Guest blogging at Points continues this week with a series of pieces by Helen Keane, who teaches gender studies and sociology at the Australian National University in Canberra. Keane is the author of What’s Wrong with Addiction? (NYUP 2002), and has written widely on the social and cultural aspects of alcohol and illicit drug use, pharmaceutical drugs and addiction. Her current research interests include ADHD and constructions of childhood; intoxication and gender; and theories of medicalization.
Much of my work is focused on the concept of addiction and its mix of medical, ethical and social elements. I don’t see this mix as reducible: it seems to me that this collection of biological markers, clinical evaluations, and ethical and cultural judgements is what addiction is. While I think that untangling the strands that make up the idea of addiction is intellectually and politically important, dis-entanglement does not necessarily clarify the true nature of the disorder. What it does reveal is what is at stake in such classificatory and definitional exercises. In this series of posts I want to look at some different medical definitions of addiction: in pain medicine, in the draft DSM-V, and in addiction neuroscience.
Recent guest blogger Siobhan Reynolds, of the Pain Relief Network, stated that addiction was an entirely distinct phenomenon from physical dependence on drugs. Making this categorical distinction between addiction and dependence is crucial in pain medicine because the view that opiates are universally and inevitably addictive has prevented the humane treatment of chronic pain. But it seems that addiction medicine is now joining the move to separate physical dependence from addiction.
The DSM-V Substance Disorders Work Group has made the disambiguation of addiction and dependence central to their draft revision of the relevant DSM-IV diagnostic categories. They propose that the term “substance dependence” no longer be used because it confuses the disorder of compulsive and harmful drug use with physiological dependence, which is “a normal response to repeated doses of many medications” such as opiates. They state that this confusion has resulted in pain patients being denied adequate medication because of the fear of causing addiction. To replace the term “substance dependence” the group resurrects the term “addiction,” previously abandoned as unscientific and stigmatizing. While the work group’s revision retains withdrawal and tolerance as two out of eleven possible diagnostic criteria for addiction, these criteria are explicitly “not counted” as signs of disorder when experienced by patients taking drugs under medical supervision.
Despite the authority of the DSM and the eminence of the work group (headed by Professor Charles O’ Brien), I suspect that extracting drug dependence from addiction and refiguring it as a normal response to drugs will be a long struggle. From the 18th century on, the status of addiction as a disease (rather than a moral failing or lifestyle choice) has been based on the existence of altered physiological response.
When the study of drugs and alcohol was being established as a legitimate area of medicine, pioneers such as E.M. Jellinek used the physiological phenomena of withdrawal and tolerance to argue that alcoholism was a genuine disease which could be objectively diagnosed. Physical dependence retained its status as a definitive sign of addiction right through the 20th century – a textbook for medical students published in 1994 uses “a demonstrated withdrawal syndrome” as the criterion which indicates whether a user is “actually addicted to a chemical.”
The belief that physical or physiological dependence is somehow more real, more powerful and more disease-like than psychological dependence persists, despite the advances made by neuroscience and the “it’s all in the brain” model of addiction. I’ve noticed that while many of my students are readily won over by neuroscientific accounts of addiction (especially those illustrated by brain scans) they habitually dismiss some addictions as “only psychological” (usually to things like video games, shopping, and sex). Real addictions, usually involving alcohol and drugs, are presumably something in addition to psychological – but the question is: what?