Addiction is a chronic, often relapsing brain disease that causes compulsive drug seeking and use, despite harmful consequences to the addicted individual and to those around him or her. Although the initial decision is voluntary for most people, the brain changes that occur over time challenge a person’s self-control and ability to resist intense impulses urging them to take drugs.
—U.S. National Institute on Drug Abuse, Drug Facts: Understanding Drug Abuse and Addiction, 2011
The Liberal View is not so minimal that it cannot say what addictions are. They are strong appetites towards pleasure … Addiction is an illiberal term invented to describe those who seek pleasure in a way that expresses our social disapproval.
—Bennett Foddy and Julian Savulescu, “A Liberal Account of Addiction”
Distortions of motivation occur in people who can and do carry out intentional actions. At the moment of acting, they intend what they do, but the intention may express an overwhelming desire they would not choose to have.
Choices motivated by addiction seem less free than many other choices. Why is this so? This raises the question of what an addiction is. Most people think they have a clear intuitive idea of addiction, but the clarity fades when questions are asked. Here these questions will be raised by contrasting medical models of addiction with what Bennett Foddy and Julian Savulescu have called a “Liberal” account.1
When is a habit an addiction? The “chemical addictions” form the inner circle. Why is it so hard to give up alcohol, nicotine, heroin, Ecstasy, and so on? The bad experience of withdrawal has been seen as the key. But it is rare for withdrawal symptoms to be as terrible as their reputation. And “recovered” addicts sometimes relapse long enough after withdrawal for it not to be an issue.
There is evidence that addictive drugs mimic neurotransmitters. Different addictions involve different kinds of neurochemical disruption, but the dopamine system is often involved. Release of dopamine at the relevant sites in the brain used to be thought of as the chemical correlate of pleasure. But when monkeys have been trained to recognize a signal that apple juice will soon come, the relevant dopamine neurons fire as soon as the signal comes.2 The dopamine system seems to be part of a more complex process of learning to seek and repeat pleasure. The dopamine release might embody, not pleasure, but enthusiastic anticipation: what in humans might be expressed as “Wow! Yes, please!”
William James, writing before modern understanding of neurotransmitters, said of many drunkards that “their nervous centers have become a sluiceway pathologically unlocked by every passing conception of a bottle and a glass. They do not thirst for the beverage; the taste of it may even appear repugnant; and they perfectly foresee the morrow’s remorse. But when they think of the liquor or see it, they find themselves preparing to drink, and do not stop themselves: more than this they cannot say.”3 Drinking even when the taste is horrible shows that wanting and liking do not have to go together, something that fits the evidence about the anticipatory acceptance system.4
In one route into addiction, drugs mimic “natural” anticipatory signals of pleasure by releasing dopamine directly at the key points in the brain. The high levels of dopamine release may trump conflicting signals. In this way, as Steven Hyman puts it, addictive drugs hijack ordinary systems of motivation and learning.5
The hijacking metaphor has been criticized for implying that addicts are compelled to act in a way that allows no possibility of choice.6 I want to retain the vivid word “hijacking,” but without this implication. The word is striking, but also ambiguous. When pirates hijack a ship, they can either force the captured sailors to sail the ship under orders or lock them away. If forced to work, the captives still may have a chance to disobey the orders. Locked away, they have no power to change anything. In the addict with the hijacked dopamine system, it may be exceptionally hard, but still possible, to override the anticipatory acceptance. Or it may be literally irresistible. There may be no sharp boundary between the two, only a difference of degree. But in responding to addiction, the distinction matters.
Advocates of the Liberal view of addiction are skeptical about appealing to chemical changes in addicts’ brains to support a conclusion that addictive desires are irresistible. Foddy and Savulescu point out that brain changes are not peculiar to addictive drugs but are also found in other desires. They remind us of neuroplasticity: “Living our lives changes our brains.” They argue that these “supposedly compulsive adaptations” are caused by dopamine release in the brain’s reward pathways, not only as a result of drugs but also in regular pleasures of other kinds. They reject any sharp line between drug addiction and other habits.7
It seems likely that the systems of learning and reward will be active in nonaddictive pleasures ranging from sex to what Hume called “calm passions.” Even birdwatching may have its share of dopamine release. And it may be true that, for strength of desires, there is no sharp boundary between drug addiction and other desires for pleasure. These are important points, but they do not end the debate. The milder version of the hijacking claim is that the level of dopamine release may still make it very much harder to resist the associated desire. There might be no sharp distinction between the motivational force of drug addiction and of other strong desires. But there is still an empirical question whether there are differences of degree great enough to justify the intuitive view that addiction is a trap from which it can be either impossible or at least extraordinarily difficult to escape.
