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

Written by Stanton Peele

Withdrawal is a term for which meaning has been heaped upon meaning. Withdrawal is, first, the cessation of drug administration. The term "withdrawal" is also applied to the condition of the individual who experiences this cessation. In this sense, withdrawal is nothing more than a homeostatic readjustment to the removal of any substance—or stimulation—that has had a notable impact on the body. Narcotic withdrawal (and withdrawal from drugs also thought to be addictive, such as alcohol) has been assumed to be a qualitatively distinct, more malignant order of withdrawal adjustment. Yet studies of withdrawal from narcotics and alcohol offer regular testimony, often from investigators surprised by their observations, of the variability, mildness, and often nonappearance of the syndrome (cf. Jaffe and Harris 1973; Jones and Jones 1977; Keller 1969; Light and Torrance 1929; Oki 1974; Zinberg 1972). The range of withdrawal discomfort, from the more common moderate variety to the occasional overwhelming distress, that characterizes narcotic use appears also with cocaine (van Dyke and Byck 1982; Washton 1983), cigarettes (Lear 1974; Schachter 1978), coffee (Allbutt and Dixon, quoted in Lewis 1969: 10; Goldstein et al. 1969), and sedatives and sleeping pills (Gordon 1979; Kales et al. 1974; Smith and Wesson 1983). We might anticipate the investigations of laxatives, antidepressants, and other drugs—such as L-Dopa (to control Parkinson's disease)—that are prescribed to maintain physical and psychic functioning will reveal a comparable range of withdrawal responses.

In all cases, what is identified as pathological withdrawal is actually a complex self-labeling process that requires users to detect adjustments taking place in their bodies, to note this process as problematic, and to express their discomfort and translate it into a desire for more drugs. Along with the amount of a drug that a person uses (the sign of tolerance), the degree of suffering experienced when drug use ceases is—as shown in the previous section—a function of setting and social milieu, expectation and cultural attitudes, personality and self-image, and, especially, lifestyle and available alternative opportunities. That the labeling and prediction of addictive behavior cannot occur without referring to these subjective and social-psychological factors means that addiction exists fully only at a cultural, a social, a psychological, and an experiential level. We cannot descend to a purely biological level in our scientific understanding of addiction. Any effort to do so must result in omitting crucial determinants of addiction, so that what is left cannot adequately describe the phenomenon about which we are concerned.

Physical and Psychic Dependence

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" (p. 10).

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. [italics in original]

While Jaffe's terminology improves upon previous pharmacological usage by recognizing that addiction is a behavioral pattern, it perpetuates other misconceptions. Jaffe describes addiction as a pattern of drug use even though he defines it in behavioral terms—that is, craving and relapse—that are not limited to drug use. He devalues addiction as a construct because of its inexactness, in contrast with physical dependence, which he incorrectly sees as a well-delineated physiological mechanism. Echoing the WHO Expert Committee, he defines physical dependence as "an altered physiological state produced by the repeated administration of a drug which necessitates the continued administration of the drug to prevent the appearance of . . . withdrawal" (p. 536).

The WHO committee's efforts to redefine addiction were impelled by two forces. One was the desire to highlight the harmful use of substances popularly employed by young people in the 1960s and thereafter that were not generally regarded as addictive—including marijuana, amphetamines, and hallucinogenic drugs. These drugs could now be labeled as dangerous because they were reputed to cause psychic dependence. Charts like one titled "A Guide to the Jungle of Drugs," compiled by a WHO pharmacologist (Cameron 1971b), classified LSD, peyote, marijuana, psilocybin, alcohol, cocaine, amphetamines, and narcotics (that is, every drug included in the chart) as causing psychic dependence (see figure 1-1). What is the value of a pharmacological concept that applies indiscriminately to the entire range of pharmacological agents, so long as they are used in socially disapproved ways? Clearly, the WHO committee wished to discourage certain types of drug use and dressed up this aim in scientific terminology. Wouldn't the construct describe as well the habitual use of nicotine, caffeine, tranquilizers, and sleeping pills? Indeed, the discovery of this simple truism about socially accepted drugs has been an emerging theme of pharmacological thought in the 1970s and 1980s. Furthermore, the concept of psychic dependence cannot distinguish compulsive drug involvements—those that become "life organizing" and "take precedence over . . . other coping mechanisms"—from compulsive overeating, gambling, and television viewing.