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Historical Understandings of Addiction
C H A P T E R
1 Historical Understandings of Addiction Joseph Westermeyer*, $ *
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University of Minnesota, Minneapolis, MN, USA Minneapolis VA Medical Center, Minneapolis, MN, USA
O U T L I N E Background Rationale for Addiction Terms and Concepts Models for Episodic Intoxication in Traditional Societies Intoxication Gone Awry: Appearance of Widespread Addiction
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Personality Disorder Model Neurotransmitter Model Neuroanatomic Model Learning Model Dyadic Enabling/Rescuing Model Route-of-Administration Model Comorbidity Model Salutogenic or Self-treatment Model Genetic Model Externalizing Disorder Model Recovery Model Readiness-to-Change Model The Harm Reduction Model
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Models for Understanding Addiction Existing Prior to 1600 AD Moral Model Criminal Model Preternatural Model
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Models Appearing Between 1600 and 1900 AD Epidemic Model Illness Model
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Models Appearing Since 1900 AD
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Conclusion
BACKGROUND
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alcohol may be called khun-kee-lao or literally personexcrement-alcohol. A person who spent most of the day intoxicated on opium might be referred to as khun-kee-dyafeen or person-excrement-opium. The populace at large uses these terms commonly in societies with widespread alcohol or drug addiction. They are not technical terms employed only by healers, jurists, or literati. Their popular usage indicates that addiction occurs sufficiently often to warrant a special term. When enough people manifest addiction, a term has evolved to ease communication about them, their behavior, or their own personal experience (e.g. “When I became ill after I stopped using, I realized I was addicted”). These special terms foster abstract thought about addiction. Not surprisingly, models have appeared
Rationale for Addiction Terms and Concepts The term addiction, from the Latin addictionem or a devoting, first appeared in the English language around the sixteenth century. During recent historical times, words that indicate alcoholism or opiate addiction have appeared in many languages. Even in societies without written language, such terms exist. For example, in the Tai-Lao languages of Southeast Asia, these terms involve one word meaning attached to or stuck to be followed by the term for alcohol or opium (e.g. teat-dyafeen, literally stuck, attached, or connected to opium for opium addiction). At times, these terms have a derogatory connotation. For example, in the Tai-Lao languages, a deteriorated person dependent on Principles of Addiction, Volume 1 http://dx.doi.org/10.1016/B978-0-12-398336-7.00001-2
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1. HISTORICAL UNDERSTANDINGS OF ADDICTION
over the centuries to explain or elaborate on the experience or observation of substance use. Related concepts have also evolved, such as ideas regarding causation, related manifestations, or solutions to addiction-related problems. As with all terms in common lay usage, they involve not only denotative or cognitive aspects but also connotative or value-laden aspects. For example, a homeless alcohol-dependent patient wanted me to know that he considered himself a common drunk, but under no circumstances was he an alcoholic.
Models for Episodic Intoxication in Traditional Societies All cultures have forms of time out in which the daily customs or rules governing roles, responsibilities, and behavior are temporarily in abeyance. These are often time-limited periods of celebration, socialization, relaxation, and/or feasting. For example, Roman festivities involved wine drinking with feasting on special foods. The so-called “drunken comportment” may itself signal respite from one’s usual roles and responsibilities. In some cultures, substance use may involve a highly valued altered state of consciousness. The latter states may provide a means of communing with spirit world, so that individuals may be guided, inspired, or instructed on how to proceed with their lives. For example, in the Americas, aboriginal cultures often employed psychoactive substances to commune with the spirit world. Other methods, including fasting, sleeplessness, and isolation from other people, were used in the quest of supernatural guidance. In addition to ceremonial use at important annual ceremonies (e.g. Passover, New Year), psychoactive substance use has attended numerous rituals in the life of individuals. Examples include important social contracts (e.g. the du-tsen in Germanic cultures, sheltering a stranger in the Middle East, commercial or political relationships in Southeast Asia, life milestones such as graduation, marriage, childbirth, or death). Medicinal use of psychoactive substances has long been used to relieve illness, or at least the symptoms of illness. For example, opium can relieve acute pain, diarrhea, cough, fear, dysphoria, and other forms of misery. In areas where alcohol was distilled, people added various herbal compounds to alcohol (including opium) for their presumed medicinal properties. Sometimes healers added objects to alcohol (e.g. snakes, insects, minerals) to bring the presumed special attributes of these objects to the suffering individual. Preparation of beer, wine, and distilled beverages permitted the storage of carbohydrates in the form of alcohol. Used in this way as a foodstuff, beverage alcohol could augment the diet during times of the year that food was not being produced. These drinks
introduced tastes that could enhance the taste of food. Beverage alcohol could substitute water in settings where potable water was not readily available (although excessive doses purge body fluids through its diuretic effect). Small doses of some psychoactive substances, such as cannabis, have long been used as condiments in soups and baked goods. Use of alcohol and drugs served several religious and spiritual functions. During religious ceremonies and rituals, priests and sometimes devotees at large consumed sacramental alcohol and drugs. The latter included consumption of hallucinogenic mushrooms and other plant products (such as peyote) in the Americas. The Native American Church in North America has continued this practice in modern times as a means of communicating with the spiritual world, addressing conflicts and personal distress, and finding one’s way into a moral, productive future. Societal control predominated over individual choice in the traditional use of these psychoactive substances in earlier times. For example, all individuals might have their beverage containers filled at the same time so that no one drank more (or less) than a socially prescribed amount. Occasions of use were socially determined, limiting the frequency of use. This traditional form of control began eroding when masses of people received beverage alcohol as payment for work in industrialized England. People began to drink daily, sometimes even before starting work in the morning. This daylong drinking favored individual choice over drinking, as well as physical dependence on alcohol.
Intoxication Gone Awry: Appearance of Widespread Addiction Addiction required daily consumption. Such use led to increasing dosage to obtain the desired effects for certain psychoactive substances, including alcohol, opium, cannabis, sedatives, and tobacco. Increased frequency and dosage almost inevitably produced consequences: economic, psycho-physiological adaptation, and biomedical complications. Depending on the substance, these consequences occurred within a few years to a decade or longer. For example, drugs such as heroin and cocaine can produce consequences sooner. Substances such as alcohol and opium require several years to a decade or longer in the average case. A common manifestation with most psychoactive substances is the need for increasing doses to produce the same, desirable effects. Thus, an alcohol drinker who experienced relaxation and other positive effects from 1 or 2 oz. of alcohol will need twice, then four, and later ten times that amount to produce the same desired effects. The same occurs with opium and heroin, with even higher multiples in some cases. Similar escalations occur with
I. THE NATURE OF ADDICTION
MODELS FOR UNDERSTANDING ADDICTION EXISTING PRIOR TO 1600 AD
tobacco, cocaine, and other stimulants, and certain other drugs (e.g. sedatives, cannabis, phencyclidine). Economic and technical advances have permitted the expenditure of time, resources, and wealth to permit widespread addiction. In past centuries, much effort was required to produce sufficient carbohydrate, opium poppy, or tobacco to permit many people to engage in daily use of large doses. In the Caribbean, slaves on plantations grew sugarcane used to distill rum and gin. Trading ships from England distributed goods along the eastern coast of North America. Before heading back home to England, they picked up ballast in the form of beverage alcohol. Likewise, the English raised poppy in India to use in trade with Southeast Asia, China, and Japan. Thus, the worldwide phenomenon of widespread addiction after 1600 AD depended on such innovations as the following: • Production of excess carbohydrate in large amounts, as a result of slave labor, or plantation-based mass production, and/or technical innovations (such as the iron plow, use of fertilization, irrigation) to produce alcohol. • New methods of growing labor-intensive drugs, such as opium, tobacco, or betel-areca nut, again using plantations and new agro-technology. • Distillation of beverage alcohol and drug preparations to extract active agents (e.g. morphine or heroin from opium), which reduced the cost of transportation over great distances, making lower cost alcohol or drugs available in areas that had no experience, and hence no resistance to their use. • The short half-life of some purified substances (e.g. heroin) as compared to the parent compound (e.g. opium) hastened the development of addiction as well as the consequences wrought by addiction.
MODELS FOR UNDERSTANDING ADDICTION EXISTING PRIOR TO 1600 AD People cannot avoid positing causes for observed behaviors, especially when these behaviors are problematic. Inevitably, these causal explanations, also called models or paradigms, tend to lead to interventions.