Chemical accounts of addiction bring out the importance of drawing on each of the two sides of Spinoza’s picture of mental states as embodied in states of the brain. Without the neurobiology, we would never know the underlying mechanisms. We would also miss the clues suggesting that the key to addiction might not be pleasure itself but anticipated pleasure. Equally, without being able to talk about the psychology, we would have little chance of seeing the human significance of the various patterns of neural firing in the dopamine system and so on. Whether or not the “two perspectives” model is ultimately right, at least it is a corrective to views where only one is taken seriously.
What about what are sometimes called “behavioral addictions”—addictions that seem to lack the obvious chemical basis of direct stimulation of neurotransmitters? Can there be behavioral addictions to the Internet or to gambling?
Or is this to wrongly medicalize strong ordinary desires? Foddy and Savulescu, making this objection, quote an 1851 case from the New Orleans Medical and Surgical Journal. Dr. Samuel Cartwright reported a new disease among local slaves. “Drapetomania” was an addiction to running away from their owners. The currently claimed behavioral addictions are not so ludicrous. But the question remains: Does this way of thinking medicalize ordinary unhijacked motivation?
There are people who spend so much time on the Internet that they disrupt other important things in their lives.8 Are they addicts? Grounds for skepticism can come from another case. In 1796 a German writer was alarmed by what he saw as the addictiveness of books: “Readers of books … rise and retire to bed with a book in their hand, sit down at table with one, have one lying close by when working, carry one around with them when walking, and … once they have begun reading a book are unable to stop until they are finished. But they have scarcely finished the last page of a book before they begin looking around greedily for somewhere to acquire another one … they take it away and devour it with a kind of ravenous hunger. No lover of tobacco or coffee, no wine drinker or lover of games, can be as addicted to their pipe, bottle, games or coffee table as those many hungry readers are to their reading habit.”9
But skepticism may be too easy. Perhaps repeated use of the Internet could be linked to changes in brain chemistry of strong motivational force. Could the “nonchemical addictions” just be those whose chemical basis has not yet been discovered?
If the brains of London taxi drivers are changed by learning “the Knowledge,” why should not habitual gambling or use of the Internet have as great an impact? Perhaps everything we do both influences and is influenced by chemical states of the brain, so that it may be more fruitful to replace the question about chemistry with a question at the psychological level. Intuitively, gambling seems a more plausible addiction than reading. One way of thinking about this intuition is to ask whether the psychology of gambling has anything special about it.
Another win! That meant I now had altogether eighty friedrichs d’or! I moved all eighty to the dozen middle numbers … the wheel turned and twenty-four came up … now I had altogether 200 friedrichs d’or …
Feeling as though I were delirious with fever, I moved the whole pile of money to the red—and suddenly came to my senses! For the only time in the course of the whole evening, fear laid its icy finger on me and my arms and legs began to shake. With horror I saw and for an instant fully realized what it would mean to me to lose now! My whole life depended on that stake!
“Rouge!” cried the croupier, and I drew a deep breath, while my whole body tingled with fire …
Possessed by frenzy, I seized the 2,000 florins I had left and staked them on the twelve first numbers—haphazard, at random, without stopping to think! …
I no longer feared anything, whatever it might be, and I flung down 4,000 florins on black …
Black turned up. After that I remember neither the amount nor the order of my stakes. I only recall, as if it was a dream, that I had already won, I think, about sixteen thousand florins …
But I, with strange perversity, deliberately went on staking on red after noticing that it had turned up seven times running … I really was overcome by a terrible craving for risk. Perhaps the soul passing through such a wide range of sensations is not satisfied but only exacerbated by them, and demands more and more of them, growing more and more powerful, until it reaches final exhaustion.
