When people speak about addiction it is common to think about alcoholism. There is good reason for this. Alcoholism has been the most studied problem in addiction. Alcoholics Anonymous was the first mutual help organization for addiction to come to the fore. Finally, alcohol’s being legal has lent alcoholism more “social acceptability” than addiction involving illegal drugs.
I say this reference to alcoholism is common, but it is also unfortunate. The focus on alcoholism distorts the picture of addiction in more than one way. To understand this it is first important to understand what we mean when we say alcoholism. As with all things with names, the use of the names conjures in the listener’s mind a picture that they expect to see associated with that name.
The picture conjured by alcoholism is not a picture of the disease of addiction. Rather it is a mosaic of elements of the illness, elements of the drug effects of alcohol and epiphenomena of both. For example we could consider the “look” of an alcoholic.
When people think of a “beer belly” or a big red nose they are thinking of specific drug effects of alcohol. Alcohol’s effects on the liver, circulation and blood cell morphology are unique to that drug. But these drug effects are not the disease of addition or even markers for the disease.
Indeed, many alcoholics lack these signs. In any case these body changes are unimportant to the alcoholic and are rarely noticed by them unless pointed out by others. These changes are not central phenomena of people with addiction using alcohol; they are epiphenomena that are unique to that drug.
There are other epiphenomena that we confuse as central themes. The violence of alcoholics is a good example. The violence causing drug effects of alcohol on some people are not generalizable to all addicts, all drug users or even all alcoholics. And yet this picture of violence is generalized to those others in the belief it is a central issue.
Several social issues will arise with alcohol that have long been unique to it for a variety of scientific and social reasons. The primary one is that alcohol is legal, common, and socially acceptable to a certain degree. Many law-abiding people drink and gather together to drink at parties. Because it is common and often seen, alcohol will often be seen as the single cause of complex social problems such as divorce and children born out of wedlock. One can tell when another has been drinking often just by smell. A scientific example is the clear correlation between blood alcohol level and impairment coupled with technology that can noninvasively measure this level. Because this is true of alcohol we generalize it to all drugs even though such technology is not available.
One far-reaching effect of seeing the problem of alcoholism as the core chemical presentation of addiction, and all its epiphenomena together as a whole illness, is the research is done on alcoholism that is mistaken for research on addition. I suggest that when social scientists say they are studying the disease of alcoholism they are studying the problem of alcoholism.
So what is the central core of the problem of addiction as expressed with alcohol? The same as with any other drug or behavior. Writings from both the lab and the personal experiences of alcoholics suggest a two-fold answer. First, in an alcoholic who takes a drink, the ability to not take a second drink becomes a greatly diminished or is erased entirely. Second is that when an alcoholic tries not to drink an obsession develops which generally leads to failure of abstinence.
Others may say, “What about using alcohol in spite of adverse consequences? ” Isn’t that a core criterion for alcoholism in the DSM IV? Is it really a core phenomenon or is it an epiphenomenon seen in most people because most people have consequences. Consider a king who has unlimited resources and whom no one will oppose. If he has no consequences yet cannot control his intake and cannot abstain is he not an alcoholic?
Others will say, “What about tolerance? ” Isn’t that a criterion as well? Yes it is but one generally limited to sedative hypnotics and opioids.
“Well, what of withdrawal? That’s got to be central to alcoholism and addiction.” One would think, but the issue is far from what it appears. If one lets a drug habituated rat self-administer small amounts of drug directly to the brain’s reward center it will do this almost to the exclusion of all else. Now what if you suddenly cut off the supply of drug, say heroin or alcohol, after several weeks. Wouldn’t one expect withdrawal? Yet, it does not occur. However if you put the catheter in another part of the brain, the PAG, you would find there is no drug taking behavior. The animal will not self administer drug to that area. However if you administered it to that area everyday for a few weeks and suddenly stopped, the animal would go into withdrawal in spite of never having enjoyed the drug. So is withdrawal a central core part of addiction or an epiphenomenon stemming from the fact that human drug addicts don’t administer drugs with micropipettes directly to individual parts of their brains?
What of the other criteria? I think that failure to fulfill role obligations could be a consequence of either compulsive use or continuing obsession. Spending a great deal of time thinking about or using the drug, also both. Broken limits, clearly compulsive use. Failed attempts to quit, clearly continuing obsession.
If we accept that these two core phenomenon and these alone represent addiction without the complication of epiphenomena, then we should be able to find a biology common to all people with addiction that explains both of these phenomena. It is that biological explanation which is the main thrust of this blog. And once we know the biology, the drug doesn’t matter. Using food, gambling, sex, spending, heroin, cocaine, alcohol or anything else in the disease of addiction is still the disease of addiction. The biology of addiction is still the biology of addiction, and the treatment of addiction is still the treatment of addiction. We won’t solve the problem of addiction in our society while we focus on one drug or another.