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"We should demystify the term addiction"

By Hans Olav Fekjær.

http://vintermann.paranoidkoala.org/archives/000087.html

Published in rus & avhengighet nr 1 1998, translated by Harald Korneliussen. I

have not asked the parties in question for permission, this is an unofficial

translation.

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Drug addiction, gambling addiction, internet addiction, sex addiction......

"Addiction" sounds like a scientifically justified diagnosis describing a

pathological process. But does the term really represent an increased insight

over the popular synonyms like to "be hooked on" something?

The word "addiction" seems to have got its current meaning through AA's theory

of alcoholism. When epidemiological and experimental research had removed the

basis for AA's alcoholism theory, WHO choose in 1979 - as a compromise - to

replace it with "alcohol addiction syndrome". The usual interpretations show

that many of the implications of the alcoholism theory now live on under the

name "the addiction syndrome".

The diagnosis of addiction

The official diagnosis systems ICD and DSM currently have identical criteria

for addiction to alcohol, illegal drugs and tobacco. Addiction to gambling,

sex, internet etc are not mentioned, but psychologists who care about these

addictions obviously use equivalient definitions.

The diagnosis systems mention 6-7 possible symptoms which can be classified

into three groups:

- increased tolerance and/or abstinence problems

- signs of loss of control (strong craving/ compulsiveness or drinking more

than planned or failed to cut down on use)

- damaging effects (social, health or work-related)

Currently no "symptoms" are mandatory. The addiction diagnosis demands that one

has at least 3 of 6 symptoms through the previous year (ICD-10) or 4 of 7 at

one point in life (DSM-IV). One does not need to have symptoms from all three

groups, for instance is lack of control not a prerequsite.

Compared to regular medical diagnoses, it's remarkable that the important

boundary between healthy and ill is set at an arbitrarily chosen number of

symptoms (3 out of 6 or 4 out of 7)

Can "addiction" explain behaviour?

It follows from the diagnosis criteria that addiction describes a dangerous and

/or harmful lifestyle. Often, however, addiction is not used merely as a

description of behaviour, but as an explanation - with pretentions of

diagnosticating a psychopathological process: "He does it because he is

addicted"

The psychologist William Rohen(1) pointed out that "addiction" is a

"ghost-in-the-machine"-explanation: We see behaviour that we cannot immediately

explain, and say that there is something mystical, invisible inside man that is

the cause.

"Continued use despite harmful effects" is not a clear symptom of illness, as

we all can do things despite knowing that they are risky, or that we shouldn't

really do them.

Recreational drugs give physical addiction, defined by increased tolerance and

abstinence symptoms. This contributes to the postponement of rehabilitation.

But almost all drug abusers are sober in periods. The problem is that they

resume use later. Hospital patients who recieve morphine often get worse

physical addiction than street users, but they accept the unpleasantness

associated with withdrawal.

Lack of control was the main point in the alcoholism theory. But many people

with a high consumption of drugs feel they are in control, and demonstrate it

by abstention when the situation demands it. This is also shown in experimental

research.

Lack of control can not explain activities we can choose to abstain completely

from (drug use and gambling), merely activities we can't avoid (like eating).

Is addiction the main part of the problem?

In the area of drugs, and also gambling, it is currently common to speak as if

"addiction" is the main problem.

There has been most research on the issue of alcohol. There, most of the

problems are related to drunkenness among young and young adult men, not to

daily drinking in those age groups which dominate alcoholist-treatment.

Epidemilogical research shows consistently that when our grandparents connected

alcohol problems to "drunkenness", they were more right than those who now

connect it to "addiction" or "alcoholism".

The individualisation of collective problems

Our grandparents met the old social problems of alcohol and gambling through

collective measures. In a poor society without professional rehabilitators, the

intuitive understanding was that these were collective problems, in other words

that high alcohol consumption and gambling in a society would cause problems

(as science has shown in the last decades, both for alcohol and gambling). The

problem-causing activities were strongly reduced through personal abstention

and legal regulations. The measurable problems from alcohol reached a low point

before second world war, and gambling problems were minimal until the legal

deregulation of the nineties.

Even though treatment can help individuals, our current focus on addiction has

probably not become popular for its results. Alcohol damages are for instance

highest in those regions where consumption is highest, despite these regions

having the highest number of alcoholist rehabilitators.

However, the focus on the addicted has popular consequences for society's way

of fighting the problems: It implies promises that society can both have their

cake and eat it, too - have plenty of alcohol and gambling without being

punished by the harmful effects.

Through the media, professionals form the popular opinion. Today, most

professionals in these fields earn their living by treatment of individuals. It

may seem that the rehabilitators' problem is that they see many trees

(individuals), but they rarely notice the forest (society's problems as a

whole). The rehabilitators' professional interests are also served by a strong

focus on those idividuals who seek treatment. But population studies have shown

that only a very small part of problem users ever seek treatment for their

problems.

