The Sciences, July/August 1989, pp. 14-21.
Addiction Has Become an All-Purpose Excuse
Morristown, New Jersey
Swept up in the hurly-burly of an American presidential campaign, Kitty Dukakis looked to be in her element. Throughout the gaudy carnival of speechmaking and handshaking, she exuded warmth and a kind of kinetic energy that, to many observers, offered a refreshing contrast to the rather stolid manner of her husband, Massachusetts Governor Michael S. Dukakis, the Democratic aspirant. And, though candidate Dukakis was repudiated at the polls, his wife seemed to have emerged a winnerpopular and admired, with a lucrative career as an author and lecturer looming before her. But scarcely three months after the election, it was a weary, wistful Kitty Dukakis who appeared on the cover of Newsweek, with the headlines "Addictive Personalities: Who gets hooked on drugs and alcoholand why" and "Kitty Dukakis: Her private struggle."
Inside the magazine were more photographs showing her face haggard and tormented, accompanied by an account of why she had checked herself into Edgehill-Newport, a Rhode Island treatment center for alcohol and drug dependency. Mrs. Dukakis (who, in the past, had frankly discussed her apparently successful recovery from a twenty-six-year bout with amphetamines) had suddenly begun drinking to excess. As Governor Dukakis said at the time, "She clearly recognizes she has a sicknessand it is a sicknessand she had to deal with it."
Two weeks later, New York Newsday ran a front-page photograph of Grace Ann Machate, taken as she followed a flag-draped casket bearing the body of her husband, police officer Robert Machate, down the steps of a Brooklyn church. In the early-morning stillness several days before, Machate, twenty-five years old, had been slain with his own revolver on a deserted city street while attempting to arrest a suspected drug dealer. He was the seventh New York-area law officer killed in the line of duty within a year whose death was tied to drug trafficking. That day's newspaper also carried an Associated Press Wirephoto of Kitty and Michael Dukakis, smiling and waving buoyantly upon arriving home after Mrs. Dukakis's completion of treatment at Edgehill-Newport.
These stories exemplify the range of news about alcohol and drug problems that, through various media, bombards the American public. At one end of the spectrum are tales of high-powered celebrities entertainers, athletes, political figures some of whom, like Kitty Dukakis, enter expensive rehabilitation clinics. In stark contrast are grim reports from city streets, where random violence associated with heroin, cocaine, and, recently crack (a potent, inexpensive cocaine derivative) has infected many neighborhoods, threatening grandmothers, toddlers, and police officers alike. Between these extremes are constant reminders of how substance abuse threatens children of the middle class: one is hard put to find a town in New Jersey, for instance, without a street sign bearing the caution Drug-free School Zone. Similarly, organizations such as Mothers Against Drunk Driving have arisen from suburban, middle-class roots.
In the minds of most Americans, narcotics and alcohol are linked inextricable with addiction, an idea that conjures up images of the crazed user, oblivious to anything but obtaining more of his or her particular poison, who will stop at nothing to get it. To be sure, drugs and alcohol have chemical effects, and withdrawal from habitual use of those substances can elicit a raft of irritating physical sensations. But beyond that, science, and now the public, has embraced the notion that addicts suffer from a physiologically well-defined phenomenonas Governor Dukakis put it, "a sickness"even though repeated attempts to prove that addiction is a clear-cut medical condition have been, at best, inconclusive. The addiction-as-disease idea has spread wildly, to encompass not only chemical dependency but also a host of other compulsive behaviors, including gambling, overeating, undereating, shopping, and fornication. The "addiction" issue of Newsweek, for example, carried an unrelated story about the travails of Boston Red Sox third baseman Wade Boggs, who was being sued for twelve million dollars by a woman who had long provided him with companionship on road trips. In explaining the liaison, the married Boggs confessed that he was "addicted to sex"to which his former mistress responded, "I guess what I thought was love was just a disease."
The pervasive and growing influence of the disease model of addiction has serious ramifications for American society. The more psychologists and attorneys dismiss forms of misbehavior as uncontrollable compulsions, the less people are held accountable for their actionseven when they have harmed others. Often, the only penalty for gross, even criminal misconduct is undergoing counseling in a treatment center. Creating a world of addictive diseases may mean creating a world in which anything is excusable, one that must inevitably slide into chaos.
While the word is attached to a growing crowd of compulsive behaviors, addiction still is most commonly associated with narcotics useso much so that drug and addiction seem almost synonymous. The drugs most often thought of as addictive are the opiates (derivatives of opium, the dried milky discharge of the poppy plant), which are unsurpassed as pain-killers and sleep inducers and include heroin, morphine, and the milder formula, codeine.
