The Concept of Addiction
The conventional concept of addiction this book confronts??"the one accepted not only by the media and popular audiences, but by researchers whose work does little to support it??"derives more from magic than from science.
The core of this concept is that an entire set of feelings and behaviors is the unique result of one biological process.
No other scientific formulation attributes a complex human phenomenon to the nature of a particular stimulus: statements such as "He ate all the ice cream because it was so good" or "She watches so much television because it's fun" are understood to call for a greater understanding of the actors' motivations (except, ironically, as these activities are now considered analogous to narcotic addiction).
Even reductionist theories of mental illness such as of depression and schizophrenia (Peele 1981b) seek to account for a general state of mind, not specific behavior. Only compulsive consumption of narcotics and alcohol??"conceived of as addictions (and now, other addictions that are seen to operate in the same way)??"is believed to be the result of a spell that no effort of will can break.
Addiction is defined by tolerance, withdrawal, and craving. We recognize addiction by a person's heightened and habituated need for a substance; by the intense suffering that results from discontinuation of its use; and by the person's willingness to sacrifice all (to the point of self-destructiveness) for drug taking.
The inadequacy of the conventional concept lies not in the identification of these signs of addiction??"they do occur??"but in the processes that are imagined to account for them.
Tolerance, withdrawal, and craving are thought to be properties of particular drugs, and sufficient use of these substances is believed to give the organism no choice but to behave in these stereotypical ways.
This process is thought to be inexorable, universal, and irreversible and to be independent of individual, group, cultural, or situational variation; it is even thought to be essentially the same for animals and for human beings, whether infant or adult.
Observers of addictive behavior and scientists studying it in the laboratory or in natural settings have uniformly noted that this pure model of addiction does not exist in reality, and that the behavior of people said to be addicted is far more variable than conventional notions allow.
Yet unexamined, disabling residues of this inaccurate concept are present even in the work of those who have most astutely exposed the inadequacy of conventional models for describing addictive behavior. Such residues include the persistent view that complex behaviors like craving and withdrawal are straightforward physiological reactions to drugs or are biological processes even when they appear with nondrug involvements.
Although these beliefs have been shown to be unfounded in the context in which they first arose??"that of heroin use and heroin addiction??"they have been rearranged into new notions such as drug dependence, or used as the basis for conditioning models that assume that drugs produce invariant physiological responses in humans.
It is the burden of this book to show that exclusively biological concepts of addiction (or drug dependence) are ad hoc and superfluous and that addictive behavior is no different from all other human feeling and action in being subject to social and cognitive influences. To establish how such factors affect the dynamics of addiction is the ultimate purpose of this analysis.
In this reformulation, addiction is seen not to depend on the effects of specific drugs. Moreover, it is not limited to drug use at all. Rather, addiction is best understood as an individual's adjustment, albeit a self-defeating one, to his or her environment. It represents an habitual style of coping, albeit one that the individual is capable of modifying with changing psychological and life circumstances.
While in some cases addiction achieves a devastating pathological extremity, it actually represents a continuum of feeling and behavior more than it does a distinct disease state.
Neither traumatic drug withdrawal nor a person's craving for a drug is exclusively determined by physiology. Rather, the experience both of a felt need (or craving) for and of withdrawal from an object or involvement engages a person's expectations, values, and self-concept, as well as the person's sense of alternative opportunities for gratification.
These complications are introduced not out of disillusionment with the notion of addiction but out of respect for its potential power and utility. Suitably broadened and strengthened, the concept of addiction provides a powerful description of human behavior, one that opens up important opportunities for understanding not only drug abuse, but compulsive and self-destructive behaviors of all kinds.
This book proposes such a comprehensive concept and demonstrates its application to drugs, alcohol, and other contexts of addictive behavior.
Since narcotic addiction has been, for better or worse, our primary model for understanding other addictions, the analysis of prevailing ideas about addiction and their shortcomings involves us in the history of narcotics, particularly in the United States in the last hundred years.
This history shows that styles of opiate use and our very conception of opiate addiction are historically and culturally determined. Data revealing regular nonaddictive narcotic use have consistently complicated the effort to define addiction, as have revelations of the addictive use of nonnarcotic drugs.
Alcohol is one drug whose equivocal relationship to prevailing conceptions of addiction has confused the study of substance abuse for well over a century. Because the United States has had a different??"though no less destructive and disturbing??"experience with alcohol than it has had with opiates, this cultural experience is analyzed separately in chapter 2.