Moral Model In many societies after 1600 AD, citizens no longer hued to one tradition governing use of psychoactive substances. Organized religion often fed this diversity, as adherents of one sect forbade use while those in other sects approved moderate use. Eventually, decisions whether to use, when to use, and how much to use fell
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to individual choice in many times and places. In turn, this led to presumed morality in making such choices. Abstention or moderate use was deemed as morally good, whereas excessive, problematic use was judged as morally bad. Those consistently making bad decisions came to be viewed as morally weak, corrupt, or full-of-sin (sinful). This model prevails today in many instances. For example, if a society values individual responsibility and accountability, people will view many, if not most of their important decisions as having moral implications. Purchase and consumption of alcohol in significant amounts can deplete families of necessary resources, result in poor health that drains family wellbeing, and led to irresponsible behavior that harms family members or other members of society. As addicted persons fail in their attempts to change or curb their own behavior, they often apply this model to themselves. That is, they perceive themselves as morally bad or having weak character. Families and friends may also apply a moral model in judging the consumptive behavior of an addicted person. The moral model may lead to changes in behavior that can be successful in early stages of heavy use or addiction. Later, these models seldom work for any length of time. Most clinicians learn that this model seldom helps in the case of severe addiction. Organized religions have addressed excessive substance use and addiction as a moral dilemma for their adherents. Many religions have prescribed total abstention as a solution. For example, Hinduism, Buddhism, and Islam have opposed the use of alcohol and recreational drug use for centuries. Although some use may be permitted in some Hindu, Buddhist, and Islamic societies, the clergy and the religious laity have been urged toward total abstinence. In Judaism and Roman Catholicism, the use of alcohol in religious rituals has imparted a message that this sacramental substance should be respected and not abused. Following widespread addiction in the seventeenth and eighteenth centuries, many abstinent-oriented Christian and other sects arose, forbidding use among their members.
Criminal Model The criminal model bears a strong relationship to the moral model, from which it stems. As societies experienced increasing social problems associated with addiction, some societies defined addictive behavior or excessive alcohol–drug consumption as a crime against society, and not simply a moral failing. Depending on the society and the point in time, any public intoxication might be punished. Or only dangerous behavior associated with intoxication (such as fighting or beating family members) might be punished.
I. THE NATURE OF ADDICTION
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In colonial times in the United States, heavy or addicted drinkers might be placed in wooden stocks, located in a public place. Not only would this punishment restrict the addict’s freedom, it would also impose discomforting immobility in the stocks. Since stocks were typically located in a public place, the punishment involved public shaming. Whether it proved effective in ameliorating or reducing addiction is unknown, but it did create a public attitude against addiction. This model still persists in many venues today. For example, some communities publish the names of those arrested for drunken driving or public intoxication. Pregnant mothers whose use of alcohol or drugs may threaten the development of their baby in utero may have their freedoms circumscribed until childbirth. The war on drugs policy in many modern nations, in which drugs are viewed as foisted on innocent people by criminal producers and traffickers, owes its persistence to this model.
Preternatural Model In many cultures, alcohol and drugs were imbued with preternatural or even supernatural powers. The preternatural model also owes its origins partially to the moral model, as people believed that no rational person would choose addiction over abstinence of moderate use. That is, the psychoactive substance was viewed as having the ability to take over the person’s mind, will, or soul through means that transcended the natural world. This model has sometimes been called the devil in the drug model. In this view, substances such as alcohol, opium, or cannabis are so inherently evil and even demonic that any use is evil. Such use may then be labeled as sinful, so that the person’s inherent goodness may be doubted or denied. Although this model is still popular in many settings, increasing knowledge of the neurotransmitter, neuroanatomical, and genetic nature of addictogenic psychoactive substances has challenged these early supernatural explanations, while also providing explanations regarding why alcohol and drugs can weaken the will and moral resolve of addicted persons.
MODELS APPEARING BETWEEN 1600 AND 1900 AD
Moreover, they both involved a complex of new behaviors not modified by tradition, plus international trade. The English gin epidemic (which also involved rum) involved the import of cheap distilled beverage alcohol from the Caribbean area. In the early stages of the Industrial Revolution, English ships brought merchandise to Canada, the American colonies, and then the Caribbean. Needing ballast for the return trip to England, they first used stones, then sugarcane and other agricultural products, and finally distilled alcohol. On the docks of Liverpool, a calorie of beverage alcohol could be purchased for less than calorie of bread. Factory owners often paid workers in alcohol. Unfettered by the traditions governing use of mead, workers made their own decisions regarding when and how much to drink. The result was widespread excessive drinking. Other places in Europe as well as North America similarly became enamored with heavy drinking. Led by England, several responses gradually led to a reduction in alcohol addiction. One of these interventions involved taxing alcohol beverage. Abstinence-oriented Christianity began around this time. In England, popular eight-page booklets described the depredations of alcohol, together with wood-block pictures of the consequences, including fetal alcohol syndrome, child neglect and abuse, fights, accidents, theft, and poor workmanship. In the United States, small residential asylums were developed to treat chronic alcohol abuse. Within years after contact was established between the Americas and Eurasia, tobacco smoking appeared in the Orient. Tobacco smoking houses appeared, frequently by youth, political dissidents, and other independent-minded people. Several nations of Asia closed these public smoking houses. The result was the wedding of opium, an old substance once consumed only by eating, and smoking, a new method of administration. Opium smoking spread like wildfire in Southeast Asia and the East Orient, including China, Korea, and Japan. As in Europe, many strategies against opium addiction began. One of these was anti-opium societies, whose members endeavored to bring addicted people to residential facilities that provided withdrawal treatment, nourishment, and respite. Several countries also passed laws against the production and/or import of opium. In China, a cabinet-level minister was appointed to limit production, commerce, and use of opium. The United States mimicked many of these measures over time.
Epidemic Model Two epidemics of addictive disorder appeared in the 1600s and spread notably by the early 1700s. They occurred around the same time, although they involved different substances in different parts of the world.
Illness Model As noted above, this model evolved in Asia, Europe, and North America to counter widespread opium and alcohol addiction. During that period, it typically
I. THE NATURE OF ADDICTION
MODELS APPEARING SINCE 1900 AD
involved admission to a hospital or residential facility, often in a rural area. So-called moral treatment, developed for psychiatric disorders, included shelter, nourishment, daily activities, supervision, and respectful social interactions. This model is often inappropriately described as the medical model of addiction. Although the term medical model may apply to the downstream attempts to reverse addiction in medical settings or by physicians, it is the illness model that gave rise to treatment in the first place. This model evolved over two centuries ago when addicted persons were unable to cease addictive use of psychoactive substances on their own. One of the first instances of this model occurred in the United States around 1800. Small therapeutic households (or asylum) developed in rural areas to provide a period of supervised abstinence for alcohol addicts. Although some physicians were active in developing this resource, nonphysicians established and ran these recovery-oriented households. During the Opium Epidemic in China and other parts of Asia, small clinics and hospitals were established to support addicted persons through withdrawal and a return to health. Locally established anti-opium societies provided material support and referred addicts to these facilities. A social concern related to this model has focused on the fear that addicts might present the illness model as a rationale for continued addictive use of a substance. Although this does occur rarely in addicted persons who may want to continue their addictive use, most addicted persons develop a moral imperative to return to responsible living, once they have some months of healthful sobriety. Another fear relates to the worry that unethical clinicians might provide ineffective treatment as a means of accumulating wealth. Again, this can occur; but ethical clinicians do not experience enhanced self-esteem in their healing roles by sponsoring ineffective therapies. The illness model involves processes that proceed along psychological, psychosocial, and cultural lines. First, the addicted person must view himself or herself as a blighted or diseased person in need of outside help. This step, involving illness behavior, occurs after a period of misery and dysfunction. Second, those around the person must be willing to deed the person a period of relief from ordinary social expectations and responsibilities, in order to permit treatment and recovery. This involved social assignment of a temporary sick role. Third, a culturally approved or licensed health care worker must ordain that disease exists and treatment is warranted. The social assignment of a sick role usually continues as long as the suffering person is willing to undergo the physical, psychological, or social burdens associated with treatment.
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MODELS APPEARING SINCE 1900 AD Personality Disorder Model During the early 1900s, diagnostic classifications included alcoholism and drug addiction as a personality or character disorder. These disorders were viewed as a form of antisocial personality, since the individual broke social mores, acted primarily in their own apparent self-interest, and often transgressed the rights of others while intoxicated or drug seeking. According to this view, addiction evolved in irresponsible or selfcentered people who ignored the effects of their choices and behaviors on others. The second edition of the Diagnostic and Statistical Manual of the American Psychiatric Association typified this perspective. During this period, personality and character disorders were seen as untreatable. Thus, this model justified the noninvolvement of many clinicians in the care of these patients. Despite this professional viewpoint, many states provided asylum-type care. Private asylum or dry-out farms also operated. Abandoned by the medical profession, alcoholics in the United States supported one another’s recovery in the brotherhood of Alcoholics Anonymous (AA). One of the founding members of AA, himself a physician, used the analogy of allergy to describe the individual, and presumed idiosyncratic response of alcoholics to alcohol. This analogy bears strong resemblance to the Illness Model from the previous century. Alcoholics Anonymous borrowed heavily from an English self-improvement group that aimed at maturity and balance, using early Christian principles. Although not sponsored by organized religion, it employed spiritual guidance and growth as a means of achieving a rewarding, responsible life way in the modern industrialized world.
