Sunday, 25 October 2015

The concept of addiction

I've been thinking quite a lot recently about the nature of addiction.  This is prompted by an exchange on Twitter that mentioned 'functional alcoholism', and a presentation given by Mark Gilman at a recent conference hosted by the treatment provider CRI.

I'm certainly not the person to develop a new or more nuanced understanding of addiction, and this wouldn't be the place for me to do it.  But there is something I want to do here that I hope will be useful.  It's more of a general point about definitions and how we use concepts.  I wrote last week about how pleasure and happiness probably aren't very useful analytic concepts, even if they mean something useful to us in everyday conversation.

You could take an academic, intellectual perspective and suggest that concepts need clarity to ensure we have perfect, Habermasian communication.  I struggled to read and understand Habermas, but there's definitely a point something like this that should be made.

I've seen Mark Gilman talk a number of times now, and the central assumptions and conclusions of his presentations have been the same for the past two years at the very least.  One of his key contentions is that there are alcoholics or addicts as defined in the 'big book' of the fellowships.  And not simply that people who fit that characterisation exist, but they are the only people who are really addicted to substances; there might be others who drink too much for their health, but they're not addicts.  This particular group of people who are addicted are best treated using that 'big book'.

This seems perfectly reasonable, if it works.  That is, if AA or NA work for that category of people, we should absolutely be encouraging them to access these services.

I'm not going to question that evidence base here.  There's plenty of lively (and often uninformed) debate on that issue already.

But here's the rub.  When we talk about 'addiction', what do we mean?  Some people would argue that the term is so disputed and inexact that we should cease using it entirely.

But Mark Gilman would argue that he's doing the opposite of this: he's using it precisely, with a very narrow but clear definition - taken from the 'big book'.  And for these people, the idea of 'controlled drinking' could be hugely destructive.  This is certainly a different perspective from the New Directions conference I attended this summer where there was something of a retrospective on 'controlled drinking', and researchers like Marc Lewis expressed their admiration for this stream of work.

And here's where my sociological, methodological objection comes in.  I don't subscribe to some Platonic model whereby concepts pre-exist human thought and signify some kind of absolute reality (that we may or may not grasp) and we're on a process of working out what addiction 'really' is.

Instead, I'd argue that any such concept isn't god-given, but only exists as a human construct, and is only useful insofar as it helps us to understand the world around us.

And so the authors of the study I link to above are right: if 'heavy use' gets us further to understanding what's going on and how to address it, then let's stop using the term addiction as a technical, clinical term.  I happen to disagree, but at least the debate is taking place on the right terms.

By this understanding, there's no problem with the Mark Gilman approach or the 'big book' definition of addiction, but equally it's important to note that if this is 'addiction', then there's also lots of people who have something more problematic than simply drinking at a level that is harmful to their physical health who don't then 'recover' from their issues in the way suggested.

There's a further problem too: the reflexivity or self-awareness of human beings.  Concepts about human behaviour don't simply exist in a vacuum; they also reflect back and shape that behaviour.

Think of economics.  Lots of critical theories of neo-liberalism note that economics and its metaphors haven't simply described the world of human interaction; they have also shaped that behaviour by making people think not only that they do behave like 'economic man', but that they shouldWe internalise the tenets of neoliberalism.

This argument is closely linked to certain claims regarding the influence of psychology - as well as trying to describe and explain our behaviour, these theories or worldviews change it.

You might not agree with the arguments in these particular examples, but there's no doubt that if you get a diagnosis of your behaviour - which is inevitably determined by a mix of structure and agency, individual choice and wider determinants - this diagnosis (knowing what you are 'like') will affect those conscious elements of behaviour.  In fact, that's one of the reasons the AA model of addiction is opposed by people like Stanton Peele: it deprives people of their agency at precisely the time when they need to be toldthey can change long-term patterns of behaviour.

