Dopamine and the Neural "Now": Essay and Review of Addiction: A Disorder of Choice.

Rather than view addiction as a disease, Heyman sees it as a choice-one that works like other choices, whereby immediate rewards outshine long-term gains. He rejects neuroscientific explanations of addictive behavior, because he believes they cast it as involuntary or disease-like. I argue that the disease-versus-choice debate creates a false dichotomy: Neuroscience does not have to frame addiction as a disease. Rather, it can help explain how addicts make impulsive choices in the moment and distort appraisal and decision-making habits in the long run. Specifically, the salience of drug-related cues is enhanced by dopamine activity in the ventral striatum, orbitofrontal cortex, and amygdala, due to the intense hedonic impact of repeated drug experiences. Moreover, dopamine-based craving peaks when drug (or alcohol or gambling) rewards become available, in the moment, and this rapid increase in attractiveness preempts rational judgment. Finally, repeated dopamine enhancement modifies brain structures to maximize the appeal of addictive activities, minimize the appeal of competing rewards, and undermine the cognitive capacities necessary to choose between them. I conclude that addiction is not a monolithic state but a recurrent series of choices that permit negotiation, and sometimes cooperation, between immediate and long-range goals.