank you for yet another illuminating explanation to help people understand addition.

I implore you to make another video like Constant Craving. It's about 15 years old, was produced by the BBC and featured you, AnnaRose Childress, Colin Brewer, Ernie Noble, Scripps Institute). It is the single best teaching tool that I have for helping students understand the disease process of addiction and how the brain in hijacked. The video features a woman going through opiate detox and getting a natrexone implant; a man with an unparalleled nicotine addiction that was helped with Zyban; a young man with cocaine addiction who was in a vaccine trial; an Australian man with alcohol dependence who explains the difference between genetic/environmental factors. It had old footage of a rat running across an electrified grid for cocaine.

There needs to be an update but it needs to be just as compelling and include clients. Is there any chance of such an update?

Thank you!!

NIDA does not have plans to

NIDA does not have plans to update Constant Craving. You might consider looking at the Emmy Award-winning HBO series, produced in partnership with NIDA, called Addiction - http://www.hbo.com/addiction/thefilm/ The “NIDA TV” page of our site also contains many useful short videos. One that addresses the processes of addiction is: http://www.drugabuse.gov/videos/swiss-cheese-model-drug-addiction

Beyond our ability

Unfortunately, the Dr. can only speak to the scientific basis for the addiction/free-will relationship. I acknowledge that science illuminates the biochemistry behind our addiction. However, the loss of free will, or rather, the initial decision to place oneself into bondage (or cope with pain) and thus lose one's free-will and replace it with an addiction is a spiritual act that can only be fully treated with spiritual intervention. Breaking personal bondage is ultimately the work of God, not man. Find a bible, read it, and pray for divine intervention in your life! Don't be surprised if man's solutions disappoint...

Help Finding Treatment

We frequently receive comments to this blog from persons asking for help finding treatment. We sometimes cannot publish these comments out of privacy concerns. If you think you have a substance use or mental health problem, the following website can help you find a treatment service 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. You can also visit: www.suicidepreventionlifeline.org. On our website we also have a series of frequently asked questions on what to do to help yourself, a friend, or a family member.

Addiction is not a disease

It's a repeated series choices that make a pattern of behavior. Once that behavior is engrained into the neural pathways it gets harder and harder to stop making the decision but it is a decision. There are physical addictions for some substances, to be sure. But there is no pathogen, just a choice. Calling it a disease lets people who CHOOSE to make the decision over and over again off the hook. Like somehow they're powerless to stop making the decision. That is a lie. There are psychological issues that can make someone more predisposed to become addicted to substances, but that doesn't mean they can't stop. I wouldn't see any "doctor" that called addiction a disease. It's disappointing that NIH employs/supports witch-doctors and masquerades them as actual health practitioners.

