Wednesday, February 25, 2009

Addiction: A New Paradigm

This is my first addiction paper. Unfortunately I got too distracted in the middle of writing it and had a rather awkward change of focus. While it will work for the assignment, I am less than pleased with the results. I will try to amend it when time and opportunity allow. Here is a link to the annotated bibliography.

I should mention that any comments and criticisms are quite welcome, especially those that are constructive in nature. I know that some of the folks who come by are quite well versed in psychology and addiction. Please don't hesitate to point out errors, either factual or implied. And of course I welcome criticism of the writing itself.

Substance abuse and addictions cost American taxpayers more than $500 billion a year (NIDA). And more than sixty-five percent of Americans are affected by substance abuse issues, either directly as an addict, or because they are close to someone with substance abuse issues (Riskind). Yet twelve step programs, the dominant method for treating addictions in the U.S. has proven itself woefully inadequate at reducing the harms associated with addictions. Only a very small percentage of addicts and substance abusers who utilize twelve step therapies manage to get control over their addictions, and the percentages associated with cognitive-behavioral approaches are equally dismal. Society is in desperate need for a new addiction paradigm, a paradigm that addresses not only treatment, but our very perception of addiction and successful addiction management.

According to the American Psychology Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), addiction is defined as "impaired control over drug use” (APA). The NIH's MedlinePlus medical dictionary defines addiction as "...compulsive physiological need for and use of a habit-forming substance..."(Merriam-Webster), while the MedlinePlus encyclopedia claims that "A physical dependence on a substance (needing the drug to function) is not always part of the definition of addiction”(NIH & USNLM) Stedman's Medical Dictionary defines addiction thus; "Habitual psychological and physiological dependence on a substance or practice beyond one's voluntary control”(Houghton Mifflin).

While the aforementioned definitions may seem to be quite similar, there are important differences. The distinction between overt chemical dependence and the underlying psychological dependence is particularly critical. It's also a major point of contention for those involved in addiction science. Another critical point of contention is whether or not non-substance addictions are addictions at all. Language largely defines reality and in regards to addiction it fails us in the most fundamental context: addiction science. It's no wonder that many of the people who work with addicts and substance abusers tend to eschew the word “addiction.” Lacking a coherent, cohesive clinical definition, addiction has become a very loaded term, even in the realm of hard science.

In Over the Influence Dr. Denning et al. express concern that “addiction” is often used too loosely “and does not speak to the user's relationship with a drug” (Denning 141). Instead the authors prefer to restrict “addiction” to the very top of a definitive spectrum that describes specific characteristics of the different relationships that people have with drugs. Moreover, the authors prefer to use the word “chaos” to define that point on the spectrum (Denning 28-30). While their desire to eschew the using the word addiction and it's related connotations is understandable, doing so ignores the broader social perception of what “addiction” means. And there is nothing to prevent describing the important distinctions between the different sorts of relationships people have with drugs, within a broader contextual framework of “addiction.”

The generalized social perception of what “addiction” means is in parts more simplistic and more complex than the confusion surrounding it in the clinically-oriented definitions presented above. Outside the hard science and clinical frameworks, context becomes even more important when discussing “addiction.” From the myriad pop songs that describe a romantic relationship as “addiction” to describing a homeless drunk who exists in a perpetual stupor, the connotations of “addiction” range from something warm and loving to something very dark and ugly. While on it's face it might appear that the use of “addiction” in the context of a romantic relationship or other ambivalent/benevolent contexts is irrelevant to the discussion at hand, it cannot be ignored. Again, language largely defines reality. More clearly our use of language largely defines reality. So like it or not, in the broader social context, ambivalent/benevolent behaviors are an important aspect of the discussion of “addiction.”

When Denning et al. shy away from the negative implications of “addiction,” they are also shying away from the positive connotations. While those connotations aren't part of any clinical framework of “addiction,” they are an important part of the broader social connotations. There is no reason not to take advantage of these implications in a clinical setting and many ways it could be used to effectively help people who are significantly hampered by substance abuse or other negative “addictive” behaviors. Words, with their implications, hidden meanings and quiet connotations are incredibly powerful tools. We should never be afraid to explore the possibilities that these tools have to offer. Especially when we are working with the intricacies of the human mind. There is no reason, when discussing addictions in a clinical setting, to ignore the less negative connotations of addiction. When someone comes forward with concerns about their substance use issues or other negative addictive behaviors, “addiction” is in the room, whether the therapist wants it to be or not. Instead of trying to change their language, it would be much easier to work on the association they have with the language they're thinking in.

