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.
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.
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.
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.”