This emphasis notwithstanding, alcohol is understood in this book to be addictive in exactly the same sense that heroin and other powerful drug and nondrug experiences are.
Cultural and historical variations in ideas about drugs and addiction are examples of the range of factors that influence people's reactions to drugs and susceptibility to addiction.
These and other salient nonpharmacological factors are outlined and discussed in this chapter. Taken together, they offer a strong prod to reconceive of addiction as being more than a physiological response to drug use. Drug theorists, psychologists, pharmacologists, and others have been attempting such reconceptualizations for some time; yet their efforts remain curiously bound to past, disproven ideas.
The resilience of these wrongheaded ideas is discussed in an effort to understand their persistence in the face of disconfirming information. Some of the factors that explain their persistence are popular prejudices, deficiencies in research strategies, and issues of the legality and illegality of various substances.
At the bottom, however, our inability to conceive of addiction realistically is tied to our reluctance to formulate scientific concepts about behavior that include subjective perceptions, cultural and individual values, and notions of self-control and other personality-based differences (Peele 1983e). This chapter shows that any concept of addiction that bypasses these factors is fundamentally inadequate.
Opiate Addiction in the United States and the Western World
Contemporary scientific and clinical concepts of addiction are inextricably connected with social developments surrounding the use of narcotics, especially in the United States, early in this century.
Before that time, from the late sixteenth through the nineteenth centuries, the term "addicted" was generally used to mean "given over to a habit or vice." Although withdrawal and craving had been noted over the centuries with the opiates, the latter were not singled out as substances that produced a distinctive brand of dependence.
Indeed, morphine addiction as a disease state was first noted in 1877 by a German physician, Levenstein, who "still saw addiction as a human passion 'such as smoking, gambling, greediness for profit, sexual excesses, etc.'" (Berridge and Edwards 1981: 142-143). As late as the twentieth century, American physicians and pharmacists were as likely to apply the term "addiction" to the use of coffee, tobacco, alcohol, and bromides as they were to opiate use (Sonnedecker 1958).
Opiates were widespread and legal in the United States during the nineteenth century, most commonly in tincturated form in potions such as laudanum and paregoric. Yet they were not considered a menace, and little concern was displayed about their negative effects (Brecher 1972).
Furthermore, there was no indication that opiate addiction was a significant problem in nineteenth-century America. This was true even in connection with the enthusiastic medical deployment of morphine??"a concentrated opiate prepared for injection??"during the U.S. Civil War (Musto 1973).
The situation in England, while comparable to that in the United States, may have been even more extreme. Berridge and Edwards (1981) found that use of standard opium preparations was massive and indiscriminate in England throughout much of the nineteenth century as was use of hypodermic morphine at the end of the century.
Yet these investigators found little evidence of serious narcotic addiction problems at the time. Instead, they noted that later in the century, "The quite small number of morphine addicts who happened to be obvious to the [medical] profession assumed the dimensions of a pressing problem??"at a time when, as general consumption and mortality data indicate, usage and addiction to opium in general was tending to decline, not increase" (p.149).
Although middle-class consumption of opiates was considerable in the United States (Courtwright 1982), it was only the smoking of opium in illicit dens both in Asia and by Chinese in the United States that was widely conceived to be a disreputable and debilitating practice (Blum et al. 1969).
Opium smoking among immigrant Asian laborers and other social outcasts presaged changes in the use of opiates that were greatly to modify the image of narcotics and their effects after the turn of the century. These developments included:
1 A shift in the populations using narcotics from a largely middle-class and female clientele for laudanum to mostly male, urban, minority, and lower-class users of heroin??"an opiate that had been developed in Europe in 1898 (Clausen 1961; Courtwright 1982);
2 Both as an exaggerated response to this shift and as an impetus to its acceleration, the passage in 1914 of the Harrison Act, which was later interpreted to outlaw medical maintenance of narcotic addicts (King 1972; Trebach 1982); and
3 A widely held vision of narcotic users and their habits as being alien to American lifestyles and of narcotic use as being debased, immoral, and uncontrollable (Kolb 1958).
The Harrison Act and subsequent actions by the Federal Bureau of Narcotics led to the classification of narcotic use as a legal problem. These developments were supported by the American Medical Association (Kolb 1958).
This support seems paradoxical, since it contributed to the loss of a historical medical prerogative??"the dispensing of opiates. However, the actual changes that were taking place in America's vision of narcotics and their role in society were more complex than this.
