Failings Of The Disease Model Of Addiction

H U M A N PSYCHOPHARMACOLOCY. VOL.

11, S33-S38 (1996)

Failings of the Disease Model of Addiction GI0 BATTA GORI The Health Policy Center, 6704 Barr Road, Bethesda, M D 20816, USA

Colloquially, addiction ranges in meaning from addiction to good deeds to addiction to substances of abuse. Especially during the last four decades, ‘addiction’ in this extreme pejorative meaning has been portrayed alternatively as a disease or a sin, and has been subject to social and moral sanctions. In an open society of free individuals such a coercion cannot be justified unless the condition is defined precisely by the simultaneous attributes of severe psychotoxicity, severe withdrawal symptoms, and recurrence tied to the loss of self-control and individual volition. Still, these attributes are open-ended, and an explicit metric of severity at which they may trigger socia] objection has not been clarified. ASa consequence, ‘addiction’ allegations are left to elicit emotional, subjective, and value-laden responses ready to be exploited. A clamorous example is the claim by US officials that cigarette smoking is equal to the abuse of heroin or cocaine. An unequivocal definition of ‘addiction’ may restore some sense of proportion to official normative intervention. KEY

wows-addiction;

smoking; regulation; substance abuse

INTRODUCTION What addiction is, whether addiction is a diseaseand if so, what kind of disease-cannot be determined purely from a medical or behavioural angle, but rather from more basic considerations, given the logic and semantic instabilities surrounding the term. I believe it was Voltaire who said that an intelligent discussion beings with a statement of dialectic premises and assumptions. To d o so, I propose the following line from Horace, the prominent Latin poet, who wrote some 2000 years ago ‘nullius addictus jurare in verba magistri’: [I am] not in the habit of swearing by the words of any master (Horace, Epistulcz I, I, 14 (1921)). First, this line gives a fitting description of the good-natured scepticism that should inform the most optimistic scientific analysis. Second, it is a line in a language that took pride in its conciseness and precision, as should be the aim of any intelligent and logically fair analysis. Third, it mentions addiction as the Latin meant it, namely to signify a habit, an insistent way to keep doing

* The original Latin meaning was a iegai one. The winner in a legal dispute could be assigned property or even the person of the loser. Whatever this assignment, it was said to be ‘addicted‘ to the winner. The word gradually also took the meaning used by Horace and in current language.

CCC 0885-6222/96/S 10833-06 0 1996 by John Wiley & Sons, Ltd.

things*. In fact, this has been the meaning of the word down to this day when colloquially we describe people ‘addicted’ to good deeds, to chocolate, to food, to sex, to the good life, as well as to gambling, alcohol, hard-drugs, and so on. Such various attributions of ‘addiction’ imply a continuum of valuations, from the laudable to the condemnable. Still, more and more during the last decades in medical, behavioural, regulatory, and legal talk ‘addiction’ has been assigned the pejorative meaning of a syndrome identified with the abuse of psychotoxic substances. It is presented as a repetition of abuses that eventually cancel volition and personal responsibility, thus generating the need of therapies and other interventions, and leading to social costs and crime. Official and social sanctions have been assigned to this syndrome, even though assorted interests have resisted a defensible definition of precisely why and in whose eyes ‘addiction’ becomes objectionable. Because the resulting ambiguities have been left open to exploitation and resentment, this essay explores plausible standards of semantic fairness. ADDICTION DEFINED Today-when ‘addiction’ becomes of medical or normative interest-it invariably carries the pejorative ethical meaning of recurring uncontrollable excess. Because the word has moral

