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. 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 to drug overdose (not including deaths from alcohol abuse). So in effect, 72,000 “drowned”, that’s more than most football stadiums hold, while people debated.
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 that they should not do. For instance, many took the risk of having unprotected sex when they were in high school, most 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, 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 posed 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 “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 reasons, in particular third party reimbursement (insurance) for the treatment of addiction and alcoholism. There have also been recent studies that challenge the classification of addiction or alcoholism as a disease. But right now, almost all major 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. Nobody willingly chose to become an addict or an alcoholic, but by the same token nobody contracted addiction because an addict sneezed on them. 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), so the debate rages on. However 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 pains 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 the predisposition for addiction – genetic vs. environment, nature vs. nurture, inherited vs. acquired, or just an accident. 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 returning until it became a habit, then a physical/mental dependency, and ultimately an addiction.
Once The Escape Road was heavily paved and we became mired in full blown addiction, the shame of our addiction, and the guilt of those activities, got 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 loss of our escape hatch, but the return of the weight of the pain we were trying to obtain relief from, and we were also faced with the paralyzing anxiety and crushing misery of withdrawal. In the case of drugs like alcohol, suddenly withdrawing from it can be life-threatening. Our minds are intuitively aware of this, so a fight or flight response was triggered when confronted by withdrawal. Because our addiction backed us into a corner, our hijacked minds imagined that our lives were threatened by withdrawal, and we were faced with the loss of our only escape route, 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. When all of these things are taken into consideration, when someone is in full blown addiction, the decision to continue using may not even be a choice (arguably), but rather a survival-type auto response.
Now 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. Which is completely understandable and tragically heart-breaking. But maybe a modicum of understanding in how and why this often happens might help take a baby 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 been helped to make the choice to recover, there are a variety of different recovery programs and recovery paths that they can follow. There are some arguments and studies on whether abstinence-based recovery is the best approach or not. However, for people who have had major issues with addiction to alcohol for example, 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 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 already walking on the shoulder), so then returning to chemical dependency full physical/mental addiction would be an all-too-easy natural progression, and would only take one small push.
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 will always be possible to consciously or subconsciously get 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 in those programs that says “once an addict, always an addict”. Because the mind will never forget The Escape Road and the feeling of that euphoric escape, from that view, that catchphrase is not at all inaccurate (albeit perhaps stigmatizing). I knew someone who had been sober and abstinent for 25 years, regularly worked a recovery program, was happy with her life working as a nurse, and was in a state of overall well being. One winter 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 never forgotten.
If we are helped to make the decision 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 for anything, so fear of drugs/alcohol, or fear of relapse or returning to The Escape Road, may not be the best approach, just by itself. But even fear can still keep people off of that road. A much better approach is using reputable recovery programs and/or group support, individual therapy, learned coping mechanisms for dealing with life’s difficulties, safe medication for people suffering from mental illnesses who have a substance abuse history, and physical/mental activities that release things like endorphins and natural dopamine. Any 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 (or recovered), and traveling on these new neural pathways, we are able to always ‘make the choice to avoid the disease’, permanently stay off The Escape Road, and remain cured on the healthy new highways we have paved.