Though opiates have been used commonly for most of recorded history, only since the eighteenth century have their addictive effects been explored in any detail. In one of the earliest descriptions of withdrawal symptoms, written in 1701, the English physician John Jones cited perspiration, frequent urination, loose bowels, depression, and chronic itching as likely results of sudden curtailment of habitual opium ingestion. Similar notes were sounded in scattered English medical journals over the next one hundred and fifty years, and in 1850, Jonathan Pereira, in Elements of Materia Medica and Therapeutics, one of the most respected medical manuals of the time, warned that excessive opium intake brings on moral, as well as physical, deterioration and that children of drug addicts were apt to be "weak, stunted, and decrepit."
Despite these caveats, the use of opiates in Europe and the United States spiraled upward. Physicians dispensed narcotics indiscriminately, and for the most part, neither the general public nor the medical profession had any notion that opiates were especially dangerous. While their consumption often was described as addictive, the opiates themselves were not considered any more habit-forming than other pharmacological agents. Indeed, prominent turn-of-the-century pharmacologists, such as Clifford Allbutt and Walter E. Dixon, of England, were just as concerned about withdrawal from caffeine, often resulting from curtailment of habitual coffee drinking:
The sufferer is tremulous and loses his self-command; he is subject to fits of agitation and depression. He has a haggard appearance.... As with other such agents, a renewed dose of the poison gives temporary relief, but at the cost of future misery.
At that time, according to the English research team of historian Virginia Berridge and psychiatrist Griffith Edwards (writing in 1981, in Opium and the People, an extensive review of English opiate use during the nineteenth century), addiction was viewed as any indulgence in an act that was mildly damaging to health and perhaps a little bit of a nuisance.
In the final quarter of the nineteenth century a small number of German scientists began to conduct research into drug addiction. In 1878, one of them, the physician Eduard Levinstein. published The Morbid Craving for Morphia in which he described morphia addiction as "the uncontrollable desire. . . to use morphine as a stimulant and a tonic and the diseased state of the system caused by the injudicious use of the said remedy." And, presaging modern notions, he argued, albeit without experimental evidence, that the compulsion to take narcotics results "from the natural constitution"that, in effect, drug addicts are victims of physiology. Still, Levinstein remained true to the established view of his time (and, increasingly, our own), making no distinction between addiction to drugs and other "passions," including smoking, gambling, greed, and sexual excess.
The reclassification of drug addiction as a medical condition rather than as a passion, vice, or other behavioral phenomenon did not occur as a result of startling new studies of narcotics users or even of animal experiments. Instead, the idea slipped unseen into the realm of conventional wisdom on the coattails of other scientific developments. In finding bacterial and viral causes for infectious diseases, Louis Pasteur, Robert Koch, and other researchers of a century ago helped create a climate in which a medical cure for almost any ill seemed possible. And since drug addiction has physical manifestations, it seemed safe to assume that it, too, was a disease that could be cured, even in the absence of evidence that addiction displays specific symptoms, follows a particular course, or responds to treatment as infectious diseases do.
Coincidental with the medicalizing of addiction was a dramatic rise in the number of drug addicts. The reasons are unclear, but when alcoholism and compulsive drug use gained acceptance as forms of illness, during the 1890s, narcotics addiction had ebbed in England and America. Then, during the next ten years the trend reversed, and by 1910 the level of English opium consumption had returned to its nineteenth-century peaks.
The situation in the United States was in some ways more extreme. Like the English, Americans consumed massive quantities of opium at the turn of the century, especially in the form of patent medicines available at local dime stores and peddled by itinerant salesmen. Another important catalyst for American addiction had come in 1898, with the invention by the Bayer company of the morphine derivative heroin. Legal at the time, heroin was easily administered by syringe and was ten times more potent than its parent drug.
America went on to become the world leader in narcotics addiction. In many nations the opium poppy is cultivated openly, yet addiction is virtually nonexistent: native peoples consider the drug harmless and use it only for ceremonial purposes. European nationsincluding France, where much of America's heroin supply is processed also have had negligible addiction problems. Even England has had dramatically lower levels of heroin addiction than the United States. Indeed, drug use in America has come to be surrounded by a kind of mystique, which intensified when control of narcotics began to shift from physicians to government and law-enforcement officials. (In 1914, the Harrison Act, passed by the U.S. Congress, regulated the use of opiates and other drugs.) And as drugs became an object of social disapproval, there was a change in the groups that used them.