Opiates first had been removed from the list of accepted pharmaceuticals, then their use was labeled as a social problem, and finally they were characterized as producing a specific medical syndrome.
It was only with this last step that the word "addiction" carne to be employed with its present meaning. "From 1870 to 1900, most physicians regarded addiction as a morbid appetite, a habit, or a vice.
After the turn of the century, medical interest in the problem increased. Various physicians began to speak of the condition as a disease" (Isbell 1958: 115). Thus, organized medicine accepted the loss of narcotic use as a treatment in return for the rewards of seeing it incorporated into the medical model in another way.
In Britain, the situation was somewhat different inasmuch as opium consumption was a lower-class phenomenon that aroused official concern in the nineteenth century. However, the medical view of opiate addiction as a disease arose as doctors observed more middle-class patients injecting morphine later in the century (Berridge and Edwards 1981: 149-150):
The profession, by its enthusiastic advocacy of a new and more "scientific" remedy and method, had itself contributed to an increase in addiction.... Disease entities were being established in definitely recognizable physical conditions such as typhoid and cholera.
The belief in scientific progress encouraged medical intervention in less definable conditions [as well] .... [S]uch views were never, however, scientifically autonomous. Their putative objectivity disguised class and moral concerns which precluded a wider understanding of the social and cultural roots of opium [and later morphine] use.
The evolution of the idea of narcotic??"and particularly heroin??"addiction was part of a larger process that medicalized what were previously regarded as moral, spiritual, or emotional problems (Foucault 1973; Szasz 1961).
The idea central to the modern definition of addiction is that of the individual's inability to choose: that addicted behavior is outside the realm of ordinary consideration and evaluation (Levine 1978). This idea was connected to a belief in the existence of biological mechanisms??"not yet discovered??"that caused the use of opiates to create a further need for opiates. In this process the work of such early heroin investigators as Philadelphia physicians Light and Torrance (1929), who were inclined to see the abstaining addict wheedling for more drugs as a malcontent demanding satisfaction and reassurance, was replaced by deterministic models of craving and withdrawal.
These models, which viewed the need for a drug as qualitatively different from other kinds of human desires, came to dominate the field, even though the behavior of narcotic users approximated them no better than it had in Light and Torrance's day.
However, self-defined and treated addicts did increasingly conform to the prescribed models, in part because addicts mimicked the behavior described by the sociomedical category of addiction and in part because of an unconscious selection process that determined which addicts became visible to clinicians and researchers.
The image of the addict as powerless, unable to make choices, and invariably in need of professional treatment ruled out (in the minds of the experts) the possibility of a natural evolution out of addiction brought on by changes in life circumstances, in the person's set and setting, and in simple individual resolve.
Treatment professionals did not look for the addicts who did achieve this sort of spontaneous remission and who, for their part, had no wish to call attention to themselves. Meanwhile, the treatment rolls filled up with addicts whose ineptitude in coping with the drug brought them to the attention of the authorities and who, in their highly dramatized withdrawal agonies and predictable relapses, were simply doing what they had been told they could not help but do. In turn, the professionals found their dire prophecies confirmed by what was in fact a context-limited sample of addictive behavior.
Divergent Evidence about Narcotic Addiction
The view that addiction is the result of a specific biological mechanism that locks the body into an invariant pattern of behavior??"one marked by superordinate craving and traumatic withdrawal when a given drug is not available??"is disputed by a vast array of evidence.
Indeed, this concept of addiction has never provided a good description either of drug-related behavior or of the behavior of the addicted individual. In particular, the early twentieth-century concept of addiction (which forms the basis of most scientific as well as popular thinking about addiction today) equated it with opiate us.
This is (and was at the time of its inception) disproven both by the phenomenon of controlled opiate use even by regular and heavy users and by the appearance of addictive symptomatology for users of nonnarcotic substances.
Nonaddicted Narcotics Use
Courtwright (1982) and others typically cloud the significance of the massive nonaddicted use of opiates in the nineteenth century by claiming local observers were unaware of the genuine nature of addiction and thus missed the large numbers who manifested withdrawal and other addictive symptomatology.
He struggles to explain how the commonplace administration of opiates to babies "was unlikely to develop into a full-blown addiction, for the infant would not have comprehended the nature of its withdrawal distress, not could it have done anything about it" (p. 58).
