At this point in history, it is necessary to drive a careful path between the shoals of those who medicalize, biologize, and generally reify the addiction concept, and those who deny its existence. In this article, Stanton clarifies the problems with both extremes in the debate (although those in the "reification" camp are far more dangerous), while laying out exactly where in reality addiction exists, its causes, and why all this matters for understanding and dealing with the malady.
Addiction Research, 8:599-607, 2000
What Addiction Is and Is Not
The Impact of Mistaken Notions of Addiction
Fellow, The Lindesmith Center
New York City
The addiction concept varies cross-culturally and historically in significant ways. The reification of the addiction concept by addiction "experts" is actually an important window for understanding the nature of addiction in our society. Both proponents of the concept who incorrectly misidentify it as a Platonic ideal and critics who dismiss it because of its irregular and unreliable nature and appearance miss the boat on addiction. How we think about addiction influences how individuals become addicted, since we learn to be addicted through the expectations we develop about specific involvements.
From historic experience to "science" - The reification of addiction
The United States (and the Western World generally) has suffered in the throes of a cultural delusion - the idea that addiction is a specific biological syndrome. The current administrations of the National Institutes on Drug Abuse (NIDA) and Alcohol Abuse and Alcoholism (NIAAA) are both pursuing this delusion, ad infinitum (cf. Hyman, 1996; Leshner, 1997). Addiction is real, it can occur with any involvement in which people can become immersed, and it is identified by human experience, which means that individual and cultural outlooks are crucial to its appearance.
Based partly on my work (Peele, 1985/1998) indicating that addiction is not a specific invariant biological phenomenon, some sociologists, anthropologists, psychologists, and others involved in substance abuse research have deduced that addiction itself is not real. They make this assertion because people do not invariably become addicted to any given substance (e.g., heroin), even after repeated exposures to it; because people may feel and act addicted with (that is, are addicted to) powerful nonsubstance activities, such as gambling, eating, shopping, and sex; and because even those classifiable as addicts more often than not terminate their addictions, usually without treatment.
But addiction remains a powerful, useful, and evocative concept. People become, act, and feel addicted, and to say otherwise is to argue with incontrovertible phenomena and experience - what is it called when someone enters a worsening spiral of drinking or drug use that leads to self-destruction (as infrequent as this is)? Those who discard the idea of addiction, when confronted with some supposedly physiological indicator of addiction or some sad case of addiction that cannot be gainsaid, then scurry back to notions that sound like addiction but seem more scientifically based but are not - notably the concept of "physical dependence."
The addiction concept is a hoary one that has actually been both meaningfully and correctly applied in common parlance (until the public has been misled by claims posited by the fields of pharmacology and medicine). That is, prior to the modern scientific discovery of addiction, people used the term to indicate that some people, unlike most others involved in any of a number of activities, comport themselves with such abandon and experience such bad consequences that their self-destructive preoccupation is worthy of note - they are addicted (Peele, 1990). For example, Shakespeare - in Twelfth Night - speaks of Olivia as "being addicted to a melancholy." People likewise were noted to be addicted to love, to tobacco, to alcohol, to opiates, to tea and coffee - but not as though this were some trait of the substance or activity.
Previous to nineteenth and twentieth century claims for the addictiveness of first alcohol and then narcotics and then an expanding range of substances (e.g., barbiturates, nicotine, cocaine, marijuana), simple observation and common sense proved that it could not be the substance which was at the heart of compulsive consumption or preoccupation. Why else did most drinkers and consumers of opiates fail to become destructively engaged with these involvements (as well as most coffee/tea imbibers, shoppers, lovers, and gamblers)? A whole new industry of post hoc hypothesis has evolved to explain the range of addictive activity, cantilevering from the belief that heroin addicts are slaves of neurochemical mechanisms to posit farther-reaching and more unsupportable notions that people have brain diseases resulting in addiction to pleasure, or endorphins, or dopamine.