Neurotransmitter Model Alcohol, opium, and other substances of abuse mimic or affect naturally occurring neurotransmitters. Neurotransmission was key to understanding pain and analgesia, anxiety and relaxation, dysphoria and euphoria, dissociation and vigilance. Increased understanding of drug/alcohol-related effects on brain and behavior has led to other theories, as well as to new therapies of addiction. In turn, new information accruing from successful treatment of addiction has enriched our theoretical perspective on addiction. Various drugs of abuse relate to specific neurotransmitter systems. For example, opioid drugs mimic the effects of endogenous opioid-like substances (i.e. endorphins). Cocaine, amphetamines, and other stimulants affect the adrenergic and dopaminergic systems.
I. THE NATURE OF ADDICTION
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Nicotine affects muscarinic receptors. Cannabis and its active compound tetrahydrocannabinol stimulate an endogenous cannabinoid receptor. Benzodiazepines and other sedatives trip a benzodiazepine receptor, which in turn affects the actions of gamma-aminobutyric acid. Medications anatagonistic to these substances (e.g. disulfiram for alcohol, naltrexone for opioids) have been used in treatment.
Neuroanatomic Model Certain areas of organelles of the brain are related to alcohol or drug effects. For example, the dopaminergic locus accumbens appears to be a site involved in the reward experienced with psychoactive substance use. Alcohol, sedatives, and opioids reduce the contributions of the frontal lobes that facilitate recall, executive decision-making, interpersonal sensitivity, judgment, and morality. Awareness of these brain functions and their dysfunction during addiction contributes to an understanding of why addictive behaviors may persist despite their damaging effects on the individual. Damage of particular areas of the brain can aid clinicians in recognizing certain stereotypic conditions associated with addiction. For example, damage to the mammillary body area of the brain can produce a chronic inability to store recent memory, a lesion that produces an inability to live independently. Damage to the frontal lobes can foster disinhibited, intrusive speech and behavior.
Dyadic Enabling/Rescuing Model Described first by Eric Berne, this model involves the interaction between at least two people. One of these could be an addicted person, who relates to the second person in a child-like or dependent role. The second individual relates to the addicted person as a parent, helper, or authority figure. This role relationship is apt to accentuate the dependent behavior of the addicted person, while frustrating the second person who expects the proffered help to ameliorate the addiction (which it seldom does, if given without contingencies). The helper may enable the addictive behavior by providing shelter, food, resources, or even drugs or alcohol to the addicted person. Enabling fosters continued using alcohol or drugs without experiencing the social, economic, or other consequences of use (e.g. poverty, no food or shelter). The ultimate effect is a worsening of the addicted person’s condition. Rescuing involves the parental, helping person saving the child-like, dependent person from social or other consequences of addiction. For example, a policeman may cite a drunk driver for another, lesser offense than the actual offense. Or a judge might not exact a legal punishment because it is a first offense. Rescuing, like enabling, is often undertaken in hopes that the beneficent action will goad the addicted person toward recovery. Unfortunately, rescuing generally exacerbates rather than alleviates addiction.
Route-of-Administration Model Learning Model This model views addiction as a learned behavior that follows upon certain learned stimuli. For example, a person might experience withdrawal symptoms in a setting where alcohol or drug use had previously occurred. In this example, the effect of the alcohol or drug use is the unconditioned response and the alcohol or drug itself is the unconditioned stimulus. The environmental cues associated with the presence of alcohol or drugs are the conditioned stimuli that can produce drug seeking and drug using. This model can be used therapeutically by avoiding cues that stimulate urges to use and by extinguishing craving responses to these cues. Recalling and imaging the aversive consequences brought on by use may also be employed. Medications that eliminate the desired drug or alcohol effects can be useful in extinguishing addiction-related learned behavior. On the level of the community, learning can be used to reward behaviors inconsistent with alcohol or drug abuse (e.g. family interactions, employment, abstinentoriented recreation).
Many substances can be consumed by more than one route of self-administration. Routes that have utilized over time include the following: Route Eat/drink Subcutaneous
Absorption absorption
skin tissue (injection) Intramuscular muscle tissue (injection) Chewing oral mucosa Rectal Vaginal Snuffing Smoking Intravenous
I. THE NATURE OF ADDICTION
Rapidity of effect slow (10 to 20 minutes) slow slow to medium
medium (several minutes) rectal mucosa medium vaginal mucosa medium nasal mucosa rapid (< one minute) pulmonary very rapid alveoli (< 10 seconds) blood stream very rapid (injection)
MODELS APPEARING SINCE 1900 AD
Biomedical consequences may be linked to the mode of administration, to some extent independent of the substance used. For example, alcohol drinking can cause ulcers or cancers. Tobacco, cannabis, or opium smoking can produce chronic lung infections and airway/pulmonary cancers. Chewing astringent substances, such as tobacco or betel nut, can cause gum inflammation, dental lesions, and oral cancers. Snuffing with cocaine or heroin can produce ulceration and even perforation of the nasal septum. Subcutaneous, intramuscular, or intravenous injection can produce bacterial, fungal, or viral infections. More rapid routes of administration tend to be more addicting, especially if the onset-ofaction of the drug is rapid.
Comorbidity Model This concept suggests that all or much substance use occurs in association with other comorbid conditions. Some of these conditions may occur before the onset of substance use disorder and conduce toward subsequent substance use disorders. This could occur if chronic pain led to excessive opioid drug use, or chronic insomnia or anxiety led to excessive use of sedatives. On the contrary, substance use disorder could lead to comorbid conditions. For example, losses associated with substance use disorder might precipitate depression. Or various routes of administration (see above) might favor the development of biomedical complications. Virtually any psychiatric disorders can accompany substance use disorders. However, mood, anxiety, and other externalizing disorders are most frequent psychosocial disorders. Psychosis and brain injury occur more often than chance. Numerous medical problems can accompany substance use disorder. These also include various infectious, gastrointestinal, cardiovascular, genitourinary, and traumatic maladies. Alcohol involves several unique metabolic and nutritional problems.
Salutogenic or Self-treatment Model Drug or alcohol use may be used for various salutogenic purposes. For example, a person may use a substance to feel relaxed in a social situation, to augment sexual experience, or to remain alert when fatigued. Khantzian extended this model to include self-treatment for discomforting or even disabling symptoms. For example, an anxious person might use sedative or opioid drugs or alcohol to relieve chronic anxiety, panic, or phobias. A depressed person may use cocaine or amphetamine to relieve fatigue or lack of concentration. With time, the drug may have an effect opposite to that intended. For example, opium might enhance
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sexual function early in its use but ultimately cause loss of libido and impotence. Or alcohol might facilitate social interaction at the beginning but lead to social alienation and isolation with excessive abuse. Moreover, more than one type of drug could be used for a specific disorder. For example, sedatives might be used to relieve insomnia, stimulants to alleviate fatigue, and opioids to relieve a lowered pain threshold.
Genetic Model The genetic model posits that genes either increase or decrease one’s vulnerability to alcohol or drug addiction. Studies of twins and adoptive studies both confirm that genetic inheritance contributes to the development of addiction. Having two parents with addiction further contributes to the severity of addiction. Nonetheless, up to 40% of patients presenting for treatment of addiction do not have a parent with an addictive disorder (but may have a grandparent or other relative with substance abuse). Genetic inheritance may not be a sine qua non for addictive disorders, or genetic vulnerability may not be manifest without certain environmental factors. Recent data suggests that disruptive environment during childhood or adolescence interacts with genetic vulnerability to increase the risk of addiction.
Externalizing Disorder Model Child–adolescent psychologists and psychiatrists first described externalizing disorders as those involving behavior, including conduct disorders, substance use disorders, pathological gambling, and other behavioral problems. Internalizing disorders consisted of mood, anxiety, and somatic disorders. More recently these concepts have been applied to adults. This model suggests that a person with any one externalizing disorder is prone to develop another externalizing disorder at some point. For example, an individual recovered from substance use disorder may be at risk for pathological gambling. The application of these concepts in adults remains in its early phases at this time, but early work suggests that this model may be important in ameliorating the longitudinal development of comorbid disorders, among those who already have had a psychiatric disorder of some sort.
Recovery Model Treatment alone by clinicians cannot alleviate addiction. The active, committed participation of the addicted person is critical to a successful outcome. This patientfocused aspect of the treatment process is often referred to as recovery.
I. THE NATURE OF ADDICTION
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Recovery occurs over time in stages, rather than in a single, sudden step. The first stage of recovery involves breaking from addictive use. The goal of this phase is safety from continued addictive use, with treatment of associated biomedical and psychosocial disorders. Under optimal circumstances, this phase may last several weeks. The second phase involves stability, including shelter, daily structure, and social support in a setting that reduces continued exposure to alcohol or other drugs of potential abuse. Recurrence of addiction is most apt to occur during this period of increasing comfort, independence, and growing self-esteem. This phase may be as short as several months, but can last longer. The third stage of recovery involves a return to a comfortable, responsible, and productive life way. The risk to recurrence is present but decreases once the person has achieved 2 years of sobriety. This phase, if successful, requires several years or longer to become firmly established. This eventual self-actualization associated with this model may lead relatives, clinicians, and various social gatekeepers to insist that the addicted person voluntarily seek recovery. However, the early steps toward recovery are not always so simple. Coercive treatment can help in motivating the initially unmotivated patient. Early on, coercive abstinence or treatment may aid the patient in joining the recovery pathway. In recent years, so-called drug courts have facilitated many addicted persons in turning from a life of property crime and family irresponsibility to a sober, productive life style.
