Friday, November 24, 2006

A History of Addiction

Dani Molintas who writes for PCIJ has written an excellent history of addiction. What the public and medical communities believe and how those ideas about the nature of addiction have changed over time. This article at PCIJ about addiction was based on what Dani wrote.

Dani has sent me her unedited copy and I have taken the liberty to edit it to focus on the history of addiction. There is a lot of material here that was not included in the PCIJ article. So without further adoo:

THERE IS NO dearth of literature chronicling the dangers of addiction, particularly to drugs and alcohol: Parents who abuse and neglect their children often alcoholics or drug dependents. Domestic violence is linked to substance abuse — men who beat up their wives often drink or do drugs; those who sexually exploit children are often drunk or high when they do so. Drugs and alcohol are also used to perpetuate the cycle of violence and abuse: Sometimes, abusers use alcohol and other drugs as a way of luring and manipulating their victims. Or, they can use these to diminish their feelings of guilt or shame, or to help them deny their abusive acts.

These dangers have been noted by authorities such as the United Nations Office on Drugs and Crime as a global problem. In 2001, too the European Union passed a Declaration on Young People and Alcohol, seeking to protect youth from the dangers of alcohol misuse.

In the bigger picture, such abuse is blamed for broken families and weakened communities, lost wages and soaring health care costs. Intravenous drug use is also faulted for fuelling the rapid spread of HIV/AIDS, another huge and intractable global problem.

Drug cartels undermine governments and corrupt legitimate businesses. In some countries, addicts to support their habits commit more than 50 per cent of thefts. Revenues from illicit drugs fund some of the most deadly armed conflicts.

But what are addictions? What is this evil power that can easily overturn thousands of years of evolution that fashioned thinking, praying and creative beings out of apes, then reduce these dignified humans into depraved and out-of-control creatures?

What causes addictions? Can the blame be placed on the substances themselves; are these inevitably “addictive” substances? Are some activities inescapably addictive? Or are the addicts themselves to blame? Does a character flaw, a lack of will power on the part of the addict, cause addictions? Or is it a flaw in the genes, with some people prone to addiction, in the same manner that they are predisposed to diabetes or heart disease? Are addictions just a matter of habits gone awry, of becoming too attached to a sensation, an object – or even a person – until such time that the “addict” is reduced to becoming dependent on an addiction as his only source of happiness? Do some environments cause addictions? Do some cultures encourage addictions? Do some societies cause addictions?

IN THE 19th century, drug addiction, alcoholism, and other addictions were seen as a sign of akrasia—or a weakness of ones will. But after much scientific research into the brain made possible by technological advances in the late 20th century replaced this “psychosocial model” with the “disease model”.

Under this model, some substances are seen as naturally addictive, that after taking them for a certain length of time a person is inevitably bound to become an addict.

Shabu can quickly transform casual users into junkies. With meth, there's no such thing as a casual user. Heroin is so good; don't even try it once. Crack cocaine is instantly addictive. Just Say No.”

Such slogans reflect the powerful and commonly-held view that drugs themselves cause addiction. This belief now drives the world’s current “War on Drugs”, into which enormous sums of money are poured, spent every year to strengthen police forces, border patrols, courts and rehabilitation programs.

ADDICTION, like all behaviors, is "the business of the brain," says Avram Goldstein, Professor Emeritus of Pharmacology at Stanford University, and a leading researcher into drug addiction.

Way back in 1979, Goldstein made the claim that heroin and all other narcotics worked on a bundle of neurons deep in the brain called the mesolimbic dopaminergic pathway. This is the brain’s reward pathway that regulates how a person feels or does not feel pleasure. Here, addictive drugs cause dopamine neurons to release dopamine, the pleasure hormone. Normally, these neurons are held in check by inhibitory neurons. But narcotics shut these inhibitory neurons down, and the dopamine neurons become overstimulated. Hence, the rush after a hit.

But because the stimulation is excessive, the brain has to protect itself from this abnormal surge of pleasure. It does this by becoming less sensitive to the drug. Over the long run, the user needs more of the drug to produce the high. At the same time, the reward pathways become less sensitive to the effects of endorphins, the brain’s own pleasure hormone. Thus, without the drug, the user now survives with a persistent feeling of sickness.

Following this “brain-based” view, a person who uses a drug again and again becomes tolerant and dependent, and undergoes withdrawal symptoms when the drug is stopped. The user loses control and becomes an addict.

