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.
"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).
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).
Alcohol is a nonnarcotic drug that, like the narcotics and sedatives, is a depressant. Since alcohol is legal and almost universally available, the possibility that it can be used in a controlled manner is generally accepted. At the same time, alcohol is also recognized to be an addicting substance.
The divergent histories and differing contemporary visions of alcohol and narcotics in the United States have produced two different versions of the addiction concept.
Whereas narcotics have been considered to be universally addictive, the modern disease concept of alcoholism has emphasized a genetic susceptibility that predisposes only some individuals to become addicted to alcohol (Goodwin 1976; Schuckit 1984).
In recent years, however, there has been some convergence in these conceptions. Goldstein (1976b) has accounted for the discovery that only a minority of narcotic users go on to be addicts by postulating constitutional biological differences between individuals.
Coming from the opposite direction, some observers oppose the disease theory of alcoholism by maintaining that alcoholism is simply the inevitable result of a certain threshold level of consumption (cf. Beauchamp 1980; Kendell 1979).
Why milder stimulant use like that manifested by coffee and cigarette habituŽs should be more potent than cocaine and amphetamine habits is mystifying. In fact, as cocaine has become a popular recreational drug in the United States, severe withdrawal is now regularly noted among individuals calling a hot line for counseling about the drug (Washton 1983). In order to preserve traditional categories of thought, those commenting on observations of compulsive cocaine use claim it produces "psychological dependence whose effects are not all that different from addiction" because cocaine "is the most psychologically tenacious drug available" ("Cocaine: Middle Class High" 1981: 57, 61).
A concept that aims to describe the full reality of addiction must incorporate nonbiological factors as essential ingredients in addiction-up to and including the appearance of craving, withdrawal, and tolerance effects.
Different cultures regard, use, and react to substances in different ways, which in turn influence the likelihood of addiction. Thus, opium was never proscribed or considered a dangerous substance in India, where it was grown and used indigenously, but it quickly became a major social problem in China when it was brought there by the British (Blum et al. 1969).
The external introduction of a substance into a culture that does not have established social mechanisms for regulating its use is common in the history of drug abuse. The appearance of widespread abuse of and addiction to a substance may also take place after indigenous customs regarding its use are overwhelmed by a dominant foreign power.
Thus the Hopi and Zuni Indians drank alcohol in a ritualistic and regulated manner prior to the coming of the Spanish, but in a destructive and generally addictive manner thereafter (Bales 1946).
Sometimes a drug takes root as an addictive substance in one culture but not in other cultures that are exposed to it at the same time. Heroin was transported to the United States through European countries no more familiar with opiate use than was the United States (Solomon 1977).
Yet heroin addiction, while considered a vicious social menace here, was regarded as a purely American disease in those European countries where the raw opium was processed (Epstein 1977).
Because alcohol is so commonly used throughout the world, it offers the best illustration of how the effects of a substance are interpreted in widely divergent ways that influence its addictive potential. As a prime example, the belief that drunkenness excuses aggressive, escapist, and other antisocial behavior is much more pronounced in some cultures than in others (Falk 1983; MacAndrew and Edgerton 1969).
Such beliefs translate into cultural visions of alcohol and its effects that are strongly associated with the appearance of alcoholism.
That is, the displays of antisocial aggression and loss of control that define alcoholism among American Indians and Eskimos and in Scandinavia, Eastern Europe, and the United States are notably absent in the drinking of Greeks and Italians, and American Jews, Chinese, and Japanese (Barnett 1955; Blum and Blum 1969; Glassner and Berg 1980; Vaillant 1983).
A person's desire for a drug cannot be separated from the situation in which the person takes the drug. Falk (1983) and Falk et al. (1983) argue, primarily on the basis of animal experimentation, that an organism's environment influences drug-taking behavior more than do the supposedly inherently reinforcing properties of the drug itself.
The idea that opiate use caused personality defects was challenged as early as the 1920s by Kolb (1962), who found that the personality traits observed among addicts preceded their drug use. Kolb's view was summarized in his statement that "The neurotic and the psychopath receive from narcotics a pleasurable sense of relief from the realities of life that normal persons do not receive because life is no special burden to them" (p. 85).
Chein et al. (1964) gave this view its most comprehensive modem expression when they concluded that ghetto adolescent addicts were characterized by low self-esteem, learned incompetence, passivity, a negative outlook, and a history of dependency relationships.
A major difficulty in assessing personality correlates of addiction lies in determining whether the traits found in a group of addicts are actually characteristics of a social group (Cahalan and Room 1974; Robins et al. 1980).
On the other hand, addictive personality traits are obscured by lumping together controlled users of a drug such as heroin and those addicted to it. Similarly, the same traits may go unnoted in addicts whose different ethnic backgrounds or current settings predispose them toward different types of involvements, drug or otherwise (Peele 1983c).
Personality may both predispose people toward the use of some types of drugs rather than others and also affect how deeply they become involved with drugs at all (including whether they become addicted).
