Wednesday, May 25, 2022

"The Biology of Desire: Why Addiction is Not a Disease" by Marc Lewis

Marc Lewis explores the neurobiology of addiction in this short book, with proposed approaches to better understanding and helping people who are struggling with addictions.  

He comes across very clearly as a compassionate person, with a good understanding and personal experience in this area.  Probably someone who would be good to have as a therapist or support in the context of addictive problems.   

The book presents several case stories, which is always a compelling style in describing health care issues.  They could be a source of inspiration that could help people in their own journeys through addiction.  But of course testimonial accounts have only limited value in a scientific study, since they can introduce very strong biases in the reader, if not accompanied by references to large controlled studies.    

He has good reasons for disparaging what he calls "medicalization" of addiction, and emphasizing his opinion that addiction should not be considered a "disease."    Many of these reasons involve emphasis on what most of us would consider "bad medicine," i.e. institutional or even punitive treatment, simple remedies such as drug treatments given without addressing social or psychological issues, etc.    He particularly disparages psychiatrists, as though he thinks all psychiatrists enjoy the narrow or excessive brandishing of labels and dispensing of medications without attending to deep understanding, therapeutic compassion, and a biopsychosocial focus, with patients.  

So I found this part of his message to be tiresome.  Excessive narrow "medicalization" of almost any issue is not good medicine.  Almost any health condition, such as type II diabetes, heart disease, hypertension, and certainly conditions such as anxiety or depression, have spectrums of severity or chronicity; there are very important psychosocial factors, often present for years before the onset of the condition, that influence symptoms, severity, and progression.   There are feedback loops involving behaviour which cause spiralling exacerbations or rapidly accumulating harms in all of these conditions.  And treatments for diabetes or heart disease need to involve understanding and help with lifestyle, social, and economic factors affecting these conditions, with long-term goals in mind.    But it is not necessary to avoid calling diabetes a "disease."  Rather, the approach should be, in my opinion, to recognize that any disease state occurs on a continuum.  In many cases, there is no clear-cut line between disease or non-disease.   The word "disease" does not necessarily imply permanence, or need for invasive, narrow,  or institutional treatments.  For example, we could agree that viral pharyngitis is a disease, but is not one which normally requires medical intervention.  Just as in addiction, many conditions uncontroversially considered "diseases" or at least pathological states, such as pneumonia, COVID, migraine, sciatica secondary to disc prolapse, psychotic episodes, or brain injury, can often  recover on their own without any treatment at all; but for some sufferers of these conditions, the symptoms become relentlessly chronic or more difficult to deal with.    Just because something has the possibility of improving on its own, or through lifestyle improvements, after days, months, or years, does not mean that it shouldn't be considered a disease.  Furthermore, the improvements in many conditions can sometimes be associated with improved perspective or lifestyle, but sometimes the improvements are just random.  Many patients I've seen have engaged in all the healthy perspective-taking and good lifestyle habits you can imagine, but are still afflicted by the same tormenting symptoms.  Other patients somehow recover from severe problems without changing their lifestyles much at all.  

Hypertension is a disease, with multifactorial causes, which often requires medication but always requires attention to lifestyle factors.   Simple, overly reductionistic medical treatments can sometimes help with certain disease states (such as repairing a broken limb) but in many or most disease states, medical treatments are only one branch of helping.  The other branches require attention to lifestyle factors, community or social supports, and possibly an existential focus, to help people regain an awareness and passion for long-term goals.  But this multi-pronged focus is what I consider to be normal medical care.  

Lewis argues that because the neurobiology of addiction features entirely "normal" activations of normal brain pathways, akin to learning or falling in love, addiction therefore should not be considered a disease.  But many conditions in medicine feature activation of normal physiologic functions as a component of their pathology.  For example, inflammatory states resulting from infection (this is a major pathology in COVID) are activations of the body's defenses to fight off pathogens, but the inflammation itself ends up causing severe tissue destruction.  The processes are all "normal" but the circumstances of the disease state (germ + host) cause the reaction to be disastrous.  A clear understanding of disease states, mechanisms, and medical interventions to interrupt this cycle, are indicated to save lives and prevent widespread tissue destruction.  

Addictive states can lead to similar destruction of bodies, minds, relationships, and careers.  Just because the mechanisms involve activations of normal neural pathways does not mean we should avoid diagnostic language.    Problems associated with pathologizing labels, such as stigma (from others or from self) do not mean we have to avoid such labels entirely, but it may mean that the labels should be used with care and humility, rather than in a pejorative manner.  

There is interesting neuroscience describing addictive processes, but sometimes discussion of this can devolve into making overly strong literal claims (e.g. about neuroplasticity), often based on compelling testimonial accounts, without as much robust statistical evidence to back these up.  This is a pitfall I've seen with other authors touching on this, such as Doidge.  The use of the neuroscientific language then becomes a tool of persuasion, which sounds impressive to most people.  But it is much more important in this area to back up claims, especially those based on case studies or testimonial accounts, with careful reference to large controlled studies.   

Lewis has good ideas and a passion for his subject, but his focus on addiction not being a "disease" is needless--it is to some degree a semantic squabble, which subtracts needlessly from the impact of his book.  

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