The Meaning of Addiction - 1. The Concept of Addiction - Prejudices about Drugs

Written by Stanton Peele

The WHO committee, while perpetuating prejudices about drugs, claimed to be resolving the confusion brought on by the data showing that addiction was not the biochemically invariant process that it had been thought to be. Thus, the committee labeled the psychic-dependence-producing properties of drugs as being the major determinant of craving and of compulsive abuse. In addition, they maintained, some drugs cause physical dependence. In "A Guide to the Jungle of Drugs" and the philosophy it represented, two drugs were designated as creating physical dependence. These drugs were narcotics and alcohol. This effort to improve the accuracy of drug classifications simply transposed erroneous propositions previously associated with addiction to the new idea of physical dependence. Narcotics and alcohol do not produce qualitatively greater tolerance or withdrawal—whether these are imputed to physical dependence or addiction— than do other powerful drugs and stimulants of all kinds. As Kalant (1982) makes clear, physical dependence and tolerance "are two manifestations of the same phenomenon, a biologically adaptive phenomenon which occurs in all living organisms and many types of stimuli, not just drug stimuli" (p. 12).

What the WHO pharmacologists, Jaffe, and others are clinging to by retaining the category of physical dependence is the idea that there is a purely physiological process associated with specific drugs that will describe the behavior that results from their use. It is as though they were saying: "Yes, we understand that what has been referred to as addiction is a complex syndrome into which more enters than just the effects of a given drug. What we want to isolate, however, is the addiction-like state that stems from these drug effects if we could somehow remove extraneous psychological and social considerations." This is impossible because what are being identified as pharmacological characteristics exist only in the drug user's sensations and interactions with his environment. Dependence is, after all, a characteristic of people and not of drugs.

The Persistence of Mistaken Categories

While there has been some movement in addiction theorizing toward more realistic explanations of drug-related behavior in terms of people's life circumstances and nonbiological needs, old patterns of thought persist, even where they don't agree with the data or offer helpful ways of conceptualizing drug abuse problems. This is nowhere more apparent than in the writing of investigators whose work has effectively undermined prevailing drug categorizations and yet who rely on categories and terminology that their own iconoclastic findings have discredited.

Zinberg and his colleagues (Apsler 1978; Zinberg et al. 1978) have been among the most discerning critics of the WHO committee's definitions of drug dependence, pointing out that "these definitions employ terms that are virtually indefinable and heavily value-laden" (Zinberg et al. 1978: 20). In their understandable desire to avoid the ambiguities of moral categories of behavior, these investigators seek to restrict the term "addiction" to the most limited physiological phenomena. Thus they claim that "physical dependence is a straightforward measure of addiction" (p. 20). However, this retrenchment is inimical to their purpose of satisfactorily conceptualizing and operationalizing addictive behavior. It is also irreconcilable with their own observation that the effort to separate psychological habituation and physical dependence is futile, as well as with their forceful objections to the idea that psychic dependence is "less inevitable and more susceptible to the elements of set and setting" than is physical dependence (p. 21). At the same time that they complain that "The capacity of different individuals to deal with different amounts of substances without development of tolerance is sufficiently obvious . . . [that] one must question how the complexity of this phenomenon could have been missed" (p. 15), they trumpet "the inevitable physical dependence which occurs following the continued and heavy use of substances such as the opiates, barbiturates, or alcohol, that contain certain pharmacological properties" (p. 14). They then contradict this principle by citing the case, described earlier by Zinberg and Jacobson (1976), of the doctor who injected himself with morphine four times a day for over a decade but who never underwent withdrawal while abstaining on weekends and vacations.

Zinberg et al. (1978) find that "the behavior resulting from the wish for a desired object, whether chemical or human," is not the result of "differentiation between a physiological or psychological attachment.... Nor does the presence of physical symptoms per se serve to separate these two types of dependence" (p. 21). Yet they themselves maintain exactly this distinction in terminology. While noting that people may be just as wedded to amphetamines as to heroin, they claim that the former are not "psychologically addicting." (Probably the authors meant to say that amphetamines are not "physiologically addicting." They employ "psychological addiction" elsewhere in this article to describe nondrug or nonnarcotic involvements and "physiological addiction" to describe heavy heroin use characterized by withdrawal. Their use of both phrases, of course, adds to the confusion of terms.) Zinberg et al. claim without supporting citations that "if naloxone, a narcotic antagonist, is administered to someone who is physically dependent on a narcotic, he will immediately develop withdrawal symptoms" (p. 20). It is puzzling to compare this declaration with their statement that it "is now evident many of the symptoms of withdrawal are strongly influenced by expectations and culture" (p. 21). In fact, many people who identify themselves in treatment as narcotic addicts do not manifest withdrawal even when treated by naloxone challenge (Gay et al. 1973; Glaser 1974; O'Brien 1975; Primm 1977).

The Zinberg et al. formulation leaves unexplained the hospital patients Zinberg (1974) studied who, having received greater than street level dosage of narcotics for ten days or more, almost never reported craving the drug. If these people are physically dependent, as Zinberg et al. (1978) seem to suggest they would be, it amounts to saying that people can depend on what they can't detect and don't care about. Surely this is the reductio ad absurdum of the concept of physical dependence. That amphetamines and cocaine are labeled as not physical-dependence inducing or addictive (see discussion above), despite the fact that users can be wedded to them in ways that are indistinguishable from addiction, invalidates these distinctions among drugs from the opposite direction. Apparently, those pharmacological effects of a given drug that are unique and invariant are irrelevant to human functioning. Here scientific terminology approaches the mystical by identifying distinctions that are unmeasurable and unrepresented in thought, feeling, and action.

Finally, Zinberg et al.'s illustrations of the "difficulty of separating physical dependence from psychic dependence and of differentiating both from overpowering desire" (p. 21) go to show the futility of using different terms to describe drug-related and nondrug-related variants of the same process. A primitive logic dictates that a chemical introduced into the body should be conceived to exert its effects biochemically. However, any other experience a person has will also possess biochemical concomitants (Leventhal 1980). Zinberg et al. emphasize that craving and withdrawal associated with intimate relationships are substantial and unmistakable. In detecting withdrawal symptoms on the order of those reported for barbiturates and alcohol among compulsive gamblers, Wray and Dickerson (1981) noted that "any repetitive, stereotyped behavior that is associated with repeated experiences of physiological arousal or change, whether induced by a psychoactive agent or not, may be difficult for the individual to choose to discontinue and should he so choose, then it may well be associated with disturbances of mood and behavior" (p. 405, italics in original). Why do these states and activities not have the same capacity to produce physical dependence?