In The Heart of Addiction, Lance Dodes, MD doesn't shy away from it. He takes a very broad approach that strikes to the core:

Addictions have been segregated as though they are different from other human problems, as though they required a unique approach (as in Alcoholics Anonymous), and as though they could not be understood as emotional issues by either the people treating them or the people suffering with them. But if addictions and compulsions are basically the same, psychologically, there can be no reason to think of or treat them differently. Like compulsions, addictions the mainstream of the human condition (Dodes 185).

And this is why it is so very important to embrace the use of the term “addiction.” Not so addicts can cower in fear, in the hopelessness of their ability to ever manage their addictions, as the dominant approach to addiction treatment would have them do. Nor so they can exist apart from society, as some are wont to do. We should embrace the term “addiction” because we are human and addictions are very much a part of the human condition. Not just the negatives either, by embracing the language of “addiction” we are embracing it in all of it's glory, the good, the bad and everything in between. By embracing the language of “addiction” we are embracing the humanity of the addict and facing head on the problems of the addict's addictions. By embracing the language of addiction, addiction becomes less scary – less insurmountable, because we come to understand that addictions, like every other aspect of the human condition, aren't inherently good or bad, it's the expression that defines its positives/negatives.

Unfortunately, many of the expressions of addiction are quite negative and destructive. Substance abuse alone really is a mainstream human condition, all in itself. As NIDA tells us, it costs more than five-hundred billion dollars a year (NIDA). And as the survey posted by Faces and Voices for Recovery points out, addictions affect more than sixty-three percent of Americans (Riskind). Addressing the definitions of addiction only gets us so far, while definition is important, we also need to address the approaches of addiction treatment. There are three basic approaches to addiction treatment, which I will discuss in the order of their prevalence in practice. But it is important to understand that when dealing with addictions, there is no “one size fits all” approach. While I am going to be rather critical of the most prevalent, twelve step programs, it's important to keep in mind that for some addicts, the twelve steps not only work, but are critical – in many cases a lifesaving approach. The problem is not with the twelve step programs, it's with the broad assumptions that go with them.

The twelve steps to recovery are based on the disease model of addiction. The disease model of addiction is rather controversial, with notables in the field, such as Dr. Stanton Peele and the authors of Over the Influence, Denning et al., disputing its validity altogether. But a lot of research suggests a fairly definite link between alcoholism and genetics and there is a growing body if evidence to suggest a link between dopamine deficits and substance abuse. At the same time it's pretty clear that not all addictions are founded in that disease model and even those that are, don't necessarily fit into a single treatment approach. The Narcotics Anonymous: Basic Text typifies the basic assumptions that dominate the social and political addiction paradigm.

We realize that we are never cured, and that we carry the disease within us for the rest of our lives. We have a disease, but we do recover. Each day we are given another chance. We are convinced that there is only one way for us to live, and that is the NA way.(NA International 8)

Over time some addicts lost contact with other recovering addicts and eventually returned to active addiction. They forgot that it is really the first drug that starts the deadly cycle all over again. They tried to control it, to use in moderation, or to use just certain drugs. None of these

control methods work for addicts. (NA Inernational 78)

The problem with this, is that it presupposes that any addict who doesn't follow the NA or some other twelve step program, is doomed to a life of addictions. It also presupposes that it doesn't matter if someone alters their drug use to be less harmful. Any use is considered failure and any other method of treatment for addictions cannot possibly succeed. This is patently false and the repercussions of this position resonate throughout our society to the detriment of the vast majority of addicts.

This position has a huge influence on public policy in the U.S., including the sentencing guidelines for a variety of civil and criminal offenses. From drunk driving, to simple possession of an illicit drug, hundreds of people are sentenced to twelve step drug treatment programs every day in the U.S. Many of these people aren't addicts at all. Others are simply not going to successfully respond to twelve step treatment plans. In spite of several studies, including studies in which AA and NA were involved with (AA 12), showing that coercion into twelve step programs is ineffective and possibly counterintuitive, the principle that only the twelve steps can successfully treat addictions provides the momentum to keep such policies alive.

This position also has a detrimental effect on the perception of society as a whole. First off, it provides many addicts with an excuse not to try anything. They believe that because the twelve steps failed them, they should just give up – or that because they know they can't quit everything they won't bother trying to quit using the substances that are causing them the most harm. Second, it creates a perception in our society, that more people have addiction problems than really do. It convinces parents and friends, that because an individual has had substance abuse issues in the past, that any use on their part is a “relapse,” which can lead to alienation. And finally, this view segregates addicts from the rest of society. It says that addicts are somehow different from everyone else, that we're somehow damaged, weak or otherwise unfit.

