Marc Lewis, a former drug addict and current neuroscientist, says the medical model of treating addiction needs to be challenged.
Fresh supplies from a needle exchange. Photo via Flickr user Todd Huffmann
Marc Lewis traveled the long, tenebrous road of opiate addiction, but he emerged out the rabbit hole a neuroscientist, science writer, and author. His best-selling memoir, Memoirs of an Addicted Brain, chronicled his descent into substance abuse, splicing the narrative with neuroscientific lessons about the brain's reaction to each chemical. His latest literary endeavor, The Biology of Desire: Why Addiction Is Not a Disease, asserts labeling addiction a disease is not only specious, it's downright harmful. VICE caught up with the University of Toronto Professor Emeritus, and current faculty member at Radboud University in Nijmegen, Netherlands, via Skype.
VICE: You're critical of the rehab industry because, according to you, it pulls addicts in under the ruse of medical treatment. However, it offers little more than 12 steps and pep talks. You've called it a canard. Can you elaborate?
Marc Lewis: I don't see it as an evil conspiracy, exactly, but it depends where you are. In the US, there are a lot of violations, a lot of improprieties. Treatment is inadequate. Opiate substitution doses are wrong; the period of time for getting off it is often wrong. Individual care is lacking. They have generic policies, which often don't benefit people, and the medical care is a fairly small aspect of the program in general. Eighty to 90 percent of the program is dominated by 12-step methodology. You also throw in a whole bunch of group sessions, in which people are lectured on anything from how to stop making excuses to all sorts of hodgepodge rants. For some people, it can work, because they get them out of their environment and drugs, so they dry out. But it doesn't work for long because they go back to their environments, and all the triggers are there. They don't get the psychological skills addicts need to move on. What you do need is a number of skills: They have to self-regulate and be conscious in order to put their lives into perspective.
I've never been to rehab, so I don't know much about the ways in which they treat patients. Do they claim their methods are predicated upon medicinal practices, and why do some rehab centers charge exorbitant sums of money for treatment?
That's exactly the point. When you get to the upper end, $50,000 to $100,000 for a month, you're basically paying for five-star luxury treatment. I know people who have done that and they're getting gourmet meals, over a Pacific Ocean view, and foot massages. The nuts and bolts of treatment doesn't cost that much. You're also paying for the time, the doctors and other professionals. But a lot of people running rehabs are under-skilled, recovered addicts who got a crash course. They're unregulated and unsupervised. It's a big mess. If you don't pay a large amount, there are state-run rehabs, but often there are waiting lists and other compromises that you need to go through. The waiting period itself can be a real problem because people are often willing to (get sober) within a small window. But that window closes, so timing is also important.
Do rehab centers purposely send patients down a path towards failure so they return and spend more money?
That's a subject of debate these days. I don't know if anybody really knows. I don't think that's the norm, but I think for some that can be a strong motivator, and that's just speculation, because who knows?
Some of the centers in the States are run by a consortia that operate a number of rehabs in different locations. Some patients can be snuck from one location to another in sneaky, insidious ways. You start off in residence in a house with eight people, and a few weeks later you're sent to another house, which is a dormitory. They feel like they're being trampled on and frustrated, and there isn't much they can do because they're in the system and they've made a huge financial commitment. They're stuck and nobody's watching over these guys. It's basically a free-for-all.
I'm criticizing the way the medical model is used both to conceptualize addiction and to underpin, support, and reinforce the philosophy of the rehab industry. Because it fails people so often, the medical model and definition of addiction should be seriously challenged, but it isn't and there's something really wrong with that. It's a self-reinforcing system that waves this banner that says you have a chronic disease that will kill you, so you better come to us.
The rationale that they have a disease has a lot of weight, especially because it's backed up by a lot of high-level bodies, like NIDA (National Institute on Drug Abuse). NIDA funds about 90 percent of addiction research in the world, according to some reports. You're giving money to people who are doing research on the biological or cellular mechanisms involved in addiction, but they're not giving money to people who are challenging the disease model, so that in itself is a self-perpetuating system.
In other words, medicine does not have much to offer addicts? Does that mean treatment is really a testament of will?
Will has an awful lot to do with it. A lot of addiction experts feel that self-empowerment, self-motivation, self-directed activities, self-designed goals for [addicts'] own progress are critical steps on the road of overcoming addiction. The medical model says you're a patient and you have to do what the doctor tells you.
[Del. Dan Morhaim, a doctor and Maryland legislator] is quoted as saying addiction is "a medical issue that has disastrous social consequences." That's very typical. Take those words, turn them around and you have something that's much more accurate: It's a social issue that has disastrous medical consequences.
Throwing people in jail and prohibition are responsible for a lot of the harm that comes with addiction. The prohibitions create this narrow passageway by which addicts have to squeeze themselves through, which drives them into crime, which breathes life into criminal organizations and cartels that get rich on the war on drugs. What Morhaim is proposing, though, is basically giving heroin to heroin addicts in Maryland, making it free by doctors. That's a very credible idea these days. It's been tried it in Switzerland, Germany, and Denmark, and it certainly reduces crime.
Your new book, The Biology of Desire: Why Addiction Is Not a Disease, eponymously puts forward that addiction is not a disease, and calling it such gets in the way of proper treatment.
Firstly, defining addicts as patients makes them passive. It makes them fatalistic and it makes them pessimistic. If you're told you have a chronic brain disease that causes you to do all this nasty shit, you don't think you'll ever get free of it. But, in fact, most addicts do recover and the statistics are very clear on that, whether they're soft drugs or harder drugs like heroin. So, it's a chronic disease? Really?
