In 1956, the American Medical Association absolved alcoholism from the charge of being a moral failing or a destructive bad habit and labeled it an official disease. Acknowledging the changes in brain structure among severe problem drinkers and eventually in other addicts, the AMA concluded that addiction paralleled other diseases such as Alzheimer’s or diabetes.
In many ways, this was good news for those struggling with addiction. Weakness and a lack of moral fiber don’t have biological correlates, but researchers discovered that alcoholism and other addictions do. Among other things, this meant that by the mid-1980s, insurance companies were paying for treatment. It also led to the development of extremely effective drugs to ease the symptoms of withdrawal and the rise of a highly profitable industry for addiction services. Today the National Institute on Drug Abuse reflects the standard approach, succinctly describing addiction as a “disease that affects both the brain and behavior.”
The disease model also brought legitimacy to an addict’s claim that willpower was not enough to control the habit. How could someone with Alzheimer’s be criticized for forgetting where the keys are? And how could an alcoholic who was wired for a drink be criticized for not being able to stop?
But, in fact, addicts can and do stop. And according to Marc Lewis in “The Biology of Desire,” this reveals a basic problem with the medicalization of addiction. “People choose to stop when they have suffered more than enough,” he writes. “And when circumstances lend a hand. And when the possibility of self control becomes as attractive — more attractive — than any other possibility, including temporary relief.”
The title of his manifesto lays out Lewis’s basic argument, which he insists upon throughout the book. “I’m convinced that calling addiction a disease is not only inaccurate, it’s often harmful,” he writes (repeatedly). “Harmful first of all to addicts themselves.” The alternative, he asserts, is to call addiction what it is: a really bad habit caused by a constellation of variables and a brain that is receptive to compulsively reinforcing really bad habits. Most important, that habit is possible to break, not by becoming a “patient” getting medical attention in order to “recover” but by becoming a responsible adult with a solid vision of the future who has at last decided to break a destructive habit.
Lewis speaks not just from the Mount Olympus of academic science — he’s a neuroscientist and professor of developmental psychology now in the Netherlands and previously at the University of Toronto — but as a former addict. His book “Memoirs of an Addicted Brain,” which appeared in 2011, chronicled his tormented résumé, from binge drinking in high school (with a chaser of a bottle of cough syrup), to LSD and cannabis in college, to a young adulthood spent mainlining heroin and taking so many amphetamines that he once went psychotic. This memoir was about both his behavior and his brain. He approached the subject with this same duality — as someone who struggled through the dark days of addiction and as a scientist; as a former junkie on the streets and as someone inside the academy.
“The Biology of Desire” is less autobiographical but no less personal. Lewis is still the former addict, but in this book the neuroscientist takes charge, and the stories of other addicts provide the narrative drama. We meet Natalie, the girl-next-door heroin addict. Brian, the loser-father-meth-addict. Donna, the nurse who stole painkillers from her family and once, when paying a condolence call, went so far as to rifle through the medicine cabinet of the dearly departed. Johnny, the Irish Catholic alcoholic businessman who lost everything. And Alice, always insecure, who became anorexic, addicted to starving and then to eating and vomiting. Their lives follow the shopworn and sadly riveting addictive trajectory from normal to some grisly nadir of experience that leads to the pivotal moment when they decide (or someone helps them decide) they need to change things.
Before we meet these former addicts, however, we meet the biological star of the show: the brain. One of Lewis’s nine chapters is titled “A Brain Designed for Addiction.” The change in addicts’ brains is usually pointed to as proof positive that addiction is a medical condition, but Lewis argues that this is a false and damaging causality. Every experience changes brains, and “the brain changes that underlie addiction and recovery are more normal than abnormal, though their outcomes can be extreme.” He lays out the major areas in the brain that make us designed for addiction, especially in the limbic system and the pre-frontal cortex. Spoiler alert: The striata — both ventral and dorsal — rule. They ride roughshod over the more modulating brain structures, urging us to keep riding the roller coaster of impulsive actions, feelings of desire, anticipation and craving that then move from impulsive to compulsive.
Of these fleeting feelings, desire is the key to sustaining addiction and to beating it. Lewis claims that “addiction can only be beaten by the alignment of desire with personally derived, future oriented goals.” And that is another aspect of the medical model that is doomed to make addicts fail. Medically based treatment rarely helps in fostering that agenda, he says, because treatment for serious addicts typically occurs in institutional settings in which there are long waits, and the “self direction that addicts may have mustered to get them to the door” becomes very difficult to sustain. Scientific data too often does not correspond in a useful way to the addict’s actual experiences. That disconnect results in a complete misunderstanding of the way addicts perceive themselves and, most important, get over their addiction.
“Most of the recovered addicts I’ve talked to would rather think of themselves as free — not cured, not in remission,” he notes. “Having overcome their addictions by dint of hard work, intense self-examination, and the courage and capacity to regrow their perspectives (and their synapses) they’d rather see themselves as having developed through addiction and become stronger as a result.” The italics are his.
And they are revealing because Lewis’s fundamental argument is that addiction is a choice that some people make, sometimes, admittedly, with devastating effects, although they do learn a lot about themselves in the process. And addiction is overcome when people (or rats or mice) change their minds and choose to stop. Some revealing research proves his point. For example, when rats in isolated steel cages were given a choice between morphine and water, they chose the morphine. After demonstrating all the signs of addiction — always going for the morphine instead of the water — in their physically constraining, socially isolated cages, they were then moved into nice, wide-open, wooden cages with non-addicted rats. What happened? They socialized, enjoyed themselves and decided that morphine was for losers and drank water instead — even though the morphine was still available.
Addiction, Lewis explains, is “a habit that grows and self-perpetuates relatively quickly, when we repeatedly pursue the same highly attractive goal. Or, in a phrase, motivated repetition that gives rise to deep learning.” After his own experience with addiction and his conversations with others who suffered from it, he sees it as a “vivid instance of the role of suffering in individual growth.” Of course, these passages could just as easily apply to someone studying music, becoming an elite athlete or learning French. Motivated repetition is a good thing, until it’s not. And suffering is part of the human condition.
But despite the legitimizing heft of brain science, romanticizing the addict and turning recovery into a heroic narrative seems one of the central and unsettling aspects of Lewis’s perspective. When he writes that addiction is a “vivid instance of the role of suffering in individual growth,” he seems to imply that addiction is not just not a disease but noble. Addicts become heroes and addiction their heroic vehicle. It is difficult not to see this as a way of inserting himself, as an addict, into the story, while playing down the staggering social costs of addiction.
Lewis is by no means the only person waging the lonely war against addiction as a disease. Psychiatrists such as Sally Satel have long objected to overzealous medicalization of the variety of human experiences, addiction being one of them. Lewis’s book is wonderfully readable when delving into the stories of Natalie, Brian, Donna and others, and accessible in the descriptions of complicated brain science, but his insistence on the fallacy of the disease model becomes exhaustingly repetitive. One finishes “The Biology of Desire” with a greater understanding of the striata and an appreciation for the argument that we may be thinking about addiction all wrong, but also with the sense of having spent a long evening in the company of a zealot.