During the 1800s, much attention was focused on Chinese opium smoking, but the leading consumers of opium were, in fact, white, middle-class women, who apparently preferred the drug to their husbands' alternative, alcohol. By 1920, however, drugs had moved underground, to urban ghettos, where they were used predominantly by poor immigrant and minority males. Narcotics, especially heroin, had become an exotic source of horror and fascination for Americans. What once had been available at any local apothecary now was seen as the agent of an insidious compulsion that was an inevitable consequence of its use. Still, despite all the research into the pathology of cholera, malaria, influenza, and other diseases, the first quarter of this century passed before any attempt was made to find physiological evidence that narcotics use meant inescapable physical bondage.
The pioneering effort to demonstrate a biomedical basis for addiction in human drug users was begun in 1925, at Philadelphia General Hospital. A team of researchersan internist, a pathologist, a psychiatrist, and a chemistadministered a series of heavy doses of morphine to a group of drug addicts. To check for signs of physiological addiction, they measured the subjects' body functions and observed their performance on several tasks during withdrawal. But they found little evidence that addiction was much more than a result of the subjects' imaginations. In one of a series of articles based on this research, published in 1929 in the Archives of Internal Medicine, two of the Philadelphia physicians, Arthur B. Light and Edward G. Torrance, described the amazing behavior of their most recalcitrant subject, a man who was the quickest to express his displeasure when there was even the slightest delay in the administration of a drug. He refused to continue the experiment thirty-six hours after withdrawal, demanding instead that he be given more morphine. Light and Torrance administered a placebo and were bemused when the man "promptly went to sleep for a period of eight hours," never aware that he had been given "nothing but sterile water."
The researchers noted that, in general, though "the incessant begging and annoying behavior of the addict" during withdrawal "becomes at times almost unbearable," there were no marked changes in their patients' metabolism, circulation, respiration, or blood composition. Light and Torrance did observe such withdrawal symptoms as vomiting, diarrhea, perspiration and nervousness, but because these occurred inconsistently, they did not appear to indicate a medical syndrome. In fact, the researchers reported that similar symptoms can be found among members of a university football team just before the proverbial big gamesymptoms that disappear "when the whistle starting the game is blown."
Over the years, this work has been all but dismissed by the scientific community. Light and Torrance have been accused of ignoring the biological realities of addiction by mistaking physiological withdrawal for malingering. But this criticism fails to account for some of the most striking aspects of their findings. The addicts in their studies had been given extremely high levels of morphinecertainly in comparison with standard doses of narcotics available to American street addicts todayyet, when eventually denied their fixes, they overcame the ensuing withdrawal symptoms and lost their cravings. Some did so under forced regimens of physical exertion (when withdrawal set in, they were made to climb steps, for instance); others, after placebo injections.
In contrast, today's heroin addicts typically manifest severe, unremitting withdrawal symptoms when deprived of the drug at treatment centerseven though, as opposed to the addicts in the 1925 study, they often enter rehabilitation with no detectable concentrations of narcotics in their systems. (Drugs sold on the street typically are mixed with liberal amounts of benign substances, so the user is not exposed to large doses of narcotics.) Nevertheless, physicians continue to maintain that withdrawal and readdiction are inevitable consequences of habitual narcotics use, inherent in the chemical properties of the drugsand that people who rake these drugs are bound to consume them more frequently, compulsively, and invariantly than do users of other, so-called nonaddictive pharmacological products.
One of the most damning refutations of this belief is research into narcotics use by American soldiers who served in Vietnam. A vast proportion of the men used opiates at one time or another during the war. This panicked American officials, who anticipated a wholesale influx of addicts stateside when the veterans returned home. The U.S. Department of Defense commissioned a research team, led by the epidemiologist Lee N. Robins, to study the military drug problem. Robins and her colleagues interviewed more than five hundred men who had used narcotics in Vietnam (identified by urine screening upon their departure) one year and then three years after their return home. Most had received a concentrated form of the drugs while in Southeast Asia, and of those who took narcotics five or more times, nearly three-quarters reported becoming addicted: they suffered significant withdrawal symptoms when they were forced to stop using heroin for various reasons (they could not get any while out on patrol, for example).
According to all widely accepted ideas about heroin abuse, recovery depends on total abstinence. So, most of the returning soldiers who had been addicts, had they sought the drug back in the United States, should have become readdicted in short order. But Robins discovered that, while fully half of those who had been addicted in Vietnam used narcotics again upon their return home, only one-eighth became readdicted after three years back in the United States. And only half of those who used heroin frequentlymore than once a week for what Robins described as "a considerable period of time" became readdicted.