In any case, Courtwright agrees that by the time addiction was being defined and opiates outlawed at the turn of the century, narcotic use was a minor public health phenomenon. An energetic campaign undertaken in the United States by the Federal Bureau of Narcotics and??"in England as well as the United States??"by organized medicine and the media changed irrevocably conceptions of the nature of opiate use.
In particular, the campaign eradicated the awareness that people could employ opiates moderately or as a part of normal lifestyle. In the early twentieth century, "the climate . . . was such that an individual might work for 10 years beside an industrious law-abiding person and then feel a sense of revulsion toward him upon discovering that he secretly used an opiate" (Kolb 1958: 25). Today, our awareness of the existence of opiate users from that time who maintained normal lives is based on the recorded cases of "eminent narcotics addicts" (Brecher 1972: 33).
The use of narcotics by people whose lives are not obviously disturbed by their habit has continued into the present. Many of these users have been identified among physicians and other medical personnel. In our contemporary prohibitionist society, these users are often dismissed as addicts who are protected from disclosure and from the degradation of addiction by their privileged positions and easy access to narcotics.
Yet substantial numbers of them do not appear to be addicted, and it is their control over their habit that, more than anything else, protects them from disclosure. Winick (1961) conducted a major study of a body of physician narcotic users, most of whom had been found out because of suspicious prescription activities. Nearly all these doctors had stabilized their dosages of a narcotic (in most cases Demerol) over the years, did not suffer diminished capacities, and were able to fit their narcotic use into successful medical practices and what appeared to be rewarding lives overall.
Zinberg and Lewis (1964) identified a range of patterns of narcotic use, among which the classic addictive pattern was only one variant that appeared in a minority of cases. One subject in this study, a physician, took morphine four times a day but abstained on weekends and two months a year during vacations. Tracked for over a decade, this man neither increased his dosage nor suffered withdrawal during his periods of abstinence (Zinberg and Jacobson 1976).
On the basis of two decades of investigation of such cases, Zinberg (1984) analyzed the factors that separate the addicted from the nonaddicted drug user. Primarily, controlled users, like Winick's physicians, subordinate their desire for a drug to other values, activities, and personal relationships, so that the narcotic or other drug does not dominate their lives. When engaged in other pursuits that they value, these users do not crave the drug or manifest withdrawal on discontinuing their drug use.
Furthermore, controlled use of narcotics is not limited to physicians or to middle-class drug users. Lukoff and Brook (1974) found that a majority of ghetto users of heroin had stable home and work involvements, which would hardly be possible in the presence of uncontrollable craving.
If life circumstances affect people's drug use, we would expect patterns of use to vary over time. Every naturalistic study of heroin use has confirmed such fluctuations, including switching among drugs, voluntary and involuntary periods of abstinence, and spontaneous remission of heroin addiction (Maddux and Desmond 1981; Nurco et al. 1981; Robins and Murphy 1967; Waldorf 1973, 1983; Zinberg and Jacobson 1976).
In these studies, heroin does not appear to differ significantly in the potential range of its use from other types of involvements, and even compulsive users cannot be distinguished from those given to other habitual involvements in the ease with which they desist or shift their patterns of use. These variations make it difficult to define a point at which a person can be said to be addicted.
In a typical study (in this case of former addicts who quit without treatment), Waldorf (1983) defined addiction as daily use for a year along with the appearance of significant withdrawal symptoms during that period. In fact, such definitions are operationally equivalent to simply asking people whether they are or were addicted (Robins et al. 1975).
A finding with immense theoretical importance is that some former narcotics addicts become controlled users. The most comprehensive demonstration of this phenomenon was Robins et al.'s (1975) research on Vietnam veterans who had been addicted to narcotics in Asia.
Of this group, only 14 percent became readdicted after their return home, although fully half used heroin??"some regularly??"in the United States. Not all these men used heroin in Vietnam (some used opium), and some relied on other drugs in the United States (most often alcohol). This finding of controlled use by former addicts may also be limited by the extreme alteration in the environments of the soldiers from Vietnam to the United States.
Harding et al. (1980), however, reported on a group of addicts in the United States who had all used heroin more than once a day, some as often as ten times a day, who were now controlled heroin users. None of these subjects was currently alcoholic or addicted to barbiturates. Waldorf (1983) found that former addicts who quit on their own frequently??"in a ceremonial proof of their escape from their habit??"used the drug at a later point without becoming readdicted.
