Editor’s Note: In this post, Points Assistant Managing Editor Kyle Bridge offers a textual overview of the “Addictions Old and New” conference, convened October 22-23 at the University of Richmond. Follow the link above to see the professionally-recorded presentations in their entirety.
Increased specialization in scientific research has yielded nuance but added little coherence to how we conceptualize addiction. More broadly across disciplines, the study of addictions is fraught with disagreements over methodologies, treatment and policy implications, and even defining what “addiction” actually is. So it was no surprise that last week’s conference, “Addictions Old and New,” which featured a variety of presenters with current and historical perspectives on the phenomenon, was an enlightening and provocative experience.
Psychiatrist Charles O’Brien’s keynote address, “What is Addiction and What do Addictions Have in Common?”, set the tone for the event. Taking the long view of history—meaning from-the-dawn-of-man long—he argued that addiction is a “coincidence of evolution.” Anything that can activate the neurological reward system has addictive potential, though more data is needed before we label new, discrete addictions. As for etiology, it turns out that addiction and memories are formed the same way and one is as hard to “forget” as the other. Though, O’Brien did differentiate “addiction,” characterized by drug seeking despite adverse consequences, from “dependence,” what he called a natural physical adaptation. Furthermore, he claimed, all addictions are influenced in some way by genes. He also addressed what constitutes sound treatment, which may include medicine, talk therapy, and even potentially electrical stimulation of particular parts of the brain.
The keynote covered far more than can be addressed here, but two main points were raised in the subsequent Q&A. The first took issue with the criteria for recognizing iterations of addictions. Fortunately for anyone curious, two of the next day’s presentations made the case for adding some new acts in addiction’s big tent: food and sex. In “Food as a Drug: How Good is the Analogy?”, historian David Courtwright found that the comparison holds because, at a basic level, food addicts look like drug addicts, exhibiting similar patterns of use and co-morbidity with other disorders. They also recover like drug addicts; for example, promising therapeutic medications like naltrexone suggest biological commonalities between addictions. In fact, food addict behavior often fits neatly within the National Institute on Drug Abuse’s disease model of addiction. Thus, it may only be a matter of time before public health reformers and capitalist interests clash over the availability of hyperpalatable foods, for, almost inevitably, “economic rationality begets social irrationality.”
In a similar vein, sex addiction therapist Robert Weiss lamented that the American Psychological Association does not officially recognize the disorder in its Diagnostic and Statistical Manual. His presentation, “Hyperstimulation and Digital Media,” laid out what sex addiction is not, including an excuse for infidelity, a high sex drive, or criminal sexual offenses. Though his presentation was cut short for time, Weiss made a compelling case that sex addiction is not really about the act of sex at all. Instead, it is the thrill of anticipation and underlying intimacy issues which compel sexually addictive behavior. Hopefully historian Virginia Berridge’s talk, “Whatever Happened to Alcoholism?”, which focused on the twentieth-century British concept of alcoholism, gave Courtwright and Weiss some historical optimism. Alcoholism’s time came, passed, and then came again, bolstering the perennial truth that popular ideas about addiction are subject to change.
Later, in “Addiction by Design,” communications scholar Natasha Schull presented on technological gambling addiction, or, more accurately, the efforts of gaming companies from Las Vegas to Silicon Valley to maximize user “time on device” through innovative ergonomics, deceptive wagering patterns, and sensory gratification. Gambling addiction’s long history relative to food or sex certainly makes it a less contentious notion, but Schull’s research introduced a counterintuitive idea about the practice: that chronic gamers are not actually in it to win it. Really, they play to get in what she calls “the zone” and numb themselves to reality. After her thoroughly fascinating discussion of the increasing sophistication of game design, she considered some policies that would mandate occasionally rousing gamblers from “the zone” while allowing them to still use machines and remain profitable for casino companies. But, she concluded, the latter’s interests may stifle or simply work around any legislative interventions.