Robins's research yielded other surprising results. The returning veterans in her sample commonly consumed a variety of drugs besides heroin, including marijuana and amphetamines, though heroin addicts supposedly are possessed by a monomaniacal obsession for heroin. Moreover, their indulgence in heroin was no more compulsive or uncontrollable than their consumption of the other substances. All this evidence calls into question the long-held claim that opiates are special agents of addiction. Remarkably, however, such findings have had virtually no impact on addiction research and theory.
More influential has been a large body of experiments in which rats or monkeys continually self-administer drugs in the laboratorystudies often cited in support of the argument that narcotics are uniquely addictive. Yet, what many of these experiments have demonstrated is that it can be extremely difficult to addict animals. John L. Falk, a behavioral pharmacologist at Rutgers University, in New Jersey, found it necessary to alter the accustomed feeding regimen of rats to get them to drink significant amounts of alcohol. When a normal feeding regimen was resumed, the rats lost nearly all interest in alcohol. As Falk pointed out in a 1983 article entitled "Drug Dependence: Myth or Motive?" these results are consistent with other investigations showing that the motivational power of drugs over animals is "altered radically by seemingly small changes in the behavioral context." For example, many studies in which animals are required to press a bar to earn a narcotic injection have shown that increasing only slightly the number of requisite bar presses can halt the animal's drug consumption.
In one series of experiments, Bruce K. Alexander, a psychologist at Simon Fraser University, in British Columbia, found that rats housed together in a large cage would not choose an opiate solution over water but that rats isolated in small cages drank significantly more of the opiate. Moreover, even after a period of being allowed to drink only the drugged liquid, the animals that had been isolated also chose water over the opiate when they were placed in the roomier cage and could once again enjoy the companionship of other rats. These experiments strongly suggest that drug dependence is a consequence of behavior and environment, and that, although animals and some people will, under certain circumstances, consume drugs excessively and compulsively, it does not follow that narcotics are inherently addictive.
Certainly, the Vietnam experience also served as a kind of laboratory demonstration of how environmental factors can create a climate hospitable to addiction. In Southeast Asia, most American soldiers encountered a range of emotions and sensations unlike anything they had experienced at home: incessant fear, constant physical discomfort, intense loneliness for family and friends, the necessity for killing, a sense of complete helplessness the inability to control their own destinies or even to know whether they would live to see the next dawn. In this alien world, the numbing, analgesic effects of narcotics were welcomed. But when returned to the secure familiarity of home, most of the men who were hooked in Vietnameven if they felt moved to take a drug now and againdid not find narcotics addictively alluring.
As Harold Kalant, a pharmacologist at the Addiction Research Foundation, in Toronto, observed after decades of work, given that the drug user or alcoholic often continues to seek the intoxicated state even after completing the period of withdrawal, there can be no pharmacological or biological explanations for this behavior. Clearly, any habit has an impact on a person's body and mind, but interpreting how a pharmacological experience feels, deciding that this feeling is desirable, concluding that it is impossible to live without it, and seeking more of it all are matters of individual perception and choice.
Given that there is no evidence for a purely physiological explanation of addiction, the whole process of labeling a drug addictive is arbitrary at best. One of the more telling examples of this is the evolution of American public policy concerning cocaine. As difficult as it may be to fathom today, cocaine once was an active ingredient in soda pop: Coca-Cola contained a dose of the drug until 1903. Though narcotics researchers have explored the addictive potential of cocaine for the past fifty years in the laboratory, only upon a sudden rise in recreational cocaine consumption, as well as a proportional rise in compulsive use, during the early eighties, did government agencies ordain that the drug be regarded as addictive. In fact, that judgment directly contradicted the most comprehensive experimental findings available.
In a recent survey, investigators at the Toronto addiction-research center found that twenty percent of the recreational cocaine users they studied had frequently been seized by an urge to continue taking the drug, but, even among this minority, most did not become fully addicted. A review of the literature on cocaine use, by the Yale University psychiatrist David Musto, pointed out that less than ten percent of regular cocaine users descend into a pattern of compulsive, uncontrollable consumption. Nonetheless, we are warned repeatedly that to "say yes" to cocaine is to slide inexorably into chemical bondage and, ultimately, death.
As Berridge and Edwards point out, this publicity campaign echoes an earlier time: "The nineteenth - century discovery that the addict is a suitable case for treatment is today an entrenched and unquestionable premise, with society unaware of the arbitrariness of this come-lately assumption." The researchers add that any suggestion that addicts be "left to their own devices would be dismissed only as outrageous and bizarre." In the light of the failure of researchers to link narcotics addiction or, for that matter, alcoholism with physiology, it seems all the more absurd that so many sexually driven people, compulsive shoppers, and other obsessive types have joined substance abusers in the special programs and treatment centers that have proliferated across the country.
