The irrationality of decision-making in addiction.

A key characteristic of drug addiction is that the individual suffering from it continues to use despite harmful consequences. The behavioral economic perspective views addiction as a consequence of falling victim to decision failures that lead to a preference for the addictive behavior (Bickel et al., 2014). The following are 10 ways in which addictive consumption choices can be pathologically impaired. These dysfunctional decision-making processes also predict whether individuals retain the capacity to improve their choices (Heyman, 2009).

1. Genetic vulnerability.

Why do only certain individuals become and remain addicted? There is substantial evidence for a genetic predisposition to develop addiction (Kreek et al., 2005). For example, studies of twins and adopted children suggest that about half of a person’s vulnerability to alcohol problems is inherited. It is also possible that heavy drinking causes major changes in the
brain.

2. Self-medication.

When emotional suffering is caused by the intolerable conditions of life (tragedy), a quick “fix” offers immediate satisfaction and escape from misery (Khantzian, 2012). For example, alcohol can make us relax and forget our worries. Unfortunately, over time, the brain of a heavy drinker adjusts to the continuous consumption, resulting in anxiety and irritability. And instead of drinking to feel good, the person ends up drinking to feel normal.

3. Lack of alternative rewards.

The lack of alternative, non-drug rewards partly explains the demand for drug consumption.
Professor Hart (2013) notes that if you are living in a poor neighborhood deprived of options, there’s a certain rationality to keep taking a drug that will give you some temporary pleasure. There is now extensive research showing that providing alternative rewards to those who formerly lacked them may improve addiction treatment outcomes. That is, environmental conditions can play a major role in treating drug addiction and in preventing
relapses.

4. Impaired insight.

Chronic drug abuse is associated with impaired self-awareness (dysfunction of the insular cortex), which manifests as a denial of the severity of addiction and the need for treatment (Naqvi et al., 2007). For example, only a small fraction of heavy drinkers admit they have a drinking problem. This is one reason why some people keep drinking even after they realize it’s destroying their lives. Mindfulness is an important approach shown to improve
awareness and inhibitory control (Paulus and Stewart 2014).

5. A love-hate relationship with the drug.

Chronic drug use can lead to a separation between the predicted value of reward from the drug and its actual enjoyment (Kringelbach and Berridge, 2009). For addicts, intense wanting or craving for addictive substances is not necessarily accompanied by an enjoyment of their consumption. That is, even after the drug no longer brings pleasure, an addict can still feel a strong urge to use. They are craving the drug even when the drug is no longer
pleasurable.

6. Deadly attraction.

Attentional bias for substance-related stimuli is one’s tendency to readily notice and attend to stimuli in the environment that are related to the person’s substance use. Studies have concluded that drug-related attentional bias predicts post-treatment relapse among drug abusers (Field et al., 2009). However, there are ways to reduce its effects, the simplest of which is to avoid situations and stimuli that are related to substance use.

7. Falling off the wagon.

The late addiction psychologist Marlatt (2005) coined the term abstinence violation effect (AVE) to refer to situations in which addicts respond to an initial indulgence by consuming even more of the forbidden substance. And they feel utterly defeated. For example, “just one cigarette” quickly turns into half a pack; have “just one drink,” and before you know it, the whole bottle is gone. The bias occurs when an individual views his relapse as a deviation
from his commitment to absolute abstinence.

8. Overvaluation of the immediate reward.

Impulsivity is the inclination to seek out immediate gratification at the cost of long-term gains. For an addict, the decision to continue to use may reflect the impulsive system dominating the deliberative process. Thus, events that are more immediate in time (such as having the drug now as opposed to the delayed consequences) have a stronger capability to influence decision making. Moreover, research suggests that alcohol and other drug abuse
may impair the reflective mind, which is responsible for a wide range of control, including inhibition, sustained attention and planning (Volkow and Baler, 2014).

9. Stress.

There is solid evidence on the link between chronic stress and the motivation to abuse addictive substances (Al’Absi, 2007). For instance, research in human studies shows that adverse childhood experiences, such as physical and sexual abuse, neglect, domestic violence, and family dysfunction, are associated with an increased risk for addiction. High emotional stress is associated with a loss of control over impulses and an inability to delay gratification. Moreover, poverty or the scarcity of resources is stressful in nature and can lead to emotional distress and subsequent drug use.

10. Projection bias.

This bias describes the tendency for individuals when “cold” (i.e., not craving) to mispredict how they will behave when “hot” (i.e., craving). The behavior stems in part because people cannot recall the intensity of their own past cravings. The failure to vividly recall or anticipate the discomfort of craving can explain why people overestimate their own abilities to resist the craving. The challenge for an ex-addict is to keep “alive” memories of the unpleasantness and power of craving.

In summary: Drug addiction is associated with altered decision making that appears to overvalue pleasure, undervalue risk, and cause failure to learn from repeated mistakes. Thus, addiction might be best viewed as a chronic disease, such as heart disease or diabetes, and not a moral failure, so that most addicts will require long-term treatment, and relapse can be expected to occur sometime during the treatment. Therefore, the occasional relapse
is only a predictable setback, not a failure of the treatment.

References

Al’Absi Mustafa (2007). Stress and Addiction: Biological and Psychological Mechanisms (2007) Academic press.

Bickel, W. K., Johnson, M. W., Koffarnus, M. N., MacKillop, J., & Murphy, J. G. (2014). The behavioral economics of substance use disorders: Reinforcement pathologies and their repair. Annual Review of Clinical Psychology, 10, 641-677.

Field M., Munafò M. R., Franken I. H. A. (2009). A meta-analytic investigation of the relationship between attentional bias and subjective craving in substance abuse. Psychol. Bull. 135 589–607.

Hart, Carl (2013) High Price: A Neuroscientist’s Journey of Self-Discovery That Challenges Everything You Know About Drugs and Society Harper.

Heyman G.M. (2009) Addiction: A disorder of choice. Cambridge, MA: Harvard University Press.

Khantzian, E. J. (2012). Reflections on treating addictive disorders: a psychodynamic perspective. The American Journal of Addictions, 21, 274-279.

Kreek et al. (2005), Influences on impulsivity, risk taking, stress responsivity and vulnerability to drug abuse and addiction Nat. Neurosci., 8 (11): 1450-1457.

Kringelbach ML, Berridge KC (2009). Towards a functional neuroanatomy of pleasure and happiness. Trends Cog Sci.;13:479–487.

Marlatt GA, Witkiewitz K. In: Relapse Prevention for Alcohol and Drug Problems. 2. Marlatt G Alan, Donovan Dennis M, editor. Relapse prevention: Maintenance strategies in the treatment of addictive behaviors; 2005. pp. 1–44. 2005.

Naqvi, Nasir H., David Rudrauf, Hanna Damasio, and Antoine Bechara (2007). Damage to the Insula Disrupts Addiction to Cigarette Smoking. Science 315: 531-534

Paulus MP, Stewart JL. (2013). Interoception and drug addiction. Neuropharmacology. 2014 Jan;76 Pt B:342-50.

Volkow, N.D., Baler, R.D. (2014), Addiction science: Uncovering neurobiological complexity, Neuropharmacology,76, 235-249.