The Meaning of Addiction - 1. The Concept of Addiction - Addiction Meaning

Written by Stanton Peele

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.

Cognitive

People's expectations and beliefs about drugs, or their mental set, and the beliefs and behavior of those around them that determine this set strongly influence reactions to drugs. These factors can, in fact, entirely reverse what are thought to be the specific pharmacological properties of a drug (Lennard et al. 1971; Schachter and Singer 1962). The efficacy of placebos demonstrates that cognitions can create expected drug effects. Placebo effects can match those of even the most powerful pain killers, such as morphine, although more so for some people than others (Lasagna et al. 1954). It is not surprising, then, that cognitive sets and settings are strong determinants of addiction, including the experience of craving and withdrawal (Zinberg 1972). Zinberg (1974) found that only one of a hundred patients receiving continuous dosages of a narcotic craved the drug after release from the hospital. Lindesmith (1968) noted such patients are seemingly protected from addiction because they do not see themselves as addicts.

The central role of cognitions and self-labeling in addiction has been demonstrated in laboratory experiments that balance the effects of expectations against the actual pharmacological effects of alcohol. Male subjects become aggressive and sexually aroused when they incorrectly believe they have been drinking liquor, but not when they actually drink alcohol in a disguised form (Marlatt and Rohsenow 1980; Wilson 1981). Similarly, alcoholic subjects lose control of their drinking when they are misinformed that they are drinking alcohol, but not in the disguised alcohol condition (Engle and Williams 1972; Marlatt et al. 1973). Subjective beliefs by clinical patients about their alcoholism are better predictors of their likelihood of relapse than are assessments of their previous drinking patterns and degree of alcohol dependence (Heather et al. 1983; Rollnick and Heather 1982). Marlatt (1982) has identified cognitive and emotional factors as the major determinants in relapse in narcotic addiction, alcoholism, smoking, overeating, and gambling.

The Nature of Addiction

Studies showing that craving and relapse have more to do with subjective factors (feelings and beliefs) than with chemical properties or with a person's history of drinking or drug dependence call for a reinterpretation of the essential nature of addiction. How do we know a given individual is addicted? No biological indicators can give us this information. We decide the person is addicted when he acts addicted—when he pursues a drug's effects no matter what the negative consequences for his life. We cannot detect addiction in the absence of its defining behaviors. In general, we believe a person is addicted when he says that he is. No more reliable indicator exists (cf. Robins et al. 1975). Clinicians are regularly confused when patients identify themselves as addicts or evince addicted lifestyles but do not display the expected physical symptoms of addiction (Gay et al. 1973; Glaser 1974; Primm 1977).

While claiming that alcoholism is a genetically transmitted disease, the director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA), a physician, noted there are not yet reliable genetic "markers" that predict the onset of alcoholism and that "the most sensitive instruments for identifying alcoholics and problem drinkers are questionnaires and inventories of psychological and behavioral variables" (Mayer 1983: 1118). He referred to one such test (the Michigan Alcohol Screening Test) that contains twenty questions regarding the person's concerns about his or her drinking behavior. Skinner et al. (1980) found that three subjective items from this larger test provide a reliable indication of the degree of a person's drinking problems. Sanchez-Craig (1983) has further shown that a single subjective assessment—in essence, asking the subject how many problems his or her drinking is causing—describes level of alcoholism better than does impairment of cognitive functioning or other biological measures. Withdrawal seizures are not related to neurological impairments in alcoholics, and those with even severe impairment may or may not undergo such seizures (Tarter et al. 1983). Taken together, these studies support the conclusions that the physiological and behavioral indicators of alcoholism do not correlate well with each other (Miller and Saucedo 1983), and that the latter correlate better than the former with clinical assessments of alcoholism (Fisher et al. 1976). This failure to find biological markers is not simply a question of currently incomplete knowledge. Signs of alcoholism such as blackout, tremors, and loss of control that are presumed to be biological have already been shown to be inferior to psychological and subjective assessments in predicting future alcoholic behavior (Heather et al. 1982; Heather et al.1983).

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. Light and Torrance (1929) failed in their comprehensive effort to correlate narcotic withdrawal with gross metabolic, nervous, or circulatory disturbance. Instead, they were forced to turn to the addict—like the one whose complaints were most intense and who most readily responded to saline solution injections—in assessing withdrawal severity. Since that time, addict self-reports have remained the generally accepted measure of withdrawal distress.