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implications and these qualifiers are prone to subjective valuation, some questions arise. For instance: who appraises ‘addiction’: the observer or the observed? Indeed, it matters if the claimant is a dogmatic authority, and if the people branded as ‘addicted’ by such an external value judgment many not feel unsound at all. Elementary fairness requires that when ‘addiction’ is used to impose social or medical labels and sanctions, it should be defined by objective attributes rather than normative judgments. Fairness further requires that these attributes not be frivolous. It should not be sufficient to rely on the mere recurrences implied by addiction, nor on pleasurable or therapeutic outcomes in the subjects iqvolved, nor on medical, physiologic, psychologic, or behavioural markers of contrived ethical implications. A social language striving to be equitably normative should explicitly identify why, to whom, and by which standards individual ‘addiction’ becomes ‘objectionable’ and therefore subject to sanction. For our analysis, ‘uncontrollable excess’ is defined in the context of some repetitive action implied by addiction. Here, however, recurrence is necessary but not sufficient because many actions in life are or must be highly repetitive-some actually carrying risks-without being defined as ‘uncontrollable’ or ‘addictive’. Think, for instance, of keyboard work and metacarpal syndromes, tennis and tennis-elbows, sweets and tooth decay, overeating and longevity loss, and so on. Indeed, in ethical, social and normative parlance ‘objectionable addiction’ has been specifically restricted to conditions involving substance abuse. Therefore, considering the features of these conditions, forcible intervention seems justified when ‘repetitive uncontrollable excess’ leads to objectionable ends or to loss of personal volition on account-for instance-of the lure of psychoactivity or because of withdrawal symptoms, both outcomes of substance abuse as commonly understood. Still, in order to be problematic, psychoactivity may not be a simple pleasurable experience but must be deranged and psychotoxic, while withdrawal must be objectively severe. We could propose, therefore, that ‘addiction’ objectively becomes a ‘repetitive uncontrollable excess’ when severe withdrawal symptoms are soon alleviated by renewing a deranged intoxicating experience, which triggers a continuing repetition that presumably cannot be controlled by personal volition. General psychotoxicity alone may not qualify ‘addiction’ because the occasional abuse and intoxication-by alcohol

or psychoactive substances-does not materialize the recurring loss of volition leading to the repetitiveness of ‘addiction’. In turn, the severity of withdrawal must be such that it compels repetition by any means. Thus, depersonalizing psychotoxicity, severe withdrawal, and loss of personal volition seem collectively the necessary attributes if ‘addiction’ is to justify social objection and sanction. These attributes. however, span a domain of severity and thus require specific definition of the intensities above which social action is justified. Unfortunately, such metrics have not been defined objectively, and as a consequence the limits of a definition are not always respected. Scientists may use ‘addiction’ without ethical implications-a value-neutral technical term defining a tentative experimental model of behavioural and physiologic descriptors. Healing authorities and professions, on the other hand, often use the same tentative descriptors and pretend scientific objectivity in calling for social and ethical objections and in justifying sanctions to ‘addiction’. In reality, among descriptors of ‘addiction’ only psychotoxicity may be a relatively narrow attribute. Severity of withdrawal and loss of personal volition are concepts open-ended to subjective valuation, even though their features could be fairly precisely identified for the syndrome of ‘addiction’ to hard-drugs, namely the standard of ‘objectionable addiction’. Yet, there has been reluctance-official and otherwise-to adopt measures of these features as the legitimate benchmarks of this condition. Behaviour and health scientists have attempted to seek objective markers for some attributes of ‘addiction’, but the results have not been persuasive. The World Health Organization (WHO) and others have struggled for 40 years with a model definition of ‘addiction’. In the 1957 WHO definition: ‘Drug Addiction is a state of periodic or chronic intoxication produced by repeated consumption of a drug (natural or synthetic). Its characteristics include: (1) an overwhelming desire or need (compulsion) to continue taking the drug and to obtain it by any means; (2) a tendency to increase the dose; (3) a psychic (Psychological) and generally a physical dependence on the effects of the drug; (4) detrimental effect on the individual and on society’ (WHO, 1957).

FAILINGS OF THE DISEASE MODEL OF ADDICTION

In the same 1957 report, WHO experts felt the need to distinguish ‘addiction’ from ‘habituation’. the latter being thus defined: ‘Drug Habituation (habit) is a condition resulting from the repeated consumption of a drug. Its characteristics include: (1) a desire (but not a compulsion) to continue taking the drug for the sense of well-being it engenders; (2) little or no tendency to increase the dose; (3) some degree of psychic dependence on the effect of the drug, but absence of physical dependence and hence of an abstinence syndrome; (4) detrimental effect, if any, primarily on the individual’ (WHO, 1957). Because of the subjective vagueness of these descriptors, WHO experts from 1964 to 1974 abandoned both concepts of ‘addiction’ and ‘habituation’ in favour of a unified concept of ‘dependence’. ‘Drug Dependence. A state, psychic and sometimes also physical, resulting from the interaction between a living organism and a drug, characterized by behavioural and other responses that always include a compulsion to take the drug on a continuous or periodic basis in order to experience its psychic effects, and sometimes to avoid the discomfort of its absence’ (WHO, 1974). This earlier definition still did not satisfy, and in 1993 ‘dependence’ was defined in even vaguer terms:

