Category: Connect

Notice, first, that I say “resulting from” choice. Nobody choses to be addicted. But as people become increasingly hooked, they may increasingly choose to take the pill or the drink, or to gamble or purge, and that’s the thing we need to examine. What is the role of choice in the onset of an addiction? What is its role in recovery?

The voices that oppose the “choice” model often argue that addictive behaviour is nothing like free choice. It is like a compulsion. There is a feeling of need and desire, and perhaps not just a feeling but an actual need, that compels them to choose to use, each and every time. From the “disease” camp, this argument is further bolstered by our understanding (as described last post) that addiction really does change the functioning of the dopamine system. Since our organ of goal-pursuit (the NAC, or ventral striatum) is thus compromised, how could we possibly make free choices. Finally, opponents of the “choice” model argue that framing addiction as choice just invites the humiliations and accusations, both from within ourselves and from others, that become so unbearable. “If it’s a choice, then you damn well need to choose differently, and that’s your responsibility!” That usually makes things worse, not better.

The problem, I think, comes with the phrase “free choice”. Who said choice is free? I’ve covered this topic in two previous posts. In the first of these, I argued that choice comes from the brain – obviously – and it specifically springs from a contest between the striatum’s goal seeking and the role of the anterior cingulate cortex (ACC) in monitoring probable outcomes. In the second, I described how neuroscientific data places the moment of choice in a stream of brain activity, occurring seconds before we’re even aware of making a choice. But I also claimed that we can insert “reflection” into that stream and nudge it one way or the other.

With addiction, the ACC is increasingly weakened by ego fatigue, and the v. striatum responds ever more strongly to gouts of dopamine triggered by addictive cues (including thoughts and memories). So choice becomes increasingly irrational, increasingly spontaneous, and increasingly uncontrollable. Then should we still call it “choice” at all?

One of the most persuasive advocates of the choice model is Gene Heyman. For Heyman, addiction is a result of choosing what is most rewarding in the moment at the expense of long-term gains: choosing ‘‘locally’’ rather than ‘‘globally.’’ He cites studies of delay discounting that investigate these effects. Remember the marshmallow test? Same idea. Rewarding events are much more attractive if they are expected “now” rather than “later”. But this poses a problem: repeatedly choosing the immediate reward makes both immediate and long-term rewards less desirable. In terms of the immediate benefits, heroin becomes expensive, boring, and smeared with self-rebuke. It’s never as good as it was at the beginning. But the value of long-term rewards goes down as well. Once your marriage is shot, you’ve lost your job, and/or you’re deeply in debt, the future doesn’t hold much attraction at all. It becomes less and less rewarding, in fact it becomes painful to contemplate. So the immediate reward, a shot of heroin, remains the best option.

On any single occasion, says Heyman, the local choice continues to be valued above the global choice. In other words, an immediate reward—‘‘one more time,’’ as addicts often tell themselves—is always more attractive than waiting for the long-term picture to get brighter. In this way, addictive choices are like normal choices. You choose what you want based on its expected value. But, unfortunately, the expected value of things gets shifted by the self-perpetuating nature of addictive behaviour.

What’s wrong with the “choice” model? It sounds pretty rational. Just a problem of behavioural economics, as they call it. We keep choosing what feels best. And that also means that we can choose differently, providing a gateway to recovery. Once the future backs right up to the present moment, then the immediate choice, the addictive choice, loses its attraction, and we can choose to stop.

What’s wrong is that the “choice” model ignores the brain. Big mistake! The brain that houses the famous dopamine pump, and its eagerly awaiting customer, the v. striatum, is the same brain as the one we use for making choices. From a brain’s-eye view, the reason people choose the immediate reward is that dopamine highlights immediate possibilities. That’s its function, and has been throughout evolutionary time. Research shows that dopamine rises proportionally as the goal gets closer and closer at hand, driving motivation with it. Now, if that’s the case for marshmallows and other normal rewards, imagine how powerful the dopamine surge is in response to addictive substances or acts! (See recent posts and comments.) That swelling wave of dopamine, announcing the availability of a supremely attractive reward, recasts the balance between present and future appeal — more quickly and more thoroughly than anything else could. To choose future gain, over immediate reward or relief, becomes incredibly difficult when every synapse in the striatum and frontal cortex is resonating to the “neural now”. Especially once ego fatigue sets in.

So, yes, the addictive act is a choice. Each and every time. That means that there is always the possibility of saying No. Yet, saying No is incredibly difficult, and that’s a problem the “choice” camp can’t solve…

…without the help of neuroscience.

I’ve generally felt critical of the “disease” label for addiction. But having read your many comments and looked up some recent literature, I can now give it its due. In my last post, I argued that models and metaphors are not intrinsically different. A metaphor is a kind of model. And I commented that the different metaphors/models of addiction work differently for different people. So the way a model functions should be a criterion for its acceptance.

