As I looked down at my prepared questions, thinking they were juvenile or topical or pathetic, to ask Dr. Marc Lewis about his new book, The Biology of Desire: Why Addiction is Not a Disease, he stopped me and said, “Before we get started, do you mind if I ask what kind of drugs you did?” Without missing a beat I said, “It began with pharmaceutical opiates.” He paused for a moment and smiled, “Those are some pretty attractive drugs.”
I knew at that moment I was speaking with a neuroscientist who not only understood the brain’s matter—its molecules, membranes, blood, and electricity—but it was clear to me that he also understood the person in which the brain is embodied. Where most neuroscientists dismiss one’s inner-life as fuzzy and immeasurable, Lewis does not. He’s totally interested and fascinated by the lived experience of drug users.
Which is why I found myself enjoying both him and our talk, especially after my nerves quieted and the 8am coffee began to wake me up—or caused my pituitary gland to secrete hormones that in turn caused my adrenal glands to produce a bit more adrenaline, thus honing my attention. See, I can sound neuroscience-y, too.
Though Lewis is busy teaching in the Netherlands, the two of us found time to connect and below we discuss his brilliantly penned Oliver Sacks-like case studies, his argument against the disease theory of addiction, and the importance of goals and time, of humans and their stories.
You write that classifying addiction as a chronic, relapsing brain disease can be harmful. But many argue this takes stigma off the user, whereas the “addiction is a choice” camp may put unnecessary blame on the user. So why is the disease diagnosis also harmful?
There is the assumption, which Dr. Nora Volkow continues to pound in, that we need to label addiction as a disease in order to remove the shame and guilt and self-remorse from it. I don’t think that is necessarily true. We can deal with remorse and shame in other ways. I also think a little bit of shame can be excellent motivation, and getting rid of it entirely is not necessarily a good idea at all.
The disease label often leads to a sense of fatalism: “I’ve got a disease, what can I do? I need to go get help and if I can’t get better it’s because I have a disease…not because of something I’m doing wrong.”
A lot of people who are in the addiction field feel that empowerment, a certain amount of self-discipline, and taking oneself in hand are extremely valuable measures and perhaps the only way to get through it.
I also think that the “disease vs. choice” argument creates a false dichotomy. Choice is not independent of the brain, naturally, so a neuroscience view does not support one or the other. And choice is far from logical in most human affairs. Addiction may not be a disease or a free choice.
You list a number of compulsions, such as overeating, where there are some remarkable similarities to chemical addiction—but you say no one would ever consider those things diseases. Why is it then, that addiction to drugs is given the special title of a brain disease?
I think that the DSM-V, the latest rendition, no longer uses the term “addiction” for drugs. They have “substance use disorders” instead. OK, well fine, but we all know what they mean by this. Maybe gambling is the only thing still labeled “an addiction.” So there are also eating disorders and they all have compulsive tendencies, and the point at which we call something a disease, where we draw this line in the sand, is pretty arbitrary. It depends a whole lot on societal values and morals, rather than on any kind of logical scientific or other rational criteria.
If drugs are really offensive, if getting high or getting stoned is really offensive to the society, we’re going to call it a disease. For eating, everybody eats and a lot of us are fat, so they’re not going to call that a disease.
Why do you not like the term “recovery”?
It’s derived from medical parlance, right? You have a disease and you need to recover from it, which means going back to the previous equilibrium that your body is at peace in, or stable in. I want to be careful about this, though. I don’t think the term “recovery” is all that helpful in a scientific discourse. But a lot of people use the term and we know what they mean and they talk about being “in recovery.” I don’t want to in any way criticize or denigrate the use of the term for people who are getting value out of it.
Along those lines of returning to “equilibrium,” you cite a 2013 study where cocaine users who were abstinent for 35 to 60 weeks had a regrowth of reduced grey matter volume which continued to develop and grow beyond what is baseline for even non-drug users, meaning, it didn’t just return to “normal” but went past it. I think that’s interesting, because if I think about myself before, during, and post-opiate usage, I’m totally different. I bet my grey matter is, too. So in a sense, aren’t we just always changing?
Glad you brought that up. It’s a huge factor. You certainly just nailed it and a lot of people feel that way. I communicate with hundreds and hundreds of addicts from my blog and once they have “recovered” they are not the same person—they’re just not. And they’re often very pleased with that.
I’m always thinking about time and my relation to it. When I look back to when I was using I remember the future was an abstraction I couldn’t really grasp or touch, let alone imagine. Now, with some years off opiates, I can cast off a “future Zach” and work toward goals that allow me to meet up with that possibility of me. How important is one’s temporality in addiction?
That’s really where I come to at the end of the book. The main vortex that sucks us into addiction is this being trapped in the now and the present, which I call “now appeal,” which psychologists call “delay discounting.”
So you’re trapped in this now that just won’t go away because tomorrow is just another now: Where am I going to use? Where am I going to get the money to use? Or where am I going to get the drugs? You cannot extend forward in time, you can’t think about next week—it’s too hard, too far away. You lose the capacity—actually lose it—to think forward in time. And I think that corresponds to the brain changes that are taking place, particularly the functional disconnection between the striatum and the prefrontal cortex.