Readiness-to-Change Model Prochaska and DiClemente have described the addicted person’s attitude toward recovery during the process from pre-recovery to full recovery. The first attitudinal stage, the so-called pre-contemplative stage, does not involve any intent to quit substances. As problems mount, the addicted person may come to realize that continued addiction is causing these problems. The clinician may inform the person that addiction is causing the person’s growing problems. These insights may lead to the second contemplation stage, in which the addicted person begins thinking about decreasing dose or frequency of use, or quitting use altogether. Growing ambivalence toward drug or alcohol use predominates at this stage. The third step involves a decision to stop use, as the ambivalence toward psychoactive substance abuse crystallizes in the direction of reducing the amount and/or frequency of use, or perhaps the type of substance being used. Should this cut back approach fail (as it typically does), the addicted person may decide to seek treatment.
The treatment-seeking stage requires collaborating with treatment in achieving safe, then stable, and eventual comfortable recovery. Finally, continued maintenance of recovery builds a flexible resistance against recurrence. This phase may involve devotion to others, the environment, or some cause or purpose that serves a greater good. It may involve avoiding situations that precipitate craving. Avoiding excessive fatigue, hunger, or stress can also gird the recovering addict against relapse.
The Harm Reduction Model The harm reduction model has evolved as a public health approach to widespread alcohol and drug addiction. The strategy lies in reducing the consequences of drinking or drugging, while assuming that alcohol and drug addiction will continue. For example, a wet house may permit inhabitants to drink heavily in the privacy of their rooms, so long as they do not aggress others or wander out into public arenas. Similarly, drug sales and injection may be provided in a safe setting, where unsafe injection, robbery, or assault can be prevented. Provision of clean needles to prevent HIV infection is another example. In some cases, repeated attempts at treatment may end in failure and demoralization. Some addicted persons may give up the difficult struggle required for a successful recovery. For these patients, various harm reduction approaches have been employed. For example, clinicians who provide information to the patient about the harm issuing from their continued use may help the person to reduce the use. Or residence in a quarter-way house in which quiet, private drinking or drug use is permitted. Assessment of an early clinic that tried this approach revealed a high mortality rate over a 2-year period, but with eventual abstinence in a notable number of patients. At times some social programs appear to follow a harm enabling approach. Providing shelter, income, or other resources that are not tied to a reduction in harm to self and others can increase rather than reduce harm. For example, a pension, trust, or savings can facilitate the continued deterioration of an addicted person. A legally assigned payee can route these funds to pay for shelter, food, clothes, and recovery-oriented expenditures.
CONCLUSION No one model provides a complete understanding of all aspects of alcohol and drug addiction. A model that may help us in guiding our own use (or nonuse) of substances, such as the moral model, may not help us
I. THE NATURE OF ADDICTION
FURTHER READING
in coping with an addicted relative, friend, client, or patient. An illness model may be useful for the addicted person willing to enter treatment, but not help a person who wants to continue addictive use of substances. Although this list of models for understanding addiction is not exhaustive, nonetheless the list of models above shows the accelerating development of models for helping us to understand addiction. For example, in all the centuries before 1600 AD, only a limited few models were available to help people understand addiction. Major examples included the moral, criminal, and preternatural models. Then following the first appearance of the widespread alcohol and opium addiction, health-related models appeared. These included the epidemic model and then, around the same time, the illness model of addiction. These new models appeared over a relative brief period of only a few centuries, greatly increasing the rate of new model development for understanding addiction. These new models did not eliminate the earlier moral, criminal, and preternatural models, but they provided useful new models for understanding and acting upon addiction. Diagnostic typologies and novel modes of treatment evolved from these models. Over the last century, the number of new models has increased at a rate vastly greater than the rate preceding it. These new models have evolved from increased knowledge regarding learning, pharmacology, neurophysiology, and neuroanatomy. Cogent clinical observations have led to our appreciating the mode of administration, the interactions and sometimes disconnections between treatment and recovery, and the coercive role of society in requiring sobriety under certain circumstances. Randomized controlled clinical trials have increased our knowledge of what interventions work, when, and with whom. This knowledge has increased our understanding of the addictions. Other and newer models will hopefully evolve in the coming decades to aid us in further understanding addiction. The centuries-old quandaries posed by addiction have continued to challenge addicted individuals and their families, along with the best minds in our communities. The history of these developing models has shown that enhanced understanding of the drug– person–society triad ultimately leads to effective prevention, early intervention, treatment, and rehabilitation.
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Use and Mental Disorders, Minority Groups and Addictions, Spirituality and Addiction
Glossary AA Alcoholics Anonymous. Addictogenic substance a psychoactive substance whose use can produce dependence. Ballast heavy weight stored low in hold of sailing vessels to prevent the vessel from tipping over in a strong wind. Ceremonial or ritual drinking the use of alcohol takes on shared social or cultural symbolism (e.g. interpersonal, celebratory, or spiritual meanings) beyond the mere consumption of beverage alcohol. Contingencies rewards or punishments that ensue from an addicted person’s behavior. Du-sten a German ritual in which two people agree to address one another by the informal “du” rather than the formal “Sie” when conversing together. Endogenous a substance that is produced by the body. Epidemic high prevalence of disease or disorder, spreading from one person or group to others, so that an entire society may suffer its ill effects. Fetal alcohol syndrome maternal drinking causes damage to the developing fetus, so that the newborn has mental retardation and characteristic facial configuration. GABA gamma-aminobutyric acid, a substance that affects neurotransmission. Half-life of psychoactive substances the time required for half of an ingested substance to be deactivated (by excretion or metabolic breakdown of the substance). Mead an alcohol-containing beverage derived from honey. Native American Church a pan-tribal religion practiced by American Indian people in North America; it involves elements of ancient tribal religions and Christianity, with peyote consumed as a sacramental substance as a means of experiencing communication with the spiritual realm. Neurotransmitter a biologically active chemical that affects transmission from one nerve cell to another; addictive substances mimic or affect neurotransmission. Passover an annual religious celebration and feast in the Jewish religion. Peyote a hallucinogenic drug obtained from a mushroom that grows wild in the Americas. Preternatural events occurring outside of nature, such as by magic or shamanistic powers. Psychosis a mental disorder marked by hallucinations, delusions, and/or other profound cognitive impairments. Salutogenic favoring good health. Smoking the volatilization of a psychoactive substance into a gas, so that it can be inhaled into the lungs and absorbed into the blood within the pulmonary alveoli. Stocks a punishment in which the individual’s extremities, and sometimes their head, are inserted through a wooden or other structure, such that they are restrained from moving about at will. Tai-Lao languages a related family of languages spoken by hundreds of millions of people in Laos and Thailand (where they comprise the national languages), China, Vietnam, Malaysia, and Burma. Tradition beliefs or behaviors that persisted across generations within a group.
SEE ALSO The Biopsychosocial Model of Addiction, Disease Model, Self-Medication, The Terminology of Addictive Behavior, Models of Relationships between Substance
Further Reading Anawalt, P.R., Berdan, F.F., 1992. The Codex Mendoza. Scientific American 266, 70–79.
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Arif, A., Westermeyer, J. (Eds.), 1988. A Manual for Drug and Alcohol Abuse: Guidelines for Teaching. Plenum, New York. DuToit, B.M., 1977. Drugs, Rituals and Altered States of Consciousness. Balkema Press, Rotterdam. Galanter, M., Kleber, H.D. (Eds.), 2008. Textbook of Substance Abuse Treatment. American Psychiatric Press, Inc., Washington, DC. Jilek, W.G., 1977. A quest for identity: therapeutic aspects of the Salish Indian guardian spirit ceremonial. Journal Operational Psychiatry 8, 46–51. LaBarre, W., 1964. The Peyote Cult. The Shoe String Press, Hamden, CT. Musto, D.F., 1973. The American Disease: Origins of Narcotic Control. Yale University Press, New Haven, CT. Popham, R.E., Schmidt, W., De Lint, J., 2000. The effects of legal restraint on drinking. In: Kissin, B., Begleiter, H. (Eds.), The Biology of Alcoholism. Plenum Press, New York. Rodin, A.E., 1981. Infants and gin mania in 18th century London. Journal American Medical Association 245, 1237–1239.
Westermeyer, J., 1976. Primer on Chemical Dependency: A Clinical Guide to Alcohol and Drug Problems. WIlliams-Wilkins Publishers, Baltimore. Westermeyer, J., 1979. Medical and nonmedical treatment for narcotic addicts: a comparative study from Asia. Journal of Nervous and Mental Disorders 167, 205–211. Westermeyer, J., 1982. Poppies, Pipes and People: Opium and Its Use in Laos. University California Press., Berkeley, CA. Westermeyer, J., Dickerson, D., 2008. Minorities. In: Galanter, M., Kleber, H.D. (Eds.), Textbook of Substance Abuse Treatment. American Psychiatric Press, Inc, Washington, DC, pp. 639–651.
