What’s wrong with addictionFeb 6, 2023
As I watched the Four Corners program, Vape Haze, in 2022, I was struck by the program’s focus on addiction, a bad thing. A mother spoke of her devastation when her 16-year-old daughter told her she was vaping.
Addiction to alcohol and drugs is viewed through different coloured spectacles. Rose-tinted for some, and through a ‘glass darkly’ for others. It is seen as a moral issue, a legal issue, a problem of society, a health problem, and a psychosocial problem.
The English psychiatrist William Dalrymple (pseudonym) says addiction is a hoax. In his book Romancing Opiates, he claims addicts lie to doctors and that society has swallowed the lies hook-line-and sinker. “…Addiction to opiates is a pretend rather than a real illness. Treatment of which is pretend rather than real treatment.”
In his view, the addict is not an ill person. They have only themselves to blame for their problems. As a prison doctor he saw addicts come to prison starving and miserable and go out healthy and happy. In his opinion they are entitled to treatment for serious complications – abscesses, viral infections, and other conditions, but not for addiction. He blames the prevailing view of addiction on the English Romantics, Samuel Coleridge, and Thomas De Quincey. Coleridge wrote that great poem Kubla Khan under the influence of opium and De Quincey wrote the Confessions of an English Opium-Eater.
Views of addiction
The negative associations of addiction caused the American Psychiatric Association to remove the category addiction from the DSM 5, the bible of modern psychiatry.
And yet, the word and concept, is ubiquitous. It may be a strong desire, passion, or pursuit. It can be interesting and exciting. Look around; fitness centres, lingerie shops, hair and beauty salons have addiction in their brand names. It can describe a social phenomenon such as the addiction to fossil fuels. And it is so often negative, as in medicine or psychology, a bad habit, a compulsion, impaired control, and a mental disorder.
Addiction, addictus, was used in Roman times and in Shakespeare’s plays. It could mean adherence to a cause or pursuit; a commitment to a higher purpose – to poetry or a god. The medical concept emerged in the 19th century, linked to “behavioural addictions” such as gambling. In England at that time, gambling was compared to ‘cancer, leprosy, a deadly virus, a poison that affected the populace’. Then, with the hegemony of medicine and pharmacology, addiction to alcohol and drugs dominated the lexicon.
The American Society of Addiction Medicine defines addiction “as a primary, chronic disease of brain reward, motivation, memory, and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social, and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviours.”
“Hunger” for alcohol or drugs can dominate motivation and behaviour to the exclusion of social and personal obligations and relationships. Much of the theorising about addiction by philosophers and psychologists relates to the imperatives of short-term gratification versus postponed long-term rewards.
None of this means that addiction is bad or an undesirable state in itself; indeed, it could be a desirable state for some, preferable to the available alternatives.
The seriously mentally ill person looks for drugs to block out intrusive thoughts and visions, depressed people seek mood enhancement, and anxious people to have their fears quelled. For some people, drugs become a way of resetting a frightening and harmful reality. A way of blocking out meaningless and despair. For many addicted people the idea that there’s a life worth living simply doesn’t exist. Professor Kennett of Macquarie University calls these people “resigned addicts”; deferring gratification for these people will not allow the choice of a better life.
Where life has no meaning, addiction flourishes. Such are the patients so often seen in public health services. The world for them is unfriendly, a cruel place; life has dealt them much harm.
A brain disease?
The insistence that addiction is a brain disease is one way to avoid crass moralising and blame. But removing judgmental attitudes requires far more to recognise agency and justice for people labelled as addicts, than saying they have a brain disease. In fact, their brains are working as they should.
Addiction must be understood as behaviour in a social context. That there are mismatches between the social environment and the person’s predisposition does not mean the mismatches are diseases of the brain. The philosopher, Neil Levy, observes that it is a necessary condition for addiction to be a disease, it would need to cause impairment in any accessible social environment. If there is no access to alcohol or a preferred drug, the person will not be impaired, no disorder. A person dependent on benzodiazepines or e-cigarettes may suffer no impairment of rationality or agency and can go on to pursue a worthwhile life; most do.
Community as therapy
Overcoming harmful addiction, serious impairment, requires embedded patterns to be reversed. Medical and psychological treatment can help, but in the end, the person has to see themselves as someone of value in the eyes of others.
At the Ted Noffs Foundation young people as young as thirteen can change within a community of other young people. Through support and self-help, the young person can reframe their motivations, problem-solving, and ways of coping with stressors. It works – mental and physical health improves, suicide risk decreases and there are fewer interactions with police.
Other NGOs – WHOs Fellowship, Odyssey House, Karilka and many more, are based on the idea that the community itself – relationships, feedback, support, and team agency – can lead to a person regaining their personal agency.
Alcoholic Anonymous (AA) is the best known and truly self-help agency. Owen Flanagan, professor of philosophy, psychology, and neuroscience, describes AA as an episteme – a community with a certain authority and ways of speaking – about alcoholism and being an alcoholic.
AA has two streams, a series of steps acknowledging powerlessness over alcohol and the need for help from an external power to become sober – the program: and fellowship through regular meetings in a community of hope and support.
In the end, addiction is an elusive concept subject to harmful prejudices and biases. The focus must be on the person in their social setting and not solely on the individual and their failings, or their brain, or the drug, as the sole agents of their addiction. Such orientation has better outcomes and there would be fewer problems in the first place.