Transcription
Neuroscientist Mark Lewis says the disease model of addiction isn't just wrong, but that it has become an obstacle to healing. He details it all in his new book, "The Biology of Desire." And with that, we welcome Mark Lewis to our studio.
Hi.
Hi there. Welcome back.
At you. You haven't been here for a couple of years.
New book.
Oh yeah, two years, new book. Okay, so this book is all about addiction, and it approaches it somewhat differently from the normal ways we're used to talking about addiction. So let's really start at the beginning. How do you define addiction?
Okay, so the subtitle of the book, "The Biology of Desire: Why Addiction Is Not a Disease," and that's really that's the theme, although I use a lot of stories of people's addictions and quite a lot of detail to tell the human story, but I also tell the neuroscientific story. And the basic message: the disease model is very—it's very prominent, and it comes from doctors and psychiatrists and scientists at NIH, which funds 90% of the addiction research on the waterline state of health.
Right.
Yeah. And so it's a kind of a self-fulfilling prophecy because you don't bite the hand that feeds you, and from the funding world, so people keep looking at cellular mechanisms and say, okay, oh, this is wrong, this is different. And actually, what's happening is the brain is changing in addiction, and it changes a lot in addiction, but it changes a lot when you learn anything that is profound and intensely motivating. You: the brain changes when you get married, or when you fall in love, or when you have kids, or when you become a religious fanatic, or when you become a sports fan, because the brain is supposed to change.
Okay. There's so much that you've just said that—one minute there, March. What—let's break down—we'll talk about how the brain changes with addiction, but okay, if addiction is not a disease, what is it?
What is it? That's the question. It's a learning phenomenon. It's an intense, deep habit which is developed like any other habit through learning. I mean, that's how we develop our habits. And some habits become deeply ingrained. Often habits—a relationship becomes deeply ingrained. So when we fall in love and we have a partner, and those habits are there, they're there for a long time, even for life, even after if you had a separation, they're still there. In addiction, the habits have to do with seeking a particular substance or activity. And we have to recognize it's not just about drugs and booze; it's also gambling and sex addiction and porn addiction and eating disorders—quite a few eating disorders also cross into the definition. So what you're learning is a particular way of conceptualizing what's rewarding. It's absolutely: this is what I need; this is what I want; this is what I have to do; this is what makes me feel okay. And when that repeats over and over again, driven by strong emotions, because there's strong emotions and that as part of what drives the repetition, you're building synaptic networks. As I say, that happens in learning in general. So it's learned behaviors. Let's—we accept that as a premise. That's the premise that you put forth in your book. You talked about three models of addiction: disease, choice, and self-medication. We talked a little bit about disease. Let's talk about choice and self-medication.
Often the choice model is put as the diametric opposite of the disease model: either you have a disease and you can't help it, or you have a choice and you can't help it, and it's basically your own fault. That's way too simplistic. Choice is not objective; it's not rational; it's not logical.
A lot of—such—just—yeah, riding in the taxi on the way here, we made so many choices that were not logical.
That's—mean you got lost?
Yes. Yeah, a lot. Then, should we take this street? Too many cars there. Let's go this way. And choices like that. So the mind is not very often rational, and we often do things because of context, associations, motivation, mood—all these things affect our choices. So yes, addiction is a choice to a degree, but it's a choice that is constrained by deep learning and associations and strong emotions. So that—and the third model, self-medication.
Yeah, keep going. Keep going. Keep going.
The—by that, I think that that corresponds with the learning model quite well, because self-medication means that people who've experienced often neglect or rejection or trauma or other psychological nastiness in their early years, childhood and adolescence, they come out depressed, and they come out anxious, or that PTSD—I mean, it can be clinically subclinical, but one way or another, they're not feeling good; they're not feeling happy; they're not feeling whole; they're not feeling complete. And so they try stuff, and something then feels better, and that's that self-medication. And keep on trying it; you keep on doing it because it keeps making you feel better, and presto, you're hooked.