Mistaken notions of dependence
Among alcohol epidemiologist, Robin Room has been an important critic of alcohol dependence notions. In his early work, Problem Drinking Among American Men (Cahalan & Room, 1974), Room organized drinking problems into 13 categories, among which were heavy intake, loss of control (which Room regards as a purely subjective experience of alcoholism), and symptomatic drinking, defined as "short-term physiological consequences of heavy drinking" corresponding to "addictive symptoms" (p. 22). A major point of this work was to dispute disease conceptions (a) that loss of control was central to alcoholism, and (b) that symptoms of alcoholism occur in some regular and coherent sequence or are consistent over time.
Room did not find that physiological symptoms of addiction were any more consistent over time (in fact they were less so) than was loss-of-control for problem drinkers. In addition, ironically, the correlation between symptomatic drinking was highest for, among all other drinking problems, "psychological dependence" (.41), higher than for heavy intake (.34). Finally, where precedence of symptoms could be established, physiological symptoms preceded heavy intake in 68 percent of cases.
Nonetheless, rather than taking these results seriously, Room seemingly concluded that respondents were merely describing subjective states, and that these reports did not represent real physiological traits of alcoholism. In 1987, I wrote "The limitations of control-of-supply models for explaining and preventing alcoholism and drug addiction" (Peele, 1987a), in which I argued that individual and societal models indicating that greater levels of drinking -> greater dependence problems were incorrect. In a response, Room (1987, p. 81) distinguished between physiological and psychological aspects of dependence, and maintained that the former are simply "another name for sustained heavy alcohol use."
Room is wrong, however, when he asserts that the conceptual confusion about addiction can be remedied by separating the concept into physiological and psychological components. The distinction he draws here mirrors the most mundane and traditional pharmacological thinking; moreover, as I have argued in The Meaning of Addiction (Peele, 1985/1998), this whole approach is wrongheaded. It is most depressing to find as well-informed and iconoclastic a researcher and theoretician as Room held hostage by truisms that explain little about addictive behavior. (Peele, 1987c, p. 84)
Another dozen years later, Room participated with a cadre of internationally renowned epidemiologists, clinicians, and anthropologists in the World Health Organization/National Institutes of Health Cross-Cultural Applicability Research project to judge the consistency of symptoms of alcohol dependence across cultures. This distinguished body divided symptoms of dependence into psychological and physiological categories. Overall, they found that, "While descriptions of dependence symptoms were quite similar among key informants from sites that share norms around drinking and drunkenness, they varied significantly in comparisons between sites with markedly different drinking cultures." Moreover, to their surprise, "Contrary to expectation, descriptions of physical dependence criteria appeared to vary across sites as much as the more subjective symptoms of psychological dependence" (Schmidt, Room, et al., 1999, p. 448).
Actually, that something more complicated than a straightforward relationship between, on the one hand, society-wide alcohol consumption and, on the other, alcohol dependence has become evident through the national surveys conducted under Room's direction at the Alcohol Research Group (ARG), the NIAAA-funded national epidemiological research center. At the time between the late 1960s and early 1980s when the concept of alcoholism became a heavily market cultural icon, drinking did not increase in the U.S. Nonetheless, ARG surveys revealed a sharp and significant upturn in those reporting symptoms of alcohol dependence (although not of ordinary drinking problems) - a rise that has not reversed itself since. Both in this historical phenomenon and in Cahalan and Room's multivariate analysis, we see that thinking about addiction and about one's behavior precedes and determines addictive experience.
Source: Room (1989)
In other sciences, that leading figures would as a group misunderstand an anchor concept in their field would be considered shocking. My prediction about this event: it will change nothing not only in the field, but about the thinking of the individuals involved. They will continue to posit separate categories of dependence and reify physical dependence/addiction as an ironclad biological reaction due to drug use and unaffected by situation, culture, and belief. They could not do otherwise; they are blinkered forever by cultural assumptions into which they were born.