The second thing is it tends to overshadow other approaches to treating addiction that relies on much more individualized psychological methods. There are various kinds of psychotherapy, counseling, support networks, and mindfulness meditation approaches that are also being shown to be very effective. If you believe you have a chronic disease and so does your care provider, they're not very likely to recommend mindfulness meditation, but it's been shown to be very effective.
While opiate and alcohol withdrawal can wreak physical havoc on addicts, you argue that addiction is purely behavioral rather than physiological, like, say, cancer is?
That's another discrepancy. You have substance addiction on one hand, and behavioral on the other: gambling, sex addiction, porn addiction, a number of eating disorders, internet gaming. The cool thing is when you do brain scans, you get the same neural activation patterns in behavioral addictions as you do in substance addictions. That should be enough to knock out the disease model. If addiction is a disease, then people who spend 12 hours a day playing video games are suffering the same way people who are addicted to heroin do.
What all these patterns have in common is they involve deep learning—a set of assumptions of what you need to get through the day; that learning gets entrenched through repetition and you're addicted, but there's nothing disease-like about it. People recover from all addictions, which means it's all about neural plasticity. It's not that you go back to where you were, because development never goes in reverse, it's that you learn skills that help you overcome your impulses and you learn new cognitive habits. All learning involves changes in synapses, which means creation and strengthening of certain synapses, and the weakening or disappearance of synapses that aren't being used.
It isn't unreasonable to presume your theories are unpopular in the addictions treatment industry. Have you drawn criticism, and have you been publicly undermined?
Yeah, I've been chastized. A review in the Washington Postcalled me a "zealot." Mostly people in the medical camp, they try to ignore people like me and other people who also endorse a learning model or developmental model of addiction. They just ignore us. But this is part of a rising wave. I'm not the only one here. The only difference with me is I can talk their language because I know the brain. I've talked to Nora Volkow, [the director] of NIDA and a very powerful policy maker. She doesn't want to hear it. She's basically saying that addicts need to be told they have chronic brain disease because that will reduce stigmatization. But people like me come along and say, "No, it doesn't look like brain disease. Brain change, yes. But that's what a brain is supposed to do because it's learning." That's when the wall comes down.
If addiction is not a disease, does that render the "alcohol gene" a fallacy?
You get little things that show some genetic correlation with alcoholism, but there is no gene, or cluster of genes, that create addiction. Rather, there are personality traits that have a genetic loading, like impulsivity. So you get these cross-generational correlations that are real and do have genetic loading, but there's nothing like a particular gene or set of genes specific to addiction.
What is the relationship between addiction and developmental age? Is it easier to kick a junk or coke habit at a certain age?
Yes, absolutely. For one thing, each of these addictions has an average duration, an average longevity. A lot of research on this was done by Gene Heyman. The median age for quitting cocaine is four years after you start. The median age for alcohol is 12 to 15 years after you start. They're medians, so there are variations. The second thing is the brain continues to develop through the teens and 20s, and you get increasing executive control in your 20s, giving you more of the neural hardware you need to help you regulate your thinking and your behavior. The third thing is, as we age and grow up, our circumstances change. By the time you get close to 30, you realize you have to get certain things under control. Those are all strong reasons why age matters.
You're on record as saying that calling addiction a chronic brain disease combats stigma. Given that we live in an age of hyper political correctness, is there a correlation between stigmatization reduction and the persistence of the chronic brain disease theory?
Yeah, I think there is. If you have a disease and it's not your fault, you're not a lazy, decadent, self-centered, weak-willed whatever... it's that you have a disease, so you shouldn't feel so ashamed or guilty. That's a convenient way for us to forgive addicts and for addicts to forgive themselves, and that is a form of political correctness. Some people have asked me when I do talks or write blogs not to use the word "addict" because you're calling someone a name. It's politically incorrect to designate someone according to a condition they may have. My response is I get your point, but first of all, I called myself an addict for years. I was also a student once and I'm not a student anymore. That's part of the whole political correctness movement—"It's not their fault, they're just human beings." Well, yes, they are human beings, and no, I don't want see them suffer and sent to prison. The idea that these are the only two alternatives—either call it a disease or call it morally decrepit and tar and feather them is ridiculous. It's black-and-white thinking. We can still be humanistic and not slap this label on it.
In layman's terms, what is addiction if it isn't a disease?
Addiction is learning, very simply. It's learning a habit of thinking. It's deeply entrenched learning. So are relationships when you're in love with someone. If that person happens to be abusive, you might still be in love with them for 12 years or the rest of your life. That's through learning. So is being a sports fan or a Jihadist. Religion is another deep substantiation of deep learning. That's what I think it is. The fact that it could be gambling, or eating, or heroin, or meth, it shows there are certain addictions that involve substances that create physical dependency. Physical dependency is a whole other layer of shittiness on top of addiction.
Psychological and interpersonal tools are very important. Addiction has to do with isolation and feeling alone, not having a support network and not being able to deeply connect with other people. You can superficially connect and have a nice circle of addicts, but not connecting with people in a way that's harmonious and fulfilling, those are the people that are really vulnerable to addiction. They're lonely, depressed, anxious, and traumatized. It's just like the Rat Park [Canadian study into drug addiction]. What I said doesn't just apply to humans, it applies to other animals, too. Isolation is really bad for you and it's the underlining factor of addiction.