With those criticisms in mind, it is also important to remember that AA, NA and other twelve step programs do seem to work for some people. Just because they don't work for everyone, there is no reason to assume they don't work at all. There are a great many people alive today, who attribute their survival to the twelve step approach to addiction recovery. And for some addicts total abstinence from all psychoactive substances is an absolute necessity. While the assumption made by many proponents of the twelve step philosophy, that the only treatment for addictions are the twelve steps is absolutely wrong, it is equally erroneous to assume that this makes the twelve steps a categorical failure. Indeed, quite often the twelve step approach is combined with the second most prevalent approach to addiction treatment, cognitive-behavioral therapy.

The most common cognitive-behavioral (C-B) approach is really quite simple. The premise is to change the way that an addict thinks of their addictions. The goal is to empower the addict, help them think in terms of strength and success. To move them away from hopeless, defeatist thought processes (Kadden et al). It is rarely, if ever a stand-alone therapy. It is a part of almost all in-patient addiction treatment programs. Indeed, it is rarely engaged outside the context of in-patient or aggressive out-patient treatment programs. While engaged in C-B therapy, the addict will usually meet with their therapist several times a week, sometimes daily for the initial few weeks of treatment. As treatment progresses, the patient will meet with the therapist less often. Usually they will be down to one session a week with their therapist after ten to fifteen weeks. Sometimes they will stop meeting with their therapist altogether at this point (Barry ch4).

A less common form of C-B is meeting with a therapist in a more traditional psychotherapy setting. Dr. Dodes. author of The Heart of Addiction, engages is therapy in a similar manner. The idea is to redirect the thinking and actions of the addict (Dodes). Really, this form of therapy has existed for as long as we've had psychotherapy, though the individual tactics have changed considerably over the years. One of the advantages to this method is that therapy is tailored to the addict and the addict has the advantage of a trained therapist who can help him or her make decisions about treatment beyond the C-B therapy sessions. Quite often, this form of therapy forms the core of harm reduction approaches to treating addictions.

The harm reduction approach to addiction treatment is firmly entrenched in the idea that there is no and never will be a “one size fits all” approach. As Patt Denning, Phd puts it in Over the Influence, “The harm reduction way of understanding drug use and abuse takes into account the complexity of each person's relationship with drugs” (Denning 8). That's right, everyone who uses drugs has a “relationship” with the drug or drugs they use. Moreover, people who engage in any addictive behavior have a specific relationship with that behavior that is central to their addiction. This recognition that there is a relationship involved and that said relationship is unique to the person experiencing it, is the key advantage that harm reduction therapy has over other, singular methods of addiction treatment.

By understanding that everyone has their own relationship with drugs, harm reduction can help addicts find approaches that will work for them. The harm reduction approach recognizes that not everyone will be abstinent from all psychoactive substances or even the substance that is the object of their addiction. Harm reduction doesn't gauge success by arbitrary standards. Success is gaged by reducing the harm of the addictive behaviors. The harm reduction approach recognizes that success may be an ongoing process of gradual reduction of harm. But most importantly, the harm reduction approach recognizes that success is entirely relative to the addicts relationship to their drugs or other addictive behavior.

Another powerful advantage to recognizing that people have relationships with drugs and their addictive behaviors, is possibly the most powerful. “Relationships change” (Denning 28). Our relationships are always changing, always evolving – no matter the relationship being discussed. As they grow and change, my relationship with my children changes. I'm confident that it will continue to do so well into their adulthood, because my relationship with my own parents has been ever changing. Change is very much the nature of relationships.

But while the harm reduction approach sounds and ultimately is pretty remarkable, many practitioners of the harm reduction approach have a very singular view just the same. As was shown in our exploration of the definitions of addiction, many harm reduction practitioners are uncomfortable using the word addiction. In part, because they are uncomfortable with the disease model of addictions as a whole. And this is ultimately to the detriment of the addicts who come along, who would be best served by a twelve step program. Just like the dominating twelve step approach that claims that nothing else can work, many harm reduction practitioners would exclude ideas outside their purview. And even Dr. Dodes, who seems very open to many different approaches isn't immune to the language of exclusion. While he really does have a rather revolutionary approach to viewing addiction and avoids couching his terms in outright absolutes, it's clear that he has a very strong preference for his analytical approach.

