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As for crack, a front-page story on crack addiction in the New York Times trumpeted the headline "Importance of User's Environment is Stressed Over the Drug's Attributes." The first paragraph of the article stated31 "Drug experts now believe that the extreme difficulties they face in treating crack addiction stem far more from the setting and circumstances of the users than the biochemical reaction the drug produces." The Times article reported that addicts in surveys conducted in the United States, Britain, and Canada reported that they found it easier to quit cocaine--"either injected, sniffed, or smoked"--than alcohol, heroin, or cigarettes. By the other key measure of addiction in addition to difficulty in ceasing use, that is, the frequency with which use leads to compulsive use, cocaine also seems considerably less addictive than some other familiar substances. The Times cited figures from NIDA researchers indicating that five times as many cigarette smokers become addicted as crack users. In all of these data, we see that a new drug presented as the penultimate addictive substance falls into place as being no more or less addictive than other popular illicit and recreational drugs and that, moreover, situational and social factors remain crucial in determining the drug's addictive usage patterns.
Nonetheless, it appears to be obligatory to begin not only popular but scientific discussions of cocaine use with lurid descriptions of the addictive nature of the drug and of clinical or historical accounts of hopelessly self-destructive drug users. Perhaps most scientists fear that to do otherwise might encourage cocaine experimentation, including that small minority for whom such use becomes compulsive and self-destructive. The rewards and punishments are so fundamentally opposed to any announcements of controlled use of illicit substances that they are guaranteed not to appear, thus confirming the worst expectations about any drug that society and its scientists focus their attention on. The controlled-drinking dispute in the United States is another example of this trend; no one can afford to endorse the possibility of controlled drinking by alcoholics, and, indeed, not even those who discover it accept controlled drinking as a possible therapy outcome.
Pokorny, Miller, and Cleveland,32 for example, examined outcomes among a group of alcoholics treated in a hospital alcoholism program. The study revealed 23% of patients were drinking in a mild, social way, and 25% were abstinent one year after discharge from the hospital; in this study abstinence was the less stable pattern, with abstinence decreasing over time while moderate drinking increased over the course of the study. This occurred although the study reported hospital treatment insisted that "life- long abstinence is a necessity in the rehabilitation of alcoholics." Results from a highly unstable group of alcoholics who varied between abstinence and excessive drinking were so poor that the investigators concluded treatment was hardly worthwhile for them. The chief investigator wrote me about this study:
We did not have controlled drinking as a goal, and this was nowhere advocated or taught to patients, even any subgroup of patients. We simply reported the findings at follow-up, which included a substantial group of patients who were not totally abstinent but whose behavior could fairly be classed as improved, perhaps even "controlled" . . . . My personal views were then and have remained that abstinence is the only reasonable goal for clearcut alcoholics, but I try to keep an open mind on the subject. [A.D. Pokorny, personal communication, July 16, 1987]
This study and its principal author's response raise the question, "why bother to conduct research?" Clearly, we are dealing in the case of addiction with areas in which scientific investigators do not simply ask questions, get answers, and apply results.
The model of addiction as a distinct malady requiring treatment that substantially enhances prognosis has a strong economic basis. Miller and Hester33 noted in reference to comparisons between inpatient and outpatient treatment for alcoholism: "Every study has reported either no statistically significant differences between treatment settings or differences favoring less intensive settings" (p. 802). Nonetheless, hospital treatment for alcohol and drug dependence has increased several-fold during the 1980s and has become increasingly coercive and most patients are now forced into treatment by the courts and businesses.27 The principal advantages to expensive, inpatient care seem to be financial ones for providers and a sense of neat categorization and hoped-for benefits for society at large.
Berridge and Edwards6 explain that "images of addiction are consistently and relentlessly marketed--in the nineteenth century to make opium the property of the medical profession . . . . The nineteenth-century discovery that the addict is a suitable case for treatment is today an entrenched and unquestionable premise, with society unaware of the arbitrariness of this come-lately assumption . . . . [However] any suggestion that the current model is fundamentally mistaken in its assumption, and that the treatment enterprise should be closed down and people with bad habits left to their own devices, would be dismissed only as outrageous and bizarre" (pp. 250-251). Edwards may have been jaundiced by his own research experience, in which a well-controlled study of hospital treatment for alcoholism revealed just as much improvement among one group given a single session of advice as occurred in a comparable group receiving the full complement of inpatient and outpatient hospital services.34
The extent of the solidifying and broadening of the addiction concept goes beyond deciding that cocaine was previously wrongly thought to produce "psychic dependence" and is actually capable of producing "physical dependence," that alcoholism is a treatable disease so that those with a drinking problem who deny they require alcoholism treatment ought to be threatened with jail or loss of job, or, alternately, that those who commit crimes and who also drink heavily should be offered treatment in place of jail sentences. Entirely new areas have been opened to disease imagery, understanding, and treatment. Children and other relatives of alcoholics who do not themselves have drinking problems are now treated as though they have a disease, as are those who compulsively gamble, shop, overeat, fornicate, or participate in abusive relationships. Any and all of these compulsions and others (like PMS), reconceived according to the model of misbehavior as uncontrollable addiction, dominate contemporary psychological thought.27
Actually, the tail is now wagging the dog. We are not so much misconceiving addiction as we are living in a culture increasingly controlled by a new notion of individual responsibility based on the addictive model. To argue today that people--even those who drink a good deal or take drugs or have premenstrual mood swings--ought to be held liable for their conduct, particularly when they harm others, is to wage an increasingly uphill battle. The person who says people who drink too much or who misbehave when they drink are the primary agents of their actions and should be held accountable for them is actually the one least likely to become alcoholic.25 Nonetheless, one who declares such a view today is considered ignorant of modern scientific advances in the field of alcoholism and addiction.
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