Simply answered? Because people are different. People's bodies are different, people's brains are different and people's understanding and belief about the disease is different. Why do some people become diabetics and others do not? Biology and consumption.
For too many years, and still today, people treat individuals w substance use disorders as if they have a 'defect of character', are 'weak', 'lazy' or 'gluttonous please sure seekers'. This simply is not true. Often, quite the opposite is true.
One of the main factors in determining if someone has a substance use disorder is a decrease in one's ability to purposefully control that use. For example, promising oneself not to use today, only to find themselves high by the afternoon. Or, promising that they would only have one or two- and really meaning it, desiring to just have one drink- only to have blacked out after recalling having 7 drinks. The fun is gone. The intention is to control their use- just a couple, not on weekends, no hard stuff...on and on- only to find themselves in the situation they swore off.
The next significant feature of a substance use disorder is have it seep into other areas of your life, wreaking havoc, and not stopping. They use even when they strongly desires to use/drink less or not at all. Defeat. The compulsive, unwanted behavior continues- seemingly totally within their choice, in-spite of very bad things occurring in their life directly because of the substance use. Loss of relationships, financial issues, legal problems, health problems.
Why on earth would someone choose that? They don't. Choice is a very fragile human faculty. We like to think of ourselves as fully autonomous, self driven folk. Choice is a complex series of interactions within the various systems in the brain. When the cluster of 5 areas of the brain which make up the pleasure pathway is in dis-regulation- broken basically, it re-prioritizes certain chemical reactions; placing perhaps alcohol, cannabis, or opioids (heroin, Vicodin) to the top spot. Higher than food, sex, love... The experience, the manifestation of this is the obsession- the craving...the inability to make what most of us consider basic rational decisions. Like, don't shoot heroin; don't spend money on drugs when you're broke. Don't drink a case of beer, having 2 is just fine.
Why do some people appear to have 'broken' pleasure pathways, and others don't? They can have just a couple and stop; or take a few pain pills after getting their teeth pulled, and not turn into someone who rifles through your medicine cabinet looking for pills? (yes, addicted folks do that all the time when they visit there people's homes).
Well, it's a combination of factors, but mostly genetics. Some resiliency and childhood trauma factors.
Age, access and amount of consumption play a part.
The take away is- substance use disorders are biologically based brain disorders, not a character issue. Loss of control is a key indicator. We need to eliminate the stigma, encourage effective, dignified treatment.
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