Imagine there is a crowd of onlookers next to a lake where there are people in the water who are drowning. Instead of throwing a rope out to the drowning people to pull them in and save their lives, everybody just stands at the shore of the lake arguing about whether the drowning people fell into the lake or jumped in. You see where I’m going with that? Both sides of the disease vs. choice argument contain elements of truth, which fuels the fire of the circular debate which is usually just steeped in dogmatic fallacy. Meanwhile, according to the Center for Disease Control, 72,000 people lost their lives in 2017 just to drug overdose (not including deaths from alcohol abuse). So in effect, 72,000 people “drowned” – that’s more people than most football stadiums can hold.
Is it a choice? Of course – nobody was born with a bottle of vodka in their hands or a heroin needle in their arms. At some point, in everybody single person’s life, they made a choice to take a risk and do something they know they should not do. For instance, many took the risk of having unprotected sex when they were in high school. Most people in their lives gambled for the first time, smoked that first cigarette, drank that first beer or shot of whiskey, smoked that first joint, etc. People made a choice to take a risk. For most people, the choice to take that risk did not result in a life shattering series of events going forward. But for the millions of us, whether we fell into substance abuse, were pushed into substance abuse, or gladly jumped into substance abuse, we continued to make the choice to use those substances, even after it became an imminent and immediate threat to our life and threatened to destroy the lives of our families. So technically yes, we made a conscious choice.
Is it a disease? The policy of the American Medical Association under the “disease theory”, for both psychiatric and medical sections of their policies, states that addiction and alcoholism are diseases: “The AMA endorses the proposition that drug dependencies, including alcoholism, are diseases and that their treatment is a legitimate part of medical practice.” But arguments have been made that those classifications were made for economic or political reasons, in particular third party reimbursement (insurance) for the treatment of addiction and alcoholism. There have also been several recent studies that challenge the classification of addiction or alcoholism as a disease. But right now, almost all health organizations classify addiction/alcoholism as a disease. So technically yes, it is a disease, or at minimum an “illness”.
So both sides of the disease/choice debate can claim legitimate support for their positions. In reality, it is technically both a disease and a choice, or at least a choice that leads to or becomes a disease or an illness (or whatever it may be called). But in reality it is much more easily and simply defined than just a disease or a choice, because it may be both and it may be neither.
Most people don’t like the feeling of loss of control created by heavy alcohol or drug use, or the sickness that follows, so they rarely ever return to that place. But for the rest of us millions of people, the euphoria generated by alcohol or drugs created a neural pathway (a mind road) to a euphoric escape from the reality of life – “The Escape Road”. We became drawn back to The Escape Road like moths to a light. There are a variety of opinions and another hornet’s nest of debate under the root cause behind that predisposition – genetic vs. environment, nature vs. nurture, inherited vs. acquired, etc. Whatever the cause, for those of us who have abused substances, we found the feeling of euphoria and the relief of The Escape Road something that was almost impossible to resist. Drugs and alcohol provided a magic carpet ride away from mental pain, physical pain, even spiritual pain. It temporarily soothed the misery of bonafide mental illnesses like PTSD from childhood or adulthood trauma, Bipolar Disorders, Generalized Anxiety Disorders and others. So once we had a taste of that relief and the euphoria of walking on The Escape Road, we found ourselves back on it until it became a habit, then a physical/mental dependency, and ultimately an addiction.
Once The Escape Road was heavily paved and we were in full blown addiction, the shame of our addiction, and the guilt of our activities, gets added to the heavy mental illness baggage many of were carrying around before we became addicted in the first place. So we became even more thoroughly entrenched in traveling on The Escape Road to obtain relief. While we may have wanted to step off, we knew that doing so would result in, not only the return of the weight of the pain we were trying to obtain relief from, but also the addition of the heavy anxiety and horrible misery of withdrawal. In the case of drugs like alcohol, withdrawing from it could be life-threatening. Our minds are intuitively aware of this, so a fight or flight response would be triggered when faced with sudden withdrawal. When all of these things are taken into consideration, when someone is in full blown addiction, the decision to continue using may arguably not even be a choice, but rather a natural survival-type auto response. We were willing to do whatever it took to stay on The Escape Road, including lying, cheating, stealing, hurting ourselves, hurting others, risking our lives, even risking other people’s lives. None of this is intended to provide a justification for substance abuse nor is it intended to provide some rationalization to the millions of people who lost friends, family, and people they loved to addiction or alcoholism. Those people who suffered loss are filled with deep intense sadness, burning anger, smoldering resentment, agonizing frustration, and a host of other horrible emotions they are feeling. Which is completely understandable and heart breaking. But maybe a modicum of understanding in how this happened might help at least take a small step towards placating some of these emotions and provide at least a little peace.
When a person is drowning in the lake of addiction to drugs or alcohol, they cannot be “enabled” because enabling them is like pushing their heads under the water. But those people who are drowning need to have a rope thrown to them so they can be helped to make the decision to pull themselves out of the water. People need education on what can be done to help those who are struggling with addiction make that choice, and to help them without enabling them. Once people have made the choice to recover, hopefully with help, there are a variety of different recovery programs and recovery paths that people can follow. There are many arguments and studies on whether abstinence-based recovery is the best approach or not. But for people who have had major issues with addiction to alcohol for example, the idea of returning to it under a controlled drinking or moderation environment could be potentially catastrophic. Because if they are on the path of moderation, which they would argue is not traveling directly on The Escape Road, they are in effect walking along on the shoulder of that road. Major hardships, or a serious of smaller hardships that often coincidentally happen simultaneously, are common to everybody. It is not a question of if, but a question of when. When those hardships happen, The Escape Road would be right at their feet (since they are walking on the shoulder), so then returning to it would be an all-too-easy natural progression and would only take one tiny step up.
The mind will never completely forget the feeling of euphoric escape through drugs or alcohol, so The Escape Road and the knowledge of that escape hatch is always going to be there. It is always possible to be consciously or subconsciously drawn back to it, so a person who has been addicted to substances is never completely “cured”. From that standpoint, a person who has been addicted could be considered permanently “diseased”, as is a common reference in 12 step programs. There is a recovery catchphrase that says “once an addict, always an addict”. Because the mind will never forget The Escape Road and the feeling of euphoric escape, that catchphrase is not at all inaccurate. I knew someone who had been sober for 25 years, regularly worked a recovery program, was happy with her life, and in a state of well being. One morning, her car was covered with snow from the night before, she couldn’t find her keys, was late for work, her car wouldn’t start, she was yelled at by her boss, had a bad day besides, and ended up stopping at the liquor store on the way home without even thinking about it. Three days later she was in detox and almost died. The Escape Road is always there.
If we make a decision, hopefully with help, to withdraw from our drug of choice and obtain sobriety, our minds will still never ever forget the feeling of The Escape Road. Fear is one of the worst motivators there is, so fear of drugs/alcohol, or fear of relapse or returning to The Escape Road, may not be the best approach by itself. But even fear can keep people off of that road. A much better approach is using reputable recovery programs, individual therapy, learned coping mechanisms for dealing with life’s difficulties, safe medication for people suffering from mental illnesses, and physical/mental activities that release things like endorphins and natural dopamine. All of these positive things can establish brand new neural pathways, or healthy new highways that the mind can travel on, which allow it to permanently steer clear of The Escape Road. Once we are on the road of recovery, with the proper tools, support and new neural pathways, we are able to always ‘make the choice to avoid the disease’, permanently stay off The Escape Road, and stay on the new healthy mind highways we have paved.