There is a lot of evidence that this happens in addiction, but it also happens in studies of delay discounting and ego fatigue. So it’s not just addiction that’s “destroying” the brain, rather it’s a way of interacting with one’s world in the present that corresponds with changes in brain function.
If you lose the capacity to think forward then you’re really trapped because you lose the capacity to take care of yourself. To think of yourself in this kind of caring way, to put your arm around your shoulder and say, “It’s going to be okay, we’ll get to next week and things will be better.” You can’t do that anymore. You forget how. It’s a terrible state to be in.
Most of the former drug users you interviewed for the book all seemed to have gone on their own path of cleaning up outside of AA. Do you think 12-step culture propagates a lot of the disease ideas?
There has been this kind of concatenation between the core precepts of AA and the disease model. I think this really took root in the ’50s and ’60s, with Hazelden and all of that. Then there was a gradual medicalization with doctors and medical associations coming on board saying this is a disease and that crossed over into AA parlance. But Bill W. didn’t talk about it that way. He used the word “allergy” and he didn’t really think it was a disease, at least in the way people in the ’90s thought it was a disease, with the whole brain disease thing.
Plenty who either write for or comment on The Fix see AA as a real nuisance.
I don’t want to bash AA the way some people do. I don’t think there is an evil intention there. I think it does help some. We all know the success rates are not very stellar. None of the five people I interviewed in my book really got better through AA, although some of them used AA en route.
When I did my first drafts of the book, I had an editor who really knew a lot more about AA than I did. She got me thinking about it. She argued that you couldn’t necessarily assume that these ideas came out of AA. They partly were infused into AA by larger systems, like the courts: you have behaved badly, you have a disease, therefore you must go to this program. This program happens to use 12-step methods. So now you have to go to meetings. The whole disease stuff and AA then gets blended and mulched together and that’s just the way concepts evolve. It’s not really AA that’s fucking things up, per se.
So where exactly do you depart from the disease theory people and where do they depart from you? You’re all scientists looking at the same brain imaging studies, yet you come to massively different interpretations. How does that happen?
It’s a tough one. Kent Berridge (a neuroscientist) is a guy I really respect and like very much. He and I were together at this meeting with the Dalai Lama about a year and a half ago on addiction and craving. Nora Volkow of NIDA was also there. I sat with Berridge in a restaurant in Kolkata for hours and we debated this stuff and I kept asking, “How could you think about this stuff as a disease?”
He still thinks of it as pathology. I buy his theory, I buy his perspective, but we frame it in a different way. I don’t know why. Maybe it’s because he studies rats and I don’t [laughs]. Rats don’t tell stories and we humans, well, we live stories. It’s a less static or more dynamic way of looking at a phenomenon.
Obviously a lot less control in humans than rats.
Yeah, that’s right. I think one of the key insights comes from Trevor Robbins, who is probably the world expert on compulsive behavior in the brain. In my book, I quote him saying, “There is nothing aberrant or unusual about devolving behavioral control to a dorsal striatal S-R habit mechanism.” Sorry, it’s quite a mouthful. What he is saying, I think, is that the shift into compulsive behavior is not abnormal, and we do this all the time. When we eat, we shove stuff in our mouth in a kind of compulsive way. Think about how you eat a pizza, right? There are so many ways in which well-learned responses become partially compulsive.
And to me, that was the pivot point, in which you can say, “Yes! Behaviors can become compulsive and hard to control but that doesn’t make it a disease.” Rather, it makes it a kind of automatic response tendency that’s been over-learned. I don’t think Berridge would see it that way. He does things with his rats and, just, I don’t know [laughs], doesn’t quite see it the same way.
The participants in many of your case studies were able to think backward into their childhoods, while they were developing, to some kind of thing that colored their disposition or coping. Do you think that is always the case with drug users? Something specific or non-specific happened in the past that shaped their compulsive behavior in the present?
I think it is common but I don’t think it is always necessary. I’ve talked to people who were in drug-taking environments for long enough and they eventually just got into it. Looking at their past, I couldn’t see anything particularly amiss. So I don’t go as far as Gabor Maté, who argues a sort of extreme version of that idea. I just don’t think it’s quite that simple, but those kinds of events come up again and again when you talk to addicts. It’s a lot more than chance, like 60, 70, maybe 80%. It’s a lot.
So what are the implications of your ideas for the future? Where do we go from here?
Where I try to go to at the end of the book is to look to approaches to treatment and quitting, not necessarily treatment because you don’t need treatment to quit, you can do it yourself or with a friend or family member…or lots of ways.
But I think you often do need to revisit the past partly so you can forgive yourself, and see the trajectory as it has progressed through your life. I’m here not because I’m an asshole, I’m here for a reason. And I can see how it happened: how I became needy, how I became insecure and anxious and depressed. I can see how that led to wanting this kind of peace, fulfillment, relief, and that kind of self-forgiveness is tremendously important.
I see that as a bridge to the future we were talking about. That terrible sort of schism in time that’s created by now appeal can be overcome by connecting your past to your future, in a sort of continuity, where you can see yourself in time—as you and I are talking about, I know you know what I mean—seeing your life as a story.
This is not exactly a new treatment protocol, but these are ideas I hope can be useful to help explore new and more effective approaches to treatment.
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