I'd suggest that both those suggesting 'heavy use' as an alternative to 'addiction', and those sticking resolutely to either a DSM or 'big book' definition are playing a strange game of trying to pin down the myriad of complex ways people can experience problems in relation to a range of substances (or behaviours) into one unifying theory.  Perhaps such a debate clarifies what is actually problematic about certain forms of substance use, and how we might address this, but it also risks obscuring 'different' issues or patterns of behaviour.

And these definitions aren't simply academic.  Mark Gilman is proposing service design on the basis of segmenting the potential users of services by these categories, and DSM definitions will affect what sort of treatment people receive - or even if they receive any at all.  That means the 'accuracy' - or perhaps inclusivity - of these definitions is crucial tothe chances of recovering that individuals might have.

So by all means let's have a debate about what 'addiction' or 'dependence' or 'problem substance use' might be, but let's do this with an awareness that you can't capture such issues perfectly.  And such concepts, even if they're continually developing, aren't moving towards a more and more refined and correct definition.  Moreover, they need to be continually developed, as they're linked into a feedback loop as they impact on the very behaviour they're trying to describe.

At best, these concepts might become more useful as they develop.  My fear is that today these debates mean they're becoming ever less useful, as people in the field talk across each other and exclude certain people and understandings.

17 comments:

  1. Will,
    Thanks for this blog. Its good to know its not just me who is interested in this issue (possibly to the point of obsession). I like your analysis not least because it reminds us how little we really know about things like 'addiction' and even when we think we do, how little we can often agree on. My interest in defining 'alcoholics' and 'addicts' based on the AA Big Book and the NA basic text is based on the last ten years of studying recovery (anthropologically) and particularly 'long term recovery' (5 years+) is based on observing those people who read the literature, attend the meetings and identify completely with the descriptions of the 'alcoholic' and 'addict'. They also tend to bond quickly and solidly with the others in the fellowship of their choice. They experience the paradoxical freedom that comes from complete surrender. Those who make it into long term recovery also combine their new social network ('friends') with a better place to live ('homes') and some way of paying their way in the world ('jobs'). I have personal issues with lots of things, not least the whole idea of 'addiction' as a disease and there are lots of people in the rooms of the 12 step fellowships who seem to make it to 5 years+ by 'white knuckling it'. Anyway, thanks again for exploring these issues and opening up the debate. I am with Johann Hari that whatever 'addiction' is, the opposite is not sobriety or abstinence, it is human connection and that's what you get in AA, NA, CA and DAA etc. This human connection in the rooms is made so much easier if you identify with the description of the 'alcoholic' in the Big Book and the 'addict' in the NA basic text. Thanks, I will share this. Its a great contribution to our learning and discussion.

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    1. Thanks for commenting and sharing Mark, much appreciated. I'd agree that identifying with that Big Book definition makes that connection easier within the fellowships, and there can be a paradoxical freedom in surrender. I think all I'd say is that such a definition can never be complete, and will always exclude certain people - and we shouldn't forget that the definitions shape behaviour as much as they describe it. Without it being a cop-out, I'm open to the idea that there are as many definitions of problem drinking/using as there are people - just as there are multiple definitions of recovery. If we try to find one unifying definition/theory, it won't work for everyone and it could have harmful impacts in a number of ways. Here's to an ongoing healthy debate! Thanks again.

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    2. I agree Will. Addiction means so many different things to so many people that a unifying theory is probably further away than its ever been and that's fine by me as the more we know the more we realise how little we know.

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  2. I'm going to start this reply, as I always do, but mentioning that there's no right or wrong way to get better. If doing the steps suits you, great; if they don't, also great - there are decent viable alternatives now.
    It's one of this alternatives that I use, SMART Recovery. I don't want to open up the whole competitive dialogue again - see first line - but we simply don't use labels. It's a lot easier IMHO to get rid of something (dependency), than to change what you label yourself (powerless, alcoholic, junkie). In my early attempts to beat my drink problem I quite happily used "disease" (although the more I dig into it, the more I realise that concept has been hijacked), and "powerless" as the perfect reasons to use.

