The Addict as Object: trapped between moral condemnation and biological determinism

The cover of 03 March 2008 issue of Newsweek displayed the headline: "The Hunt for an Addiction Vaccine."  Inside, a more ominous title: "What Addicts Need."

"Addicts," author Jeneen Interlandi tells us, "like the rest of the public, need to recognize the fact that we are entering a new era in addiction treatment."  This comes near the end of the article, after a prim "...most people reading this article probably can think of someone they know who owes his or her life to it [AA, and by implication NA, OA, etc.].  Some readers themselves have surely benefited." (emphasis mine) The article may be about what addicts need, but it is written to the rest of the public.  Indeed, drawing a line between addict and non-addict is the focus of the article.

In order to enter the new era in addiction treatment, the biological determinism of addiction must be accepted.  Just like it was for depression.  Steven Paul, head of research for drug maker Eli Lilly (developer of Prozac), is quoted as saying, "There used to be a stigma attached to depression, too, but the development of Prozac put an end to that."

Yes and no.  The marketing of Prozac did indeed shift the stigma.  There is no longer moral condemnation for having depression.  Indeed, having depression and seeking treatment is now considered somewhat laudable.  What is not morally acceptable is being depressed; the stigma has shifted, not been obliterated.  If you are depressed, it is because you aren't willing to consume the pills offered.  Marketing depression as a biological disease has created the assumption that it is "highly treatable."  Many recipients of the message would probably be surprised to learn that only about half of patients treated with antidepressants report improvement of any kind (and so do about half of subject treated with a placebo), and fewer than that show a high level of improvement.  But a consequence of the message is that if you are depressed there is only one possible explanation: you haven't taken the treatment. And that is unacceptably irresponsible behavior.  Indeed, the tolerance for people exhibiting depression as a natural response to loss or grief seems to be on the decline.  College students upset over romantic breakups report being pressured by parents and peers to take antidepressant medication.  Widows reports being advised to, "See your doctor."

The article concludes, "...there's hope that science may some day help put that power [as opposed to the "powerlessness" that is Step One of the 12-Steps] within the reach of anyone who needs it.  And then who would choose not to grasp it, and begin the long war for sobriety-- a war without end, but one worth the fighting."

Once addiction is sold as biologically determined there will no longer be a stigma associated with being an addict, but there will always be a stigma associated with addiction.  That stigma will be wider than the stigma associated with powerlessness; it will be the moral condemnation of the irresponsible behavior of not grasping, of refusing to be treated (nevermind whether the treatment works or not), or not fighting.  The depressed addict will be double stigmatized.

Biological determinism is a metaphysical concept, not a scientific fact.  Concepts are presented and tested as scientific theorems.  The testing of the theorem is the scientific process; the conclusions are the scientific facts.  Needs and desires outside of science prompt the creation of the theorem; Edison wanted to provide light without the use of fire.  What needs and desires prompt this theorem, and why is it being prematurely sold as fact?  One reason is to reinforce the moral condemnation that biological determinism supposedly squelches.  Just as the Puritans could watch for who tripped on the church steps in order to determine who was most loved by God, moderns can determine with satisfaction that they are not-addicts.

There is no scientific dividing line between the addict and the not-addict as they are observed.  Addict to not-addict, like most things in nature, run on a continuum.  Efforts at line drawing are moral statements.  Therefore, the line between addict and not-addict is not an argument about what is, but an argument about what should be.  As scientific terminology, it has no meaning.

To set up the line-drawing fundamental to the biological determinist case, the author draws on the field of neuroscience.  "Neurological scientists don't talk about 'will-power,' which is a philosophical concept..." but rather "three kinds of self-control".  Note the line-drawing the author finds in neuroscience (emphasis mine):

• Addicts always take the immediate reward.
• Addicts typically act without processing all the available information.
• ...addicts were much less able to ["consciously stop a behavior that has become automatic"]

These three points are meant to make the biological determinist's case.  An "always" statement is always suspect.  In this case the article itself provides the exception.  From earlier in the article:

It has been years since the pleasure of drinking outweighed the pain it caused Fuller.  Looked a that way, the "social" and "spiritual" aspects of her problem seem insignificant compared with the contribution of biology.  If you weigh advances in neuroscience over the last few decades against social and spiritual progress, it's clear which field is more likely to produce the next break-through in treatments.

The paragraph is meant to support the argument that the biological determinism of addiction is so extreme that it will cause the addict to behave irrationally, against their own interests by every definition including the interest of taking an immediate reward.  Addiction, in other words, can shift fundamental laws of psychology that are not even shifted by severe mental illness such as schizophrenia or suicidal depression.

Addicts "typically"- and yet this information Interlandi gleaned from Thomas McLellan, a psychologist from the University of Pennsylvania, elsewhere in the article:

Addicts are by no means unique in their propensity to relapse.  In a study comparing alcoholics and drug addicts to patients with diabetes, asthma and hypertension, McLellan found nearly identical rates of noncompliance and relapse; between 30 and 40 percent of each group failed to follow even half their doctors' guidelines.

"Much less able" refers to a test with a clicker and a computer screen.  I'm inclined to respond that if you put a clicker and a computer screen in front of me and used it to measure my will power, at least my hands would be full and I couldn't eat.  Meanwhile, if you have a scientific definition for "typically" or "much less able," let me know.