Alright, so you started off this conversation about talking about how the medical establishment prefers to see the addiction as a disease in the self-interest of that—for them, it's not entirely self-interest. I mean, these are sincere people generally who really see it that way. My training was in developmental psychology, so I see a lot of mental and emotional phenomena as developmental, as arising out of childhood. These guys are doctors and psychiatrists; they see things in terms of pathology. In turn, pathologies approach through diagnostic categories. So you put something in a category, and we have the DSM, Diagnostic and Statistical Manual of the American Psychiatric Association, which says, okay, if you have this, this, this, and this, then you have a substance use disorder. So that's the way they think. It's not that they're, you know, some evil clan, but there are harmful effects—I think quite harmful effects—especially in the treatment community. Like what? The disease model is the basic flagship of it; it's the banner waved by most rehab centers throughout North America, throughout the world. They say this is a disease; you have a disease. The NIH defines it as a chronic brain disease. Well, what do you do in every chronic disease? You have to go and get it treated. So they bring people in the door, and this is where the problem is. They're charging sometimes vast amounts of money—ten to a hundred thousand bucks a month in the U.S., even more—and then the person is at home after 30 days or 60 days, and they're back in their lonely little apartment in Pittsburgh or whatever else, and and they start using again. So there's a very serious revolving-door problem. People come back to rehab again and again and again and again. And part of the reason for that is that the whole conceptualization of treatment is just wrong.
I want to talk about the person at the center of this. We talked about drug addiction and treatment so much; we rarely talk about the addict him or herself. When we apply the disease model, that approach to it—useful for the addict to look at it that way?
No. I get emails like several times a week. I got one this morning saying, "Thank you so much. I never felt like I had a disease. I felt like I was—I was cursed for life because I could never get rid of it, and I felt like I could never be free of it." And truly, I'm not trying to boast; I'm just trying to say that this—this is—this is a dynamic. This is—person—tell you—it didn't like to them. It felt wrong to be told I had a disease. It felt—it felt encumbering, and felt like it—like being chained down to—to a disease diagnostic label. And the idea of chronicity, and this is partly reinforced by the 12-step programs, which tell you you have to keep controlling and fighting this thing for the rest of your life. Well, she didn't feel happy about that. She thanked me for the book. She says, "Your model makes me feel free and happy, and I feel I have done the things I need to do. I can go on with my life. I don't have to carry this weight with—with me."
I'm very touching. I get that a lot.
You get that a lot?
Yeah. I mean, it's self-selecting, obviously. The people who don't agree, you probably aren't going to email me. But for her and for many of the people that I talked to—I talked to thousands of addicts through my blogging and emailing and stuff—and a lot of them don't feel they have a disease, and they—they feel the weight of that diagnosis as being counterproductive because they don't feel—I can't—I can't get over it. It's not—it's a burden.
It's a burden.
Yeah. I have to do what I'm told by the doctors. So you become a patient, which means you become passive. When you're passive, you do what you're told; you do what an authority tells you to do. And there are only a few medications actually that are available, and they'd do anything at all. But the most important thing for recovering from addiction is—is self-empowerment. It's being able to feel like, "I can change my life; I can do this," and that I think it's really, really quashed by the whole disease philosophy.
Right. Okay. I want—your neuroscientist—I want to talk about the brain, and that you—you tipped your hat to that earlier. There has been much research about what is going on physiologically in your brain when you are addicted to drugs. Tell me about what you have learned about what is happening—I'm on drugs; I'm addicted to drugs; I'm an addict—what's happening in my brain?
Um, what's happening is that when you get any kind of cues or stimuli or memories or imaginations about cocaine or alcohol or getting a drink or sex or gambling or whatever it is, you get dopamine—a particular neural neuromodulator neurotransmitter—comes up from the midbrain, goes up to a place called the striatum, which is a very old part of the brain designed for seeking goals, and it focuses attention; it collapses attention into a kind of a narrow beam, and it produces motivation, attraction, a push toward the goal. That's how we mammals, you know, achieve our goals. So the striatum—each time that happens, the striatum gets wired up a little bit more because all brain regions—when they get used—you get synaptic changes; you get changes in the synapses. The synapses that are used get strengthened; the synapses that are not used get weakened. So the ones that correspond to the drug or drink or whatever—it can bling—whatever it is, those synapses become more and more entrained, connected, reinforced, strength, and you get these highways; they continually get reinforced by the dopamine uptake. And that's basically all you can think about. That's what I need; that's what I want; that's all I can think about. Your brain—to rest—your brain shuts off—doesn't shut off entirely, but some of the other things that you used to—you used to be very—uh, attracted to—your pets, your family—here—now—movie night, eat pizza—whatever—is just falls off the edge because you're not pursuing those things very much. So the synapses that are representing those activities become weakened. And so, in that sense, yes, there's less of the rest, and a lot of focus on this one thing.