What about other addictions like gambling and shopping? Some doctors claim that it is possible that the brain creates peptides that equal the effect of drugs when addictive activities take place. Thus, when an addicted gambler or shopper is satisfying their craving, endorphins are produced and released within the brain, creating a high and reinforcing the individual's positive associations with the activity. As with drugs, consistently engaging in these addictive activities is also believed to cause excessive stimulation, and lead eventually to tolerance and dependence.

So addiction is caused by any substance – nicotine, alcohol, opium, heroin, cocaine, chocolate, greasy food– or activity –gambling, going online, texting –that wrecks havoc on the brain’s reward system?

THE SCIENTIFIC community was so certain of this hypothesis that they spent the past 40 years placing laboratory animals in experiments where they would “dope” themselves. In the early 1960s, University of Michigan researchers perfected devices that allowed rats to inject themselves with drugs by simply pressing a lever. By the end of the 1970s, there were hundreds of experiments of this sort—and they all showed that rats, mice, monkeys, and other captive mammals self-inject large doses of heroin, cocaine, amphetamines, and a number of other drugs!

But a description of the lab conditions surrounding these experiments is enough to burst the hypothesis bubble of these decades: Imagine being implanted with a needed in one vein connected to a pump that is connected to a tube. Was it then possible that the lab animals were turning into drug addicts to ease the pain of their captivity, or to cope with the stress of being isolated from other animals and from other stimulus? Were they reacting to being imprisoned in the complex self-administration apparatus?

In time, some scientists themselves began to raise these questions. Among them are two leading researchers into addictions—psychologists Dr Stanton Peele and Dr Bruce Alexander, then of British Columbia's Simon Fraser University. Peele’s work on alcoholism has won him several awards including the 1994 Alfred Lindesmith Award for Achievement in the Field of Scholarship from the Drug Policy Foundation in Washington, DC and the Mark Keller Award for Alcohol Studies in 1989 from the Rutgers Center of Alcohol Studies. Close to three decades of their work has thrown a monkey wrench into the “drugs-cause-addiction” hypothesis.

As both men noted in separate studies, the only real evidence for the belief in drug-induced addiction comes from the testimonies of addicted people who believed the drug had caused them to lose control and from the research on many laboratory animals. But what if the laboratory animals are shown to be responding to their environment?

And as for the testimonies of the addicts, was it not possible that attributing causes to their own behavior was helpful salve to their self-esteems, but a far cry from reality? “By rationalizing their intractable problems, are addicts merely escaping the enormous burden of guilt for their catastrophic lives?” Peele asks.

If drugs were so naturally addictive, how do we explain the fact that doctors who give their patients large doses of opioids to manage their pain find that the bodies of these patients become dependent on the substance, but they do not become addicted? About 20 years ago, an American research team began experimenting with an invention, a bedside self-medicating machine programmed to deliver about 1 mg of morphine intravenously to patients who pressed a hand button. But even without doctor’s supervision, patients did not exceed the doses they needed for their pain, and did not become addicted.

Even outside a supervised setting such as a hospital, people have been found to go in and out of drug use, or even addiction.

"Sure, I take to the tooter once in a while, when we go out with friends. But now that I have children to support – two sets, actually, one set from my first marriage, I don't do it as often. I like the high I get, but I don't crave it…No, I don't consider myself an addict," says Derek. Derek, 47, has been working for eight years with one of the two intergovernmental organizations that have their offices almost fully based in Manila. Before that, he worked with a government office, and has been regularly employed for over 20 years.

It may be a case of denial, but Derek's experience is backed up by the many studies done in different parts of the world, note both Peele and Alexander.

Studies such as Crack use in Canada: A distant American cousin by Cheung, Y.W. and Erickson, P.G. (1997), Cocaine use in Amsterdam in non-deviant subcultures by Cohen, P. D. A. (1989), Drug use, social relations and commodity consumption: A study of cocaine users in Sydney, Canberra and Melbourne by Mugford, S.K. and Cohen, P.J. (1989) show that in contrast to commonly belief, drug users go into and out of periods of cocaine addiction then return to controlled use or even abstinence—all without social intervention or dramatic discomfort.

Even census surveys taken for the past decades show that in United States and Canada, cocaine was widely available and cheap before the 1980s, but most North Americans never used it. And of those who used it a few times, few became even regular users. Before its “peak” as the drug of choice in the 1980s, in fact, cocaine was considered a nonaddictive drug, even incapable of producing physical dependence. It was only after the 1980s peak that pharmacologists began to claim that cocaine was addictive.

The belief in drug-induced addiction is a myth, Alexander asserts, and in a speech before the Canadian Senate in January 2001, he even called it the “pharmacological version of the belief in ‘demon possession’ that has entranced western cultures for centuries.”