Although widely circulated, the data showing that the vast majority of soldiers using heroin in Vietnam readily gave up their habits (Jaffe and Harris 1973; Peele 1978) and that "contrary to conventional belief, the occasional use of narcotics without becoming addicted appears possible even for men who have previously been dependent on narcotics" (Robins et al. 1974: 236) have not been assimilated either into popular conceptions of heroin use or into theories of addiction.
Indeed, the media and drug commentators in the United States seemingly feel obligated to conceal the existence of controlled heroin users, as in the case of the television film made of baseball player Ron LeFlore's life. Growing up in a Detroit ghetto, LeFlore acquired a heroin habit.
He reported using the drug daily for nine months before abruptly withdrawing without experiencing any negative effects (LeFlore and Hawkins 1978). It proved impossible to depict this set of circumstances on American television, and the TV movie ignored LeFlore's personal experience with heroin, showing instead his brother being chained to a bed while undergoing agonizing heroin withdrawal. By portraying heroin use in the most dire light at all times, the media apparently hope to discourage heroin use and addiction.
The fact that the United States has long been the most active propagandizer against recreational narcotic use??"and drug use of all kinds??"and yet has by far the largest heroin and other drug problems of any Western nation indicates the limitations of this strategy (see chapter 6).
The failure to take into account the varieties of narcotic use goes beyond media hype, however. Pharmacologists and other scientists simply cannot face the evidence in this area. Consider the tone of disbelief and resistance with which several expert discussants greeted a presentation by Zinberg and his colleagues on controlled heroin use (see Kissin et al. 1978: 23-24).
Yet a similar reluctance to acknowledge the consequences of nonaddictive narcotics use is evident even in the writings of the very investigators who have demonstrated that such use occurs. Robins (1980) equated the use of illicit drugs with drug abuse, primarily because previous studies had done so, and maintained that among all drugs heroin creates the greatest dependency (Robins et al. 1980).
At the same time, she noted that "heroin as used in the streets of the United States does not differ from other drugs in its liability to being used regularly or on a daily basis" (Robins 1980: 370) and that "heroin is 'worse' than amphetamines or barbiturates only because 'worse' people use it" (Robins et al. 1980: 229).
In this way controlled use of narcotics??"and of all illicit substances??"and compulsive use of legal drugs are both disguised, obscuring the personality and social factors that actually distinguish styles of using any kind of drug (Zinberg and Harding 1982). Under these circumstances, it is perhaps not surprising that the major predictors of illicit use (irrespective of degree of harmfulness of such use) are nonconformity and independence (Jessor and Jessor 1977).
One final research and conceptual bias that has colored our ideas about heroin addiction has been that, more than with other drugs, our knowledge about heroin has come mainly from those users who cannot control their habits.
These subjects make up the clinical populations on which prevailing notions of addiction have been based. Naturalistic studies reveal not only less harmful use but also more variation in the behavior of those who are addicted.
It seems to be primarily those who report for treatment who have a lifetime of difficulty in overcoming their addictions (cf. Califano 1983). The same appears true for alcoholics: For example, an ability to shift to controlled drinking shows up regularly in field studies of alcoholics, although it is denied as a possibility by clinicians (Peele 1983a; Vaillant 1983). (See chapter 2.)
The prevailing twentieth-century concept of addiction considers addiction to be a byproduct of the chemical structure of a specific drug (or family of drugs). Consequently, pharmacologists and others have believed that an effective pain-reliever, or analgesic, could be synthesized that would not have addictive properties.
The search for such a nonaddictive analgesic has been a dominant theme of twentieth-century pharmacology (cf. Clausen 1961; Cohen 1983; Eddy and May 1973; Peele 1977). Indeed, heroin was introduced in 1898 as offering pain relief without the disquieting side effects sometimes noted with morphine. Since that time, the early synthetic narcotics such as Demerol and the synthetic sedative family, the barbiturates, have been marketed with the same claims.
Later, new groups of sedatives and narcotic-like substances, such as Valium and Darvon, were introduced as having more focused anti-anxiety and pain-relieving effects that would not be addictive. All such drugs have been found to lead to addiction in some, perhaps many, cases (cf. Hooper and Santo 1980; Smith and Wesson 1983; Solomon et al. 1979).
Similarly, some have argued that analgesics based on the structures of endorphins??"opiate peptides produced endogenously by the body??"can be used without fear of addiction (Kosterlitz 1979). It is hardly believable that these substances will be different from every other narcotic with respect to addictive potential.
Alcohol is a nonnarcotic drug that, like the narcotics and sedatives, is a depressan