What, exactly, goes on inside these rehabilitation facilities? Certainly, Edwards's disillusionment with them is based, in part, on his own research experience in England (where he is considered the leading psychiatric authority on addiction). In a controlled study of hospital treatment for alcoholism, he and his colleagues found that problem drinkers given a single session of counseling improved just as much as a comparable group receiving the full complement of inpatient and outpatient hospital services, including detoxification programs and follow-up counseling. Similarly, a study by the psychiatrist George Vaillant, of Dartmouth College, checked the progress of hospital-treated alcoholics two and then eight years after their release. Though some had cut down on drinking or ceased altogether, they had done so only in roughly the same proportions as untreated alcoholics.
Still, many graduates of treatment centers passionately proclaim that their lives have been saved by the help they sought. In part, this may be because alcoholics and addicts who enter such treatment programs often are effectively brainwashed into believing they have an incurable disease. The sociologist David R. Rudy, of Morehead State University, in Kentucky, who observed several chapters of Alcoholics Anonymous, reported, in Becoming Alcoholic, that a number of those who entered these groups did so believing that they had some kind of drinking problem but not that they had succumbed to uncontrollable alcoholism. Once inside the group, however, they quickly were shown the error of their thinking; new members were pressured into acknowledging that, because of their disease, their drinking was out of control.
This brainwashing exerts a powerful influence on the addict's perception of his or her addiction. An experiment conducted by the psychologist C. Alan Marlatt, of the University of Washington, in Seattle, demonstrated the effects on active alcoholics of believing that one slip off the wagon leads to a binge. Alcoholics in the study were given highly flavored drinks either with or without alcohol. Some were told that they were drinking liquor, others that they were consuming a nonalcoholic beverage. Marlatt found that alcoholics who believed they were drinking alcoholwhether or not they weredrank significantly more than those who were actually given alcohol without their knowledge. Having learned that even a casual brush with liquor means an inevitable relapse, the alcoholics given the placebo lived out their expectations. But it had nothing to do with physiology.
The fundamental tenet of Alcoholics Anonymousthat alcoholism is never curedhas been imposed upon almost every bad habit imaginable, and as a result, a thriving addiction-treatment industry has developed in the United States. Comparing statistics from 1942 with those from 1976, Robin Room, of the Alcohol Research Group, in Berkeley, California, found that the number of people being treated for alcoholism in America, per capita, had increased twentyfold. And in the ten years since Room's survey treatment has continued to grow at an alarming rate. Yet Americans over twenty-one drink less today than a decade ago. One explanation for this paradox is that the threshold for labeling a person chemically dependent has been loweredas with Kitty Dukakis, who referred herself to Edgehill-Newport because she had gotten drunk a few times after years of moderate drinking. By attracting such alcoholics as Mrs. Dukakis, private hospital chains that specialize in treating substance abuse continue to expand.
Meanwhile, new addiction-treatment groups modeled on Alcoholics Anonymous have proliferated, as well. The National Council on Compulsive Gambling, which coalesced from numerous Gamblers Anonymous groups, has grown even more rapidly during the eighties than the AA-inspired National Council on Alcoholism. Sometimes, compulsive gamblers are treated in hospitals, frequently on the same inpatient wards as alcoholics. And there is a National Association on Sexual Addiction Problems, as well as a nationwide network of Sex Addicts Anonymous branches, both of which support hospital treatment for "victims" of compulsive copulation.
Perhaps the most dire consequence of the disease model of addiction is that it has encouraged the abdication of individual responsibility for outrageous conduct. The addict is a victim and, thus unaccountable for his actions. The misadventures of Wade Boggs, confessed "sex addict," may have provided the public with a measure of titillation. But another recent news eventthe object of even more intense public and media preoccupationhad a more chilling aspect: jurors declined to deliver a murder conviction against Joel Steinberg (the disbarred Manhattan lawyer convicted of manslaughter in the fatal beating of his illegally adopted six-year-old daughter, Lisa), partly because they felt Steinberg, a habitual drug user, was under the influence of cocaine at the time of his daughter's death and, so, was not fully responsible.
Certainly, Joel Steinberg may have been impaired by the effects of a drug when he murdered Lisa. But was he suffering from a disease? Is there something in cocaine that interacted with the cells in Joel Steinberg's body to enslave him to the drug. And if so, must we forgive him for killing a child? There is no justification within the realm of science for making that conceptual leap.