So if the drugs themselves do not cause addictions, what do?

Addictions are diseases

In 1956, the American Medical Association declared alcoholism was a disease. From that time on, scientific research into addictions that consistently bolstered the view that addictions are "chronic, relapsing brain disorders characterized by compulsively seeking and using a substance."

Finally, capping an explosion of advances in neurosciences in the early parts of the 21st century, the World Health Organization released in 2004 report, “Neuroscience of Psychoactive Substance Use and Dependence.”[pdf] The report concluded that substance dependence is a disorder of the brain like other neurological or psychiatric disorders.

Sure, the report conceded that addictions or substance dependence were caused by many factors, and that psychosocial, cultural and environmental factors played a part in their creation. But it asserted that addictions are determined largely by biological and genetic factors.

So it seems that psychoactive substances like drugs and alcohol are able to mimic the effects of neurotransmitters that occur naturally in human brains. Eventually, these drugs interfere with normal brain functioning by altering how these neurotransmitters are stored, released or removed.

Drugs may be depressants like alcohol, sedatives, volatile solvents; stimulants like nicotine, cocaine, amphetamines, ecstasy; opioids like morphine and heroin or hallucinogens like PCP, LSD and cannabis—and all these have different ways of acting on the brain to produce their effects. Depressants, stimulants, opioids and hallucinogens all bind to different brain receptors, and can increase or decrease the activity of neurons using different mechanisms. Consequently, different drugs cause different behaviors. Tolerance to them develops at different rates, and withdrawal from them causes different symptoms.

But what these different drugs have in common is that they all affect the region of the brain involved in motivation. When such drugs are repeatedly taken, they repeatedly activate the motivational systems of the brain that are normally activated by things that are important to human survival: food, water, danger, and mates.

In short, substances “trick” the brain into responding as if these drugs and their associated stimuli are things needed for survival. And with each repeated exposure, the association becomes stronger and stronger, and the brain is “tricked” more and more.

At the same time, addiction is also “learned”: A person takes a substance and experiences the “high.” Because a high is, well, highly rewarding or reinforcing, it activates circuits in the brain that will make it more likely that the user will repeat whatever it is that gave him the rush in the first place.

Both this "associative learning process," plus the fact that the brain is "tricked" into believing that it needs the drug for survival combine to cause an craving so overwhelming that it can “cause relapse to substance use, even after long periods of abstinence," the report concludes.

Genetics is the other factor. One’s genes, the report says, will determine partly why one person exposed to a drug will become addicted to it, while another with the same exposure will not.

For instance, there is growing evidence that some people may be more predisposed to addiction to cigarettes, alcohol and opioids, and scientists are now deep into the study of which specific genes are involved.

So, in the end it all boils down to damaged neurotransmitters in the brain? Or to some brains being more genetically susceptible into being tricked into thinking opium is food, or shabu is water? At its simplest, this is what the WHO report says.

Or, as Goldstein quipped way back in 1979, "A rat addicted to heroin is not rebelling against society, is not a victim of socioeconomic circumstances, is not a product of a dysfunctional family, and is not a criminal. The rat's behavior is simply controlled by the action of heroin on its brain."

TO SOME EXTENT, bringing in the age-old "nature versus nurture" debate into the discussion of addiction is insensible. The action of genes is completely intertwined with the environment in which they function, after all. In this sense, it is pointless to even discuss what gene X does – or even what genes X and Y do – and we should consider instead only what gene X and Y do in environment Z.

Some studies with monkeys can shed some light. To help find out whether genetics or environment predict the behavior of organisms, behavioral geneticists “cross-fostered” certain monkeys. They took monkeys from a group that demonstrated a certain behavior that was totally unacceptable in another group, and threw them into that new group. The monkeys, given just a few moments to learn a new response in their new environment adapted the new behavior, even when it was the opposite of the behaviors they learned throughout their lifetimes—behavior that is supposedly deeply imprinted in their genes. In this case, environment won over genes.

Peele criticizes “everything about the disease approach—from separating people and their substance use from their ongoing lives, not recognizing that addiction fades in and out with life conditions, viewing it as biogenetic in origin” as wrong.

Going even further, Historian Virginia Berridge and a psychiatrist Griffith Edwards examine the social and medical history of the addiction concept as it developed in England in their book Opium and the People: Opiate Use in Nineteenth-Century England, and conclude that “Addiction is now defined as an illness because doctors have categorized it thus." (background - ed)

So do addictions boil down to being brain-based disorders that some genetically-unlucky people are predisposed to developing in their lives? Or are they creations of a “medicalized” society? Perhaps the reality is somewhere between these two poles. Or maybe, there are other parts of the addiction puzzle that have yet to fall into place?