But what about the “disease” model? Psychiatrists – because they are doctors – rely on categories to understand people’s problems, even problems of the mind. Every mental and emotional problem fits a label, a medical label, from borderline personality disorder to autism to depression to addiction. These conditions are described as tightly as possible, and listed in the DSM (Diagnostic and Statistical Manual of Mental Disorders) and the ICD (International Classification of Diseases) for anyone to read.

The idea that addiction is a type of disease or disorder has a lot of support. I won’t try to summarize all the terms and concepts used to define it, but Steven Hyman does a good job (thanks to Elizabeth for the link). His argument, which reflects the view of the medical community (e.g., NIMH, NIDA, the American Medical Association), is that addiction is a brain disease. (Also see this piece in the Huffington Post.) Addiction is viewed a condition that changes the way the brain works, just like diabetes changes the way the pancreas works. Specifically, the dopamine system is altered so that only the substance of choice is capable of triggering dopamine release to the nucleus accumbens (ventral striatum), while other potential rewards do so less and less. The nucleus accumbens (NAC) is responsible for goal-directed behaviour and for the motivation to pursue goals, as I’ve described in detail in my book.

Different theories propose different variants. For some, dopamine means pleasure. If only drugs or alcohol can give you pleasure, then of course you will continue to take them. For others, dopamine means attraction. Berridge’s theory (which is the one I follow) shows that cues related to the object of addiction become “sensitized,” so they greatly increase dopamine and therefore attraction…which turns to craving when the goal is not immediately available. But pretty much all the major theories agree that dopamine metabolism is seriously altered by addiction, and that’s why it counts as a disease. The brain is part of the body, after all.

What’s wrong with this definition? Not much. It’s pretty accurate. It accounts for the neurobiology of addiction much better than the “choice” model and other contenders. It explains the helplessness addicts feel: they are in the grip of a disease, and so they can’t get better by themselves. It explains the incredible persistence of addiction, its proneness to relapse, and it explains why “choice” is not the answer (or even the question). That’s because choice is governed by motivation, which is governed by dopamine, and your dopamine system is “diseased.”

So, do I buy it? Not really. I do think it’s often very helpful. It truly does help alleviate guilt, shame, and blame, and it gets people on track to seek treatment. Moreover, addiction is indeed like a disease, and if I follow my own words, then a good metaphor and a good model aren’t much different. Their value depends on their usableness.

Then why don’t I buy it? Mainly because every experience that has some emotional content changes the NAC and its uptake of dopamine. Yet we wouldn’t want to call the excitement you get when you’re on your way to visit Paris, or your favourite aunt, a disease. Each rewarding experience builds its own network of synapses in and around the NAC, and that network sends a signal to the midbrain: I’m anticipating x, so send up some dopamine, right now! That’s true of Paris, Aunt Mary, and heroin. In fact, during and after each of those experiences, that network of synapses gets strengthened: so the “specialization” of dopamine uptake is further increased. London just doesn’t do it for you anymore. It’s got to be Paris. Pot, sex, music…they don’t turn you on that much; but coke sure does. Physical changes in the brain are its only way to learn, to remember, and to develop. But we wouldn’t want to call learning a disease.

So how well does the disease model fit the phenomenon of addiction? How do we know which urges, attractions, and desires are to be labeled “disease”, and which are to be considered aspects of normal brain functioning? There would have to be a line in the sand somewhere. Not just the amount of dopamine released, not just the degree of specificity in what you find rewarding: these are continuous dimensions. They don’t lend themselves to two (qualitatively) different states: disease and non-disease.

Thus, addiction doesn’t fit a specific physiological category. But what about the functionality, the useability, of the disease model? That’s disputable. It works well for some, not at all for others. And I think that’s because addiction is an extreme form of normality, if I can say such a thing. The function of modelling addiction as a disease is limited because “disease” and “normality” are overlapping, not mutually exclusive, when it comes to the mind and the brain. Yet we sure recognize addiction as distinct from “normal” in our everyday lives. That’s the problem.

My solution will come several posts from now. Meanwhile, I hope readers will comment on other aspects of the disease model that fit, or that don’t fit, the phenomenon of addiction.

Actually quite a few words. At times I seem to be in the throes of some seriously run-on sentences. I was a tad nervous. George seems like a really nice guy. Somehow he finds a way to connect with his guests and ask questions that are both challenging and friendly. That friendliness — what seemed like authentic warmth — made me feel less like a dork than I might have. I’ve always found it damn disconcerting to talk about the nasty things I did, on the air, especially on TV, where there’s really nowhere to hide. And there were a lot of cameras and lights, and real live people in the audience. So yeah, I was kind of nervous, especially at first.

For my readers outside of Canada, the Strombo show is our version of The Tonight Show…laid back chatty interviews with a very charismatic host, on national TV. When we taped this segment, way back in October, I was in awe of him. I guess I still am.

Here’s the interview, as posted on YouTube. Thanks to Sharon, a reader — no, not that Sharon! — who either posted it our found it there.