All right. Mark, if that's what is happening inside an addicted brain—that sort of trapdoor almost that keeps you really focused—is the same thing happening in my brain if I use drugs recreationally? That those synapses—shutting down the ones that were firing—being fired more often?
Yeah, it—it's complicated. Um, it's the great—the other thing that happens in addiction is the prefrontal cortex—the thinking part—becomes less connected when you're pursuing drugs. Why? Because behavior becomes automatic. With any automatic behavior—driving your car—whatever it is, you're not—you don't need to think. And so there's a kind of a shutdown of some of these synaptic pathways as well, which means you lose perspective. And that loss of perspective is—is really an insidious thing. When you lose perspective, you're really only living for the moment, and you're not able to sort of see the future and not able to think about how this is worth it, you know, because next week I'm just going to be in the same situation. When people use drugs recreationally, that's not happening. It's just—none of it is happening. I mean, they use drugs recreationally like people do social drinking. It's the—it's one of—you—of an ensemble of rewards that you can exit. So many people—isn't there—that you know—that line that you—you know—you start recreationally, and then it leads to addiction? I mean, because where does your brain switch? The stats show that uh, about eighty-five percent of people who use drugs don't get addicted; only five percent—
Yeah.
Okay. Don't get addicted. Okay. So—um, of those who do get addicted, and they're the ones we worry about, of course, uh, most of them get better; the majority get better. And those who get better, the majority of those get better without formal treatment. These stats are all available online; there—I'm not making it up.
Okay. So hello—addiction is insidious and dangerous, and it destroys lives. So we have to, of course, think of better and better ways to help addicts. It's not like this evil curse that descends on you like in Snow White, and you know, it's suddenly you're asleep for a hundred years. It's not—it's not magical.
Mm-hmm.
I think you're mixing up your fairy tales.
Okay. Fair enough. Okay. I want to—so I don't recall the sass—you just put up a number of people statistically recover—yes, some drug addiction—yes, that word—I want to focus on because—and I want to stick with the brain. If your brain does that when you're addicted, what is happening to your brain when you're in recovery?
Good question. You continue learning. The first thing that happens is that the thing that you're attracted to becomes repellent. Okay? And that can happen obviously in stages. I mean, it may take time. This is wrecking my life; this is wrecking my marriage; this is getting me in all kinds of trouble. I'm starting to hate this; I do it every day; it's boring; it's stupid; it's disgusting. I want to stop; I want to be free of it. Now you have a new desire—a desire to move in another direction—and you have less desire over there. As those scales rebalance, you start to learn methods for self-control that you haven't used for a long time, perhaps. So again, it's synaptic wiring, right? It's always—an apt—acquiring. And some of the regions—actually prefrontal cortex that I was talking about before—those syncing regions come online when the drug urge hits. So okay, this is bad for me; start thinking about something else. Okay? And now you're setting up a traffic flow again between the prefrontal cortex and the striatum—that motivational part—and that traffic flow is starting to make you—help you—with all the skills and self-regulation abilities that you need to develop the habit of abstaining.
Hmm. And that's a habit—to—learned behavior—to abstain?
Yeah. Same—same approach. Yeah, similar behavior. And I want to ask you about recovery. I chose that word deliberately.
Okay. It's a word you're not—you're not fond of also when it comes to drug addiction. Why not? What's wrong with it?
It's a medical term. So disease recovery.
Yeah. Okay. Yeah. The recovery means you get back to normal; you go back to where you were. People who overcome their addictions—the word that I prefer—they're not going backwards; they're going forwards. They're developing new skills and new ways of understanding themselves, new perspectives. They often look back on a period of suffering and say, "I'm glad I went through it. I'm a deeper, fuller person. I understand myself better now. I know my limits, and I know where I want to go and who I want to be." So I don't think of it as recovering and going backwards; I think of it as further development, growth.
Okay. So that goes back to your point earlier about empowerment of the individual.
Absolutely. And—and that's a good Segway because you write about real people—yeah—in—in—in real time in this book. So there's Brian, who—if we had more time, I would ask you about it, but I want to talk about Alex—Alice—sorry, Ellis. Ellis is someone who has anorexia. At the top of our conversation, you said, you know, sometimes we assume when we talk addiction, we're talking about drugs and booze, but there are all kinds of addictions—gambling—right?—sorry, anorexia.