Part of the answer is found in the WHO report itself: "Substance dependence is a chronic and often relapsing disorder, often co-occurring with other physical and mental conditions," said Dr Catherine Le Galès-Camus, WHO's Assistant-Director General, Noncommunicable Diseases and Mental Health.

According to the report, some studies in the US show that more than 50 percent of people with mental disorders also suffer from substance dependence, compared to 6 percent of the general population.

Does this mean that both illnesses and addictions have similar neurobiological bases? Or are addicts taking drugs to alleviate the symptoms of their mental illnesses? Does drug use bring on mental illnesses or lead to biological changes that simulate mental illnesses—such as the paranoia or psychosis caused by a shabu crash, or the altered mood states of a marijuana high?

The report has no answers to these questions, and today, there is evidence for all of these hypotheses.

If most mental illnesses are involved in anguish and mental pain, how does this relate to seeking a “high”? Could it be that addicts are people trying to alleviate some unknown pain? Could it be that addicts are self-medicating?

Drug Addiction Is Pain Management

To solve the conundrum of addiction, we can start by studying the different parts of the puzzle that already know.

The disease model tells us that one’s genetic makeup may determine how prone one is to an “addictive” substance, and how easily attached one may become attached to a pleasurable routine. It also tells us that addictions often come together with other mental illnesses.

But various studies with twins show that genetics are only half the cause of addictions. What then is the other half?

First, we also know that addictions are inextricably linked with violence, but the relationship is complex and not fully understood. We know that people can get violent under the influence of drugs and alcohol. But we also know that while addicts may engage in violence to get money to buy drugs, it is not true that the drugs themselves cause violence. Often, violent behavior comes before the use of drugs. The link between the two is still a mystery.

But what we do know for sure is that victims of violence often turn to drugs and alcohol to numb their pain. Medical research shows that victims of sexual abuse and severe physical abuse are many times more likely to get addicted to opioids than the general public. People working to heal women know that women who were abused in the past—or those still stuck with abusive partner –often use alcohol or other drugs to deal with their pain, anxiety and fear. Many survivors of children abuse use substances to deaden the pain of past memories.

Way back in 1985, Edward John Khantzian, professor of Clinical Psychiatry at the Harvard University found that many of the people who experimented with heroin and cocaine who later became “hooked” on it suffered from chronic, severe depression, anxiety, or physical pain.

“If the pain is sufficiently intense, people who become aware of the analgesic or tranquilizing effects of heroin or cocaine are likely to cling to the drug to relieve this pain, in spite of all the difficulties that this entails,” he writes in his paper, The self-medication hypothesis of addictive disorders: Focus on heroin and cocaine dependence, published in 1985 by the American Journal of Psychiatry. This "self-medication hypothesis," is supported by much of the literature of clinical and research psychiatry. Khantzian wrote a follow-up to this paper in 1997.

Vietnam combat veterans who were found to be suffering from post traumatic stress disorder were also found to be abusing drugs and alcohol, American psychiatrists led by T.M. Keane found in 1988.

"The neurotic and the psychopath receive from narcotics a pleasurable sense of relief from the realities of life that normal persons do not receive because life is no special burden to them," notes Lawrence Kolb, the pioneer in research into addictions. Kolb, whose studies of opiate addicts at the U.S. Public Health Service in the 1920s are collected in a volume entitled Drug Addiction: A Medical Problem, found that most addicts had psychological problems well before their addictions.

“Addiction is a pattern of drug use that occurs in people who have little to anchor them to life,” decide Isidor Chein, Donald L. Gerard, Robert S. Lee, Eva Rosenfeld and Daniel M. Wilner, in their portrait of the day-to-day existence of the street heroin user, The Road to H: Narcotics, Delinquency, and Social Policy, published in 1964. Their work is touted as one of the most comprehensive studies of juvenile use of heroin in New York City.

Equally intriguing are studies of medical patients who are exposed to narcotics as part of their medication. Psychologist Stanton Peels notes that while these patients build a physical dependence on the opioids, they are able to protect themselves against addiction by “thinking of themselves as normal people with a temporary problem, rather than as addicts.”

“The difference between not being addicted and being addicted is the difference between seeing the world as your arena and seeing the world as your prison… where life is seen as a burden, full of unpleasant and useless struggles, addiction is a way to surrender,” notes Jozef Cohen in his 1970 work, Secondary Motivation. Jozef Cohen quotes the addict who says, "The best high . . . is death.".