‘A cluster of physiological, behavioural and cognitive phenomena of variable intensity, in which the use of a psychoactive drug (or drugs) takes on a high priority. The necessary descriptive characteristics are a preoccupation with a desire to obtain and take the drug and persistent drug-seeking behaviour ... The existence of a state of dependence is not necessarily harmful in itself, but may lead to self-administration of the drug at dosage levels that produce deleterious physical or behavioural changes .. .’ (WHO, 1993). It is apparent that the experts became less and less comfortable with attributes ‘of variable intensity’ and ended up with an all-encompassing definition lacking specificity. By declaring that ‘... a state of dependence is not necessarily harmful in itself ...’ the word ‘dependence’ now seems to cover the same range of situations as the

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generic term of addiction. namely from the laudable to the objectionable. Sceptics have surmized that this vagueness might have been designed to ease the inclusion of otherwise conjectural syndromes in medical costs reimbursement programmes. More likely, it was the outcome of mounting semantic confusion fostered by multiple and competing professional interests, and by the resulting incapacity or unwillingness to identify objectively a specific scientific, medical, social, regulatory, and legal construct as ‘objectionable addiction’. To make matters more complex, an hypothesis has been advanced that the definition of ‘addiction’ might not place overwhelming responsibility on the substances that may be abused, when many people use the same substances sporadically and without being socially labelled as ‘objectionably addicted’. Others may chronically use the same substances for stress or pain relief, without ‘objectionable’ or ‘addiction’ consequences-for instance, the users of opiates and benzodiazepines for pain or mood control. Indeed, and despite the vagueness of the words, only a small fraction of people end up being classified as ‘objectionably addicted’, even though substances that can be abused are easily available. Thus, the conjecture surmizes that what makes ‘addicts’ are ‘addiction-prone’ personalities--‘addiction’ being viewed as an endogenous predicate while the substances abused are seen as contingent external accessories. In this context, the hypothesis of causality has invoked the concept of cognitive dissonance, negative sociocultural influences, devastating family environments. and so on: collectively a multifactorial construct of causation, where the substances that may be abused are circumstantial complements. In any event, the WHO expert definitions of ‘addiction’ are unsatisfactory both in a semantic and scientific context. A certain routine is not necessarily objectionable if it should have psychoactive effects-presumably pleasurable, euphoriant or even hallucinogenic-which reinforce an insistence to repeat the experience. It is not necessarily problematic if it should include the development of tolerance, namely an assuefaction to a substance. For instance, the traditional use of alcoholic beverages as food or entertainment fits these conditions without social offence. The occasional drunkenness of otherwise sober individuals or the occasional experience with harddrugs seem to elicit hardly more than raised

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eyebrows. The occasional loss of volition and ‘free will’ is not a controlling determinant of social disapproval. Indeed, excluding ever present puritanical fringes, ancient and current mores seem largely indifferent to occasional psycho-intoxications of individuals. Nevertheless, ‘addiction’ defined by an ever recurring triad of severe psychotoxicity, withdrawal symptoms, and loss of personal volition control is bound to create personal, social, and material concerns. Still, we have seen how vague the medical and behavioural definitions of ‘addiction’ have been made. ‘Addiction’ can be defined dialectically but apparently not in precisely quantifiable scientific terms, ljkely on account of the ethical value implications of the word. A legitimate operational definition would be possible by adopting as benchmarks the intensities of psychotoxicity, severe withdrawal and loss of volition, at the levels that characterize the classic ‘addiction’ to harddrugs. Yet, this has not happened. Semantic ambiguities have been left festering arguably with intention and-given human nature-they seem ready-made for exploitation. A clamorous example is the 1988 claim by the US Surgeon General that smokers are as addicted to cigarettes as others are to heroin and cocaine.

addictive power of crack versus powdered cocaine (US Code). By all measurable evidence, if cigarette smoking-or chocolate craving, for that matteris to be called addictive, it should be accorded a comparatively more extreme reduction of intensity when compared to powdered cocaine. An explicit gradient of intensity is apparent in the definitions of ‘addiction’ and ‘habit’ advanced by the healing professions. In fact, the World Health Organization has characterized smoking as a habit, not an ‘addiction’, and even statements by previous Surgeon Generals in the US also qualified smoking as a habit. For instance, the original 1964 Surgeon General’s report reads: ‘The tobacco habit should be characterized as an habituation rather than an addiction, in conformity with accepted World Health Organization definitions, since once established there is little tendency to increase the dose; psychic but not physical dependence is developed . .. No characteristic abstinence syndrome is developed upon withdrawal ... Discontinuation of smoking . . . is accomplished best by reinforcing factors which interrupt the psychogenic drives. Nicotine substitutes or supplementary medication have not been proven of major benefit in breaking the habit’ (USSG, 1964, p. 354). ‘The overwhelming evidence points to the conclusion that smoking-its beginning, habituation, and occasional discontinuation-is to a large extent psychologically and socially determined’ (USSG, 1964 p. 40).