Relevant Website Harper, D., 2010. Addiction. Available from www.etymonline.com.
I. THE NATURE OF ADDICTION
1 Historical Understandings of Addiction Joseph Westermeyer*, $ *
$
University of Minnesota, Minneapolis, MN, USA Minneapolis VA Medical Center, Minneapolis, MN, USA
O U T L I N E Background Rationale for Addiction Terms and Concepts Models for Episodic Intoxication in Traditional Societies Intoxication Gone Awry: Appearance of Widespread Addiction
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Personality Disorder Model Neurotransmitter Model Neuroanatomic Model Learning Model Dyadic Enabling/Rescuing Model Route-of-Administration Model Comorbidity Model Salutogenic or Self-treatment Model Genetic Model Externalizing Disorder Model Recovery Model Readiness-to-Change Model The Harm Reduction Model
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Models for Understanding Addiction Existing Prior to 1600 AD Moral Model Criminal Model Preternatural Model
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Models Appearing Between 1600 and 1900 AD Epidemic Model Illness Model
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Models Appearing Since 1900 AD
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Conclusion
BACKGROUND
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alcohol may be called khun-kee-lao or literally personexcrement-alcohol. A person who spent most of the day intoxicated on opium might be referred to as khun-kee-dyafeen or person-excrement-opium. The populace at large uses these terms commonly in societies with widespread alcohol or drug addiction. They are not technical terms employed only by healers, jurists, or literati. Their popular usage indicates that addiction occurs sufficiently often to warrant a special term. When enough people manifest addiction, a term has evolved to ease communication about them, their behavior, or their own personal experience (e.g. “When I became ill after I stopped using, I realized I was addicted”). These special terms foster abstract thought about addiction. Not surprisingly, models have appeared
Rationale for Addiction Terms and Concepts The term addiction, from the Latin addictionem or a devoting, first appeared in the English language around the sixteenth century. During recent historical times, words that indicate alcoholism or opiate addiction have appeared in many languages. Even in societies without written language, such terms exist. For example, in the Tai-Lao languages of Southeast Asia, these terms involve one word meaning attached to or stuck to be followed by the term for alcohol or opium (e.g. teat-dyafeen, literally stuck, attached, or connected to opium for opium addiction). At times, these terms have a derogatory connotation. For example, in the Tai-Lao languages, a deteriorated person dependent on Principles of Addiction, Volume 1 http://dx.doi.org/10.1016/B978-0-12-398336-7.00001-2
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1. HISTORICAL UNDERSTANDINGS OF ADDICTION
over the centuries to explain or elaborate on the experience or observation of substance use. Related concepts have also evolved, such as ideas regarding causation, related manifestations, or solutions to addiction-related problems. As with all terms in common lay usage, they involve not only denotative or cognitive aspects but also connotative or value-laden aspects. For example, a homeless alcohol-dependent patient wanted me to know that he considered himself a common drunk, but under no circumstances was he an alcoholic.
Models for Episodic Intoxication in Traditional Societies All cultures have forms of time out in which the daily customs or rules governing roles, responsibilities, and behavior are temporarily in abeyance. These are often time-limited periods of celebration, socialization, relaxation, and/or feasting. For example, Roman festivities involved wine drinking with feasting on special foods. The so-called “drunken comportment” may itself signal respite from one’s usual roles and responsibilities. In some cultures, substance use may involve a highly valued altered state of consciousness. The latter states may provide a means of communing with spirit world, so that individuals may be guided, inspired, or instructed on how to proceed with their lives. For example, in the Americas, aboriginal cultures often employed psychoactive substances to commune with the spirit world. Other methods, including fasting, sleeplessness, and isolation from other people, were used in the quest of supernatural guidance. In addition to ceremonial use at important annual ceremonies (e.g. Passover, New Year), psychoactive substance use has attended numerous rituals in the life of individuals. Examples include important social contracts (e.g. the du-tsen in Germanic cultures, sheltering a stranger in the Middle East, commercial or political relationships in Southeast Asia, life milestones such as graduation, marriage, childbirth, or death). Medicinal use of psychoactive substances has long been used to relieve illness, or at least the symptoms of illness. For example, opium can relieve acute pain, diarrhea, cough, fear, dysphoria, and other forms of misery. In areas where alcohol was distilled, people added various herbal compounds to alcohol (including opium) for their presumed medicinal properties. Sometimes healers added objects to alcohol (e.g. snakes, insects, minerals) to bring the presumed special attributes of these objects to the suffering individual. Preparation of beer, wine, and distilled beverages permitted the storage of carbohydrates in the form of alcohol. Used in this way as a foodstuff, beverage alcohol could augment the diet during times of the year that food was not being produced. These drinks
introduced tastes that could enhance the taste of food. Beverage alcohol could substitute water in settings where potable water was not readily available (although excessive doses purge body fluids through its diuretic effect). Small doses of some psychoactive substances, such as cannabis, have long been used as condiments in soups and baked goods. Use of alcohol and drugs served several religious and spiritual functions. During religious ceremonies and rituals, priests and sometimes devotees at large consumed sacramental alcohol and drugs. The latter included consumption of hallucinogenic mushrooms and other plant products (such as peyote) in the Americas. The Native American Church in North America has continued this practice in modern times as a means of communicating with the spiritual world, addressing conflicts and personal distress, and finding one’s way into a moral, productive future. Societal control predominated over individual choice in the traditional use of these psychoactive substances in earlier times. For example, all individuals might have their beverage containers filled at the same time so that no one drank more (or less) than a socially prescribed amount. Occasions of use were socially determined, limiting the frequency of use. This traditional form of control began eroding when masses of people received beverage alcohol as payment for work in industrialized England. People began to drink daily, sometimes even before starting work in the morning. This daylong drinking favored individual choice over drinking, as well as physical dependence on alcohol.
Intoxication Gone Awry: Appearance of Widespread Addiction Addiction required daily consumption. Such use led to increasing dosage to obtain the desired effects for certain psychoactive substances, including alcohol, opium, cannabis, sedatives, and tobacco. Increased frequency and dosage almost inevitably produced consequences: economic, psycho-physiological adaptation, and biomedical complications. Depending on the substance, these consequences occurred within a few years to a decade or longer. For example, drugs such as heroin and cocaine can produce consequences sooner. Substances such as alcohol and opium require several years to a decade or longer in the average case. A common manifestation with most psychoactive substances is the need for increasing doses to produce the same, desirable effects. Thus, an alcohol drinker who experienced relaxation and other positive effects from 1 or 2 oz. of alcohol will need twice, then four, and later ten times that amount to produce the same desired effects. The same occurs with opium and heroin, with even higher multiples in some cases. Similar escalations occur with
I. THE NATURE OF ADDICTION
MODELS FOR UNDERSTANDING ADDICTION EXISTING PRIOR TO 1600 AD
tobacco, cocaine, and other stimulants, and certain other drugs (e.g. sedatives, cannabis, phencyclidine). Economic and technical advances have permitted the expenditure of time, resources, and wealth to permit widespread addiction. In past centuries, much effort was required to produce sufficient carbohydrate, opium poppy, or tobacco to permit many people to engage in daily use of large doses. In the Caribbean, slaves on plantations grew sugarcane used to distill rum and gin. Trading ships from England distributed goods along the eastern coast of North America. Before heading back home to England, they picked up ballast in the form of beverage alcohol. Likewise, the English raised poppy in India to use in trade with Southeast Asia, China, and Japan. Thus, the worldwide phenomenon of widespread addiction after 1600 AD depended on such innovations as the following: • Production of excess carbohydrate in large amounts, as a result of slave labor, or plantation-based mass production, and/or technical innovations (such as the iron plow, use of fertilization, irrigation) to produce alcohol. • New methods of growing labor-intensive drugs, such as opium, tobacco, or betel-areca nut, again using plantations and new agro-technology. • Distillation of beverage alcohol and drug preparations to extract active agents (e.g. morphine or heroin from opium), which reduced the cost of transportation over great distances, making lower cost alcohol or drugs available in areas that had no experience, and hence no resistance to their use. • The short half-life of some purified substances (e.g. heroin) as compared to the parent compound (e.g. opium) hastened the development of addiction as well as the consequences wrought by addiction.
MODELS FOR UNDERSTANDING ADDICTION EXISTING PRIOR TO 1600 AD People cannot avoid positing causes for observed behaviors, especially when these behaviors are problematic. Inevitably, these causal explanations, also called models or paradigms, tend to lead to interventions.
