philcain

by Matt Field

Consider someone addicted to alcohol, drugs, or a behaviour like gambling. Why do they continue, even when they say they want to stop? It’s a question that highlights a fundamental disconnect: the gap between intention and action.

This apparent contradiction aligns with clinical definitions of addiction and with brain disease models, which suggest that repeated substance use changes brain function, making drug use compulsive and automatic, bypassing conscious decision-making. These brain adaptations help explain why addiction is so hard to overcome.

But there’s another important piece to the puzzle. People often use substances for reasons that make sense to them – to feel good, to relieve stress, or to connect socially. These motivations don’t disappear just because a substance becomes harmful.

Yet, over the past few decades, this insight has been sidelined in addiction science. Some critics have jumped on this gap to argue, reductively, that addiction is simply about people choosing pleasure: nothing more than “people take drugs because they enjoy it.”

Both the brain disease model and the “just say no” view contain partial truths. But both, on their own, are fundamentally flawed.

The brain disease model gained popularity in part because it seemed to offer two things: a foundation for developing new medical treatments and a way to reduce stigma. But it’s largely failed on both fronts. Despite billions invested in neuroscience, few new medications have emerged.Meanwhile, the most effective treatments remain psychosocial: talking therapies and harm-reduction strategies that have been around for decades. Worse, describing addiction as a chronic brain disease may increase stigma and pessimism, making recovery seem unlikely or out of reach.

Additionally, research shows that addiction is not entirely beyond voluntary control. People with addiction can and do reduce or stop their drug use in response to its consequences. This can be related to meaningful life changes — such as getting married, having children, or starting a new job — which may increase the costs or reduce the perceived benefits of continued use.

These findings challenge the view that addiction is purely compulsive, highlighting that people retain a degree of agency, even under difficult circumstances.

At the same time, these observations don’t justify the cynical view that addiction is just hedonism or bad choices. A more accurate, and more helpful, framework considers how people make decisions and how their environment shapes the value of different choice options.

Neuroeconomics
This is where insights from neuroeconomics – the study of how the brain makes value-based decisions – become useful. For example, one study found that when people are hungry, they pay more attention to how food tastes and less to how healthy it is, making unhealthy choices more likely.

Similarly, alcohol users who were craving alcohol and in a negative mood were shown to value alcohol more than food, shifting their choices accordingly. Other research has found that the set of available alternatives strongly influences how appealing (or not) a choice options becomes. As applied to addiction, when healthier or more rewarding options are limited, the relative value of drugs increases.

This suggests that addiction is less about losing the ability to choose and more about how context shapes choice. When someone is in treatment, they may genuinely want to stop using because the environment emphasises recovery, support and future goals. But once they return to a setting where drugs are easy to access and attractive alternatives are few, the relative value of drug use increases – and relapse becomes more likely.

This perspective also helps reconcile the role of brain changes in addiction. Neuroadaptations still matter: they can heighten cravings or make rewards harder to experience – but they don’t eliminate the ability to choose. Instead, these brain changes interact with a person’s environment to make certain choices more likely than others.

Crucially, this view also highlights why poverty is such a powerful driver of addiction. In deprived settings, alcohol, drugs and gambling outlets are often more accessible, while opportunities for meaningful alternatives – employment, education, stable housing – are scarce. These are deep-rooted structural issues, and they’re not easily fixed. But they matter.

On a more hopeful note, this model points to new pathways out of addiction. Rather than blaming individuals or pathologising them as brain-damaged, we can focus on reshaping environments to make non-drug alternatives more visible, available and valuable. This approach carries less stigma and more optimism: it views people not as broken, but as people who can make decisions and respond rationally to difficult situations.

Yes, the psychology of decision-making makes addiction tough to overcome. But by understanding how people weigh their options, and by improving the appeal and accessibility of alternatives to substance use, we can support real, lasting change. ■

Matt Field Professor of Psychology, University of Sheffield. This article is republished from The Conversation under a Creative Commons license.