    The bit that is really starting to get me a bit antsy is why there appears to be this "able/not able" to drink in moderation. The work I put in to change the way I react to situations , using SR tools, leaves me in a place where I can't imagine WHY I would want to drink again - without sounding obvious it solves nothing, at best blots shit out for a short time, and leaves you feeling worse. The way I should "test" if I'm an "alcoholic" is to go to a bar and try to drink "normally" on a regular basis. Why?? Class A was never my poison, but if I tried to use Mark's bête noir of brown powder I can be pretty sure I'd develop a habit - so I don't do it! Once you get the "drinking like a normie" concept out of your head, you simply become a non-drinker. Of far more interest to me than "clinical definition" (which let's be frank is like trying to put string vest on an octopus) is the WHY people use. As ever we're looking at the problem from the end result. Steppers "white knuckle" recovery; SMARTIES change the way they react to life's low balls - but no-one appears to be looking right at the front as to why people are using. We use a basic business-style Cost/Benefit in SR to start to build motivation, and in the 5 years I've been brainstorming it in groups I can guarantee "escape/blot out" will be up there as a motivator.
    "Addict, addiction, junkie, smackhead" all dovetail nicely into "homeless, friendless, unemployed, skint". Until we start looking at society as a whole, we're just arguing about the best brand of plaster to stick on. Mark's hit it - why are peer support groups becoming so popular? Because they're a place to go among friends - probably the only night out some poor soul has.
    Thanks to Mark Gilman for starting me on this thought process 2 years ago.
    Sorry I've rambled on a bit there - I get a bit passionate when I have a platform....

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    1. Thanks for this comment, and I think the open-minded point that there's no right or wrong way to get better. And I'd completely agree about needing to address why people use - this video summarising the Johann Hari argument is pretty good on that (though I disagree with some elements of it): https://youtu.be/ao8L-0nSYzg

      And it's definitely worth thinking about this idea of 'moderation' or 'controlled' drinking. Drinking or using any substance is in my mind no better or worse in itself than any other pastime. It just so happens that drinking is more embedded in (UK) society than many others, and therefore not drinking can make you seem somehow 'not normal'. I wouldn't appreciate it if my dislike of cycling (for whatever reason) made me seem 'not normal' - the key is for us to not be too prescriptive or enforcing about those norms. But at the same time, it's worth having a debate about whether certain pastimes are more or less harmful/beneficial than others. Is our drinking culture really positive? Why should anyone be aiming to drink 'normally'? Thanks for getting me thinking again...

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  4. The 'opposite of addiction is lack of connection' (lovelessness?) theory is not supported by research evidence, which clearly shows that there are multiple reasons for and causes of drug use, whether occasional or regular. My 30 years research has consistently identified people who use drugs habitually and even problematically whilst having many friends and loved ones, and no more problems with relationships than the average person. This 'addiction = lack of connection' idea is a modern drug myth, and will soon be rejected by anyone who regards evidence as important.
    As for 'addiction', there are so many theories about what it is, with no theories holding the sway, that the concept has become meaningless and worse than useless. Much more can be gained by conceptualizing drug use in terms of measurable behaviours (consumption), notably drugs used, frequency of use, amount of use, and method of use. When history leaves the myth-laden notion of 'addiction' behind, greater progress will be made in both practice and research.

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    1. Thanks for this, Russell. I agree that there are big problems with the 'lack of connection' theory. It certainly can't explain all incidences of 'addiction' or wider mental health issues, for example.

      However, there is something in the idea of recovery capital, or resilience, that means while people from all walks of life can and do suffer issues relating to substance use, they don't all have equal access to the resources that *in general* help support recovery.

      And that's important when designing substance misuse treatment services, as I would suggest these should be targeted at those who most need them - which isn't necessarily those who are already well endowed with 'recovery capital'.