A user in “the zone”
Market capitalism’s addictive potential was the subject of many talks. Like Schull, public policy professor Mark Kleiman was skeptical of allowing commercial interests free reign over a vice, in his case cannabis consumption. He argued in his presentation, “Science and Policy in the Legalization Debate,” that removing criminal penalties for marijuana sales and sanctioning mass production would likely reduce price with the undesirable side effect of increased availability and use. Comparing a potential legal cannabis market to the extant alcohol trade is reasonable, Kleiman allowed, but the modal drinking occasion consists of one or two drinks while the modal smoking session only concludes when participants get stoned. The public health costs of increased smoking will fall on the disadvantaged minority who currently bear the brunt of harms from other legalized commercial vices. Still, he made clear, this is no reason to continue incarcerating millions for marijuana possession.
Circling back, the second major flashpoint following O’Brien’s keynote was the boundary between “addiction” and “dependence.” Clinician-researcher Andrew Kolodny addressed this most directly in his presentation, “The Prescription Opioid Epidemic and the Heroin Revival.” The “bright line” separating the two concepts was in large part contrived by pharmaceutical interests looking to change the culture of opioid prescribing. He dated the current opioid addiction epidemic to 1996, when Purdue Pharma introduced Oxycontin and rolled out an extensive marketing campaign to convince doctors that long-term use of addictive drugs was safe under medical supervision. They reinforced their message through sponsoring mandated continuing education classes for physicians and propping up “grassroots” (or “astroturf”) patient advocacy groups that called for considering pain the “fifth vital sign.” The takeaway was that the current crisis is almost entirely rooted in medical practice. Overdose deaths are highest among older folks with easy access to prescriptions. And the media narrative of a mass migration to heroin following police crackdowns on “pill mills” is wrong on two counts: first, the “migration” has actually been a gradual, consistent process over the last two decades among young, healthy people with sporadic access to legitimate prescriptions or expensive black market versions; and second, there is no evidence of a substantial “crackdown” at all.
Kolodny concluded that to address the epidemic we must prevent new cases of opioid addiction with more cautious prescribing and expand access to treatment for people who are already addicted. And at one point, during another Q&A, even a self-described “drug warrior” conceded that the hardline drug war is lost. Most attendees and presenters seemed sympathetic to or enthusiastic about the goals of harm reduction, or mitigating the negative outcomes of drug use as opposed to simply imposing abstinence. Though this principle is usually applied to illegal drugs, given that their consequences are generally exacerbated by prohibition, in an innovative presentation titled, “Old Drug in a New Container?”, pharmacologist Robert Balster applied it to tobacco and e-cigarettes. Abstinence campaigns have been hugely successful in reducing the prevalence and incidence of smoking, but they may suffer diminishing returns and implicitly accept the harms accrued by the minority that continues to light up. Alternatively, a harm reduction approach of encouraging e-cigarette or other electronic nicotine delivery system (ENDS) use, might maintain or even increase nicotine consumption but at a much lower public health cost. No matter the ethos going forward, he urged for more research into ENDS, which are severely under-regulated by state authorities.
Better than the alternative, but worth the risk?
In “Uppers and Downers,” an historical evaluation of under-regulated pharmaceuticals, historian David Herzberg offered that the mid-twentieth-century’s narrow definition of addiction “shielded sedatives and stimulants from regulation.” Laws passed in the decades after the 1914 Harrison Act targeted “dangerous,” not “addictive” drugs. They imposed few if any manufacturing limits, little required record-keeping, and mild penalties for offending pharmacists. Even as barbiturate overdoses mounted by the 1950s—perhaps as high as over 7 per 100,000 in 1953—public concern did not translate to punitive laws. Harms from prescription drugs were widely viewed as accidental poisonings. It took the 1960s culmination of the civil rights movement and experimental white hippies to overturn mainstream American ideas about who actually used drugs. Meanwhile, a series of public scandals within the pharmaceutical industry made it an easier legislative target. Of course, New York’s Rockefeller drug laws and the crack epidemic reoriented public discourse toward illegal drugs once again, allowing for new pharmaceuticals like Valium and, ultimately, Oxycontin to establish relative legitimacy.
In real, tangible ways, we continue to grapple with the historical and more contemporary issues broached by the presenters, and this report did not even address every issue discussed (see the videos linked above). I can only hope that this conference serves as a model for more interdisciplinary gatherings in the future.