Saturday Q&A 2.8.20 – How Does Addiction Develop?

Jacob asked, “How does addiction develop?”  I’m pretty sure this knowledgeable, thoughtful reader has his own extensive theory on the topic. Still, I will do my best to provide as succinct an answer I can while appropriately answering this important question.  There are a many links used as references in this article; I’d encourage you to click on them and help you form an opinion of your own.

For many years, people believed that addiction was an indictment of someone’s moral fiber.  If you were an alcoholic or an addict, then there must be something wrong with your soul, or you must be a bad person.  There is, of course, no science to support this archaic belief, but that doesn’t stop uneducated and stubborn, usually angry people from continuing to think it.

Many people also place blame on the substance abuser and do not understand why they keep making bad choices over and over.  “Just stop already,” is a phrase I’ve heard more than once from loved ones of people afflicted with addiction.

I broke one of my life-rules and read the comments on this article and was amazed to see so many people posting vitriolic responses.  There is a common theme in their posts, though.  Many people are deeply hurt by the choices that addicted people make.

It’s no wonder they’re so angry.

(To understand the hurt addiction can cause, I recommend the book, Beautiful Boy by David Sheff.  And for a stylized Hollywood thriller that accurately demonstrates what it’s like to deal with an addicted loved one, “Ben is Back” starring Julia Roberts and Lucas Hedges is terrific.)

There’s a lot of debate about addiction as a disease or as a choice.  But what if addiction is actually a disease of choice?  What if psychologically the disease of addiction prevents one from being able to make the choice to stop using?  I don’t know anyone who grew up choosing to be an addict.  I ask kids nearly every day, “What’s your dream job?”  Not one of them has ever said “Drug addict.”  I’ve had some say “drug dealer” and even one cheeky fella said “porn star” once.  Those answers are both about greed, by the way.

No one aspires to the life of a junkie.  Also, everyone who struggles with addiction makes daily choices about their substance use.  Some of them are able to choose sobriety but others choose to keep using.  Usually, if you ask they’ll affirm their desire to be free from the bonds of addiction.

Without the element of circumstance, people would be able to make the right choice 100% of the time.  But there are factors that dictate our ability to choose wisely.  For instance, if I’m hungry I could choose to go to McDonald’s or I could choose to go to Jeff Ruby’s Steakhouse.  In a world where money doesn’t matter, I could choose either.  And 100% of the time, without circumstances in the way, I’d go with the high-end steak. Every single time.

The problem is that circumstances are a factor and as a result, McDonald’s fits squarely inside my budget.  There’s also a million locations and some of them are even open 24 hours.

While definitely not the same thing (hunger isn’t nearly as powerful as opiate withdrawal) for an addict who’s feening for a hit, the choice might be whether or not to buys drugs or alcohol or to go to an AA or NA meeting.  Which of those is easier?  If it’s 4am, which of those is more accessible?  Depending on where they live, it might be that they can walk outside and down to the corner to get their fix.  It’s likely that they don’t have access to an AA meeting at 4am.  Which is cheaper – a 40 ounce or an Uber?  That late at night, their sponsor might not hear the phone ring.  The dealers and convenience stores are up all night.

My point is, life circumstances make choices harder for some people.

People often feel like the disease-model of addiction gives people an out for bad choices.  However, if we understand that part of the disease is how the brain is affected, maybe we’d have a little more compassion.  Still, It hurts when people let us down, take advantage of us, or even abuse us in the name of addiction.  Empathy isn’t always easy.

Addiction is genuinely a complicated medical and philosophical problem.  I’ve found, though, that judgmental attitudes rarely help someone heal.




ASAM (American Society of Addiction Medicine) published an updated definition of addiction on September 15, 2019:

Addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences.  Prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases. 

I agree with ASAM because the research – and my professional experience – supports their assertion.  While there are people who get hung up on the term “disease”, we must approach the treatment of addiction the way we treat other chronic conditions.  People with diabetes have to change their behavior in order to be healthy; so do those afflicted with addiction.

While I could write pages and pages about the broad topic of addiction, the question was, “how does addiction develop?”  Sometimes this is asked, “nature or nurture?”  By simplifying the issue with a closed question, we may be missing the more significant problem.  If we limit the root causes to upbringing or genetics, then we really only have two treatment philosophies.  We either give people medicine to change their biology, or we therapize them with conversations unpacking their family of origin, trauma history, and life experiences and provide them with a toolbox of strategies to help them cope with the things they cannot change.  If you want to explore more of this topic, I recommend this TEDTalk from Johann Hari (and this contrasting article) and this short video featuring celebrity doctor, Dr. Drew.

If we agree that it might be a combination of both nature and nurture, we can combine the two options.  This is the current best-practice model in addiction treatment.  Medicated-assisted treatment, which combines cognitive-behavioral interventions with medication like Suboxone or Vivitrol, is standard – and as effective as anything we’ve tried before.

But what if it’s something else?

For instance, what about the sixteen-year-old basketball star who broke his ankle on the court was prescribed a highly powerful opiate and then became addicted to it?  He has no history of addiction in his family.  He comes from a well-adjusted, loving home. He’s not had anything awful happen to him, and he’s generally a nice kid.  How do we explain the development of his addiction? Do we blame the doctor who prescribed his medication?  Do we blame his parents for not monitoring his dosage better?  Do we blame him for making poor choices?

Why does someone always have to be at fault?