—Fyodor Dostoyevsky, The Gambler
This is lightly disguised personal experience. While writing Crime and Punishment Dostoyevsky took a month off to alleviate his acute money problems. He dictated the whole of The Gambler for publication. Describing the casinos of Wiesbaden, he knew what he was writing about. As a desperate money-raising strategy, he invented a system for roulette. At first he won 10,000 francs. “The next morning I got excited, abandoned the system and immediately lost. In the evening I returned to the system, observed it strictly, and quickly and without difficulty won back 3,000 francs. Tell me, after that how could I help being tempted, how could I fail to believe that I had only to follow my system strictly and luck would be with me? And I need the money, for myself, for you, for my wife, for writing my novel … Suddenly I began to lose, could no longer keep my head and lost every farthing.”10
The sense of loss of control comes over strongly: “feeling as though I were delirious,” “possessed by frenzy,” and “could no longer keep my head.” Of course one case, even when the person is Dostoyevsky, does not prove that all passionate repeat gamblers are the same. But Dostoyevsky’s gambling seems far more possessed than the enthusiastic German readers who so worried their critic in the 1790s.
Dostoyevsky’s frenzy suggests a view of the boundaries of addiction. He knew he needed the money for himself and for his wife, and for writing his novel. In the fictionalized version, with icy fear he came to his senses: his whole life depended on that stake. But in real life he did not act on these thoughts. The frenzy was dominant. He lost his head and lost all his money too. Full-blown addiction is the pull that often trumps even total awareness of how much more is at stake. Chemical tests can sometimes be decisive evidence, but what they are evidence for is this motivational force.
In the fictionalized version, Dostoyevsky describes being overcome by a terrible craving for risk. On the Liberal view, the word “overcome” misdescribes his state: He did not lose control, he simply acted on a very strong desire to take the risk. His choices were against his best interests, but this is not decisive proof of loss of control. He might just have cared more about taking the risk than about needing the money for himself, his wife, and his novel. And this is extended to addicts in general. The reason the view is called “Liberal” is its reluctance to discredit people’s own choices in the name of an outside view of their best interests.
It is admirable to respect other people’s different values. Still, the picture is too simple. The conflict is not usually between the happily unconventional hedonist and intrusively advice-giving outsiders. More typically it is within the addict’s own mind, often between conflicting priorities at different times.
The apparently cheerful addict, single-mindedly pursuing pleasure, needs interpretation. The Liberal view is right that, when people act in ways that seem to go against a good life, this does not prove they have lost control. But most people do feel the pull of many of the “normal” ingredients of the good life. So going against that pull may still suggest diminished control. Few people would not care at all about needing money for themselves, for those they love, or for writing their novel. At the moment of betting, Dostoyevsky’s craving for risk trumped everything else. But some internal conflict is still a reasonable expectation. And at other moments he did come to his senses, shaking with horror on seeing “My whole life depended on that stake!”
There are also different inner stories behind addictions. “Primary” addiction is driven by the love of a drug or of an activity such as gambling for its own sake. “Secondary” addiction is a means of dealing with other problems, such as escaping from worries and stress. Mark Griffiths says that secondary addicts lose control more than primary addicts do, though sometimes secondary addiction can be overcome by dealing with the other problems.11 He quotes cases of adolescent boys whose slot machine addiction was an escape from feelings of having no control over their lives at home. Their gambling problems stopped when they moved away from their homes.12
The Liberal view fits willing addicts. Whatever may be true of heroin addiction or frenzied gambling, some other addicts are very much in control. Foddy and Savulescu cite the willing coffee addict who becomes irritable and slightly unwell without it. They claim that the neurological changes in coffee addiction are weaker versions of those in heroin addiction. “You are obviously addicted. Nevertheless, you endorse your desire for coffee; when you satisfy your cravings each day you do not regret it; and you do not yearn for the power to abstain. You are a willing addict.”13
Willing coffee addicts do not call on psychiatrists. The addicts needing help are the unwilling ones. They do care about their damaged relationships, lost money, lost jobs, bad reputation, impaired health, or risk to life. That they do care about them yet still give way to the addiction is evidence (though not decisive proof) that their “guidance control”—their responsiveness to reasons for acting differently—is impaired.14 Control is a matter of degree. Paradoxically, while it is the control they do not have that calls for psychiatric help, the effectiveness of the help usually depends on the control they do have.