Moral Model In many societies after 1600 AD, citizens no longer hued to one tradition governing use of psychoactive substances. Organized religion often fed this diversity, as adherents of one sect forbade use while those in other sects approved moderate use. Eventually, decisions whether to use, when to use, and how much to use fell
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to individual choice in many times and places. In turn, this led to presumed morality in making such choices. Abstention or moderate use was deemed as morally good, whereas excessive, problematic use was judged as morally bad. Those consistently making bad decisions came to be viewed as morally weak, corrupt, or full-of-sin (sinful). This model prevails today in many instances. For example, if a society values individual responsibility and accountability, people will view many, if not most of their important decisions as having moral implications. Purchase and consumption of alcohol in significant amounts can deplete families of necessary resources, result in poor health that drains family wellbeing, and led to irresponsible behavior that harms family members or other members of society. As addicted persons fail in their attempts to change or curb their own behavior, they often apply this model to themselves. That is, they perceive themselves as morally bad or having weak character. Families and friends may also apply a moral model in judging the consumptive behavior of an addicted person. The moral model may lead to changes in behavior that can be successful in early stages of heavy use or addiction. Later, these models seldom work for any length of time. Most clinicians learn that this model seldom helps in the case of severe addiction. Organized religions have addressed excessive substance use and addiction as a moral dilemma for their adherents. Many religions have prescribed total abstention as a solution. For example, Hinduism, Buddhism, and Islam have opposed the use of alcohol and recreational drug use for centuries. Although some use may be permitted in some Hindu, Buddhist, and Islamic societies, the clergy and the religious laity have been urged toward total abstinence. In Judaism and Roman Catholicism, the use of alcohol in religious rituals has imparted a message that this sacramental substance should be respected and not abused. Following widespread addiction in the seventeenth and eighteenth centuries, many abstinent-oriented Christian and other sects arose, forbidding use among their members.
Criminal Model The criminal model bears a strong relationship to the moral model, from which it stems. As societies experienced increasing social problems associated with addiction, some societies defined addictive behavior or excessive alcohol–drug consumption as a crime against society, and not simply a moral failing. Depending on the society and the point in time, any public intoxication might be punished. Or only dangerous behavior associated with intoxication (such as fighting or beating family members) might be punished.
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In colonial times in the United States, heavy or addicted drinkers might be placed in wooden stocks, located in a public place. Not only would this punishment restrict the addict’s freedom, it would also impose discomforting immobility in the stocks. Since stocks were typically located in a public place, the punishment involved public shaming. Whether it proved effective in ameliorating or reducing addiction is unknown, but it did create a public attitude against addiction. This model still persists in many venues today. For example, some communities publish the names of those arrested for drunken driving or public intoxication. Pregnant mothers whose use of alcohol or drugs may threaten the development of their baby in utero may have their freedoms circumscribed until childbirth. The war on drugs policy in many modern nations, in which drugs are viewed as foisted on innocent people by criminal producers and traffickers, owes its persistence to this model.
Preternatural Model In many cultures, alcohol and drugs were imbued with preternatural or even supernatural powers. The preternatural model also owes its origins partially to the moral model, as people believed that no rational person would choose addiction over abstinence of moderate use. That is, the psychoactive substance was viewed as having the ability to take over the person’s mind, will, or soul through means that transcended the natural world. This model has sometimes been called the devil in the drug model. In this view, substances such as alcohol, opium, or cannabis are so inherently evil and even demonic that any use is evil. Such use may then be labeled as sinful, so that the person’s inherent goodness may be doubted or denied. Although this model is still popular in many settings, increasing knowledge of the neurotransmitter, neuroanatomical, and genetic nature of addictogenic psychoactive substances has challenged these early supernatural explanations, while also providing explanations regarding why alcohol and drugs can weaken the will and moral resolve of addicted persons.
MODELS APPEARING BETWEEN 1600 AND 1900 AD
Moreover, they both involved a complex of new behaviors not modified by tradition, plus international trade. The English gin epidemic (which also involved rum) involved the import of cheap distilled beverage alcohol from the Caribbean area. In the early stages of the Industrial Revolution, English ships brought merchandise to Canada, the American colonies, and then the Caribbean. Needing ballast for the return trip to England, they first used stones, then sugarcane and other agricultural products, and finally distilled alcohol. On the docks of Liverpool, a calorie of beverage alcohol could be purchased for less than calorie of bread. Factory owners often paid workers in alcohol. Unfettered by the traditions governing use of mead, workers made their own decisions regarding when and how much to drink. The result was widespread excessive drinking. Other places in Europe as well as North America similarly became enamored with heavy drinking. Led by England, several responses gradually led to a reduction in alcohol addiction. One of these interventions involved taxing alcohol beverage. Abstinence-oriented Christianity began around this time. In England, popular eight-page booklets described the depredations of alcohol, together with wood-block pictures of the consequences, including fetal alcohol syndrome, child neglect and abuse, fights, accidents, theft, and poor workmanship. In the United States, small residential asylums were developed to treat chronic alcohol abuse. Within years after contact was established between the Americas and Eurasia, tobacco smoking appeared in the Orient. Tobacco smoking houses appeared, frequently by youth, political dissidents, and other independent-minded people. Several nations of Asia closed these public smoking houses. The result was the wedding of opium, an old substance once consumed only by eating, and smoking, a new method of administration. Opium smoking spread like wildfire in Southeast Asia and the East Orient, including China, Korea, and Japan. As in Europe, many strategies against opium addiction began. One of these was anti-opium societies, whose members endeavored to bring addicted people to residential facilities that provided withdrawal treatment, nourishment, and respite. Several countries also passed laws against the production and/or import of opium. In China, a cabinet-level minister was appointed to limit production, commerce, and use of opium. The United States mimicked many of these measures over time.
Epidemic Model Two epidemics of addictive disorder appeared in the 1600s and spread notably by the early 1700s. They occurred around the same time, although they involved different substances in different parts of the world.
Illness Model As noted above, this model evolved in Asia, Europe, and North America to counter widespread opium and alcohol addiction. During that period, it typically
I. THE NATURE OF ADDICTION
MODELS APPEARING SINCE 1900 AD
involved admission to a hospital or residential facility, often in a rural area. So-called moral treatment, developed for psychiatric disorders, included shelter, nourishment, daily activities, supervision, and respectful social interactions. This model is often inappropriately described as the medical model of addiction. Although the term medical model may apply to the downstream attempts to reverse addiction in medical settings or by physicians, it is the illness model that gave rise to treatment in the first place. This model evolved over two centuries ago when addicted persons were unable to cease addictive use of psychoactive substances on their own. One of the first instances of this model occurred in the United States around 1800. Small therapeutic households (or asylum) developed in rural areas to provide a period of supervised abstinence for alcohol addicts. Although some physicians were active in developing this resource, nonphysicians established and ran these recovery-oriented households. During the Opium Epidemic in China and other parts of Asia, small clinics and hospitals were established to support addicted persons through withdrawal and a return to health. Locally established anti-opium societies provided material support and referred addicts to these facilities. A social concern related to this model has focused on the fear that addicts might present the illness model as a rationale for continued addictive use of a substance. Although this does occur rarely in addicted persons who may want to continue their addictive use, most addicted persons develop a moral imperative to return to responsible living, once they have some months of healthful sobriety. Another fear relates to the worry that unethical clinicians might provide ineffective treatment as a means of accumulating wealth. Again, this can occur; but ethical clinicians do not experience enhanced self-esteem in their healing roles by sponsoring ineffective therapies. The illness model involves processes that proceed along psychological, psychosocial, and cultural lines. First, the addicted person must view himself or herself as a blighted or diseased person in need of outside help. This step, involving illness behavior, occurs after a period of misery and dysfunction. Second, those around the person must be willing to deed the person a period of relief from ordinary social expectations and responsibilities, in order to permit treatment and recovery. This involved social assignment of a temporary sick role. Third, a culturally approved or licensed health care worker must ordain that disease exists and treatment is warranted. The social assignment of a sick role usually continues as long as the suffering person is willing to undergo the physical, psychological, or social burdens associated with treatment.
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MODELS APPEARING SINCE 1900 AD Personality Disorder Model During the early 1900s, diagnostic classifications included alcoholism and drug addiction as a personality or character disorder. These disorders were viewed as a form of antisocial personality, since the individual broke social mores, acted primarily in their own apparent self-interest, and often transgressed the rights of others while intoxicated or drug seeking. According to this view, addiction evolved in irresponsible or selfcentered people who ignored the effects of their choices and behaviors on others. The second edition of the Diagnostic and Statistical Manual of the American Psychiatric Association typified this perspective. During this period, personality and character disorders were seen as untreatable. Thus, this model justified the noninvolvement of many clinicians in the care of these patients. Despite this professional viewpoint, many states provided asylum-type care. Private asylum or dry-out farms also operated. Abandoned by the medical profession, alcoholics in the United States supported one another’s recovery in the brotherhood of Alcoholics Anonymous (AA). One of the founding members of AA, himself a physician, used the analogy of allergy to describe the individual, and presumed idiosyncratic response of alcoholics to alcohol. This analogy bears strong resemblance to the Illness Model from the previous century. Alcoholics Anonymous borrowed heavily from an English self-improvement group that aimed at maturity and balance, using early Christian principles. Although not sponsored by organized religion, it employed spiritual guidance and growth as a means of achieving a rewarding, responsible life way in the modern industrialized world.
