Is Addiction a Moral Failing?

Is Addiction a Moral Failing? March 21, 2016


Something that, as an atheist, I always insist upon is that we are biochemical machines. There’s no spooky, supernatural ghost in the machine directing our bodies, no Cartesian Theater where the nervous system feeds into a single ineffable locus of consciousness. Our thoughts and our desires arise from patterns of electrochemical activity in our heads, and drugs and other interventions that alter those patterns of connectivity produce corresponding changes in our minds.

But even if we know this to be true, we’re often slow to attend to the implications. Today, I want to write about one particularly startling example of how the materialist viewpoint can change what we think we know about the mind. I learned about this from an episode of the excellent science podcast Radiolab, titled “The Fix“.

Our society thinks of addiction as a moral failing, a culpable lack of willpower. That’s why we sentence (some) people to prison for being addicted to drugs. That’s also why one of the most popular treatments, Alcoholics Anonymous, is couched in religious language that shames the addict and frames their behavior as a character flaw: the sixth of AA’s twelve steps is “asking God to remove defects of character”. Atheists and secularists have long pointed out the explicitly religious nature of these programs, especially when courts require addicts to attend AA meetings.

Additionally, there’s AA’s barefaced religious affiliations to consider. True, the 12 steps have been worded in such a way as to suggest a certain amount of leeway in which God (or “higher power”) one ultimately surrenders to; but AA is a self-identified Christian organization with a significant portion of its methodology rooted in prayer. As it says in AA’s founding literature, known as the Big Book, “To some people we need not, and probably should not, emphasize the spiritual feature on our first approach. We might prejudice them. At the moment we are trying to put our lives in order. But this is not an end in itself. Our real purpose is to fit ourselves to be of maximum service to God.”

What’s more, the evidence that twelve-step programs work is a lot thinner than you might think. As Gabrielle Glaser writes in the Atlantic:

In his recent book, The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry, Lance Dodes, a retired psychiatry professor from Harvard Medical School, looked at Alcoholics Anonymous’s retention rates along with studies on sobriety and rates of active involvement (attending meetings regularly and working the program) among AA members. Based on these data, he put AA’s actual success rate somewhere between 5 and 8 percent.

A treatment program steeped in religion, founded before the modern scientific understanding of the brain, with a success rate in the low single digits. It seems as though we should be able to do better than this. And we can.

There’s a drug called baclofen, invented in the 1920s. It’s a muscle relaxant, used to treat spasticity in ailments like multiple sclerosis and cerebral palsy. But some baclofen users who are drug addicts report a surprising and unexpected side effect: their previously uncontrollable cravings simply disappear. Dr. Oliver Ameisen, a successful physician who grappled with severe alcoholism and had tried other therapies like AA acupuncture and hypnosis with no success, heard these anecdotes and decided to experiment on himself with the drug. It worked:

Each time he increased the dose he would feel sleepy, but this wore off after a couple of days. That was until, in February 2004, he reached 270mg – a dose 150-190mg above the maximum dose for most countries. At this level, the sleepiness did not wear off, but he noticed something else: his desire to drink had gone. “I was completely and effortlessly indifferent to it,” he wrote.

Other evidence supports this claim, including a study by an addiction research center in Los Angeles in which cocaine addicts who took baclofen reported that it reduced their cravings for the drug, a claim that was correlated by urine tests.

In fact, baclofen is just one of a whole family of drugs with similar effects. Most of them are opioid antagonists – they block the pleasure-inducing neurotransmitters that are part of the brain’s reward system. One of these drugs that you may have heard of is naloxone, a medicine with a near-miraculous ability to revive people dying of heroin overdose. (Baclofen seems to work through a different, related pathway: it strengthens the effect of GABA, an inhibitory neurotransmitter that’s linked to relaxation and calm.)

This reward system is deeply imprinted on our brains by evolution and motivates us to seek out pleasurable experiences like food or sex. Since living beings that shun these experiences wouldn’t survive or reproduce, the reward pathways are very powerful and exert a strong pull on behavior, one that can usually be counterbalanced only by some other compelling interest, and sometimes not even then. (Just think of how many powerful people have thrown away marriages and careers for the sake of a one-night stand.) But drugs that act directly on the brain’s reward pathways can hijack this system, creating a superstimulus even stronger than that.

Under the ghost-in-the-machine model, all that means is that a person has to double down and exert more willpower to resist the unwanted craving. But under the materialist model of psychology, in which we are our brains, these drugs literally rewrite the hierarchy of a person’s desires. Like a heavy weight on a rubber sheet, it distorts all other goals and priorities and exerts an inexorable pull on behavior.

But with anti-addiction drugs, we can counterbalance that malign influence with a benign one. Baclofen and opioid antagonists don’t change the sensory qualities of an experience, but they remove the pleasure component that produces cravings. Gabrielle Glaser’s article recounts her own experiment with another opioid antagonist, naltrexone:

The first night, I took a pill at 6:30. An hour later, I sipped a glass of wine and felt almost nothing — no calming effect, none of the warm contentment that usually signals the end of my workday and the beginning of a relaxing evening. I finished the glass and poured a second. By the end of dinner, I looked up to see that I had barely touched it. I had never found wine so uninteresting.

Although they’re more common in Europe, these drugs aren’t nearly as well-known or widely prescribed in America as they should be, partly because of institutional inertia and partly because of a deficit of doctors qualified in addiction medicine. But I think a larger part is a lingering reluctance to let go of the addiction-as-sin idea. It still seems unnatural – it seems like cheating – that you can beat addiction just by taking a pill, without having to suffer and endure suffering, without having to buckle down and show true grit.

But when a properly materialist, scientific theory of the mind is more widely adopted, this irrational holdover will largely dissolve. None of this is to say that moral character-building is irrelevant, or that willpower isn’t real, or that individual effort isn’t needed to accomplish anything. But what it does mean is that we should think of the brain like any other physical system, meaning that it’s susceptible to breakdown in ways that can’t be overcome just by force of will. If your computer was broken, you’d find the malfunctioning part and replace it. So too, when our brains malfunction in ways that impair the ability to think and plan rationally, it makes perfect sense for us to seek external treatments that correct the malfunction and restore the balance.

Image credit: Chaval Brasil via Wikimedia Commons; released under CC BY-SA 2.0 license

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