Another reason to promote the hypothesis of biological determinism is to increase money and power.  The scientist out to make a name for herself in her field; the pharmaceutical executives out to make a profit; the government agency out to create a constituency and a block of support.  The support is required from the non-addict and the addict alike.  To get support from the non-addict, aside from appealing to his elevated standing, one can also appeal to his fear that drugs really do alter the laws of psychology.  This magical view of drug use, countered in the book The Cult of Pharmacology and discussed in an earlier Cactus Juice entry, is trotted out for the article.

The appeal to the addict is simple:  this problem, this enormous problem that you have been cursed with, can be solved with no input from you.  And it can be solved with a pill.  Addicts are resistant to that message for a variety of reasons.  One is that after being offered opium and cocaine as treatments for addictions to substance such as alcohol addicts know that drugs get pushed on them premature to science.  Heroin addicts are simply switched to methadone, a synthetic heroin available through the legal drug market.  The author acknowledges all of that, but also describes a heroin-turned-methadone addict as being "in recovery for 20 years."  The addict states "some people feel recovery from addiction should not be easy or convenient."  I don't know about that, but I do know it should involve recovery.  Most addicts know that their addiction isn't a separate part of them but, for better or worse, integral to their place in the world and their experience of it.

Despite the appeal of the biological model, the director of the pharmacotherapies division of the National Institute of Drug Abuse, Frank Vocci, is quoted expressing caution:

The idea that we can restore "self-control" or "free will" with medication is a very, very exciting one.  It could be paradigm shifting.  But we need more studies to see how consistently that impacts recovery.

The author continues on about biology: discussing the difficulties in shifting the biochemistry of the brain.  But that isn't what Vocci's quote is about; the question is how does shifting biochemistry impact recovery.  It is possible that biological determinism is false; that even with perfect brain chemistry the psychosocial elements of addiction will prevail.

Injection drug studies and an actual real word event (where what amounted to placebo heroine was released onto American streets) have shown that addiction to injection drug use can be shifted to addiction to the injection ritual itself (with more innocuous drugs such as caffeine or without any drug at all).  Chemistry isn't everything.

Following Ms. Interlandi's article, is a one-page rebuttal by Mitchell S. Rosenthal, M.D., writing in opposition to biological determinism.  His statement includes the following line, which I read with an amusement that was probably unintended:

...we should recognize that drugs alone are not the answer to addiction.

His conclusion is that treatment "can be empowering" and "...it is hope, grounded in self-awareness, that is the best safeguard for recovery we now have."

There is no line between the addict and the not-addict.  The motivations that put science in the place of ethics must be recognized, and cheap efforts to simplify both science and ethics must be avoided.

Comments

[Diana]

I think I tend to agree more with the second guy. I grew up hearing that my personality was just like my grandmother - an alcoholic. I was warned almost constantly that if I wasn't careful, I'd end up with the family curse of addiction. For not only my grandmother was an alcoholic but two of her three sons were, too. The third, my father, vowed at a young age to never drink and he never has. So right there, he was not powerless.

I've never had a problem with alcohol. It just doesn't tempt me. I feel lousy when I even drink socially. But in college, a roommate gave me some crystal meth one day when I was worried about pulling off three final exams in addition to an 8-hour shift at my job. "It will help you with your energy," she said. Back then, crystal meth wasn't well-known. I had no idea what it was.

Well, I tried it and I LOVED it! I felt invincible, like three finals and a full day of work were nothin'. I sailed through the day. At work that night I did the work of three people.

And my father's warnings came back to me and I knew that this stuff, this could be my undoing. This stuff could hook me, bring out the addict.

So I never, ever tried it again. That scared me, that brush with a drug that seemed to fill in the missing parts of me. I totally get how people can feel that euphoria, that plugging in of the missing piece, and get addicted. But I wasn't powerless, either. I chose to never cross paths with the stuff again.

Long, self-righteous story, I know. But it's just a start. I still feel the personality of an addict just under the surface, only I feed it with sugar and chocolate and adrenaline/drama. I read that first article and found myself wishing I could try one of those pills to make me stop looking for my innocent highs, you know?

Fascinating topic.

[loafingcactus]

The original post was written on uppers perscribed to treat an asthma crisis. My house was clean, and paperwork was in order, and the very long blog post was written over several nights. Today I'm tired, I've flown too many places, there are no drugs in me, and I just wrote a blog post that only makes sense if you read my mind.

I've left this comment sitting because I couldn't think of anything to say to it. But I think that today I can identify with the idea that certain drug experiences can make a person seem more-than-herself. I suppose the separation between completing-self and addiction is the presence or absence of fear of living without the addictive substance. Can I try to write "sober"? The answer is yes, and so I am one of the fortunate and/or tough for whom an asthma drug is just an asthma drug.

[Diana]

"...presence or absence of fear of living without the addictive substance."

Interesting. Yes. I try to remember that experience (it was a loooong time ago) and recall what the source of my fear was and I really think that my fear was in not being able to live without it, or fear of *needing* it, which I had been raised to see as a very bad thing. Thus I was able to push it away, something I am very grateful for.

I am very wary of parents who think that a more relaxed attitude towards drug education is a good thing; my father's stance was an extremely unequivocal "you do drugs/alcohol you will fry your brain and die" kind of approach and hey, I think it's a good one! I do my part to instill in my young teens that fear of a very dangerous substance. Without that fear, I just don't know...

(If only I'd also been raised to fear sugar and chocolate.)