“I truly believe no treatment will work on a person with an addiction if the patient hasn’t fully given themselves over to the fact that they have a disease that does not heal itself.”

Margaret F.’s words capture a core belief of the traditional type of treatment program she attended, one common in 12-step-based facilities. Leading professional organizations – including the American Medical Association, American Psychiatric Association, World Health Organization, and American Society of Addiction Medicine (ASAM) – subscribe to the notion that alcohol and other drug addictions are diseases.

However, a growing number of experts are challenging this view. One of them is neuroscientist Marc Lewis, Ph.D., who eloquently elucidates his reasoning in a new book, The Biology of Desire: Why Addiction is Not a Disease. Real-life stories of five different people who have struggled with addiction flesh out the framework he’s constructed from the latest neuropsychological findings.

From his home in the Netherlands, this Canadian expat and Pro Talk columnist gave me several hours of his time to answer the following questions:

Q: The ASAM defines addiction as “a primary, chronic disease of brain reward, motivation, memory and related circuitry” and goes on to say that “dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations… reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.” What’s wrong with this?

A: It’s not that all these brain changes aren’t involved in addiction – they are, but they’re also involved in becoming a basketball fan, falling in love, in becoming a jihadist, in developing any new passion. So why would we call addiction a disease that requires medical treatment?

Saying addiction is a disease suggests that the brain can no longer change…that it’s an end state. But no, it’s not end state. -MARC LEWIS

We know that treatment isn’t required by most to overcome addiction, so in that sense it’s not a disease. And the changes in the brain that occur because of addiction are not irreversible. We’ve been talking about neuroplasticity for decades. That is, the brain keeps on changing – due to changes in experience, self-motivated changes in behavior, as a result of practice, being in a different environment.

Saying addiction is a disease suggests that the brain can no longer change…that it’s an end state. But no, it’s not end state.

Q: If addiction isn’t a disease, what is it?

A: First, I’m not saying that addiction is not a serious problem – clearly it can be for many people. In terms of brain change, you could say that neuroplasticity has a dark side. But rather than a disease, I would say that addiction is a habit that grows and perpetuates itself relatively quickly when we repeatedly pursue the same highly attractive goal. This results in new pathways being built in the brain, which is always the case with learning: new pathways are formed and older pathways are pruned or eradicated.

…rather than a disease, I would say that addiction is a habit that grows and perpetuates itself relatively quickly when we repeatedly pursue the same highly attractive goal.-MARC LEWIS

But with addiction, much of this rewiring is accelerated by the action of dopamine, a neurotransmitter released in response to highly compelling goals, creating an ever-tightening feedback loop of wanting, getting, and loss.

As the addiction grows, billions of new connections form in the brain. This network of connections supports a pattern of thinking and feeling, a strengthening belief, that taking this drug, ‘this thing,’ is going to make you feel better – despite plenty of evidence to the contrary.

It’s motivated repetition that gives rise to what I call “deep learning.” Addictive patterns grow more quickly and become more deeply entrenched than other, less rewarding habits. In general, brain changes naturally settle into brain habits – this is the case in all forms of learning. In addition, the habits are learned more deeply, locked in more tightly, and are bolstered by the weakening of other, incompatible habits, like playing with your pet or caring for your kids. [In the book, Lewis describes in detail how addiction changes the brain.]

Q: You note that the neurobiological mechanics of this process involve multiple brain regions, interlaced to form a web that holds the addiction in place and that gouges “deep ruts in the neural underpinnings of the self.”  Yet you go on to say that “brain change – even more extreme brain change – does not imply that something is wrong with the brain.” How can that be?

A: Such brain change may signify that by pursuing a single high-impact reward and letting other rewards fade, someone hasn’t been using his or her brain to its best advantage.

The notion that you never forget how to ride a bike reflects our recognition that normal habits can be deeply ingrained. Thus, deep ruts in the brain don’t make the brain damaged. And new ruts can be formed on top of or beside old ruts. For example, when you lose a relationship, the deep ruts are still there – they can cause pain and create barriers to a new relationship. But then you say, “Enough of that.” And with some effort, you meet a new person and the brain modifies itself, which it constantly does.

The notion that you never forget how to ride a bike reflects our recognition that normal habits can be deeply ingrained. Thus, deep ruts in the brain don’t make the brain damaged.-MARC LEWIS

Psychiatrist Norman Doidge, author of The Brain that Changes Itself reminds us of a classic remark by Alvaro Pascual-Leone, a renowned Harvard neuropsychologist: The brain is plastic, not elastic. It doesn’t just spring back to its former shape. Rather, like Play-Doh [before it hardens], it can continue to be modified from whatever shape it’s currently in.

Q: Why does “The Biology of Desire” assume importance over your subtitle, “Addiction is Not a Disease”?

A: Basically, most of our attention is committed to achieving the goal, not to the goal in and of itself – it’s all about the drive to get to the pot of gold at the end, not the pot itself.

Basically, most of our attention is committed to achieving the goal, not to the goal in and of itself – it’s all about the drive to get to the pot of gold at the end, not the pot itself.-MARC LEWIS

According to recent advances in addiction neuroscience, there is a “wanting” system (desire) that’s mostly independent of the “liking” system. “Wanting” is really what drives addictive behavior. In the book, I talk about eating pasta – before you eat it, your attention is converged on getting that food into your mouth. But once it’s there, your attention goes elsewhere; perhaps back to the people you’re dining with or the TV show you’re watching. How much attention you pay to the taste of that bite of food is a drop in the bucket compared with the amount you spent to get it to your mouth.

Desire and expectancy make up most of the experience. The “wanting” part of the brain, called the striatum, underlies different variations of desire (impulsivity, drive, compulsivity, craving) – and the striatum is very large, while pleasure itself (the endpoint) occupies a relatively small part of the brain. Addiction relies on the “wanting” system, so it’s got a lot of brain matter at its disposal.

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