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

Written by Stanton Peele

However, self-defined and treated addicts did increasingly conform to the prescribed models, in part because addicts mimicked the behavior described by the sociomedical category of addiction and in part because of an unconscious selection process that determined which addicts became visible to clinicians and researchers. The image of the addict as powerless, unable to make choices, and invariably in need of professional treatment ruled out (in the minds of the experts) the possibility of a natural evolution out of addiction brought on by changes in life circumstances, in the person's set and setting, and in simple individual resolve. Treatment professionals did not look for the addicts who did achieve this sort of spontaneous remission and who, for their part, had no wish to call attention to themselves. Meanwhile, the treatment rolls filled up with addicts whose ineptitude in coping with the drug brought them to the attention of the authorities and who, in their highly dramatized withdrawal agonies and predictable relapses, were simply doing what they had been told they could not help but do. In turn, the professionals found their dire prophecies confirmed by what was in fact a context-limited sample of addictive behavior.

Divergent Evidence about Narcotic Addiction

The view that addiction is the result of a specific biological mechanism that locks the body into an invariant pattern of behavior—one marked by superordinate craving and traumatic withdrawal when a given drug is not available—is disputed by a vast array of evidence. Indeed, this concept of addiction has never provided a good description either of drug-related behavior or of the behavior of the addicted individual. In particular, the early twentieth-century concept of addiction (which forms the basis of most scientific as well as popular thinking about addiction today) equated it with opiate us. This is (and was at the time of its inception) disproven both by the phenomenon of controlled opiate use even by regular and heavy users and by the appearance of addictive symptomatology for users of nonnarcotic substances.

Nonaddicted Narcotics Use

Courtwright (1982) and others typically cloud the significance of the massive nonaddicted use of opiates in the nineteenth century by claiming local observers were unaware of the genuine nature of addiction and thus missed the large numbers who manifested withdrawal and other addictive symptomatology. He struggles to explain how the commonplace administration of opiates to babies "was unlikely to develop into a full-blown addiction, for the infant would not have comprehended the nature of its withdrawal distress, not could it have done anything about it" (p. 58). In any case, Courtwright agrees that by the time addiction was being defined and opiates outlawed at the turn of the century, narcotic use was a minor public health phenomenon. An energetic campaign undertaken in the United States by the Federal Bureau of Narcotics and—in England as well as the United States—by organized medicine and the media changed irrevocably conceptions of the nature of opiate use. In particular, the campaign eradicated the awareness that people could employ opiates moderately or as a part of normal lifestyle. In the early twentieth century, "the climate . . . was such that an individual might work for 10 years beside an industrious law-abiding person and then feel a sense of revulsion toward him upon discovering that he secretly used an opiate" (Kolb 1958: 25). Today, our awareness of the existence of opiate users from that time who maintained normal lives is based on the recorded cases of "eminent narcotics addicts" (Brecher 1972: 33).

The use of narcotics by people whose lives are not obviously disturbed by their habit has continued into the present. Many of these users have been identified among physicians and other medical personnel. In our contemporary prohibitionist society, these users are often dismissed as addicts who are protected from disclosure and from the degradation of addiction by their privileged positions and easy access to narcotics. Yet substantial numbers of them do not appear to be addicted, and it is their control over their habit that, more than anything else, protects them from disclosure. Winick (1961) conducted a major study of a body of physician narcotic users, most of whom had been found out because of suspicious prescription activities. Nearly all these doctors had stabilized their dosages of a narcotic (in most cases Demerol) over the years, did not suffer diminished capacities, and were able to fit their narcotic use into successful medical practices and what appeared to be rewarding lives overall.

Zinberg and Lewis (1964) identified a range of patterns of narcotic use, among which the classic addictive pattern was only one variant that appeared in a minority of cases. One subject in this study, a physician, took morphine four times a day but abstained on weekends and two months a year during vacations. Tracked for over a decade, this man neither increased his dosage nor suffered withdrawal during his periods of abstinence (Zinberg and Jacobson 1976). On the basis of two decades of investigation of such cases, Zinberg (1984) analyzed the factors that separate the addicted from the nonaddicted drug user. Primarily, controlled users, like Winick's physicians, subordinate their desire for a drug to other values, activities, and personal relationships, so that the narcotic or other drug does not dominate their lives. When engaged in other pursuits that they value, these users do not crave the drug or manifest withdrawal on discontinuing their drug use. Furthermore, controlled use of narcotics is not limited to physicians or to middle-class drug users. Lukoff and Brook (1974) found that a majority of ghetto users of heroin had stable home and work involvements, which would hardly be possible in the presence of uncontrollable craving.

If life circumstances affect people's drug use, we would expect patterns of use to vary over time. Every naturalistic study of heroin use has confirmed such fluctuations, including switching among drugs, voluntary and involuntary periods of abstinence, and spontaneous remission of heroin addiction (Maddux and Desmond 1981; Nurco et al. 1981; Robins and Murphy 1967; Waldorf 1973, 1983; Zinberg and Jacobson 1976). In these studies, heroin does not appear to differ significantly in the potential range of its use from other types of involvements, and even compulsive users cannot be distinguished from those given to other habitual involvements in the ease with which they desist or shift their patterns of use. These variations make it difficult to define a point at which a person can be said to be addicted. In a typical study (in this case of former addicts who quit without treatment), Waldorf (1983) defined addiction as daily use for a year along with the appearance of significant withdrawal symptoms during that period. In fact, such definitions are operationally equivalent to simply asking people whether they are or were addicted (Robins et al. 1975).