CIGARETTE SMOKING, HEROIN, AND COCAINE In an effort to discourage cigarette smoking, the US Surgeon General in 1988 declared thatbehaviourally-cigarette smokers are on the same To smokers, smoking is pleasant in many ways level as heroin or cocaine addicts. On the face of it, this incredible assertion defies common sense and therefore it could be expected to be mildly because the daily experience of everyone tells that reinforcing as any pleasant experience tends to be. smokers and hard-drug addicts are not the same There is no good evidence of tolerance in smokers. people. In effect, the Surgeon General trivialized A certain dose is attained early when people start the pejorative behavioural connotations of heroin smoking and that dose is not exceeded because and cocaine addiction. Could anyone show that exceeding it makes smoking unpleasant. Uncigarette smoking comports such an extreme a controllable, compulsive use is not apparent in behaviour as heroin and cocaine addiction? Should smokers: the Surgeon General acknowledges that we invent other words for substance abuses with over 40 million smokers quit on their own in the true objectionable sequelae, when common lan- United State alone, in a climate where cigarettes guage itself separates different habits in different are legally and readily available. The all important categories of intensity? In the context of fair qualifier of psychotoxicity is absent in smokers. policies we should rather demand a precise use of Finally, there is no evidence of physical dependefinitions and language, insisting that if a generic dence: withdrawal symptoms are usually absent, ‘addiction’ attribute is to be used ubiquitously, transient and mild at best when present, and less then its intensity should be graded in each instance. noticeable than the withdrawal symptoms experiOfficial precedent recognizes this need, implicit in enced by people on strict diets. Jack Henningfield, the legal distinction of a 100: 1 ratio for the a principal architect of the US Surgeon General’s

FAILINGS OF THE DISEASE MODEL OF ADDICTION

claim of smoking ‘addiction’, himself wrote a few years ago that: ‘The following constraints and inconsistencies should be noted when considering the evidence for a tobacco withdrawal syndrome. First, a syndrome of reliable physiologic signs ... has not been described ... w i t h the exception of the desire to smoke ... other phenomena typically occur only in a fraction of all subjects abstinent from cigarettes . .. For instance . . . weight gain, gastrointestinal disturbances, or anxiety may each occur in less than one-third of all subjects; and up to one-half of abstinent subjects may report no symptoms at all. The second major issue is that while tobacco withdrawal is commonly equated with nicotine withdrawal, there is little evidence that nicotine produces physiologic dependence ... Administration of nicotinereceptor antagonists .. . has not been shown to evoke a withdrawal syndrome ... [Plroviding abstinent smokers with a nicotinecontaining chewing gum only partially attenuates physical complaints ... [and] in animal studies, abrupt abstinence is not followed by . . . a withdrawal syndrome. These inconsistencies ... impose constraints on the comparison ... of tobacco withdrawal with that of withdrawal from opioids, sedatives, and ethanol ... The relevance of this point goes beyond semantic issues of classification .. . [because] when withdrawal is considered in the context of drug dependence it generally connotes a more narrowly specified set of conditions (viz. a reliable syndrome of behavioural and physiologic changes)’ (Henningfield, 1984, pp. 147-148). Such a statement amounts to an admission thatby comparison to withdrawal from hard-drug abuse-smoking withdrawal simply does not exist. Most smokers quit without consequence whatsoever. A few may experience some discomforts that quickly disappear spontaneously or are curable by the mildest intervention. Severe cases are said to exist, but are undocumented in the scientific literature, even at the anecdotal level. If anything, it can be argued that at present smokers may be somewhat less comfortable about quitting because the ‘addiction’ label and the proliferation of cessation clinics and devices makes them thinkconsciously or not-that quitting has become a