THESE DIFFERENT pieces of the puzzle fell into place the same year that WHO published its report.

An article published in Scientific American, entitled "The Brain's Own Marijuana" [pdf] (scroll past the graphics - ed) showed that the human brain produces its own equivalent of cannabis, and that such endogenous cannabinoids –or endocannabinoids—act as bioregulatory mechanisms for most life processes in the human body.

More notably, the article reported how, in 2002, scientists under Giovanni Mersicano of the Max Planck Institute of Psychiatry in Munich, Germany found that people need endocannabinoids to help them “extinguish bad feelings and pain triggered by memories of past experiences.”

“The discoveries raise the possibility that abnormally low numbers of cannabinoid receptors or the faulty release of endogenous cannabinoids are involved in post-traumatic stress syndrome, phobias and certain forms of chronic pain,” the report noted.

As M. Simon, a 62-year old aerospace engineer and former nuclear reactor operator in the US Navy explains in his blog,
Power and Control, (a list of drug war and drug addiction articles - ed) “All humans show fear reactions to dangerous situations. However, in the case of one out of ten people–surprisingly the same percentage of people who are susceptible to substance addiction—the fear does not die down in the absence of the dangerous situation. The fear stays at debilitating levels.”

In most people, the endocannabinoids help the brain clear these fearful memories. But for about a tenth of the population, the memories remain and become permanently debilitating.

“The amount it takes for pain memories to decay depends on the severity of the trauma and the genetic make-up of the individual,” notes M. Simon, whose brother was killed in the drug war. He is now passionate about the study of addiction and devotes a large part of his blog to a discussion of these issues.

Simon cites the work of Roger Pertwee, professor of neuropharmacology at Aberdeen University, who claims that genetics account for a half of the nature of addictions. Pertwee’s work shows that persons with a mutated copy of the FAAH 385 gene may need more cannabinoids than the body produces to feel normal. This is probably why cannabis use is so popular among ten to twenty percent of the population, Pertwee theorizes.

BUT THE MOST COMPELLING piece of the puzzle had turned up earlier, in July 2001, in a study by Dr. Lonnie Shavelson, entitled Hooked: Five Addicts Challenge Our Misguided Drug Rehab System.

In his study of 200 addicts, Dr. Shavelson found that a high proportion of them had been severely abused children: either they were beaten, raped, or had siblings who were raped. Seventy percent of female heroin users in his sample were sexually molested before they started using heroin. Male heroin users were 25 to 50 times more likely to have been sexually abused, compared to the general population.

M. Simon writes in his blog: “At first, Shavelson questioned his study methodology. He thought there must have been a flaw in how his sample was selected or in how the questions he asked were framed. Then while he was doing his research, an article came out in the Journal of the American Medical Association that said that the addiction rate goes up for male sexually abused children. And it doesn't just double or triple. It is 25 to 50 times higher than the rest of the population.”

“In other words, those heroin addicts are suffering from severe post traumatic stress disorder,” M. Simon infers.

Meanwhile, Pankaj Sah. of Australian National University offers the view, based on his work, that chronic marijuana users are self medicating for anxiety problems.

In his blog, M. Simon sums up the latest findings on drug addiction:

1. We now know that severe PTSD may be the cause of 70% or more of heroin use.
2. We know that there is a genetic connection.
3. We know there is a trauma connection.

Trauma is the other piece of the addiction puzzle, together with genetics and the effects of the drugs themselves.

Instead of “addicts,” what society may have is a “seriously untreated population with various mental problems. “Addiction, M. Simon notes, “may be in fact self treatment of undiagnosed pain.”

“I was surprised to find that this is a well-known secret in the medical community,” M. Simon concludes.

“Why are there no researches being conducted systematically to prove this?” he asks. His views are echoed by Psychologist Bruce Alexander. In his 2001 speech to the Canadian Senate he says: “If this interpretation were correct, the drug would not be the cause of addiction, but instead the pre-existing pain and the person's desperate attempts to control it would be.”

“It would be assumed that if the pain were removed, the person would abandon their compulsive use of the drug,” Alexander adds.

Or as Peele says, “cure the pain and the desire for drugs vanishes.” Could this also be true of not only drug addicts but also alcoholics, addicts to food, gamblers, compulsive shoppers, and other sorts of addicts?

If addiction is self-medication, and people in pain will do almost anything to relieve their pain, does it make sense to criminalize people for their addictions? Must society really be protected from these addicts?

Is the crime and violence related to drugs result from the sale of these substances being forced to go underground? If we took drugs away from the hands of the dealers and made them legal, would violent acts related to drug use become less? Has the world’s “War on Drugs” been a failure?