It is time for us to chart a new course for dealing with addictions in our society and at the very top of the list is a driving need to get over our petty turf wars. You saw the figures in the introduction to this paper. We aren't running out of addicts any time soon, there are more than enough to go around. Unfortunately all too few of them are getting any help at all. While this is largely due to the exclusivity of the dominant paradigm, it is also due to the claims by various elements that they have the method to help the addict with their addictions. What the message to addicts should be, is that one way or another, there is a way to help them reduce the harm caused by and ultimately overcome their addiction. That if one approach doesn't work, there are other options available.

Beyond that, we need to fundamentally change our perception of addictions. Addiction is a mainstream, even a fundamental aspect of the human condition. Humans are creatures of habits and compulsions. When taken out of the context of negative, harmful behaviors, “addiction” takes on a great many connotations that range from benign to outright positive. While searching for a coherent clinical definition for addiction, it was hard not to notice that there are probably hundreds of pop songs with addiction in the title or as the title. People talk about their addictions to books, walks in the park, hiking, spending time with their kids, community service – the list is endless. And there isn't a single thing in that list that couldn't be taken to a unhealthy, negative extreme. There are few, if any humans who can truly claim to have never manifested some sort of addictive behavior that was taken to an unhealthy extreme.

Yet as a society, we feel justified in segregating the “addicts” into a special group. And “addicts” are just as guilty of anyone else in perpetuating this tendency. Because people want to believe that there are addicts and there are “addicts.” It's easier that way. Segregative labeling is also, quite unfortunately in the mainstream of the human condition.

There are a great many things that would make a major difference in helping people reduce the harm of their addictions. Policy changes, such as legalizing, regulating and taxing currently illicit drugs, for example, would make it much easier for people with serious addictions to get help, while removing a lot of people who don't have addiction issues with those drugs out of the treatment system. Making sure that people who commit crimes such as driving under the influence of intoxicating substances both pay for their crime and get treatment that will help them get control of their addictions, instead of just pawning them off on AA or NA. Providing kids with a realistic view of drugs and drug use, that doesn't make claims they're going to know are false but ensures that they understand the very real dangers involved with drug use and other risky behaviors.

But most important, is fundamentally altering our view of addictions as a society. Language largely defines reality. Before humans developed language, we were little different than any other omnivore out there. It could be and in fact has been argued that language is what makes humans human. We need to be using our language to move us forward with regards to addictions. Because right now we are failing and failing badly. Considerably more than half of the people in our society are dealing with the effects of harmful substance addictions. We are spending more than $500 billion every year in the U.S. alone, just dealing with substance addictions. And according to the median of several statistics I saw, from sources at the NA website, to the harm reduction sites and substance abuse help clearinghouse sites, we are failing more than seventy percent of the people who actually go looking for help. No way of knowing what percentage of actual addicts we fail, because most of them never look for help.


Juniper Shoemaker said...

HA! Hilarious! You dissed it so hard in your post preamble that I felt trepidation. Then I read it.

I'm emailing you feedback.

JLK said...

Great paper. I'm also emailing you feedback.

leigh said...

if you want to build an argument with drug use stats, you will have a field day with this:

i use it frequently.

DaisyDeadhead said...

I am not an educated person like the people whose opinions you have sought, but I did spend many years in 12-step groups. I would recommend Elayne Rapping's book, THE CULTURE OF RECOVERY, if you haven't read it.

I used to speak in front of groups (back in the 80s) using the "chaos" concept... I feel like it made its way into academia and I should be collecting some royalties. :P

My question is, why is some drug-use/abuse called addiction, and some is not? I feel like it is the legality and status of the substances themselves that determines this. (Also, the class of the people under discussion, if they had a proper diagnosis, etc) Are people "addicted" to anti-depressants? Of course. But those are acceptable and legal, so we don't call it that. But the definition you have given, "Habitual psychological and physiological dependence on a substance or practice beyond one's voluntary control”--absolutely applies. They can't stop, they have been made into addicts by the medical profession. And this is true of so many psychoactive drugs, such as Valium, Librium, Elavil, etc. (My mother was a prescription drug addict, and it's a sensitive subject with me.) I still think it goes largely untreated and is in fact often encouraged by doctors/pushers/BigPharma.)

Another point: The founders of AA *SAID* that you cannot force it on anyone (see the 12 Traditions, specifically #11--"attraction rather than promotion"!)... then the courts went and forced it on people. Fail!

