Staying in an active addiction is a choice. I know that’s a controversial statement, but I believe it to be true. This is not to suggest that addiction itself is a choice — it isn’t — addiction itself can be considered a mental illness, and an illness is never a choice. That said, when a person continues in their addiction, that is a choice. I wish people would acknowledge that. This becomes particularly salient for those with bipolar disorder as more than half of people with bipolar disorder abuse substances.
What Is an Addiction? What Is a Substance Use Disorder?
“Addiction” is more of a colloquialism than a medical term. Medically, people have substance use disorders, not addictions, per se. Substance use disorders are categorized by substance. So a person might have an alcohol use disorder, for example.
A substance use disorder is diagnosed by 11 criteria:
- Consuming the substance in larger amounts and for a longer amount of time than intended
- Persistent desire to cut down or regulate use; the individual may have unsuccessfully attempted to stop in the past
- Spending a great deal of time obtaining, using, or recovering from the effects of substance use
- Experiencing craving, a pressing desire to use the substance
- Substance use impairs the ability to fulfill major obligations at work, school, or home
- Continued use of the substance despite it causing significant social or interpersonal problems
- Reduction or discontinuation of recreational, social, or occupational activities because of substance use
- Recurrent substance use in physically unsafe environments
- Persistent substance use despite the knowledge that it may cause or exacerbate physical or psychological problems
- Experience of tolerance: Wherein an individual requires increasingly higher doses of the substance to achieve the desired effect, or the usual dose has a reduced effect; individuals may build a tolerance to specific symptoms at different rates
- Experience of withdrawal: A collection of signs and symptoms that occurs when blood and tissue levels of the substance decrease. Individuals are likely to seek the substance to relieve symptoms
Note: People can develop addictions to behaviors as well, for example, a gambling disorder.
Note #2: Individuals can have a substance use disorder with prescription medications, but tolerance and withdrawal in the context of appropriate medical treatment do not count as criteria for a substance use disorder. (In other words, you may experience tolerance and withdrawal with appropriate medical treatment, but that doesn’t mean you have a substance use disorder.)
Substance use disorders are classified as:
- Mild: 2-3 criteria
- Moderate: 4-5 criteria
- Severe: 6 or more
Addiction in Relation to Substance Use Disorders
One might consider a particularly severe substance use disorder to be an addiction.
(I’ve always thought of addiction as the presence of both dependence on and abuse of a substance. The above 11 criteria take these concepts into account.)
Addiction Isn’t a Choice; Substance Use Disorders Aren’t Choices
According to the American Psychiatric Association, people with substance use disorders (bold mine):
“may have distorted thinking and behaviors. Changes in the brain’s structure and function are what cause people to have intense cravings, changes in personality, abnormal movements, and other behaviors. Brain imaging studies show changes in the areas of the brain that relate to judgment, decision making, learning, memory, and behavioral control.
“Repeated substance use can cause changes in how the brain functions. These changes can last long after the immediate effects of the substance wears off, or in other words, after the period of intoxication.”
In other words, once you have a substance use disorder, it’s because your brain has changed. This is not anyone’s fault. Addiction itself is no one’s fault. While some might argue that not avoiding addiction (by avoiding substances of addiction) when you know you are prone to it (say, because your parents are) places some of the blame at your feet, still, no one wants to have a substance use disorder, and no one asks for their brain to change.
Why do some people develop those brain changes due to substance use while others don’t? That’s an unknown, but just like a propensity to illness exists for cancer, a propensity to addiction also exists. We know that addiction is an inherited trait in many cases.
Staying in an Active Addiction Is a Choice
An active addiction is an addiction wherein the person is still using the substance/behavior of addiction. So, it’s a gambling addict that’s still gambling, for example. And staying in an active addiction is a choice. Your behavior, an addict’s behavior, is a choice. I know people say it isn’t, but it is. Behavior is always a choice. (Yes, there’s an exception there for people who are experiencing psychosis, but that’s not what we’re talking about here.)
