The prevailing view that addiction is a disease, just like depression or diabetes, is wrong, according to a leading neuroscientist.
The brain changes seen in addiction have more to do with learning and development -- not a chronic brain disease, said Lewis, who became addicted to opiates during his undergraduate years at Berkeley but got clean at age 30 and earned a PhD in developmental psychology. Viewing addiction as a behavioral issue, which has drawn critics and supporters, may pave the way for new approaches to recovery that target the psychological roots of addictive behavior.
Addiction is one of the most pressing public health issues in America. An estimated one in 10 Americans suffer from alcohol or drug dependency, while others have behavioral addictions, including porn, sex and gambling.
HuffPost Science caught up with Lewis to learn more about the neurobiology of addiction, his challenge to the disease model and some promising new directions for addiction treatment.
What's wrong with the disease model of addiction?
I know what scientists are looking at when they say addiction is a disease. I don't dispute the findings, but I dispute the interpretation of them. They see addiction as a chronic brain disease -- that's how they define it in very explicit terms.
My training is in emotional and personality development. I see addiction as a developmental process. So the brain changes that people talk about and have shown reliably in research can be seen as changes that are due to learning, to recurrent and deep learning experiences. But it's not an abnormal experience and there's nothing static or chronic about it, because people continue to change when they recover and come out of addiction. So the chronic label doesn't make much sense.
What's problematic about the way we treat addiction, based on the disease model?
Well, lots. The rehab industry is a terrible mess -- you either wait on a long list for state-sponsored rehabs that are poorly run or almost entirely 12-Step, or else you pay vast amounts of money for residential rehabs that usually last for 30-90 days and people often go about five to six times. It's very difficult to maintain your sobriety when you go home and you're back in your lonely little apartment.
What I emphasize is that the disease label makes it worse. You have experts saying, "You have a chronic brain disease and you need to get it treated. Why don't you come here and spend $100,000 and we'll help you treat it?" There's a very strong motivation from the family, if not the individual, to go through this process, and then the treatments offered in these places are very seldom evidence-based, and the success rates are low.
There are lots of ways to trigger a humanistic response besides calling something a disease.
So you would say that telling people who are in recovery for addiction that they have a "chronic disease" is actually doing them a disservice?
Well, the chronic part is really a yoke that people carry around their necks. [Proponents of the disease model] say that this is important because this is how to prevent the stigmatization of addicts, which has been a standard part of our culture since Victorian times.
But I think that's just bullshit. I don't think it feels good when someone tells you that you have a chronic disease that makes you do bad things. There are ways to reduce stigmatization by recognizing the humanity involved in addiction, the fact that it happens to many people and the fact that people really do try to get better -- and most of them do. There are lots of ways to trigger a humanistic response besides calling something a disease.
It can be difficult to comprehend the idea that something as severe as a heroin addiction is a developmental process. Can you explain that?
First of all, let's include the whole bouquet of addictions. So there's substances -- drugs and alcohol -- and there's gambling, sex, porn and some eating disorders. The main brain changes that we see in addiction are common to all of them, so they're not specific to taking a drug like heroin, which creates a physical dependence. We see similar brain changes in a region called the striatum, which is an area that's very central to addiction, which is involved in attraction and motivational drive. You see that with gambling as much as you do with cocaine or heroin. So that's the first step of the argument -- it's not drugs, per se.
From there, it's important to recognize that certain drugs, like opiates, create physical dependency. There's a double whammy there. They're hard to get off because they're addictive, like sex or porn is, but they also make you uncomfortable when you stop taking them. People try to go off of them and get extremely uncomfortable and then they're drawn back to it -- now for physical as well as psychological reasons.
In the case of any type of addiction, what's going on in the brain?
The main region of interest is the striatum, and the nucleus accumbens, which is a part of the striatum. That region is responsible for goal pursuit, and it's been around since before mammals. When we are attracted to goals, that region becomes activated by cues that tell you that the goal is available, in response to a stimulus. So you feel attraction, excitement and anticipation in response to this stimulus, and then you keep going after it. The more you go after that stimulus, the more you activate the system and the more you build and then refine synaptic pathways within the system.
The other part of the brain here that's very important is the prefrontal cortex, which is involved in conscious, deliberate control -- reflection, judgment and decision-making. Usually there's a balance between the prefrontal cortex and the striatum, so that you don't get carried away by your impulses. With all kinds of addictions -- drugs, behavior, people -- the prefrontal system becomes less involved in the behavior because the behavior is repeated so many times. It becomes automatic, like riding a bike.
What would a scientifically informed approach to addiction look like?
That's a really hard question because the fact that we know what's happening in the brain doesn't mean that we know what to do about it.
A lot of recent voices have emphasized that addiction tends to be a social problem. Often addicts are isolated; they very often have difficult backgrounds in terms of childhood trauma, stress, abuse or neglect -- so they're struggling with some degree of depression or anxiety -- and then they are socially isolated, they don't know how to make friends and they don't know how to feel good without their addiction.
So what can we do about that?
Other than certain drugs that can reduce withdrawal symptoms, there's nothing much medicine can offer, so we have to turn to psychology, and psychology actually offers a fair bit. There's cognitive behavioral therapy, motivational interviewing, dialectic behavioral therapy, and now there are mindfulness-based approaches, which I think are really exciting.
There's been good research from Sarah Bowen in Seattle [on Mindfulness-Based Relapse Prevention] showing that mindfulness practices can have a significant impact on people, even on people who are deeply addicted to opiates.
This interview has been lightly edited for length and clarity.
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