Modern Society Creates Addictions

"Economist Milton Friedman predicted in Newsweek nearly 34 years ago that Richard Nixon's ambitious 'global war against drugs' would be a failure. Much evidence today suggests that he was right. But the war rages on with little mainstream challenge of its basic weapon, prohibition."

High Times? No, George Melloan [pdf], deputy editor of The Wall Street Journal's editorial page.

Of course Melloan offered the usual disclaimer that he "never sampled any of the no-no stuff and (had) no desire to do so." Still, it is no small matter that the editor of this paper, the citadel of conservatism, declared America's Drug War possibly a failure, and questioned the very idea at its core.

For indeed, despite the enormous sums of money spent every year to fight the world’s American-led War on Drugs, the late 20th century prohibitionist approach to drug substance use has failed in the same manner that the Prohibition in the United States failed to stop alcohol use in the late 19th century.

The prohibition laws of 1846-51 (I think she means 1920 to 1933 - ed.) in the United States only sent the manufacture of liquor underground, causing hundreds of people to die from cheap, toxic substances mixed in their liquor by unscrupulous brew makers.

Similarly, the today’s ongoing drug war has been waged for many decades, but it has failed to stop the growth of the $500-billion narcotics industry (2001 figures)

To a large degree, the failure stems from contradictions in the understanding of addictions themselves. For one, while most addiction models—such as the disease theory— claim to be value free, they actually convey distinct values about human responsibility and about the desirability of certain kinds of behavior.

As Peele notes, the modern disease view of addiction transferred the source of the evil from the addict to the drug itself. “It locates the source of evil in the drug (and) dictates that the addict's moral responsibility is to avoid the substance entirely—(or) abstain,” Peele points out. “The moral message is of the evil and allure of the illicit drug experience, and of the need totally to avoid such experience,” Peele explains.

But it was this very same reasoning that led to the Prohibition, which failed. The 19th century temperance movement—which drove the Prohibition in the U.S.—had argued that alcohol inevitably provoked loss of control, a fact that we now know to be untrue. In the 20th century, this same view toward alcohol was extended to all narcotics. Today, the belief that drugs are so inherently addictive that their regular use ultimately enslave the individual and lead progressively to moral collapse and death, is commonplace. Such moral reasoning – that drugs control and corrupt users – was graphically depicted in the classic drug film, "Reefer Madness," that has since become an inadvertent comedy.

BUT historical and cross-cultural cases show us that our modern view of addiction is not a universal concept or a universal phenomenon, but a historical “glitch”.

Since ancient history, various cultures knew about and used psychoactive drugs, but the phenomenon of drug addiction was only identified by physicians—and brought to the public mind—in the 19 th century, and in the industrialized, Western world.

Theorists in the earlier 16th to 19th centuries described narcotic addiction, but they did not differentiate addiction to opium from addiction to ubiquitous things like coffee, snuff, alcohol or sugar plums. In 1877, German physician Levinstein was the first to describe drug addiction in detail. But even so, addiction at this time was seen as just another human passion such as smoking, gambling, greediness for profit, sexual excesses, and most physicians regarded addiction as a morbid appetite, a habit, or a vice.

It was only in the 19th century that the temperance movement argued that alcohol inevitably provoked loss of control, and this same view was extended to narcotics in the 20th century. The term “alcoholic”, in fact, was accepted as a popular designation for the chronic drinker only after World War I, after the Alcoholics Anonymous was founded. Dr. William Silkworth became the first to treat alcoholics based on the idea that they suffered from an inbred allergy to alcohol that caused them to lose control of their drinking. Together with one of his patients, William Wilson, he founded Alcoholics Anonymous in 1935, and their view of alcoholism is now most widely-accepted.

Today’s existing definitions of addiction incorporate advances in neurosciences, but still bear traces of these temperance views. The most up-to-date version of the disease theory of addictions – contained in the 2004 WHO report – sees these as dangers only for a small group of biologically predestined individuals. Or in short, only this group has to abstain, lest they progress to the “moral collapse and death” outlined in the past for all drinkers.

As Peele notes wryly, “such a revised disease theory was required because the Prohibition was repealed in 1933…and the world was now a place where drinking was ubiquitous, popular, and largely benign.”

IT IS WORTHY TO NOTE that cultures since ancient times used mood-altering and hallucinogenic substances as a way to reach profound spiritual experiences, or to get closer to God.

Taboo in Christian and Islamic societies, entheogens are both ordinary and prominent in the spiritual traditions of other cultures, which is probably why the word means “that which causes God to be within an individual”.