Yeah. And she's—again, anorexia is—I mean, you don't hear often—it's seen as an addiction. You are sick; you have anorexia; you have a disease. It is called anorexia. How is anorexia an addiction, but it's not a disease? I mean, it's not—it's a disorder. Okay? It's certainly destructive; it's insidious; it's all that. Alice had anorexia for several years, got extremely skinny, and then started—and that developed into binge eating disorder—another disorder—but anorexia is really complicated, and I don't tend to understand it completely, but people talk about it as an addiction to—to control or an addiction to—yeah, it's—it's—it's difficult to think of it as an addiction partly because most addictions are about putting stuff into you; anorexia is about keeping stuff out of you. But with Alice—and yet each of these chapters are in the book—are really detailed. I interviewed these people over probably 15-20 hours each to get the, you know, day-by-day blow-by-blow. And she suffered terribly because when she—which—she got into the binge eating disorder, she would try very, very hard to—to control it, and she'd sit on it, and she said, "It's like trying not to think of an elephant; it's like you can't do it that way." And she would break down after hours—hours—of successfully avoiding—this is the binge eating part—she would start to eat huge amounts of guacamole and peanut butter and chocolate and all that stuff, and she was a mess. But it was all—the stages were learned and started in her childhood because her mother was very concerned about body image, very concerned—and Tumblr—coming Savior—this was back to your learned behavior.
Exactly.
Okay. We have time, celeb, because I want to talk about Brian, 'cause I guess in the end—I don't know—then with the more traditional sense—he's more traditional addict because he—it's not anorexia. So tell me about Brian.
Yeah. So Brian got into methamphetamine. He got into it in a big way. He started using it to keep himself awake at night because he had a—he was a—he worked pretty hard, and then he got started to like it more and more and became dependent on it in the way the addicts do. He went through two or three years of intense use, and the compulsive aspect—for Brian—in that chapter, I explored the compulsive aspect of addiction, and also this issue of what I was talking about before—the recurring present tense—that you can only focus on the present, and he can't think much about the future, which I call now appeal. It was always about the next hit, you know: should I have one now, or should I wait for two hours, or maybe I should wait? No, I better have another one now because I might start to come down. He was thinking like that all the time, and he's an intelligent guy, and he became so—he's a guy—he knew it was intelligent. I mean, he was hyper self-aware; he knows the damages cause—you know—it's what addicts always say.
I know that it's bad—program—
Yeah. I'm not an idiot. Except she knows that—and—and just to put a fine point on it—yet he keeps doing it. So give me the why of why he does that.
Um, it's partly because it's the things that we talked about so far—the narrowness of the goal and the push of the drive. The striatum is designed to make you go after things, so you feel the urge, and it's called—the nurses called craving. Craving is a big word in addiction. Craving is hard to resist when it's very, very strong. Um, we might feel craving when we feel—we have a little—our children—we crave our children. You want to pick you up, hug them, and kiss them and stuff like that. Well, okay, that's healthy craving; this is unhealthy craving. There's that—there's also a compulsive part. As the striatum continues to wire up, there's a part of the striatum where behavior becomes completely automatic, and it's—it's—I mean, I compared to driving—you're not thinking when you're driving; you just do—you change the lanes without thinking. And I would say he got into that thoughtless, compulsive phase, which again—it's not an addiction because it happens in many aspects of our life, but we don't worry about it because we realize that we can't be conscious all the time of, you know, turning off the lights and whatever you do—and making a bad—I mean, you're thinking about other stuff; you do stuff—well, he was doing methamphetamine automatically, and that—what's the problem? We only got about a minute left, so I'm gonna throw a big question your way. It's—you know—it really doesn't matter if you're the medical establishment, if you're a layperson, if you're a parent, if you're a kid, if you're addicted to drugs, if you're aboard drugs—people want people to be healthy. Yes. So what—what—I mean, what is the—what is one thing that we need to change right now—210—sure—that makes more addicts be less addicts? Is it—stop—just stop—the medical community forsake—just don't treat them? What is one thing? What do we need to know first?
The conventional rehab industry isn't working. Everybody knows that in the addiction field. Second, make treatment available when addicts are ready to quit, so they don't have to get on a waiting list for six months or whatever it is, because when they're ready, that's when you can most manipulate that desire engine and help send it in a different direction. Third, help people be aware of themselves—in time—they have a past; it's where they come from; this is how they got this way; and they have a future. So that—that defeats this now appeal; it stretches out this trajectory of one's life, so you can actually start to think about the future and care about the future and move toward a future that you choose.
Three things in one minute. Way to go.
Good luck.
Thank you for joining me.
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