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difficult ordeal-a view supported by prominent anti-smoking advocates (Chapman, 1995). Smoking may be a habit comporting some risks, but does not qualify as ‘addiction’ under the terms discussed above. In fact, if persistent abuse of hard-drugs exemplifies the ‘uncontrollable excess’ that includes psychotoxicity, severe withdrawal, and loss of volition-then the use of the term in connection with smoking is improper, loses force and impact, and must descend at the level of a habit, as earlier Surgeon Generals in the US have recognized (USSG, 1964). Other than in jest, ‘addiction’ cannot apply to common pleasant habits, without generating semantic confusion. IS ADDICTION A DISEASE? A true ‘addiction’ syndrome with its attending social costs indeed poses some crucial questions. Is it that a proliferation of ‘addictions’ is inevitable in an age of plenty and relative idleness? Is criminaIization of ‘addiction’ likely to remedy or to worsen the situation? Is it Utopian to think of medical and behavioural fixes? What may be the useful psychologic, sociologic and educational remedies? Despite much that has been written and argued, answers to these and other questions are by no means clear, although it may be fair to conclude that control of socially costly ‘addiction’ problems may not be attained without new social structures, In this context, if ‘addiction’ is a disease, it is more a social than a medical disease. Sociology and psychology may hold the key to its control, although not likely to its eradication-given inevitable human frailties. To begin with, it may be necessary to remedy the anarchic decay of western civility at the hands of laissez-faire New Age sociologists (Adorno ef af., 1950; Memmi, 1968; Ryan, 1971). Under their influence in the last four decades, traditional virtues of individual selfcontrol and accountability have been spumed to the point of contempt (Sykes, 1992). How much this has contributed to the proliferation of ‘addictions’ may be difficult to measure, but a return of individual responsibility could only presage improvement. Our analysis also raises broader concerns. ‘Addiction’ is a value-laden perception with ethical implications. In the absence of defensible intensity qualifiers of recurring psychotoxicity, withdrawal, loss of volition, and social cost, ‘addiction’ is ambiguously defined and open to semantic manipulations by special interests-the healing-industry

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interest in fostering victimization syndromes; the regulatory-industry interest in creating phantom health and safety hazards; the funding interests of the research establishment. Lewis Carroll had Humpty Dumpty saying that: ‘When I use a word, it means just what I choose it to meanneither more nor less’. If addiction might be a social disease, we unquestionably have a disease of words in current public discourse, a disease of rhetoric and semantic ambiguities. In this context, ‘addiction’ has rightfully become an abuse of language. Here, as always, the caveat emptor admonitionbuyer beware-is paramount. We undoubtedly buy government and regulations, and health services: both essential$ unregulated businesses. The perennial and still unresolved question is: who controls the controllers? Beware of contrived ambiguities. Is it ethical to intervene on the basis of heuristic hypotheses and of subjective-and likely interested-ethical judgments? Can a free society survive deceptive public policies even if allegedly issued with good intentions? I think not: straight public talk should be a minimum requirement of social fairness. Until that may be achieved, Horace still offers excellent advice to the common man and to the scientist: nullius addictus jurare in verba magistri.

REFERENCES Adorno, T. W. et al. (1950). The Authoritarian Personality. Harper & Brothers, New York.

Chapman, S. (1995). Smokers: why do they start-and continue? World Health Forum ( W H O ) , 16, 1-9. Henningfield, J. E. (1984). Behavioral pharmacology of cigarette smoking. In: Advances in Behavioral Pliarmacology. Thompson, T.. Dews, P. B. and Barrett, J. E. (Eds), Academic Press, New York, pp. 147-148. Horace, Q. Horati Flacci Opera, Heinze. R. (Curator). Insel Verlag, Leipzig, 1921. Memmi, A. (1968). Dominated Man. Beacon Press, Boston. Ryan, W. (1971). Blaming the Victim. Vintage Books, New York. Sykes, C. J. (1992). A Nation of Victims: The Decay of the American Chnracter. St. Martin’s Press, New York. US Code. 21 United States Code Q 841(b). USSG (1964). Smoking and Health Report of the Advisory Committee to the Surgeon General of’ the Public Health Service. US Department of Health, Education, and Welfare, Public Health Service, Publication No. 1103, Washington, DC. USSG ( I 988). The Health Consequences of Smoking: Nicotine Addiction. Report of the Surgeon General. U S Department of Health and Human Services, Public Health Service, Publication No. 88-8046, Washington, DC. WHO (1957). Expert Committee on Addiction-Producing Drugs. Seventh Report. World Health Organization, Geneva. WHO (1974). Expert Committee on Drug Dependence. Twentieth Report. World Health Organization, Geneva. WHO (1993). Expert Committee on Drug Dependence. Twentyeighth Report. World Health Organization, Geneva.