Attack on the addiction concept from the "left"
Room's subjugation to foundationless conceptions of addiction is noteworthy since he is a long-time critic of concepts of alcohol dependence. Room espouses what he calls a "nominalist" position - that is, we name things because we have to refer to them, but such labels only indirectly reflect reality. Like others involved in alcohol problem identification, however, he has surmised that there is some type of invariant relationship between drug use and alcohol consumption, on the one hand, and compulsivity and negative consequences of substance use, on the other.
Another group of critics of addiction are libertarians, who believe that all behavior is intentional and that alcoholism is unfounded at its roots since people choose each drink and exposure to drugs. In other words, there are no grounds on which to separate intensive drug use - or compulsive behavior of any sort - from ordinary intentional behavior (see Schaler, 1999). Peter Cohen (this issue) represents a point of view that has elements of nominalism and libertarianism called constructivism. This view, focusing on data showing that use of powerful drugs like cocaine is so relative, so subject to change, so often controllable or able to be brought under control, agrees with libertarians that addiction is nonexistent, a fabled concept with no real referent.
However, these critics must run for cover when confronted with individuals like David Kennedy (deceased son of Robert Kennedy), Jason McCallum (deceased son of the actors David McCallum and Jill Ireland), or Robert Downey, Jr., who report being addicted and who do not cease their drug use under the most dire threats or actual endangerment of their lives up to and including death. What should we call it when someone like Jim Morrison, of the Doors, repeatedly pours alcohol nonstop down his throat for hours and dies of a heart attack in his twenties? And there are noncelebrity examples of similar behavior. To confront a radical critic who claims addiction does not exist with such a self-destructive individual is to reveal the critic as an academic completely unprepared to deal with addicts.
It is unwise and unnecessary to deny the reality of people's experience - experience that can have crucial, even life and death, effects. People experience compulsions and enact them, leading to serious injury to themselves and others. This is not to excuse such behavior criminally or to accept that it is biologically foreordained. But a notion of addiction is required to respond to critical realities of drug use. Such an addiction concept also serves as a template - as one extreme of a continuum which, while rarely fully realized, sets up a typology the opposite end of which is controlled use. It is also helpful to have this concept in one's repertoire when required to deal with extreme cases of substance abusers - resisting the danger, again, of reifying this into the idea that such a person's behavior is immutable (which may actually exacerbate the problem behavior - Kennedy, McCallum, and Downey had collectively been through chemical dependence treatment many times).
Although dependence of every sort is at its heart a subjective experience (that is, the essence of dependence is the belief that one is dependent; cf. Peele, 1998), research shows definitive somatic consequences in terms of dependence measures. Dawson (2000), for example, assessing the relationship between alcohol consumption and mortality in a national sample of drinkers, found that light-moderate drinking prolonged drinkers' lives only for nondependent drinkers, while heavy/very heavy drinking did not increase mortality among nondependent drinkers. Of course, that some dependent drinkers in this research consume low or moderate amounts of alcohol and some nondependent drinkers are very heavy drinkers is another stake in the heart of the idea that consumption level --> dependence.
What is addiction?
The role of subjective beliefs in addiction, and yet its life-and-death consequences, show that addiction exists and that it matters. Yet, my analysis of the continuing misinterpretation of addiction by the most important addiction thinkers shows both the difficulty of coming to grips with the concept, and the ways in which cultural trends in thinking affect the addicted along with those who study addiction.