      In terms of the terminology, I'm sympathetic to the argument that the concept of addiction has so many meanings associated with it that it's no longer useful. However, I'm not convinced by concepts of heavy use, as they're only descriptions. The idea of having a concept like addiction is that it's more than a description of behaviour; it's also a diagnosis that identifies causes. It fails, because there are multiple causes of the various problems related to substance use. But then we need something more than 'heavy use', as this can be causing a whole range of problems (or not), and can be caused by a whole range of things. It's easy to observe facts about someone's use, but they don't in themselves get us very far with identifying (a) what the problem is; and (b) how to address it.

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    2. Hi again Will, I don't have time to do justice to your comments with this short reply, but would like to explore these issues more with you and others sometime (anyone going to the annual Hit Hot Topics conference in Liverpool later this month (11/15)? My key point is that it would be useful to dump 'addiction' in the toilet of worn-out concepts because there's strong arguments and growing evidence that it is not a disease - a tenet central of its mainstream use, and certainly in most Recovery-based and medical notions of 'addiction'. I refer you the new book by Marc Lewis, "The Biology of Desire: Why Addiction Is Not a Disease" for a recent demonstration of this point. In short, drug use - and its different forms - can be defined, firstly, in terms of the consumption behaviours it involves, and secondly in terms of the many causes of and reasons for using drugs (in different ways). There's no way round it, drug use (like other social behaviours) is complex: its causes are multi-dimensional and multi-level, including physical (genetic, physiological, etc.), psychological (personality, affect, cognition, etc.), and social causes (roles, relationships, drug policy/laws, economics, etc.). The evidence suggests that 'lack of connection to others' is one cause (or set of causes) underlying the drug use of some types of drug user. But it is not a salient cause of many types of drug use - even though it seems to be one salient cause of the drug use of some sub-groups, notably opiate injectors in treatment who have multiple health and social problems. I guess that this may be the sub-group from which Hari wrongly generalizes his broad conclusion about 'lack of connection' being the primary cause of drug use.

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    3. Hi Russell. I think that's a good explanation of where we're at, and a reasonable proposal for how to move forward. There's no need for a condition/disease to always be caused by the same factors, so as long as the 'consumption behaviours' defining the problem comprise not just the substance and pattern of consumption but also the wider effects of this pattern of use (the sort of things that appear on AUDIT), I'd agree that you'd have a much more straightforward model, where people would be less likely to talk across her. I haven't read Marc Lewis yet, but was very impressed by his talk at the NDSAG conference this year, and various interview pieces I've read. Sadly I can't make HIT, but thanks for contributing to the discussion here.

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  5. Just wrote a long and carefully considered piece which after I pressed 'preview' disappeared! *breathe*

    Less considered version..

    From a public health perspective I'd say we need a more nuanced understanding of 'addiction' and 'alcoholism' than disease model tends to give. From a population approahch, this is particularly important considering the range of drinkers who may experience mild/moderate levels of dependency. These drinkers are far less likely to identify with having an alcohol 'problem' because they see themselves as far removed from a dominant idea of the 'alcoholic'. As such their chances of recognising dependency 'early' and giving themselves a head start at 'recovery' - in whatever form may work for them - are diminished.

    By this I don't mean to suggest that Mark is wrong in that there are many people for whom identifying as 'alcoholics' may be hugely powerful - rather that there are many other drinkers who experience mild or 'earlier' stages of dependency but will not recognise it as early as they could - or at all. As such, from a public health perspective at least, that 'alcoholism' is too synonymous with alcohol problems is counter productive to helping many people identify a 'problem' and 'recover' at the earliest opportunity.

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    1. Thanks James. This certainly seems perfectly considered and sensible to me. I think you're right that public perceptions of alcohol-related 'problems' have been shaped by a particular understanding of alcoholism (and also, I'd suggest, public 'binge' drinking). And I'd agree this isn't necessarily helped by a conception of alcoholism as something where someone inherently 'has got the spots' (as Mark once put it), or not. That's not to say for definite that no one has that kind of disorder, but it certainly isn't the single explanation of alcohol-related problems, and if we think it is, then we exclude a huge number of people from accessing support. I'd agree that while we're operating with such a narrow definition of alcoholism/addiction, we're going to struggle with making sure support is accessed by all who might benefit. And that's why I think a more fluid or open definition might be more helpful. As I said in my reply to Russell, in a way I wouldn't mind throwing out the concept of addiction - but if we did it would still be helpful to have something to act not directly in its place, but in a similar role.