Spotts and Shontz (1982) found that chronic users of different drugs represent distinct Jungian personality types. On the other hand, Lang (1983) claimed that efforts to discover an overall addictive personality type have generally failed.
Lang does, however, report some similarities that generalize to abusers of a range of substances. These include placing a low value on achievement, a desire for instant gratification, and habitual feelings of heightened stress.
The strongest argument for addictiveness as an individual personality disposition comes from repeated findings that the same individuals become addicted to many things, either simultaneously, sequentially, or alternately (Peele 1983c; Peele and Brodsky 1975).
There is a high carry-over for addiction to one depressant substance to addiction to others-for example, turning from narcotics to alcohol (O'Donnell 1969; Robins et al. 1975).
A1cohol, barbiturates, and narcotics show cross-tolerance (addicted users of one substance may substitute another) even though the drugs do not act the same way neurologically (Kalant 1982), while cocaine and Valium addicts have unusually high rates of alcohol abuse and frequently have family histories of alcoholism ("Many addicts..." 1983; Smith 1981).
Gilbert (1981) found that excessive use of a wide variety of substances was correlated-for example, smoking with coffee drinking and both with alcohol use. What is more, as Vaillant (1983) noted for alcoholics and Wishnie (1977) for heroin addicts, reformed substance abusers often form strong compulsions toward eating, prayer, and other nondrug involvements.
When medical or public health organizations that subscribe to biological assumptions about addiction have attempted to define the term they have relied primarily on the hallmark behaviors of addiction, such as "an overpowering desire or need (compulsion) to continue taking the drug and to obtain it by any means" (WHO Expert Committee on Mental Health 1957) or, for alcoholism, "impairment of social or occupational functioning such as violence while intoxicated, absence from work, loss of job, traffic accidents while intoxicated, arrested for intoxicated behavior, familial arguments or difficulties with family or friends related to drinking" (American Psychiatric Association 1980). However, they then tie these behavior syndromes to other constructs, namely tolerance (the need for an increasingly high dosage of a drug) and withdrawal, that are presumed to be biological in nature. Yet tolerance and withdrawal are not themselves measured physiologically. Rather, they are delineated entirely by how addicts are observed to act and what they say about their states of being.
The vast array of information disconfirming the conventional view of addiction as a biochemical process has led to some uneasy reevaluations of the concept.
In 1964 the World Health Organization (WHO) Expert Committee on Addiction-Producing Drugs changed its name by replacing "Addiction" with "Dependence." At that time, these pharmacologists identified two kinds of drug dependence, physical and psychic.
"Physical dependence is an inevitable result of the pharmacological action of some drugs with sufficient amount and time of administration.
Psychic dependence, while also related to pharmacological action, is more particularly a manifestation of the individual's reaction to the effects of a specific drug and varies with the individual as well as the drug."
In this formulation, psychic dependence "is the most powerful of all factors involved in chronic intoxication with psychotropic drugs . . . even in the case of most intense craving and perpetuation of compulsive abuse" (Eddy et al. 1965: 723).
Cameron (1971a), another WHO pharmacologist, specified that psychic dependence is ascertained by "how far the use of drugs appears (1) to be an important life-organizing factor and (2) to take precedence over the use of other coping mechanisms".
Psychic dependence, as defined here, is central to the manifestations of drug abuse that were formerly called addiction.
Indeed, it forms the basis of Jaffe's (1980: 536) definition of addiction, which appears in an authoritative basic pharmacology textbook:
It is possible to describe all known patterns of drug use without employing the terms addict or addiction. In many respects this would be advantageous, for the term addiction, like the term abuse, has been used in so many ways that it can no longer be employed without further qualification or elaboration.... In this chapter, the term addiction will be used to mean a behavioral pattern of drug use, characterized by overwhelming involvement with the use of a drug (compulsive use), the securing of its supply, and a high tendency to relapse after withdrawal. Addiction is thus viewed as an extreme on a continuum of involvement with drug use . . .[based on] the degree to which drug use pervades the total life activity of the user.... [T]he term addiction cannot be used interchangeably with physical dependence.
Addiction, at its extreme, is an overwhelming pathological involvement. The object of addiction is the addicted person's experience of the combined physical, emotional, and environmental elements that make up the involvement for that person. Addiction is often characterized by a traumatic withdrawal reaction to the deprivation of this state or experience. Tolerance-or the increasingly high level of need for the experience-and craving are measured by how willing the person is to sacrifice other rewards or sources of well-being in life to the pursuit of the involvement. The key to addiction, seen in this light, is its persistence in the face of harmful consequences for the individual. This book embraces rather than evades the complicated and multifactorial nature of addiction. Only by accepting this complexity is it possible to put together a meaningful picture of addiction, to say something useful about drug use as well as about other compulsions, and to comprehend the ways in which people hurt themselves through their own behavior as well as grow beyond self-destructive involvements.
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