The Age of Addiction

Abstract

David Courtwright’s 2019 book, “The Age of Addiction: How Bad Habits Became Big Business,” offers provocative ideas that could appeal to both readers of this journal and the wider community. Accordingly, these 2 reviewers are pleased to offer this multigeneration, multiprofession critique. This book was relevant to a midcareer, world-weary, intensive care doctor concerned about using high technology to band-aid mental health crises like addiction. It was also relevant to a neuroscience undergraduate eager to understand what makes the human ape thrive or fail. In short, this topic has wide relevance, and therefore, the book may have wide appeal. The book is well written, original, and detailed: kudos to the author. However, there is a caveat for clinicians, scientists, and lay readers, who may wonder whether this warrants their finite time or dollar. This is not a book offering usable clinical insights or scientific pearls. Instead, it is written by a historian and provides >300 pages and 8 iterative chapters, arguing why the pursuit of pleasure and vice have been central to the human experience from Neolithic times to modern day. Unlike many modern books, it does not offer a “quick fix” or “ten lessons.” This is appropriate because there are no simple answers to complex problems. In brief, if you like expansive history, then buy this book. If you are a busy clinician or scientist eager to make things better for patients in the short term, then look elsewhere. David Courtwright is not a clinician, and therefore, it is not fair to expect a clinical book. Instead, he is a professor from North Florida University and the 2001 author of Forces of Habit: Drugs and the Making of the Modern World. Fast forward to 2019, and this self-described “drug historian” offers another deep philosophical dive. He explains how drug use is rooted in the innate instinct to seek pleasure, discover, and escape: so far, so familiar. What is unique are his ideas about addiction being bolstered by scientific advances, protected by state policy, and accelerated by rapacious capitalism. Courtwright offers a multicentury history of how multinational industries, complicit governments, and criminal organizations have increasingly multiplied and cheapened seductive brain rewards: from junk food to pornography to synthetic opiates. The author has also coined a useful term: “limbic capitalism,” namely, “a technologically advanced but socially regressive business system in which global industries … encourage excessive consumption and addiction [by targeting] parts of the brain responsible for feeling and quick reaction.” In short, because we are social beings, we can be manipulated by powerful forces outside of our bodies. Courtwright reminds us that we can also be manipulated by powerful forces inside of our bodies. Biochemical algorithms power nearly all human pursuits and can be hacked like the computers to which we are increasingly tethered. Our pursuit of pleasure begins in the form of “food-drugs” (such as alcohol, tobacco, and opium) but includes how we play (shopping, gambling, and video games). These same feedback loops fuel more laudable pursuits such as career advancement or seeking love. Innate neurochemical drives have always been manipulated. What has changed over time is the degree to which they can now be hijacked given our industrialization, urbanization, and globalization. Addictive behavior becomes ever more likely due to affordability, advertising, and social isolation. The logical, albeit terrifying, conclusion is that things are likely to keep getting worse. While, obviously, not all addictions have the same consequences, Courtwright outlines a clear thread not only through history, but he also links compulsive gaming, binge eating, and pharmacological abuse. It is useful to be reminded that sugar, cocaine, and social media all co-opt our biochemistry and rewire our brains. We agree that “multinational distribution and marketing machines have built a scaffolding of persuasion … around (many) products (with) a serious risk of habituation and harm.” In short, Courtwright offers the reader a richer understanding of why addiction is so widespread and intractable. Courtwright reasonably concludes that “very little” can be done systematically until we understand the history and character of global forces that create and cater to bad habits. He is hopeful that because progressives and traditionalists have united against addiction before, they can do so again. However, if we accept the author’s premise, namely that it is difficult to control biological urges, then understand why these 2 reviewers will not be holding their collective breath waiting for that to happen. Peter G. Brindley, MD, FRCPC, FRCP Edin, FRCP LondJack D. BrindleyDepartment of Critical Care MedicineDepartment of Anesthesiology and Pain MedicineDosseter Ethics CentreUniversity of AlbertaEdmonton, Alberta, Canada[email protected]