Many readers responded to my request for different perspectives and insights on the question: Is addiction a disease? I said I’d like to know what others thought before stating my own view. The strange thing is that my own view has changed considerably in light of your comments. Perspective is funny that way: it looks like a solid version of reality until the waves pick up, the boat starts to rock and pitch, and it’s time to set a new course…or jump ship.

Over my next three posts, I’m going to talk about the three most common definitions of addiction, one per post: a disease; a matter of (unwise) choice; and a process of self-medication. And for each I’m going to show the pro’s and the con’s, backed up by theory and data from psychology and neuroscience.

My own model of addiction will come at the end, in a fourth post. Here’s a sneak preview: I see addiction as an accelerated form of learning. I see it as the result of a natural learning process that has gone way too fast and way too far, yielding habits that are extremely difficult to “unlearn”. I explain this in terms of the highly emotional content of what gets learned (associative learning in the amygdala), the processes that connect emotion with action (through the ACC and premotor cortex), and the elaboration of networks (in orbitofrontal cortex and related regions) that give the addictive goal its enormous “value” or “meaning” – all of which feeds back with the narrowed focus of our primary goal-seeking system (the ventral striatum and its dopamine pump).

I’d like to think that my model of addiction is accurate and precise – a scientific model – whereas the other three are analogies or metaphors. So I refute the idea that addiction is a disease, but I agree that it can be like a disease. And I refute the idea that addiction is a free choice, yet I see that it involves choice at every step. Finally, I don’t think that addiction is self-medication, but I agree that it’s based on attempts to self-soothe, to relieve anxiety, boredom, or depression.

So I’m tempted to claim that these three models are metaphoric approximations, whereas mine is the real thing. But wait a minute. If these metaphors help us understand addiction, if they help us to classify it and deal with it, then they must have some value. And maybe my model is an approximation too, albeit a biological one.

And what’s wrong with metaphors anyway? Some scholars say that all our concepts are based on metaphors or analogies – variations on a theme. So if, for example, the “disease” concept works to organize your thoughts, and more importantly your actions, to help addicts (including yourself?) work toward recovery, then it’s worthwhile, it’s beneficial, it might even be the best show in town.

Yet there is one major qualifier: different analogies, metaphors, models, or whatever you want to call them, work for in different ways for different people. And as much as they can be constructive for some, they can also be destructive for others. If you are tuned into the helplessness, the insidious, relentless growth of addiction, if you see addiction as something that takes over one’s body, one’s mind, maybe one’s soul, then the disease model is going to be meaningful to you. And your efforts to quit will take the form of searching for a cure. But for others, seeing addiction as a disease, as something outside the self, foreign to the self, the disease concept may be harmful. Because the implication is that “you” can’t do anything about it – at least not without help. Or, if you are tuned into the choices that fashion addiction, if you focus on those fleeting moments of intention, when addicts jump the gap from let’s-stay-sober to let’s-get-stoned, then the choice model will be most meaningful. And that model can help you to make different choices, because the cause is in you, it’s something you can change. But once again, the choice model is a double-edged sword. Because, for some people, it’s the basis of blame (from outside) and guilt (from inside) – both of which can poison the recovery process.

The way we see our addicted selves or our addicted loved ones is going to determine which model rings true. So experience is going to play a crucial role in how we define addiction. Consequently, I can say that my “learning” model is the most plausible, I can say that it fits best with cognitive science and brain science, but I can’t say that the alternative models are meaningless. They can do a great deal of good, or a great deal of harm, depending on how they’re used.

Stay tuned, for a closer look at each of the three models. And while we explore their meaning, we will also explore their use, their misuse, and their capacity to help or to hinder.

Here’s some more “filler” while I prepare my next post. But I hope it’s worth the read. The Fix, which seems to be the most popular addiction/recovery magazine out there, published a Q&A interview about my book – how I wrote it, what I was trying to say, and how it changed my life. Walter Armstrong, the deputy editor at The Fix, asked some really good questions, and I hope I gave him some really good answers.

Walter seemed like a good guy: patient, tuned in, and empathic. Maybe those goes with the job. I had the strongest temptation to ask him whether he himself had been there and back. But I held my tongue on that one.

Walter clearly liked the book. Here are some of his very generous words:

Lewis’ twin expertise as a longtime addict and a brain scientist enabled him to produce a memoir mapping, in remarkably lucid and vivid detail, entirely new ground. Weaving together his objective accounts of drugs’ effects on the brain with descriptions of his mind’s subjective experience, he brings to light how the very shape of intoxication on one substance or another mirrors the shape of the specific chemical reactions taking place inside your skull.

These pioneering observations fit effortlessly into the overall narrative, which is as over-the-top suspenseful as David Carr’s classic The Night of the Gun.

And here’s the link to the interview. Take a look, and while you’re at it check out some of the other features of this unusual publication. There’s some rough stuff on these pages. Heavy-duty addicts bearing their souls, and blazing arguments about the pro’s and con’s of this and that treatment approach. Lots to learn and quite a few surprises.

My next real post is…..almost ready.