8/5/15. Sally Satel reviews Marc Lewis' new book, "The Biology of Desire."
Kicking the Habit
If
addiction is a brain disease, addicts are mad, sick and defective. If it’s a
failure of will, users are bad, immoral and weak.
By
Sally Satel
July 21, 2015 7:42 p.m. ET
The medical and treatment
establishments tell us that drug addiction is a brain disease, not an absence
of willpower. Technicolor brain scans are presented as proof, and millions of
dollars are invested in the search for pharmaceutical remedies.
What is unfortunate about this
definition is not that it plays down the willpower dimension of addiction—the
“just say no” injunction was too superficial to be of much help anyway. The
danger instead lies in the black-or-whiteness of both propositions: If
addiction is a brain disease, addicts are mad, sick and defective; if addiction
is a failure of will, users are bad, immoral and weak.
In “The Biology of Desire,” Marc
Lewis, a neuroscientist, takes a less Manichaean approach, arguing that
addiction entails both biological alterations in the user’s brain and changes
in his personal agency. He offers an insightful take on the interaction of mind
and brain against the backdrop of the addict’s life circumstances.
Mr. Lewis is no white-coated lab
shut-in. In his 20s, he consumed vast amounts of alcohol, opiates, psychedelics
and stimulants, an odyssey that he chronicled in “Memoirs of an Addicted Brain”
(2012). In that book and in this one, he writes about bursting
neurotransmitters and sinewy neural circuitry with remarkable passion and
sensuousness.
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Photo: wsj
The
Biology of Desire
By Marc Lewis
PublicAffairs, 238 pages, $26.99
When it comes to nomenclature, Mr.
Lewis prefers “habit” to “addiction”—not to minimize the devastation of what
users can incur but to point up the fact that the biology of habit formation is
relevant to the compulsive use of substances. “The neural circuitry of desire
governs anticipation, focused attention, and behavior . . . ,” he writes. “This
process is grounded in a neurobiological feedback loop that’s present in all
normal brains.”
In other words, people who discover
a substance—or an activity, such as gambling—that helps them assuage pain or
elevate their mood will form a strong attachment to it. Repeated behavior
becomes harder to stop over time, though even a strong attachment need not
create an unchangeable pattern. Addiction is “an inevitable feature of the
basic human design,” Mr. Lewis writes. That design revolves around
“neuroplasticity,” the ability of the brain to reorganize itself by forming new
neural pathways and connections in response to modes of thinking and acting as
well as inputs from the environment.
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As people repeatedly look forward to
and then experience certain drugs—or other strongly desired forms of pleasure
or relief—the brain adjusts its mechanisms, intensifying the release of
neurotransmitters in the regions involved in processing emotion and motivation.
“Each network of synapses,” Mr. Lewis writes, “is strengthened and refined, so
that the uptake of dopamine gets more selective as rewards are identified and
habits established.” The drug habit is learned more deeply than others, Mr.
Lewis explains, “due to a narrowing tunnel of attention and attraction.”
Competing desires and imperatives get shunted aside or obliterated.
“The Biology of Desire” is not
entirely a survey of brain science. Its middle part is devoted to portraiture,
presenting real people who were once in the grip of an addictive habit, tracing
the reasons for it and, finally, showing how each managed to stop. There is
Natalie, for example, a college student who is drawn to OxyContin and then
heroin because, she says, it “relaxed you by abolishing the sensation of
threat.” Natalie gets arrested and finally realizes the state she is in.
Through meditation she learns to tame her impulses and endure a craving without
giving into it. She also reunites with her mother. The sounds, sights and
experiences that, in her brain, she so tightly links with heroin lose their
associative pull.
The same basic arc applies to other
figures in Mr. Lewis’s portrait gallery: Brian the methamphetamine user, Donna
the opiate addict and Johnny the alcoholic. All these young adults are in some
way broken; all find solace in substances, both licit and illicit. They don’t
want to be addicted, and their self-loathing only intensifies once they believe
they are. But they desperately want immediate relief and so surrender.
All of Mr. Lewis’s case studies end
well or at least optimistically. At the heart of the recoveries are new, more
constructive habits, identities and relationships—and, in the brains of the
subjects, the sculpting of new synaptic patterns. As Mr. Lewis shows, the
physiology behind the addiction process can be intentionally engaged by addicts
to put them on the path to recovery. By exploiting the neuroplastic capacities
of the brain, individuals can develop strategies for self-control.
It may well be, as Mr. Lewis says,
that addiction is a form of normal habit formation. But isn’t it more like a
normal process gone awry? When outcomes are so dire, how is this not a
pathological state? Mr. Lewis is deeply humane in his regard for people trapped
in compulsive habits, so much so that he seems reluctant to impose any rules on
their behavior and ends up treating them more like patients than he might like
to admit. He is big on the so-called Vancouver model in which addicts are
guided to safer drug-using methods and gently encouraged to get themselves
together. But he de-emphasizes the importance of behavioral shaping through
external incentives and sanctions, which are at the core of drug treatments
that divert addicts from the criminal-justice system.
“The Biology of Desire” says a lot
about the brain mechanisms underpinning addiction but, to its credit, does not
stop there. With minor exceptions, we do not help addicts (and they do not help
themselves) by ministering directly to their brains. As Mr. Lewis stresses
throughout this unorthodox but enlightening book, people learn to be addicts,
and, with effort, they can learn not to be addicts, too.
Dr. Satel is a psychiatrist and
resident scholar at the American Enterprise Institute. She is co-author, with
Scott Lilienfeld, of “Brainwashed: The Seductive Appeal of Mindless
Neuroscience.”