In some of ancient Egypt’s temple walls, for instance, pictographs show Egyptians crushing, pressing and concentrating the essence of the entheogen blue lotus, Nymphaea caerulea, and mixing this with wine. Today we know that ingesting the active ingredients of the blue lotus brings a state of euphoria.

For 2,000 years, the Greek cult of Demeter and Persephone initiated their recruits in the Eleusinian Mysteries, using the drink kykeon. Scholars believe that the barley used for the drink was parasitized by the psychoactive fungus ergot. Thus, drinking kykeon ensured that initiates would be propelled into a state where their minds would find profound spiritual and intellectual revelations.

There is also evidence that nitrous oxide or ethylene may have been partly responsible for the visions of the legendary Delphic oracle, which was consulted by the Greeks before going into war, founding colonies, or undertaking anything major in the Hellenistic world.

Entheogens have also been around American cultures for thousands of years before Columbus stumbled into their lands, bringing conquest and destruction. The peyote cactus was used by many traditional cultures in what is now Mexico. From there, it spread to North America. Other well-known entheogens used by Mexican cultures include psilocybin mushrooms, which the Aztecs under the Nahuatl knew as teonanacatl, the seeds of several morning glories and many other native plants. The tribes of South America also employed a wide variety of entheogens.

As for the prehispanic Filipinos and other Malay seafarers, they used betel nut and kava as mild intoxicants, in the same way that the south Americans chewed their coca leaves.

Paul Kekai Manansala, independent researcher on history, also notes that seaweeds containing indole psychoactive alkaloids abound in the seas of the Indo-Pacific region, and that prehispanic Filipinos and other Pacific inhabitants are known to have eaten these and the many species of hallucinogenic "dream fish” (Caulerpa taxifolia, Blue seachub, damselfish and goatfishes) that had concentrated psychoactive substances in their flesh from eating psychoactive seaweed.

And in the United States and Britain—the places where addictions were first “discovered,” it is known that opiate and other drug use was massive and indiscriminate in the 19th century.

AT THE SAME TIME, there is evidence from cross-cultural studies that alcoholism does not exist outside of Western society.

In the words of several prominent ethnographers in the alcoholism field: “Drinking problems are virtually unknown in most of the world's cultures” and “solitary, addictive, drinking behavior does not occur to any significant extent in small-scale, traditional, preindustrial societies.” They also did not observe cases of antisocial aggression, alcohol withdrawal, or solitary or loss-of-control drinking.

But it is only near the very end of the 20th century when the symptoms of addiction were first recognized. Only relatively recently—and primarily in a few Western societies—did was addictions come to be perceived as biological phenomena, or as part of the natural landscape.

How is it that a phenomenon as powerful and destructive as addictions had been missed by so many of the world's cultures for so many centuries?

Clearly, for most part of human history, people and societies had ready access to the most potent of drugs, but chose to regulated their drug use–even without today’s colossal drug war and brutal drug laws. The only exceptions to this successful self-regulation—the Chinese Opium Wars and heavy drinking in Native American groups—are more the results of the cruel domination of their cultures abuse by invaders.

The earliest researchers into addiction, working in the early 20th century, noted that addicts generally “seek relief from consciousness?” What is it in modern society that addicts may be “seeking relief from”?

In his General Theory of Addictions, Stanton Peele tells us that addicts welcomes oblivion, and seek to find in the addiction an experience that can “temporarily erase their painful awareness of themselves and their situations.”

If addiction is essentially pain relief, does the widespread occurrence of addictions show that people in today’s world have more reasons to be in pain?

IF DRUG ADDICTION is pain management, and if “true” addictions only emerged and spread in the 20th century, what does this mean? What seems closer to the truth is that addictions are a distinctly modern-day phenomenon. Is it possible that modern society itself causes these addictions?

The work of psychologist Bruce Alexander at the Simon Fraser University in British Columbia, Canada, seems to imply this. Alexander had long maintained that the lab rats hooked to morphine in the many experiments from the 1960s onward –the very experiments that form the basis of our current view on addiction – were doping as a way to cope with their living conditions.

Only “severely distressed animals, like severely distressed people, will relieve their distress pharmacologically if they can,” he insisted.

To test his hypothesis, Alexander built “Rat Park”, a kind of rat utopia that sprawled 200-square-feet, 200 times the size of a standard laboratory cage. Here, the 16 to 20 rats that lived at the same time where given abundant food, balls and wheels to play with, and private places for mating and giving birth.