Addiction exists within clear parameters, which we can specify as follows:
Table II. The nature of addiction
- Known through observed behavior/subjective experience
- Not all-or-nothing
- Can occur with any involving/destructive experience
- Occurs with regard to a gestalt experience
- psychic and physical
- pharmacological and learned
- Provides essential experiential benefits
- sense of power, control
- relief of pain, anxiety
We know the fundamental factors that affect addiction and its course:
Table III. Fundamental factors in addiction and its course
- social (deprived groups have higher addiction rates even though, as groups, they often have higher abstinence rates)
- ethnic (e.g., Irish v. Italian drinking styles)
- traumatic (e.g., Vietnam or other war zone)
- developmental (e.g., maturing out)
- ritualistic (e.g., injection, smoking rituals)
- beliefs (e.g., a substance is dangerous and overwhelming - i.e., it is addictive)
- social learning (modeling of use - and of addiction - by others)
- stable (bedrock) values (e.g., achievement, consciousness)
- evolving values (e.g., parenthood)
Impoverished groups are more susceptible to addiction partly because of their absence of alternative opportunities and rewards. But their addictive susceptibility also includes their acceptance of the addictive potency of some objects, their values towards addictive involvements, and their general life attitudes. The reductive view of addiction as a biological response, of course, negates the role of values in addiction. But the relativism of nominalists and constructivists likewise rejects values as an ad hoc idea in addiction. That people take drugs at all reflects their values; but this is almost a trivial recognition. That people continue to use drugs, use them excessively, actually become addicted to drugs, remain addicted to drugs, and quit being addicted are all in large part value statements (Peele, 1987b).
Take the example of William Bennett, Secretary of Education under Ronald Reagan, in which position he continued his cigarette addiction. When, however, Reagan appointed Bennett as the first drug czar, Bennett quit smoking. It is simply impossible to be sensible about addiction and Bennett's experience with it that does not include his values - what was important to him and what he would not let himself do in a certain situation. Similarly, women frequently quit heroin addictions while they are pregnant, while Orthodox Jews quit often enormous cigarette habits for the Sabbath. Some people simply cannot imagine or allow themselves to be alcoholics or drug or cigarette addicts, or can no longer do so at some point in their lives (for example, when they become parents). Values are the most important of all the unacknowledged factors in addiction, missed by pharmacologists and sociologists and traditionalists and constructivists alike.
Cahalan D., & Room, R. (1974). Problem drinking among American men. New Brunswick, NJ: Rutgers Center of Alcohol Studies.
Dawson, D.A. (2000). Alcohol consumption, alcohol dependence, and all-cause mortality. Alcoholism: Clinical and Experimental Research, 24, 72-81.
Hyman, S.E. (1996). Shaking out the cause of addiction. Science, 273, 811-812.
Leshner, A.I. (1997). Addiction is a brain disease, and it matters. Science, 278, 45-47.
Peele, S. (1985/1998). The meaning of addiction. San Francisco: Jossey-Bass.
Peele, S. (1987a). The limitations of control-of-supply models for explaining and preventing alcoholism and drug addiction. Journal of Studies on Alcohol, 48, 61-77.
Peele, S. (1987b). A moral vision of addiction: How people's values determine whether they become and remain addicts. Journal of Drug Issues, 17, 187-215.
Peele, S. (1987c). What does addiction have to do with level of consumption? A response to R. Room. Journal of Studies on Alcohol, 48, 61-77.
Peele, S. (1990). Addiction as a cultural concept. Annals of the New York Academy of Sciences, 602, 205-220.
Peele, S. (1998, Spring). Ten radical things NIAAA research shows about alcoholism. The Addictions Newsletter (American Psychological Association Division 50), pp. 6; 17-19.
Room, R. (1987). Alcohol control, addiction and processes of change: Comment on "The limitations of control-of-supply models for explaining and preventing alcoholism and drug addiction." Journal of Studies on Alcohol, 48, 78-83.
Room, R. (1989). Cultural changes in drinking and trends in alcohol problems indicators: Recent U.S. experience. Alcologia, 1, 83-89.
Schaler, J.A. (1999). Addiction is a choice. La Salle, IL: Open Court.
Schmidt, L. , Room, R., and collaborators. (1999). Cross-cultural applicability in international classifications and research in alcohol dependence. Journal of Studies on Alcohol, 60, 448-462.