Nora Volkow, in the first two sentences of this post, provides more clarity than I think I’ve every seen on the matter of choice and the brain disease of addiction:
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.
via Nora’s Blog Addiction and Free Choice | National Institute on Drug Abuse (NIDA).
The NY Times recently had a Room for Debate feature on addiction. They published opinions from 6 different people on addiction with one being a clear advocate for the disease model. This is a little like publishing a debate feature on climate change and having 1 of 6 experts believe that global climate change is occurring.
Two of the writers, Carl Hart (previous posts on Hart) and Gene Heyman (previous posts on Heyman), emphasized pleasure.
It’s well established that addiction is a disorder of the pleasure pathways. When other parts of the brain (related to, say, vision or movement) or other organs experience disorders, we don’t devote NY Times features to whether they really are a disease or whether choice is a factor in the illness. However, when pleasure enters the picture, we have a very difficult time surrendering the notion that we are, or should be, in full control of our behavior.
Kevin McCauley addresses the role of pleasure in advocacy for the choice argument:
Addiction is a disorder of the brain’s ability to properly perceive pleasure. I think it’s this moral loading of pleasure that makes it harder to accept that this is a disease process. It’s easier to just write addicts off as bad people who just want to feel good. In fact, that’s a corollary of the choice argument. It says exactly that, “Addicts don’t shoot gasoline into their veins, they shoot drugs into their veins! And, why? Because it feels good. Addicts do it because it feels good!”
In fact, there’s a sentence in the AA big book that says basically the same thing, “Men and women drink essentially because they like the effect produced by alcohol.” And that’s exactly right. What addiction is, is a defect in the brain’s like mechanism. Pleasure is the capacity of the brain, and being a natural organ, the brain can break. And, addiction is, at it’s heart, a broken pleasure sense.