Markus Heilig. The Thirteenth Step: Addiction in the Age of Brain Science. New York: Columbia University Press, 2015. ix + 303 pp. $29.95 (cloth), ISBN 978-0-231-17236-3.

Reviewed by Kyle Bridge (University of Florida)
Published on H-Sci-Med-Tech (November, 2015)
Commissioned by Ashton W. Merck

Of Addicted Mice and Men

When it comes to addiction treatment, physician-scientist Markus Heilig is interested in results. In fact the title of his new book, The Thirteenth Step: Addiction in the Age of Brain Science, implies that we must build upon the existing “twelve-step” therapies with recent advances in neuroscience. Heilig’s book offers a brilliant and, perhaps more important, highly legible review of current addiction science. Most significant, its last chapters explore how these findings translate into practical treatments for addiction. Readers from a variety of fields—including the rightly skeptical social sciences—should benefit from Heilig’s entrée into the methods and practice of addiction research. However, some may come away disappointed by his noncritical engagement with the conceptualization of addiction as a chronic, relapsing brain disease (CRBD); the aggravating influence of punitive drug policy for illicit drug users; and the broadening definition of “addiction” beyond substance use.

The greatest strength of The Thirteenth Step is Heilig’s ability to accessibly narrate the process of scientific research about addiction and convey its findings. Along the way, he convincingly debunks some popular ideas about addiction. One such theory is that repeated drug use is most often a form of self-medication for chronic depression, anxiety, or other mood-altering disorders. He cites a number of epidemiological studies that have found no real correlation between nonmedical substance use and these conditions. Furthermore, Heilig reveals how drugs such as alcohol and cocaine may actually produce the symptoms of those disorders that for years clinicians believed were the root cause of compulsive drug use and that generally subside after a period of abstinence.

Heilig also offers evidence in support of some conventional (if controversial) wisdom, like that contained in the old adage, “once an addict, always an addict.” In a frequently repeated laboratory experiment, addicted rodents learn to seek out and self-administer drugs through, say, lever presses before the behavior is “extinguished” by removing drug delivery from the action. After extended drug-free periods, even a small “priming” dose of the drug will make most of the subjects resume their former rates of lever-pressing posthaste. It seems that “extinction” does not revert the brain to a “drug-naïve” state, but instead superimposes new learning on top of old behavior; consequently, by activating particular parts of the frontal lobe, scientists can make mice press the lever without any priming dose at all (pp. 108-109). It seems that once an addiction is “learned,” it may be exceedingly difficult if not impossible to “forget.”

Throughout The Thirteenth Step, Heilig investigates other “correlate[s] of the addictive process” for causality in addictive behavior. To consider one example, it turns out that impulsivity is a characteristic of heavy drug users across species. Among others, he describes a series of experiments “as brilliant as they were hilarious” in which scientists measured the impulsivity of rhesus monkeys through the length and height of their jumps between trees (p. 100). Sure enough, when exposed to alcohol, the monkeys who leapt from the highest, most distant branches imbibed more frequently than their more careful peers. Heilig also cites the classic series of studies wherein Walter Mischel offered preschool children one marshmallow immediately or two in fifteen minutes. Throughout the next decades, when Mischel’s subjects were followed up, their capacity to delay gratification at age four accurately predicted their capacity as adolescents. In adulthood, brain scans revealed that, when presented with attractive stimuli, “high delayers” activated parts of the prefrontal cortex that “low delayers” did or could not (pp. 96-98). In other words, sensation seeking—including drug use—may come more naturally than inhibition for some people.

Despite the obvious implications of his work, Heilig is no biological determinist; he notes that if behavior is ultimately determined by brain function (or malfunction), then “there is no free will ... [and] Adolf Hitler is no more culpable than the next person” (p. 103). But Heilig subscribes to cognitive scientist Steven Pinker’s philosophy that, free will or no, we all collectively benefit from holding each other accountable to the same standards. And even if scientists can someday claim a comprehensive, predictive model of the human brain, it may still fail to predict behavior in practice. The influence of innate biology on behavior appears to be relative: twin studies have found that the actions of impoverished people—who suffer exogenous detriments to their heritable potential through malnutrition, chronic stress, and violence—are more influenced by their environments (or “nurture”) than affluent people, for whom “nature” apparently has greater causal influence (p. 148). “Another way of saying this,” Heilig writes, “is that if a person’s material resources are very limited, they put a limit on achievement so far below the person’s full, genetically-determined potential that those heritable determinants don’t matter much. If, on the other hand, a person doesn’t have any constraint from material resources, then only biological endowment will set the limit” (pp. 147-148). Per his reading, a genetic predisposition to addiction will affect the well-to-do more than the poor given their respective social ecologies.

