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.
The disease model also brought legitimacy to an addict’s claim that will power 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’ 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 is a neuroscientist and professor of developmental psychology now in the Netherlands and previously at the University of Toronto — and a former addict himself. His book Memoirs of an Addicted Brain, 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 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 first meet the biological star of the show: the brain. The change in addict’s 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.
“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.”
Lewis’ 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 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 and decided that morphine was for losers and drank water instead.
Lewis is by no means the only person waging the lonely war against addiction as a disease. Psychiatrists such as Sally Satel and others have long objected to overzealous medicalization of the variety of human experiences, addiction being one of them. Lewis’ 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, an appreciation for the argument that we may have been thinking about addiction all wrong, but also with the sense of having spent a long evening in the company of a zealot.
Marianne Szegedy-Maszak reviewed this book for The Washington Post.