Do we today have biological explanations for addictive behaviour?

Humans are born with different inherited characteristics, and behaviour

ultimately consists of biochemical processes in cells. Will psychology and

behavioural fields soon become subfields of genetics and biochemistry, or is

that still light years away?

The biological behavioural scientists have always explained that they have made

many promising finds that soon will lead to decisive breakthoughs - and

therefore they of course need increased funding. In the previous years,

biological researchers in the drug field have claimed that the breakthrough has

partially arrived.

In 1990 reports went around the world that scientists (2) had found the "gene

for alcoholism". But later studies showed that this gene occured with precisely

the same frequency in regular people as in alcoholics.(3)

In Aftenposten, in the summer of 1997 we could read a statement from a

norwegian drug expert: "Now we know that drugs have that in common that they

increase the amount of dopamine in nucleus accumbens".(4)

By interpretations of animal studies it is currently claimed that a common

biochemical "reward"-reaction occurs in drug use, laughter, sex, a good meal

etc. The theory says that neurotransmittors and particularly the dopamine

processes in nucleus accumbens can:

- explain why drugs are used

- soon explain why some use drugs regularly and in harmful ways

- soon give us medicines which can heal drug addiction.

But to believe that we here find the main explanation for drug use we have to

disregard many known facts:

- animal experiments show that the dopamine amount in nucleus accumbens

increases not only by positive stimuli, but also from negative (aversive)

stimuli. It also happens with stimuli the animals try to avoid, such as

pinching in the tail or electric shock.

- dopamine increase is documented for only a handful of the more than 200 drugs

on the norwegian narcotics list.

- If dopamine increase was a common identifier of drugs, we could let

laboratories decide whether a chemical is a narcotic. But the decision is left

to the highly subjective experiences of drug users, coloured as they are by

expectations, experience, sats often gets a higher status than psychology and

social science. Many accept the theories because they lack their own knowledge

to dispute them. Biological and genetical explanations are currently "in",

where chemical determinism replaces the view of man as an actively deciding

individual in a social context. But how large is the transition value from

rodents in american research laboratories to humans affected by their

relations, values, social situation and so on?

It is a beautiful theory that humanity's joys, excesses and drug use all can be

explained from a single chemical reaction. One has to think of the words of the

biologist Thomas Huxley: "A beautiful theory, killed by a nasty, ugly little

fact".

Addiction is a correct, but not particularly deep, description

We are currently witnessing that many exaggregated activities are classified as

"addiction". For these activities

- psychologists make very similar diagnosis schemas

- rehabilitators establish treatment facilities

- epidemiologists map the extent of the problems in populations

- medical professionals collect physical signs, hoping to find biological

causes to the behaviour.

The rule is that those who show exaggregated behaviour, also more than usually

like this activity, even if harmful effects create an ambivalence. Therefore

the behaviour does not fit psychiatric definitions of compulsive behaviour, and

therefore very few seek treatment.

When professionals say that a person is "addicted", that can be entirely

correct. But it is probably not particularly deep, and does not really tell us

anything more than that the behaviour is exaggregated. Despite diagnosis

schemas it does not say more than common people's use of the term in norwegian

everyday speech. The adoption of the term by professionals is a sign of an

interesting cultural shift from earlier times, a so-called paradigm shift, not

that new research has shown that exaggregated use is about illness.

We shall of course not throw the baby out with the bath water. Just in case, it

needs to be pointed out: to point out that the description "addicted" is an

expression of common-sense and is not particularly deep, does not mean that

addicted people don't need help to modify their behaviour. Old habits are often

very hard to change. Drug use has been a part of their adaption to their

situation in life. Think only of drug abusers who often completely lack the

skills thrive in society!

Hans Olav Fekjær is chief medical officer in the office for drug affairs in

Oslo.

Litterature:

1. Rohan, WP (1982): The concept of Alcoholism: Assumptions and issues. S.

31-39 in Pattison, EM & Kaufman, E (red.): Encyclopedic Handbook of Alcoholism.

Gardner Press, NY.

2. Blum, K et al (1990): Allelic Association of Human Dopamine D2 receptor Gene

in Alcoholism. JAMA 263:2055-2060.

3. Gelernter, J et al (1993): A1 allele at the D sub2 Dopamine Receptor Gene

and Alcoholism. JAMA 269:1673-1677.

4. "Har rusmiddelbruk, pengespill, spising and gleder og avhengighet en felles

biologisk forklaring?" Aftenposten 26.7.1997.

The translator may be contacted at vintermann on gmail for further information.

I may do amateur translations for you if you ask.