• The OAD Clinic

The Brain and Addiction - Part I

Updated: Jul 16

I want to vs I have to

You know what you have to do, but you can’t help doing the opposite.

How many times have you been there?


Don’t worry, we all have. It is a very human thing. It is probably what makes you a real human. Internal conflict. The “have to” element is the more rational one, since it implies some level of reasoning. If you know

what you have to do, this is because you have pondered the options. Acting on the “have to” implies some degree of will power or mental energy investment. It is not a “let go”, it is going in the direction you want to go.



The “want to”, is a more immediate thought coming from the inside. It’s almost an instinctive reaction to a situation. Acting on the “want to” doesn’t require will power, it is just a “let go” situation, and usually results in instant gratification, usually some kind of physical sensation (but it can be emotional as well). This sensation may be also followed by some sense of guilt or unease afterwards, if what we did was not what we were supposed to do.

The reason for this duality is rooted in two different parts of our brains, that have developed over eons of human evolution. The “want to” is usually related to the more internal, ancient parts of the brain, and the “have to” is rooted in the frontal cortex, the highest level of brain evolution. This part is what differentiates the human brain from the rest of the mammals. Hence, the conflict between the “want to” and the “have to” is the essence of human being.

Jon is a 47 year old man, happily married to his third wife 20 years his junior. But he’s alright. Apparently. He lives fast. Doesn’t waste time in eternal ruminations or vacillations. He is a self-made man of action. Flourishing business, two daughters and a teenage boy he adores.


Jon is fit and well, perhaps too well. He spends two hours in the gym he built in his big home, every day including weekends. So he is in a good shape and looks younger. Some people say he uses his dominant physique to bully people and get what he wants in business and life in general. But Jon strongly disagrees, and I tell you he is not the kind of person you want to have an argument with.


Jon has a problem though. He snorts cocaine. Lots of it. I mean, like 7 grams a day. That makes him lose control sometimes, becoming abusive. Emotionally, but physically too.

In the past, this has been a problem for others, not for him, but now he is getting older and realizing that he can lose things he won’t be able to recover as easily as he did before. Time is becoming a precious commodity for him.


Now, after snorting a few grams he becomes verbally abusive and occasionally violent. The last two episodes were witnessed by his children and he feels guilty about it.

Jon is, believe it or not, very religious. He loves Jesus. He regrets being abusive with his children, beating his wife or smashing the face of an employee who challenged him in front of others. He knows he is losing control and he doesn’t like it.


Jon is somewhat aware that he has a personality problem that is fueled by cocaine, and steroids he used to inject until recently. He’s not stupid. He’s an intelligent man, but he is also frequently driven by impulses and gut feelings, instinctive reactions.

Jon admits that cocaine for him is like a demanding lover he can’t leave. Even worst than a lover, because he had many in the past, and leaving them cost him money, but was never a big deal. But he can’t do the same with cocaine.


That’s what he sees as his main problem. That is the conflict destroying his mind, consuming his nights, giving no hope. There is something inside he can’t control.

“This is not me. This is not the one I want to be, the one I have to be. This is killing me.”

This is not a Dr Jekyll and Mr Hyde made up story. This is real life. That man, and many like him exist. I am pretty sure a few familiar names or faces come to mind. They may use other drugs, alcohol or are about to lose everything that is left after years of betting and gambling. They are not stupid; they are all intelligent, but the big personal decisions they make are incoherent and irrational, plagued by inconsistencies and ludicrous justifications. They know what they have to do, they know why they have to do it, but they can’t help doing otherwise.


Who is the real Jon? Who is Jon actually?

Internal conflict and anxiety is as old as the moment we became humans, and we have been trying to solve this conundrum ever since. There are no straightforward answers to these essential, existential questions, but every generation adds a new twist to this story, in different and more complex settings of its age. Over eons of time our brains have evolved and we finally became humans. We call it evolution and progress, but the conflict remains and sometimes some people seem to regress in time.


The conflict between the want to and the have to, is the essence of human thinking. It is the trademark of being human. It defines us. I personally do not trust much those who pretend to be conflictless.


If you have problems, you are alive!


Dr Oscar D'Agnone, MD, MRCPsych.

Medical Director

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