What does all of this mean for addiction treatment? It’s complicated. Heilig emphasizes that clinicians need to parse addictions by substance, and dedicates an entire chapter to describing the distinctive functions of opioids, cocaine and amphetamines, and alcohol. He further reckons that treatment professionals need to understand iterations of addictions, offering “impulsive alcoholism,” “opioid-reward dependent alcoholism,” and “socially anxious alcoholism” as some examples. In the absence of individualized genome identification to potentially map these processes, which Heilig hopes will someday become a reality, clinicians must establish comprehensive case histories in order to effectively treat addicts. Heilig also enthusiastically recommends medications such as methadone for opioid addicts or naltrexone for alcoholics to complement conventional therapies, citing decades of research demonstrating their efficacy.

Heilig’s narrative is broken up with some frequency by anecdotes from his own practice. (He claims this will help readers put a human face on all the science, but it should also give them a breather from all the science.) These episodes make clear that Heilig, more than most researchers, understands that addiction treatment is in many cases an uphill battle for everyone involved. Consequently, he reserves a particular ire for faddish, expensive quackery masquerading as cures: using “herbal treatments” or “cleansing baths,” “drink[ing] carrot juice,” or having “patients sit around in a circle and talk” (p. 187). At the same time, he recognizes the practical utility of groups like Alcoholics Anonymous, likening the experience to an overweight diabetic joining a Sierra Club hiking group. Still, he warns, sufferers of both diseases need to see a doctor.

Heilig may lose some readers at this point. A frequent critique of the CRBD model is that, while it changes the way we think about addiction, it has not really changed the way we treat addiction. In a curious reversal, Heilig is so interested in treatment that he neglects to engage CRBD on a conceptual level. For example, psychologists Sally Satel and Scott O. Lilienfield argue that addiction is fundamentally different from other chronic diseases like diabetes or epilepsy, because, among other reasons, those conditions may worsen spontaneously, while addiction is always dependent on human action.[1] Heilig would counter with his findings that some people are socially or genetically more susceptible to compulsive drug taking, or that drugs actually do change the brain in fundamental ways, so we can only benefit from approaching addiction as a disease.

But even the most vocal critics of CRBD usually concede that a primary motivation for medicalization is destigmatization and decriminalization of drug use, whereas Heilig implicitly accommodates the legal status quo. He does not question why a heroin addict is “twenty to fifty times” more likely to die than a comparably healthy person while alcoholics are only five times more likely (p. 171), thereby ignoring the public health crises fostered by illegal drug markets. According to Heilig, the first goal of treatment is making sure “people don’t die,” and the second is facilitating change “so that patients don’t remain trapped in crime and prostitution” (p. 209). But there is a compelling argument that these adverse outcomes are all exacerbated by drug criminalization. At one point, perhaps unconsciously, the author equates “drunk driving, drug use, [and] crime” among a list of social “disasters” (p. 97). As a result, Heilig seems comfortable with the fact that the CRBD model reinforces the punitive, supply-side logic of the drug war. To sidestep this charge—and to live up to the book’s expansive subtitle—Heilig might have also considered other behavioral addictions, like compulsive overeating or gambling, though these conditions remain outside his research and clinical expertise.

These complaints should not obscure the book’s value for anyone looking to brush up on the state of (substance) addiction research. There is something in The Thirteenth Step for everyone. Treatment professionals will appreciate Heilig’s clinical experience, while concerned friends and family members of addicts should take to heart his findings on the influence of stress on drug taking. Truly, anyone might be interested to learn more about this persistent, nebulous phenomenon we call “addiction.” Of course, skeptical historians might simply cite The Thirteenth Step as yet another manifestation of the biological reorientation of postwar behavioral research. And to them I say: know thine enemy. Heilig’s synthesis invites us all to critically consider the addiction concept along with its implications for people, policy, and the practice of medicine.


[1]. Sally Satel and Scott O. Lilienfeld, “Addiction and the Brain-Disease Fallacy,” in Brainwashed: The Seductive Appeal of Mindless Neuroscience (New York: Basic Books, 2013), 49-72.

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Citation: Kyle Bridge. Review of Heilig, Markus, The Thirteenth Step: Addiction in the Age of Brain Science. H-Sci-Med-Tech, H-Net Reviews. November, 2015.

This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 United States License.