When I was arrested in 1986 and charged with possession of cocaine with intent to sell, I was addicted to both Coke and heroin. Even though I faced 15 years to life in prison, the first thing I did after my parents bailed me out and had a family conference was to find and surreptitiously inject some prescription opioids that I knew the police had not confiscated.
I knew that doing so would further jeopardize my life prospects and my relationships with everyone I cared about. I know it doesn’t make sense. But I don’t believe I could have coped any other way. Until I finally realized I needed therapy and began recovery in 1988—the prospect of a long prison sentence under New York’s draconian Rockefeller laws still hindering my future—I didn’t think I had any real options.
Had my brain been hijacked by drugs – or had I deliberately chosen to risk it all for a few hours of selfish pleasure? What keeps people on drugs like street fentanyl, putting them at risk of death every day?
These questions are at the heart of drug policy and the way we view and treat addiction. But simplistic answers hinder efforts to improve substance use disorders and reduce stigma.
Research now shows that being addicted does not mean being completely subject to irresistible urges, or making completely free choices. The impact of addiction on decision-making is complex. Knowing about them can help policy makers, treatment providers, and family members aid in recovery.
Claims that addicts have no control over themselves are overshadowed by basic facts. Few of us inject drugs in the presence of the police, which means most have the ability to delay use. Addicted individuals often develop complex plans over days and months to obtain the drug and hide use from others, again suggesting purposeful activity. Those who have the option will use clean needles. In addition, small rewards for drug-free urine tests—for a type of treatment called contingency management—have been very successful in helping people quit smoking, which would not be possible if addiction eliminated choice.
However, those who believe that substance use disorders are just a series of egocentric decisions also face conflicting evidence. Most notably, addiction persists despite terrible losses such as being cut off from family or friends, being fired from a job, becoming homeless, contracting an infectious disease, or being repeatedly imprisoned.
Most people who try drugs do not become addicted, even to opioids or methamphetamines, suggesting that there are factors beyond simple drug exposure that can lead to addiction. Most addicted people had other mental illnesses, traumatic childhoods, or both—only 7 percent reported no history of mental illness. Nearly 75 percent of heroin-addicted women have been sexually abused as children — and most with any type of addiction have suffered at least one, and often multiple, forms of childhood trauma. The data suggest that genetic and environmental vulnerabilities influence risk.
So how does addiction affect choice? Neuroscientists and philosophers are beginning to assemble answers that may help make policy more humane and more effective.
The brain can be thought of as a predictive engine, constantly calculating what is most likely to happen next and whether it will be beneficial or harmful. As children grow, their emotions and desires are tuned to guide them in directions that their brains predict will meet their social and physical needs. Ideally, as we evolve, we gain more control and the ability to optimize our choices.
But there are many ways these different processes can contribute to addiction and change the way a person makes choices and responds to consequences.
Traditionally, researchers have focused on changes in drug experience during drug addiction. At first, it’s fun to use, maybe exciting, maybe soothing. It addresses things like social anxiety or lack of fun. Then, however, it becomes less effective: more is needed to achieve the desired effect, and coping without it begins to seem impossible. As the addiction takes root, cravings for the drug can intensify, even if they become less pleasurable.
From my own experience with cocaine, the disconnect is stark. At first, I found it euphoric. Near the end of my addiction, I was injecting dozens of times a day and desperately wanted Coke but also knew it would make me feel terrible. Motivational salience theory suggests that addiction is a matter of excessive “wanting,” which becomes less and less accessible to cognitive control over time, despite a reduction in “likes.”
During addiction, people also tend to prioritize short-term rewards over long-term gains, meaning they often postpone the pain associated with quitting smoking indefinitely. This idea, known as “delayed discounting,” further helps explain why people with chaotic childhoods and unstable incomes are at higher risk: When a bright future seems unlikely, it’s rational to take whatever pleasure you have in the present.
Chandra Sripada, a professor of psychiatry and philosophy at the University of Michigan, believes that distorted thinking is more important than overwhelming cravings in addictive behavior, leading to what he calls “unreliable “control. He focuses on how addiction affects our stream of consciousness.
He argues that during an addiction, hopeless thoughts about oneself and the future — not just about how good the drug is — predominate. At the same time, thoughts about the negative consequences of use are minimized, as are thoughts about other ways of coping. Drugs are overrated as a way to relieve pain; everything else is underrated. The result is a precarious balance that tends to get higher and higher.
The theory helps explain who is most likely to become addicted and what is most likely to produce recovery. Risk factors such as poverty, traumatic childhood, and mental illness can create excess stress while being prone to negative thoughts about yourself. In my case, I felt depressed and isolated because I later learned I had an undiagnosed autism spectrum disorder — and hated myself for not being able to relate. The result is a mental climate conducive to drug dependence, even when the drug no longer provides relief.
Factors associated with recovery—such as social support and employment—can counteract distorted thinking and inflated valuations of drug use. Essentially, when people recognize and have access to better options, they make better choices. If you’re locked in a room with an escape route hidden under the rug that you don’t know about, you’re stuck as if that exit didn’t exist. My recovery began when I saw that there was a tolerable way out.
That’s why punitive approaches often backfire: causing more pain for those who see drugs as their only way to cope, driving them to crave drugs even more. Punishment doesn’t teach new skills that lead to better decisions. I was lucky to get help before it was too late.
But if addicted people make choices that are harmful to themselves or others, shouldn’t they be held accountable for their actions? Hannah Pickard, a distinguished professor of philosophy and bioethics at Johns Hopkins University, has called for a framework she calls “duty without responsibility.” In this view, addicted people do have some control over their decisions. However, this does not mean that they are to blame or that shaming and punishing them will improve the situation.
Instead, providing people with the skills and resources they need to change and compassionately holding them accountable as they learn to choose differently can foster recovery. (The approach is a form of therapy, not designed to adjudicate addiction-related crimes, though the idea could extend to the legal realm.)
Defining addictive behavior as an involuntary brain disease reduces the tendency to blame it on people, research has found. But this view does not necessarily lessen the stigma or desire for punishment. This may be because the belief that individuals have no autonomy dehumanizes them and makes others want to lock them up to protect society.
The concept of “responsibility without blame” offers a solution: People with drug addiction have agency, but it is compromised. This is not unique to addiction.
“If I’m exhausted, tired and distracted, I have less control if I get a good night’s sleep in a stable, happy place in my life,” said Professor Pickard, noting that “hunger” is a classic Example of reduced emotional control.
To recover, addicts need both new skills and an environment that offers better choices. This doesn’t mean rewarding people for bad behavior. Instead, we must recognize that compulsive drug use is often a response to a life where meaning and comfort seem out of reach, rather than a selfish pursuit of excess pleasure.