Is addiction a choice or a disease? Doctor explains the brain shift

Substance use may begin as a personal choice, but repeated exposure alters brain circuits that control reward and impulse, turning use into a disease for some people

Using drugs or alcohol often starts as a decision. Over time, doctors say, repeated use can rewire the brain, making addiction a medical condition rather than just a matter of willpower.

 

So where does responsibility end and illness begin? And why do some people stop easily while others spiral into addiction?

 

“Substance use always starts with a choice,” says Dr Geetanjali Kesri, Senior Consultant, Psychiatry, Yatharth Super Speciality Hospital, Faridabad. “It may be experimentation, peer pressure, or even social acceptance.”

 

Alcohol and tobacco, even though very harmful, are legal and widely used. Most people consume them without developing a disorder. But according to Dr Kesri, repeated use changes the brain, and that’s where choice slowly starts to weaken.

 

“With repeated use over time, it stops being just a choice and becomes a disease,” Dr Kesri explains.

What changes in the brain with repeated substance use?

The brain’s reward system is at the centre of addiction.

 

Repeated substance use triggers dopamine release, the chemical that signals pleasure and reward. Over time, the brain adapts. Smaller amounts no longer produce the same effect.

 

“To get the same ‘high’, a person needs higher doses,” Dr Kesri says. “This leads to tolerance.”

 

At the same time, impulse control weakens. The ability to recognise when to stop erodes. “This is why not everyone who drinks alcohol develops alcohol use disorder,” she explains. “Some people know when to stop. Others don’t, and that loss of control is what turns use into disease.”

If addiction is a disease, where does personal responsibility fit in?

Calling addiction a disease does not erase responsibility, it reframes it, stresses Dr Kesri. “Many substances like alcohol and tobacco are legal and socially accepted,” says Dr Kesri. “So yes, there is individual responsibility involved, especially in knowing when to stop.”

 

But she points out that some substances, such as opioids, amphetamines, and hallucinogens, are tightly controlled precisely because of their high addictive potential. The shift from choice to disease is gradual. A person isn’t suddenly powerless, but over time, brain changes make stopping far harder without help.

Why do some people get addicted while others don’t?

“There are identifiable genetic factors for this,” Dr Kesri says. “If a parent has alcoholism, the child’s risk is higher.”

 

But genetics isn’t the whole picture, and the environment around the person matters just as much. “If substance use is normalised in the family or among friends, or if someone starts very early, the risk increases,” she explains.

 

Early use is particularly dangerous because the brain is still developing. Reward pathways are not fully formed, making young users more prone to thrill-seeking and risk-taking, which are the patterns that can hardwire addiction later.

Do stress, trauma, and loneliness drive addiction?

“These are psychological and social factors created by society,” Dr Kesri says. “They don’t cause addiction by themselves.”

 

But they change how substances are used. “A person who is lonely or stressed may start using alcohol as a relief,” she explains. “Over time, they realise the stress is still there the next morning—but the habit has already formed.”

Is addiction officially recognised as a disease in medicine?

“Addiction is classified as a disease in the World Health Organization’s International Classification of Diseases (ICD)-8, 10, 11,” Dr Kesri says.

Is relapse a failure, or part of the illness?

“With long-term substance use, stopping suddenly can cause physical withdrawal symptoms,” Dr Kesri explains. “It’s not always possible to stop without professional help.”

 

Like diabetes or hypertension, addiction is a chronic condition that may need long-term management.

 

“With treatment and support, people can overcome this disease,” she says. “But expecting willpower alone to work is unrealistic.”

How should families support someone without blaming or enabling?

“Treatment involves motivation building,” Dr Kesri explains. “It also involves helping the person associate substance use with negative consequences.”

 

The goal is to help the person rebuild control, not shame them for losing it. So substance misuse starts as a choice, but it can become a disease in no time.  For more health updates, follow #HealthWithBS