Neurotransmitter Model Alcohol, opium, and other substances of abuse mimic or affect naturally occurring neurotransmitters. Neurotransmission was key to understanding pain and analgesia, anxiety and relaxation, dysphoria and euphoria, dissociation and vigilance. Increased understanding of drug/alcohol-related effects on brain and behavior has led to other theories, as well as to new therapies of addiction. In turn, new information accruing from successful treatment of addiction has enriched our theoretical perspective on addiction. Various drugs of abuse relate to specific neurotransmitter systems. For example, opioid drugs mimic the effects of endogenous opioid-like substances (i.e. endorphins). Cocaine, amphetamines, and other stimulants affect the adrenergic and dopaminergic systems.
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Nicotine affects muscarinic receptors. Cannabis and its active compound tetrahydrocannabinol stimulate an endogenous cannabinoid receptor. Benzodiazepines and other sedatives trip a benzodiazepine receptor, which in turn affects the actions of gamma-aminobutyric acid. Medications anatagonistic to these substances (e.g. disulfiram for alcohol, naltrexone for opioids) have been used in treatment.
Neuroanatomic Model Certain areas of organelles of the brain are related to alcohol or drug effects. For example, the dopaminergic locus accumbens appears to be a site involved in the reward experienced with psychoactive substance use. Alcohol, sedatives, and opioids reduce the contributions of the frontal lobes that facilitate recall, executive decision-making, interpersonal sensitivity, judgment, and morality. Awareness of these brain functions and their dysfunction during addiction contributes to an understanding of why addictive behaviors may persist despite their damaging effects on the individual. Damage of particular areas of the brain can aid clinicians in recognizing certain stereotypic conditions associated with addiction. For example, damage to the mammillary body area of the brain can produce a chronic inability to store recent memory, a lesion that produces an inability to live independently. Damage to the frontal lobes can foster disinhibited, intrusive speech and behavior.
Dyadic Enabling/Rescuing Model Described first by Eric Berne, this model involves the interaction between at least two people. One of these could be an addicted person, who relates to the second person in a child-like or dependent role. The second individual relates to the addicted person as a parent, helper, or authority figure. This role relationship is apt to accentuate the dependent behavior of the addicted person, while frustrating the second person who expects the proffered help to ameliorate the addiction (which it seldom does, if given without contingencies). The helper may enable the addictive behavior by providing shelter, food, resources, or even drugs or alcohol to the addicted person. Enabling fosters continued using alcohol or drugs without experiencing the social, economic, or other consequences of use (e.g. poverty, no food or shelter). The ultimate effect is a worsening of the addicted person’s condition. Rescuing involves the parental, helping person saving the child-like, dependent person from social or other consequences of addiction. For example, a policeman may cite a drunk driver for another, lesser offense than the actual offense. Or a judge might not exact a legal punishment because it is a first offense. Rescuing, like enabling, is often undertaken in hopes that the beneficent action will goad the addicted person toward recovery. Unfortunately, rescuing generally exacerbates rather than alleviates addiction.
Route-of-Administration Model Learning Model This model views addiction as a learned behavior that follows upon certain learned stimuli. For example, a person might experience withdrawal symptoms in a setting where alcohol or drug use had previously occurred. In this example, the effect of the alcohol or drug use is the unconditioned response and the alcohol or drug itself is the unconditioned stimulus. The environmental cues associated with the presence of alcohol or drugs are the conditioned stimuli that can produce drug seeking and drug using. This model can be used therapeutically by avoiding cues that stimulate urges to use and by extinguishing craving responses to these cues. Recalling and imaging the aversive consequences brought on by use may also be employed. Medications that eliminate the desired drug or alcohol effects can be useful in extinguishing addiction-related learned behavior. On the level of the community, learning can be used to reward behaviors inconsistent with alcohol or drug abuse (e.g. family interactions, employment, abstinentoriented recreation).
Many substances can be consumed by more than one route of self-administration. Routes that have utilized over time include the following: Route Eat/drink Subcutaneous
Absorption absorption
skin tissue (injection) Intramuscular muscle tissue (injection) Chewing oral mucosa Rectal Vaginal Snuffing Smoking Intravenous
I. THE NATURE OF ADDICTION
Rapidity of effect slow (10 to 20 minutes) slow slow to medium
medium (several minutes) rectal mucosa medium vaginal mucosa medium nasal mucosa rapid (< one minute) pulmonary very rapid alveoli (< 10 seconds) blood stream very rapid (injection)
MODELS APPEARING SINCE 1900 AD
Biomedical consequences may be linked to the mode of administration, to some extent independent of the substance used. For example, alcohol drinking can cause ulcers or cancers. Tobacco, cannabis, or opium smoking can produce chronic lung infections and airway/pulmonary cancers. Chewing astringent substances, such as tobacco or betel nut, can cause gum inflammation, dental lesions, and oral cancers. Snuffing with cocaine or heroin can produce ulceration and even perforation of the nasal septum. Subcutaneous, intramuscular, or intravenous injection can produce bacterial, fungal, or viral infections. More rapid routes of administration tend to be more addicting, especially if the onset-ofaction of the drug is rapid.
Comorbidity Model This concept suggests that all or much substance use occurs in association with other comorbid conditions. Some of these conditions may occur before the onset of substance use disorder and conduce toward subsequent substance use disorders. This could occur if chronic pain led to excessive opioid drug use, or chronic insomnia or anxiety led to excessive use of sedatives. On the contrary, substance use disorder could lead to comorbid conditions. For example, losses associated with substance use disorder might precipitate depression. Or various routes of administration (see above) might favor the development of biomedical complications. Virtually any psychiatric disorders can accompany substance use disorders. However, mood, anxiety, and other externalizing disorders are most frequent psychosocial disorders. Psychosis and brain injury occur more often than chance. Numerous medical problems can accompany substance use disorder. These also include various infectious, gastrointestinal, cardiovascular, genitourinary, and traumatic maladies. Alcohol involves several unique metabolic and nutritional problems.
Salutogenic or Self-treatment Model Drug or alcohol use may be used for various salutogenic purposes. For example, a person may use a substance to feel relaxed in a social situation, to augment sexual experience, or to remain alert when fatigued. Khantzian extended this model to include self-treatment for discomforting or even disabling symptoms. For example, an anxious person might use sedative or opioid drugs or alcohol to relieve chronic anxiety, panic, or phobias. A depressed person may use cocaine or amphetamine to relieve fatigue or lack of concentration. With time, the drug may have an effect opposite to that intended. For example, opium might enhance
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sexual function early in its use but ultimately cause loss of libido and impotence. Or alcohol might facilitate social interaction at the beginning but lead to social alienation and isolation with excessive abuse. Moreover, more than one type of drug could be used for a specific disorder. For example, sedatives might be used to relieve insomnia, stimulants to alleviate fatigue, and opioids to relieve a lowered pain threshold.
Genetic Model The genetic model posits that genes either increase or decrease one’s vulnerability to alcohol or drug addiction. Studies of twins and adoptive studies both confirm that genetic inheritance contributes to the development of addiction. Having two parents with addiction further contributes to the severity of addiction. Nonetheless, up to 40% of patients presenting for treatment of addiction do not have a parent with an addictive disorder (but may have a grandparent or other relative with substance abuse). Genetic inheritance may not be a sine qua non for addictive disorders, or genetic vulnerability may not be manifest without certain environmental factors. Recent data suggests that disruptive environment during childhood or adolescence interacts with genetic vulnerability to increase the risk of addiction.
Externalizing Disorder Model Child–adolescent psychologists and psychiatrists first described externalizing disorders as those involving behavior, including conduct disorders, substance use disorders, pathological gambling, and other behavioral problems. Internalizing disorders consisted of mood, anxiety, and somatic disorders. More recently these concepts have been applied to adults. This model suggests that a person with any one externalizing disorder is prone to develop another externalizing disorder at some point. For example, an individual recovered from substance use disorder may be at risk for pathological gambling. The application of these concepts in adults remains in its early phases at this time, but early work suggests that this model may be important in ameliorating the longitudinal development of comorbid disorders, among those who already have had a psychiatric disorder of some sort.
Recovery Model Treatment alone by clinicians cannot alleviate addiction. The active, committed participation of the addicted person is critical to a successful outcome. This patientfocused aspect of the treatment process is often referred to as recovery.
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Recovery occurs over time in stages, rather than in a single, sudden step. The first stage of recovery involves breaking from addictive use. The goal of this phase is safety from continued addictive use, with treatment of associated biomedical and psychosocial disorders. Under optimal circumstances, this phase may last several weeks. The second phase involves stability, including shelter, daily structure, and social support in a setting that reduces continued exposure to alcohol or other drugs of potential abuse. Recurrence of addiction is most apt to occur during this period of increasing comfort, independence, and growing self-esteem. This phase may be as short as several months, but can last longer. The third stage of recovery involves a return to a comfortable, responsible, and productive life way. The risk to recurrence is present but decreases once the person has achieved 2 years of sobriety. This phase, if successful, requires several years or longer to become firmly established. This eventual self-actualization associated with this model may lead relatives, clinicians, and various social gatekeepers to insist that the addicted person voluntarily seek recovery. However, the early steps toward recovery are not always so simple. Coercive treatment can help in motivating the initially unmotivated patient. Early on, coercive abstinence or treatment may aid the patient in joining the recovery pathway. In recent years, so-called drug courts have facilitated many addicted persons in turning from a life of property crime and family irresponsibility to a sober, productive life style.