In 2016, the Cincinnati Zoo suffered a tragedy when Harambe the gorilla was shot and killed after a toddler made his way into his habitat. Immediately, the public rushed to judgment. Everyone had an opinion on who’s fault it was.  Was it the zoo? Was it the parents? It’s human nature to blame someone.  But here’s some hard truth: sometimes bad things happen.  Sometimes there’s no rhyme or reason.

Sometimes shit happens.

In the case of the 16-year-old above, some would say there must have been some genetic predisposition in his brain chemistry that was unlocked by this particular medication regiment.  Perhaps. Or maybe he had some underlying mental health problem that was lying beneath the surface of his privileged life.  Perhaps his privilege led him to not understand the consequences of opiate misuse?  All of the above are possible.




The value of understanding how addiction develops is two-fold; yes, it informs our treatment practices, but it also helps us know how best to provide prevention programming.  We know that the 1980’s “War on Drugs” method was a giant failure“Just Say No” is just like “Just stop already.”  The memorable, “This is your brain. This is your brain on drugs” ad might have had some effect on the Gen-Xers who grew up with those commercials, but overall scare-tactics don’t workD.A.R.E. hasn’t been all that successful as prevention programming, either.

In this study, researchers found some evidence that relationships positively impact recovery.  “Strengthening bonds with the social world can weaken bonds with substance use.”  It’s worth a read, and it makes me wonder how much having positive relationships aids in the prevention of addiction, as well.

There’s not much research about the correlation of how much positive mentorships like Big Brothers/Big Sisters programs, youth ministers, coaches, teachers, and even parents and older siblings have on the development of addiction – but I believe that they certainly can’t hurt.

I subscribe to a counseling theory called “Relational-Cultural Therapy.”  At its essence, RCT places emphasis on the relationship as the healing mechanism by which people get better.  Therefore, it makes sense that I would gravitate towards the idea that connection is crucial in recovery.

Therefore, the proactive thing to do as a society would be to do our best to ensure people are well-connected to others.  If we open our hearts to others, love each other, and engage in supportive relationships we just might eradicate all the evil in the world.  I’m not sure how feasible that is, though, in our currently divisive culture.  It makes me incredibly sad.


As we’ve discussed, my worldview originates mostly in Judeo-Christianity so that’s the framework by which my theories and philosophies about life are rooted.  You are entitled to your own framework, which then influences your thinking on this and many other topics.  If you do not agree with me, I hope my thesis at least causes you to evaluate your own.

In my study of the Bible, I learned a fundamental principle that has stuck with me.  When someone “sins” (you can use whatever word you’d like in its place within your own spiritual framework), the question to ask is, “what internal need is the external act fulfilling?”  For me, a “sin” is any behavior that is harmful to you or another person.  (I could write a lot more on this topic and maybe I will someday.)

The Bible chronicles what sinfulness looks like with specific examples (like those in the Ten Commandments), but I believe that “morality” is designed around God’s desire for us to be well.  Therefore, the “rules” are designed to guide us into a good, happy, satisfying, and healthy life.

When our soul is missing something, we instinctively look outwardly to find it.  A lack of self-esteem, loneliness, depression, despair – those feelings are the root of a lot of external searching.  There are a lot of unhealthy options to find, including drugs and alcohol.

So, in my opinion, addiction develops because inside we are missing something.  Drugs and alcohol (and more broadly excessive gambling, inappropriate relationships, even cell phones and video games) are all outward jackpots for someone with an absence inside.

And all are ultimately unfulfilling.

Life is like a puzzle. A few fortunate people open the box to find all the complete puzzle.  But most of us got our puzzle at a thrift store – and we didn’t get all the pieces.  Instead of figuring out how to fill our needs with the right puzzle piece, addicted people continue chasing fulfillment through whichever method their brain responds to most significantly.

Some people light up like a Christmas tree when they get a taste of whiskey.  Others find euphoria from Oxycotin.  I have friends who’d rather sit in front of a toilet and throw dollar bills down the drain than pull the arm of a slot machine.  But go to a casino at 10am on the first of the month, and you’ll see a large group of people who’s brains respond to the lights and bells of the one-arm bandit.

So, how does addiction develop?  Addiction affects people from all walks of life, all social groups, and all races, religions, and cultures in America.  Most of us are missing something.  And we look for it through whatever methods are available to us.  Some of us are able to find it (due to the right combination of privilege, physical and spiritual wellness, and good fortune) in healthier places.  Others of us have enough resources – human or otherwise – that we don’t make a misguided choice that causes our brain to light up in a dangerous way.  Still, some of us have so much privilege, so much wealth, and so much love and yet still make poor choices.  Mental illness, low self-esteem, desire to fit in with others – all of it, though, seems to boil down to that idea that unfortunately, not everyone has what they need.

We are all faced with choices; some end up defining our lives.  For some, a minor mistake can lead to a major problem.  Thankfully, with the right combination of therapy, medication, and relational healing, people can heal.

If you or a loved one need help, reach out.  If you’re in Cincinnati, I highly recommend Center for Addiction Treatment as well as Brightview Health and ASAP for Adolescents. If you’re somewhere else, call SAMSHA’s national helpline at 1-866-662-HELP. Don’t wait until its too late.

I’d love to answer your questions or respond to any feedback you have. Send any comments or questions you have to me by email or via the form below.

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Kirk Sheppard is a blogger, focusing on finding clarity through topics like spirituality, mental health, and wellness in 2020.  Subscribe to his blog, so you don’t miss a single post!