      I'd be keen to carry on the discussion!

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    2. I suspect we would probably agree on more then we disagree on. For me, whatever 'it' is (I prefer to talk about addiction and alcoholism because addict and alcoholic are the terms used by the people themselves in the mutual aid groups that I have spent so long studying - NA, AA, CA and DAA - as are the terms clean and sober etc) it most certainly isn't a disease. I can live with dis-ease though. Binge drinking/drugging and heavy drinking/drugging are different things to whatever it is that people in the 12 step fellowships have. I have many friends and some colleagues who are heavy users and drinkers and their using and drinking has caused some serious problems for them and their families and loved ones over many years. But, they have been to AA and NA and found no identification. I am also coming to think that treatment and recovery might be completely different things responding to different things. For all the work we did in PHE on Facilitated Access to Mutual Aid (FAMA) there are still very few places where you can see any significant numbers making their way to the rooms of AA and NA and CA from treatment services. I did talk in Chester on Tuesday arguing that cuts to treatment services may have no impact on the numbers of people in mutual aid based recovery at all. If people don't get to recovery from treatment then cuts to that treatment are irrelevant for recovery. As an aside, we held the first workshop yesterday of a new group called the British Addiction and Recovery Group (BARG) amongst other things this group will frame addiction and recovery as a social justice and health inequalities issue. If Dr Mark Gilman goes for treatment for his opioid habit he will go to detox, rehab and 12 step mutual aid. If plain old Mr Gilman from the estate goes for treatment for his opioid habit he will end up on methadone maintenance because the purpose of treating Mr Gilman is not designed to reduce the harm to him as an individual it is to reduce the harms to society that he (Mr Gilman) might do to us (committing crime and spreading HIV etc). The purpose of treating Dr Gilman (and his lawyer and pilot brothers) is to get him clean and sober and back to work as a valued member of OUR society. Anyway, off for a pint or three Salford City versus Notts County.

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    3. ..just remember Mr/Dr Gilman that sport spectatorship has a higher mortality risk than many forms of drug use (http://www.drugtext.org/Dance/party-drugs-clubbing/how-risky-is-ecstasy-a-model-for-comparing-the-mortality-risks-of-ecstasy-use-dance-parties-and-related-activities.html - or: www.3Dresearch.org.uk). Sport-watching is also very habit-forming. And 3 pints of most beers in one session exceeds the recommended maximum limits for daily alcohol use. Clearly, believing or disbelieving all this stuff about addiction being a disease we have to recover from is enough to drive anyone to risky drug use and activities.... Enjoy! [wink, nod, etc.]

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    4. I find this addiction / disease / functioning addict very interesting.

      I'm an ICE user *crystal meth now the norm / society tells me that I should be increasing my intake due to tolerance I should also have all these sores on my face I should also lose ability of short term memory & develop a lying personality. Here I sit 8 years on this stuff no sores, great memory, no increase intake - I wonder what makes me different to society concept??

      Do I have an addiction or habit??? I can travel / work / go out not need this drug. Only time I crave is on certain day in certain environment.

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    5. I find this addiction / disease / functioning addict very interesting.

      I'm an ICE user *crystal meth now the norm / society tells me that I should be increasing my intake due to tolerance I should also have all these sores on my face I should also lose ability of short term memory & develop a lying personality. Here I sit 8 years on this stuff no sores, great memory, no increase intake - I wonder what makes me different to society concept??

      Do I have an addiction or habit??? I can travel / work / go out not need this drug. Only time I crave is on certain day in certain environment.

      Delete