People who suddenly find themselves in a burning building rarely stop, in that moment, to determine the source of the inferno threatening them. Nor do they pause to contemplate the chemistry of combustion as walls, ceilings, floors and various substances about them combine with oxygen to create light, heat and smoke. Instead, they focus on getting out of the building. To some practitioners in the field of addiction, myself included, such should also be the case with the disease we deal with. From this perspective, treatment is a more immediate concern with regard to the condition than is the pursuit of its cause.
This is not to imply that studying the origins of addiction is folly. Just as we search diligently for clues to the mechanisms behind cancer or heart disease or any other malady, we undertake research in order to unlock information that could lead to effective remedies. Somehow, though, much of the current conversation about addiction has focused on whether the condition should be considered a disease at all, in the classic, medical sense of the term. While this is a provocative and intellectually engaging discussion—I will stop short of calling it a debate for that would imply an inherent acrimony that is neither obvious nor helpful here—the question to ask Marc Lewis, author of the newly released The Biology of Desire: Why Addiction Is Not a Disease, his second book, is whether this analysis of what to label addiction will help the suffering addict. Would our energies not be better spent on finding more effective routes to recovery?
In defence of Lewis, a respected cognitive neuroscientist and former addict (Memoirs of an Addicted Brain: A Neuroscientist Examines His Former Life on Drugs) who taught for more than 20 years at the University of Toronto before moving to the Netherlands to continue his career, he does devote much of his treatise to explaining how a new definition of addiction might lead to more effective treatments. Yet his criticism of the medical model of care leads one to believe there may be something personal going on here. He writes that psychiatrists cling to “long-standing efforts to ‘medicalize’ psychological problems, to see mental illness through a biological lens” in order to allow doctors to remain “the ruling experts on psychological matters.” While making a convincing argument that it is time for science and subjective experience “to try to get along,” he also stresses that “we have to remove brain science from the arena of medical politics and connect it back to its natural partners, psychology and personal experience.”
Yes, both the medical and rehabilitation/treatment “industries” (Lewis’s term) do profit from addiction, and that can be a problem in and of itself, but this text makes a straw man of the medical model, implying that doctors think the affliction is all neurochemical and drug-centred and that there is little hope for recovery outside of medical interventions. That may be true of psychiatry, but there is a new breed of addiction doctors who are much more nuanced than Lewis gives us credit for.
He is not alone in his promotion of the belief that addiction is not a disease. Several research camps support two other possibilities: addiction is a choice, or is simply the fallout from self-medication. In Lewis’s view, these attempts to explain addiction also do not work, and he posits that the disorder (not the disease) is a habit that develops naturally as the brain does what it does—lays down synaptic pathways through learning and development. The addict learns to engage in an addictive behaviour because this behaviour serves the function of ameliorating the results of trauma or living in an impoverished environment, and the brain is “plastic” enough to adapt.
This is where Lewis’s work veers toward the exciting possibility of treating addicts by helping them, first, to leave the self-defeating stigma of disease behind and, second, to relearn new and less destructive ways of facing the vicissitudes of life. While there may be nothing new about this approach, and many even argue that what we are dealing with here is simply semantics (you say tomato, I say tomahto) and that Alcoholics Anonymous has been teaching new ways of living soberly for more than 80 years, kudos to Lewis for doing the research and supporting his thesis with good science.
His Achilles heel, however, is this: if addiction is the result of maladjusted sociological, psychological, even biological learning, and these are repaired, can the person heal and maybe even use safely again? Although I agree with Lewis’s line of thinking in large part as well as his overall premise, all mental illness can be seen in the same light, and categorized as variants of normal behaviour that can be so poorly maladaptive as to cause impairment. But what is that if not disease? In the presence of addiction, maladaptation may be to the point where there may be no possibility for a return to normal drinking or use again. In Lewis’s defence, he is willing to admit the possibility that total abstinence from one’s drug of choice, be it alcohol, illicit drugs, gambling, dysfunctional sexual behaviour, food, etc., may be necessary.
Moreover, Lewis underestimates the practicality of short-circuiting addiction by dealing with some of its precursors—poverty, poor mental health care, unemployment. These are laudable goals but clinicians do not waste time on such hopes; we have to deal with the often life-threatening realities facing the active addict in the moment, to find workable solutions that are accessible today.
This brings us back to semantics, since Lewis’s suggestions for treatment also could be considered yet another case of a rose by any other name. The social aspects of recovery that he suggests are key are remarkably parallel to those of the world’s thousands of AA groups. Lewis is (politely) not a fan of AA, nor are any of the people whose personal stories he engagingly recounts, yet the reason that fellowship and other interventions of its ilk succeed is that they offer the very solutions he proposes (community, simplicity, repetition).
Missing from Lewis’s discourse is a thorough dissection of process addiction (pornography, sex, internet games, gambling). Other ideas he puts forth are worthy of further study. These include the notion of addiction being more about desire rather than pleasure. As Lewis notes, “pleasure is a pastry puff, a dessert, a flash in the pan. Desire is what gets us moving, whether that means calling your dealer, driving to the liquor store, or stealing twenty bucks from your aunt’s purse.” He also shows that more research needs to be done on the role of left brain/right brain functions in addiction, on how addicts progress from impulsivity to compulsivity (in his words, “a strange collusion between hot desire and the cold, almost calculating mechanics of stimulus response”), and the part that “ego fatigue” plays as an explanation for the limitations of self-control.
All these issues are likely to be developing areas of research in the near future. Where exactly the spotlight will land will be interesting to watch. But my hope remains that we not forget why we delve into these matters in the first place, for ultimately what we are really arguing is not the mechanics of what addiction is, but how to deal with it.