Readiness-to-Change Model Prochaska and DiClemente have described the addicted person’s attitude toward recovery during the process from pre-recovery to full recovery. The first attitudinal stage, the so-called pre-contemplative stage, does not involve any intent to quit substances. As problems mount, the addicted person may come to realize that continued addiction is causing these problems. The clinician may inform the person that addiction is causing the person’s growing problems. These insights may lead to the second contemplation stage, in which the addicted person begins thinking about decreasing dose or frequency of use, or quitting use altogether. Growing ambivalence toward drug or alcohol use predominates at this stage. The third step involves a decision to stop use, as the ambivalence toward psychoactive substance abuse crystallizes in the direction of reducing the amount and/or frequency of use, or perhaps the type of substance being used. Should this cut back approach fail (as it typically does), the addicted person may decide to seek treatment.
The treatment-seeking stage requires collaborating with treatment in achieving safe, then stable, and eventual comfortable recovery. Finally, continued maintenance of recovery builds a flexible resistance against recurrence. This phase may involve devotion to others, the environment, or some cause or purpose that serves a greater good. It may involve avoiding situations that precipitate craving. Avoiding excessive fatigue, hunger, or stress can also gird the recovering addict against relapse.
The Harm Reduction Model The harm reduction model has evolved as a public health approach to widespread alcohol and drug addiction. The strategy lies in reducing the consequences of drinking or drugging, while assuming that alcohol and drug addiction will continue. For example, a wet house may permit inhabitants to drink heavily in the privacy of their rooms, so long as they do not aggress others or wander out into public arenas. Similarly, drug sales and injection may be provided in a safe setting, where unsafe injection, robbery, or assault can be prevented. Provision of clean needles to prevent HIV infection is another example. In some cases, repeated attempts at treatment may end in failure and demoralization. Some addicted persons may give up the difficult struggle required for a successful recovery. For these patients, various harm reduction approaches have been employed. For example, clinicians who provide information to the patient about the harm issuing from their continued use may help the person to reduce the use. Or residence in a quarter-way house in which quiet, private drinking or drug use is permitted. Assessment of an early clinic that tried this approach revealed a high mortality rate over a 2-year period, but with eventual abstinence in a notable number of patients. At times some social programs appear to follow a harm enabling approach. Providing shelter, income, or other resources that are not tied to a reduction in harm to self and others can increase rather than reduce harm. For example, a pension, trust, or savings can facilitate the continued deterioration of an addicted person. A legally assigned payee can route these funds to pay for shelter, food, clothes, and recovery-oriented expenditures.
CONCLUSION No one model provides a complete understanding of all aspects of alcohol and drug addiction. A model that may help us in guiding our own use (or nonuse) of substances, such as the moral model, may not help us
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FURTHER READING
in coping with an addicted relative, friend, client, or patient. An illness model may be useful for the addicted person willing to enter treatment, but not help a person who wants to continue addictive use of substances. Although this list of models for understanding addiction is not exhaustive, nonetheless the list of models above shows the accelerating development of models for helping us to understand addiction. For example, in all the centuries before 1600 AD, only a limited few models were available to help people understand addiction. Major examples included the moral, criminal, and preternatural models. Then following the first appearance of the widespread alcohol and opium addiction, health-related models appeared. These included the epidemic model and then, around the same time, the illness model of addiction. These new models appeared over a relative brief period of only a few centuries, greatly increasing the rate of new model development for understanding addiction. These new models did not eliminate the earlier moral, criminal, and preternatural models, but they provided useful new models for understanding and acting upon addiction. Diagnostic typologies and novel modes of treatment evolved from these models. Over the last century, the number of new models has increased at a rate vastly greater than the rate preceding it. These new models have evolved from increased knowledge regarding learning, pharmacology, neurophysiology, and neuroanatomy. Cogent clinical observations have led to our appreciating the mode of administration, the interactions and sometimes disconnections between treatment and recovery, and the coercive role of society in requiring sobriety under certain circumstances. Randomized controlled clinical trials have increased our knowledge of what interventions work, when, and with whom. This knowledge has increased our understanding of the addictions. Other and newer models will hopefully evolve in the coming decades to aid us in further understanding addiction. The centuries-old quandaries posed by addiction have continued to challenge addicted individuals and their families, along with the best minds in our communities. The history of these developing models has shown that enhanced understanding of the drug– person–society triad ultimately leads to effective prevention, early intervention, treatment, and rehabilitation.
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Use and Mental Disorders, Minority Groups and Addictions, Spirituality and Addiction
Glossary AA Alcoholics Anonymous. Addictogenic substance a psychoactive substance whose use can produce dependence. Ballast heavy weight stored low in hold of sailing vessels to prevent the vessel from tipping over in a strong wind. Ceremonial or ritual drinking the use of alcohol takes on shared social or cultural symbolism (e.g. interpersonal, celebratory, or spiritual meanings) beyond the mere consumption of beverage alcohol. Contingencies rewards or punishments that ensue from an addicted person’s behavior. Du-sten a German ritual in which two people agree to address one another by the informal “du” rather than the formal “Sie” when conversing together. Endogenous a substance that is produced by the body. Epidemic high prevalence of disease or disorder, spreading from one person or group to others, so that an entire society may suffer its ill effects. Fetal alcohol syndrome maternal drinking causes damage to the developing fetus, so that the newborn has mental retardation and characteristic facial configuration. GABA gamma-aminobutyric acid, a substance that affects neurotransmission. Half-life of psychoactive substances the time required for half of an ingested substance to be deactivated (by excretion or metabolic breakdown of the substance). Mead an alcohol-containing beverage derived from honey. Native American Church a pan-tribal religion practiced by American Indian people in North America; it involves elements of ancient tribal religions and Christianity, with peyote consumed as a sacramental substance as a means of experiencing communication with the spiritual realm. Neurotransmitter a biologically active chemical that affects transmission from one nerve cell to another; addictive substances mimic or affect neurotransmission. Passover an annual religious celebration and feast in the Jewish religion. Peyote a hallucinogenic drug obtained from a mushroom that grows wild in the Americas. Preternatural events occurring outside of nature, such as by magic or shamanistic powers. Psychosis a mental disorder marked by hallucinations, delusions, and/or other profound cognitive impairments. Salutogenic favoring good health. Smoking the volatilization of a psychoactive substance into a gas, so that it can be inhaled into the lungs and absorbed into the blood within the pulmonary alveoli. Stocks a punishment in which the individual’s extremities, and sometimes their head, are inserted through a wooden or other structure, such that they are restrained from moving about at will. Tai-Lao languages a related family of languages spoken by hundreds of millions of people in Laos and Thailand (where they comprise the national languages), China, Vietnam, Malaysia, and Burma. Tradition beliefs or behaviors that persisted across generations within a group.
SEE ALSO The Biopsychosocial Model of Addiction, Disease Model, Self-Medication, The Terminology of Addictive Behavior, Models of Relationships between Substance
Further Reading Anawalt, P.R., Berdan, F.F., 1992. The Codex Mendoza. Scientific American 266, 70–79.
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Arif, A., Westermeyer, J. (Eds.), 1988. A Manual for Drug and Alcohol Abuse: Guidelines for Teaching. Plenum, New York. DuToit, B.M., 1977. Drugs, Rituals and Altered States of Consciousness. Balkema Press, Rotterdam. Galanter, M., Kleber, H.D. (Eds.), 2008. Textbook of Substance Abuse Treatment. American Psychiatric Press, Inc., Washington, DC. Jilek, W.G., 1977. A quest for identity: therapeutic aspects of the Salish Indian guardian spirit ceremonial. Journal Operational Psychiatry 8, 46–51. LaBarre, W., 1964. The Peyote Cult. The Shoe String Press, Hamden, CT. Musto, D.F., 1973. The American Disease: Origins of Narcotic Control. Yale University Press, New Haven, CT. Popham, R.E., Schmidt, W., De Lint, J., 2000. The effects of legal restraint on drinking. In: Kissin, B., Begleiter, H. (Eds.), The Biology of Alcoholism. Plenum Press, New York. Rodin, A.E., 1981. Infants and gin mania in 18th century London. Journal American Medical Association 245, 1237–1239.
Westermeyer, J., 1976. Primer on Chemical Dependency: A Clinical Guide to Alcohol and Drug Problems. WIlliams-Wilkins Publishers, Baltimore. Westermeyer, J., 1979. Medical and nonmedical treatment for narcotic addicts: a comparative study from Asia. Journal of Nervous and Mental Disorders 167, 205–211. Westermeyer, J., 1982. Poppies, Pipes and People: Opium and Its Use in Laos. University California Press., Berkeley, CA. Westermeyer, J., Dickerson, D., 2008. Minorities. In: Galanter, M., Kleber, H.D. (Eds.), Textbook of Substance Abuse Treatment. American Psychiatric Press, Inc, Washington, DC, pp. 639–651.
Relevant Website Harper, D., 2010. Addiction. Available from www.etymonline.com.
I. THE NATURE OF ADDICTION