The long way home - raising the hedonistic set point

Dopamine efficacy (aka: hedonistic set point) is different for every born child. Think of it (the set point) as a big volume dial with 0 being no function and turning the dial up towards 10 increases dopamine function on a continuum with clear behaviors being expressed as you turn the dial to higher or lower set points. Most of humanity dials in at a pitiful 3 or 4 with dopamine function poorly expressed which in turn reflects behaviors like poor motivation, inability to keep goal oriented behavior on track, poor stress adaptability, aversive mood being the norm and a failure to thrive. Also for a 3 or 4 dialed person there is a huge reward hit he will feel if a dopaminergic drug is introduced, something all animals are hard wired to repeat. Today's crude dopamine drugs raise the hedonistic set point temporarily often spectacularly, something nature counteracts by producing the dynorphin protein that inhibits dopamine function with a net result of a lowering of the hedonistic set point. Now compare the 3 or 4 dialed hedonistic person with a 6 or 7 dialed hedonistic set point person. They are easy to spot: Highly motivated, member of the 1% economic group, successful life goals (good or bad), resilient to extreme stress, with a very pleasant mood something a lower set point person would describe as euphoric or under the influence of an abusable drug. A 6 or 7 dialed person will not respond to a dopaminergic drug of abuse because he is already "high" normally. The usual reaction to highly addictive drug is "it made me tired, or it kept me awake, or made me nervous". Hence there is no large reward and any animal higher than an amoeba will simply walk away from repeating the drug experience. For me, 30 thousandth of a gram of Desoxyn (2 - 15 mg yellow tablets of prescription methamphetamine) produced an epiphany with this crowning euphoria on the top of my head where I suddenly saw everything before me in a positive light and instantly understood just why my neighbor was whistling while working in his flower garden. How you see this life, how you interpret what this life is and importantly the energy you will expend to change a stressful life event is directly related to where a person's hedonistic dial number is. All addicts will dial in around 2 or 3. The lower the set point number the more aversive the day to day mood will be. If the number drops too low, you will read about it in the news as the person who jumped off a bridge or in front of a freight train or gun shot to the head etc...the aversive mood state becomes unbearable. Again contrast that to a person dialed to 8 or 9 set point (over the top) and the pathology?? is expressed as euphoric mood, pressured speech, grandiose ideas, compulsive stereotype behaviors where nothing is viewed as bad or negative. The only way the "war on drugs" will ever be won and life's playing field ever leveled and fair to all, is to raise the hedonistic set point sustainably and high enough so that when dopamine increasing drugs are taken, there is no rewarding experience only an interference with an otherwise pleasant state of mind. If only those people who state they can't imagine why people take drugs, or say just lock addicts up and throw the key away or shoot them/hang them (a 6 or 7 dialed person) if they could just be dialed down to a set point of 2 or 3, there would be a huge change in how we penalize/treat addicts and an exponential increase in research funding towards the goal of sensibly and sustainably finding a way to increase dopamine function for those in need. There is nothing more important as a goal if we are serious about reducing human suffering and nothing can hold a candle to the pain and misery that results from our present predicament and handling of the dopamine releasers. This is a problem so vast it is impossible to get far enough away from it to see it in it's entirety. It effects everyone barr none. Once the goal of optimising dopamine function for all is realized, we will see addiction, drug abuse, drug cartels, overdoses and everything related to the problems of substance use disorders melt away like snow in a spring morning sun. Until that time - the beat goes on, the damage and misery continues as does the superfluous chit chat. One day, and I can see it so clearly in my mind's eye, this will come to be.

Strange Formulation

Given Dr. Volkow's neurobiological formulation, I am curious to know why a majority of people who try potentially addictive drugs do not seem to become addicted to them. That is, what prompts some people to use over and over again, and thus, using Dr. Volkow's description, to so completely dysregulate their dopamine system that only the next hit can placate them, whereas others resist? Whatever these factors are would seem to be the more crucial piece of understanding. Most probably genetics plays a role, but what about social and situational factors, as perhaps alluded to by WAlmy above? In short, it seems this reductionistic disease model of addiction plays nicely into the hands of the pharmaceutical industry while simultaneously leaving our current social structure untouched.

It is absolutely correct that

It is absolutely correct that only a subset of people exposed to drugs become addicted to them. Risk and protective factors include genetics (which ongoing research is clarifying) as well as many environmental contributors such as stress (both in early life and later), parental and peer influences, drug availability, and mental illnesses. These factors affect how we approach prevention, and certainly if we could change the predisposing social causes (social isolation, poverty, etc.) we could greatly reduce drug abuse and the number of addicted persons. That is also true of many conditions (e.g., cancers, obesity, heart disease) that have significant social and environmental contributors that can be addressed through prevention. Yet once these conditions emerge, it is crucial that they be recognized as diseases, because medical treatments are required to address them. Failure to recognize addiction as a medical condition has produced decades of stigma that has prevented people from seeking treatment, limited the development of adequate treatments, and even when they exist, kept them from being delivered to those who need them.

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.

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    Dr. Nora Volkow: Video Highlights

    NIDA Director, Dr. Nora D. Volkow Videos

    • APA TV, May 2016
      APA TV chats with Dr. Nora Volkow, the Director of NIDA to hear about her lecture on drug abuse and the opioid epidemic.
    • Kentucky Educational Television, May 2016
      One to One with Bill Goodman: Dr. Nora Volkow
    • TEDMED, January 2015
      Why do our brains get addicted?
    • The World Science Festival, May 2013
      Meet Pioneer in Science, Dr. Nora Volkow
    • Rockburn Presents, November 2012
      Dr. Nora Volkow
    • Brookhaven National Laboratory WBNL Video, October 2012
      Chemistry celebration: FDG: Contribution to Our Understanding of Addiction
    • CBS 60 Minutes, April 2012
      Hooked: Why Bad Habits Are Hard to Break 
    • Science Times, June 2011
      Dr. Nora Volkow