I enjoyed reading it.

DuWayne Brayton said...

Daisy -

Please, feel free to add your opinion. I only made specific reference to the professionals because some of them come by here and I wanted to welcome criticism of the basic psychological notions I am asserting. That was by no means intended to restrict criticism of my ideas to professionals - really it was intended to make clear that I would welcome such criticisms.

DuWayne Brayton said...

But the definition you have given, "Habitual psychological and physiological dependence on a substance or practice beyond one's voluntary control”--absolutely applies.

I apparently wasn't nearly clear enough. I absolutely disagree with that definition, as I do most of the clinical definitions I came across.

The phenom you are talking about is something different than addiction, though it can also be addiction. That is acute/overt chemical dependence. I don't think it's addiction in and of itself, when the drug in question is heroin, any more than I do when the drug is a prescribed pharmaceutical. I know a couple people who have suffered acute dependence to illicit drugs, who once they managed to detox, never had an interest in those drugs again. I don't consider their experience with those drugs addiction at all.

OTOH, I also know people who have gone beyond acute dependence on prescribed pharmaceuticals. People who even when they were detoxed from the pharmaceuticals, felt a compulsion to use those drugs anyways. In their cases, their experience absolutely qualifies as addiction.

I absolutely agree with you on the notion of coercive participation in twelve step programs - and treatment in general. I think there are cases where coerced treatment might help a few people, but it has been proven that for most people it simply doesn't work.

And at the same time, I suspect this practice really skews the figures relating to the effectiveness of twelve-step programs. I am extremely critical of twelve step programs, but I strongly suspect that for some addicts, they are extremely effective. I certainly know a lot of people who firmly believe that the reason they are alive today and sober, is due to twelve step programs.

My main problem with the twelve step paradigm, is that it claims that the twelve steps are the only way and assumes that abstinence from all psychoactives, excepting tobacco and caffeine is the only measure for success.

And I have read The Culture of Recovery, though it's been several years. She's actually on my reading list for gender issues, her work on gender and culture.

DaisyDeadhead said...

The nature of AA changed dramatically after anti-depressants came on the scene. Like, WOW, it was day and night.

The old-school AA concept, which I acknowledge comes from religion(s), was a variation of PAIN IS GOOD FOR YOU, because physical withdrawal from alcohol, in particular, can be acutely painful as are headaches from lack of nicotine, etc. I mean, you will want to slit your wrists. Not surprisingly, a variety of pharmaceuticals was introduced to make it easier. Because honey, it's not!

And then, people relapsed more, in my ever-humble opinion.

One reason I have not started smoking tobacco again (example) is the very idea of those horrific headaches starting again. NOT AN OPTION. But what if I'd had the nicotine patches and stuff they have now? (Yes, Daisy gives her age away, if I haven't already!) I might have found it relatively painless, and would have found it easy to pick up again. DETERRENCE is a fact, and jail does work on some people. If there is no jail, no deterrence, well... why the hell not?

In AA, the concept descended from On High Somewhere, that everyone was depressed or had anxiety and seemingly overnight, everyone was on drugs. As I wrote here (some general background)--I am not categorically opposed to drugs at all. But I think the 12-step DISEASE concept was made obsolete by its own self. That is to say, if you have a disease, why not medicate it?

AA was initially very anti-medication...except then the exception was made: THESE medications are good, because we WANT THEM. What is the difference between those drugs, or nicotine and caffeine (as you correctly point out) and any other substance like reefer, that someone may WANT, except the legality and availability of the substance?

If someone hoards sleeping pills for their trip to their in-laws, are they going to self-destruct for that? Shouldn't we be teaching people to apply SENSE to these habits instead? Ohhh, it's BAD to take sleeping pills when you need it, but GOOD if some doctor gives it to you to withdraw from crack! (That makes no moral sense AT ALL.)

And so, the actual 12 steps as psych concept suddenly seemed to evaporate in importance, and AA became more of a social club. Which IS important, BTW, not saying it isn't, people need sober places to hang out... but it is no longer about changing your life, finding the defects of character than made you feel entitled to destroy everyone around you, etc etc. Like many religions, it becomes more about fitting in to the whole "recovery community" than it is about changing one's psyche or personality or approach to life and problems.

Babbling, not making sense. But AA changed, and I eventually left as a result. I have not yet written about my AA apostasy and kind of afraid to go there. I'm still not sure of the words I want to use, but you have touched on several of the main issues.

So, the more sanity that gets out there about addiction, the better. :)