And did rat addicts exist in Rat Park? Apparently, no. Even rats who had been forced to drink a morphine solution for 57 days–well enough time to get them “addicted”–were brought to Rat Park and given a choice between water and water laced with morphine. For the most part, they chose the plain water. “Nothing that we tried,”Alexander wrote, “... produced anything that looked like addiction in rats that were housed in a reasonably normal environment.”

Alexander's paper appeared in the small journal Pharmacology, Biochemistry and Behavior, but was rejected by the two major biology journals, Science and Nature.

Alexander’s work was largely ignored by society, but his questions remain: “In what kind of a society would addiction run rampant, not just to drugs but to money, power, sex, work…?”

Meanwhile, the world continues to hold the brain-based, disease view of addictions. As Peele notes: “The United States is the world's leading exporter of scientific ideas…(thus) a realignment of attitudes about addiction is occurring in many countries worldwide.”


Note: I think this is so important I'm publishing it pretty much as recieved with only the links provided by Dani.

I will be adding links to the various points made and various scientific papers over time as I find them. Check back if you are interested.


Charlie Martin said...

Okay, I'll follow with the same point I made at JOM. The claim you're making here is that there is no such thing as "addition"; there's only a neurophysiological process, probably with both environmental and genetic components, that causes a large number of people to become dependent on a chemical in such a way that maintaining a normally comfortable physical state requires the repeated administration of some other chemical.

The thing is, "a neurophysiological process, probably with both environmental and genetic components, that causes a large number of people to become dependent on a chemical in such a way that maintaining a normally comfortable physical state requires the repeated administration of some other chemical" is pretty much the definition of "addiction".

You're putting yourself in the position of the apocryphal guy in Heinlein who devoted his life to proving that the Illiad and Odyssey weren't written by Homer, but by another Greek of the same name.

You ask how I distinguish this from an insulin-dependent diabetic? Two ways: first, we can clearly identify the physiological process that's being disturbed and how insulin restores it to some approximation of healthy function; second, people using insulin for diabetes mellitus have clear physiological benefits from it.

This came up in the context of tobacco dependence, and there's one really clear reason why being dependent on tobacco is different from being dependent on insulin: with insulin, if you don't take it, you'll very probably die of the effects of not taking it. With tobacco, if you keep taking it, you'll most probably die of the effects of taking it. The fact that this chemical dependence is so strong that people will continue smoking even when COPD is killing them is exactly the reason this dependence is defined as pathological --- and I'm speaking from personal experience here: my mother's COPD is severe enough that she is having trouble remaining fully conscious, but she just can't stop the cigarettes. As a result, she can't have the O2 in her apartment that she actually needs, because blowing up her apartment is even more dangerous than the COPD.

Now, does this mean I think the criminalization of opiates, amphetamines, cannabis, and increasingly tobacco is smart? It most certainly doesn't. Do I think the politicization of the word addiction is helpful? I absolutely do not. Are there people who can use opiates, tobacco, alcohol, etc, and not exhibit this dependence? You damn bet there are. Is understanding the physiological differences between those people and people who become dependent is important? Very.

This maneuver of insisting there's no such thing as "addiction", just some other syndrome with exactly the same symptoms, etiology, and prognosis, is, as I said, just dumb.

Or mendacious.

M. Simon said...

OK I buy that. If you need a substance for proper functioning then you are an addict.

You ask how I distinguish this from an insulin-dependent diabetic? Two ways: first, we can clearly identify the physiological process that's being disturbed and how insulin restores it to some approximation of healthy function; second, people using insulin for diabetes mellitus have clear physiological benefits from it.

For the drug "addict" we can satisfy your first condition no problem.

Fear memories, the amygdala, and the CB1 receptor

The second of course we can also satisfy.

Dr. Marks in England proved that with regular supplies of heroin "addicts" function did in fact improve. They led normal lives.

Class War

Treatment vs Recreation

Round Pegs In Round Holes

In fact similar drugs are prescribed to people by the medical establishment (start with Class War) to improve their function. People with money or medical insurance go to doctors for drugs that improve their mental state. Poor people go to the gypsy drug store. End result (except for the illegality and all the problems that causes) the same.

Let me give you and anecdote - I had to take a relative to a hospital who had stabbed himself due to a bad mental condition. The intake nurse questioned him about drug use and said not to worry if there was some - it was self medication.

Now you seem to be up on medicine. Why don't you know this?

A Well Known Secret

M. Simon said...

So let me ask.

If you get a drug with a certain mental effect from a doctor you are not an addict.

If you get it from the gypsy drug store you are.

Please explain the difference?

sudha said...

If you get a drug with a certain mental effect from a doctor you are not an addict.