This makes addiction or substance use disorders very unlike any other mental illness. Basically, a person with an addiction can choose to stop their addiction at any time. You get to quit drinking, or gambling, or drugging any time you want. You get to stop having the harmful effects of addiction in your life by ceasing the substance use. Is it hard? Yes, I suspect it is very hard. But life is hard. My life is especially hard. I don’t feel a lot of empathy for people who won’t change just because it’s hard.
Unlike Other Mental Illnesses, Maintaining an Active Addiction Is a Choice
I will never, ever be able to get rid of the effects of bipolar disorder — a person with an addiction can stop abusing their substance any time they want. Staying in an active addiction is a choice.
The person with the addiction will likely still have to deal with brain changes, i.e., cravings, and I have no doubt that is difficult (although it wanes over time), but try being on antidepressants, antipsychotics, anticonvulsants, and more for decades. It’s not exactly cake, either. And people do stop using their substances of addiction every single day, so while it may be very hard, obviously, it can happen. And let’s not forget, by not acknowledging the power of choice, we’re actually disempowering the people with addictions. They have control. That should be made clear.
So please, let’s not just say that “addiction is a mental illness like any other.” It’s not like any other. It’s an illness of behavior, and that behavior can change at the behest of the addict at any time. I would give anything to make a choice and be rid of bipolar disorder, no matter how hard it may be perceived, because treatments just aren’t cutting it.
I find it disheartening that a blog focused on destigmatization would say something so ignorant. You contradict yourself by saying that substance use disorder isn’t a choice, but that your behavior is always a choice. When your bipolar makes you do impulsive things, isn’t that too a choice and a part of your behavior? Both are hijacked by brains neuro chemistry. And no withdrawing isn’t “hard” it’s fatal- so you’re really putting people in a position to do themselves great harm by encouraging them to just “make better choices”. I have been dusky diagnosed for years there is no difference between the “choice” to go into psychosis, attempt suicide or shoot in heroin- they are all things I’d rather not choose to do.
Sorry, but as a PhD-level psychology professional and clinical social worker, I have to disagree with you. Addiction is by definition a relapsing brain disease, in which a person continues to use, despite negative consequences. If people can simply choose to stop one day, they aren’t addicted. Furthermore, there are genetic risk factors that set someone up for addiction, and there are overlapping genetic pathways that can contribute to both addiction and mental illness. A person who has a genetic vulnerability to addiction will never magically rid themselves of those genetic predispositions.
I just wrote down what you wrote-Behavior is Always a choice. That is a great perspective – one I need to think about quite a lot as to how my life looks!
My sister died of alcohol related heart and liver damage. My ex was a “garbage head “ addict that I was with for many years before I had to save myself or die. All the while when I was helping both my ex and my sister I was an undiagnosed Bipolar 1, OCD, Anxiety disorder person struggling to keep my successful business going with 14 hours days…I’m thinking there must be similar brain function with Bipolar and addiction…this may be very obvious but I never thought about that either.
I’m stable now but with huge swings, manic yesterday which I can’t control…grateful as heck I don’t have a chemical addiction!
When I say “I was a lot crazier clean” I’m talking about premedicated. Not now. That’s a whole nother story…
As an active addict and a bipolar mother I can say it’s a little more than “really hard”. I’ve come to look at my disease as more of on a spectrum as opposed to this kind of all or nothing thinking. It’s just not that simple. I spent years going to rehab, praying on my knees begging God, trying different medications, therapy, even got my kids taken away and thus far, nothing has stopped my addiction. It’s a bitch. I know your life hasn’t been a cup of tea but I struggle with my mental illness AND addiction. I don’t think you’re wrong per say but I do kind of.
Personally I try to preach harm reduction because it’s been the most helpful for me. I used to be an all out desperate junkie and now I have a job, my kids a whole life I just struggle with addiction. Idk it’s a complicated topic and I applaud you for trying to cover it but eh idk ease up. Some of us have been doing the really hard things to no avail and for me? When I used to try to get clean at all costs….it drove me to suicide. I was a lot crazier clean actually. All can say that all of the above (therapy, losing my kids, etc) helped me get to where I’m at and for that I am incredibly grateful. I have been pretty stable on meds for about 3 years but so far nothing has ever beaten this. All I can say is don’t give up, progress not perfection. But I’m not in the program because that shit is toxic:) hope this all made sense!!