Recent Addiction Debates: Opiate Substitution, Behavioral Addictions, and AA’s “Higher Power”

Editor’s Note: The journal Addiction occasionally features critical perspectives on debates in addiction studies. Below is a selection of recent publications dealing with topical issues in the field.

Ed DaLuke Mitcheson


Background and Aims: Clinical guidelines from around the world recommend the delivery of psychosocial interventions as part of routine care in opiate substitution treatment (OST) programmes. However, although individual studies demonstrate benefit for structured psychosocial interventions, meta-analytical reviews find no benefit for manual-based treatments beyond ‘routine counselling’.

Analysis: We consider the question of whether OST medication alone is sufficient to produce the required outcomes, or whether greater efforts should be made to provide high-quality psychosocial treatment alongside medication. In so doing, we consider the nuances and limitations of the evidence and the organizational barriers to transferring it into routine practice.

Conclusion: The evidence base for psychosocial interventions in opiate substitution treatment (OST) services can be interpreted both positively and negatively. Steering a path between overly optimistic or nihilistic interpretations of the value of psychosocial treatment in OST programmes is the most pragmatic approach. Greater attention should be paid to elements common to all psychological treatments (such as therapeutic alliance), but also to the sequencing and packaging of psychosocial elements and their linkage to peer-led interventions.

iel Kardefelt-Winther et al.


Following the recent changes to the diagnostic category for addictive disorders in DSM-5, it is urgent to clarify what constitutes behavioural addiction to have a clear direction for future research and classification. However, in the years following the release of DSM-5, an expanding body of research has increasingly classified engagement in a wide range of common behaviours and leisure activities as possible behavioural addiction. If this expansion does not end, both the relevance and the credibility of the field of addictive disorders might be questioned, which may prompt a dismissive appraisal of the new DSM-5 subcategory for behavioural addiction. We propose an operational definition of behavioural addiction together with a number of exclusion criteria, to avoid pathologizing common behaviours and provide a common ground for further research. The definition and its exclusion criteria are clarified and justified by illustrating how these address a number of theoretical and methodological shortcomings that result from existing conceptualizations. We invite other researchers to extend our definition under an Open Science Foundation framework.


Background: Alcoholics Anonymous (AA) is a world-wide recovery mutual-help organization that continues to arouse controversy. In large part, concerns persist because of AA’s ostensibly quasi-religious/spiritual orientation and emphasis. In 1990 the United States’ Institute of Medicine called for more studies on AA’s effectiveness and its mechanisms of behavior change (MOBC) stimulating a flurry of federally funded research. This paper reviews the religious/spiritual origins of AA and its program and contrasts its theory with findings from this latest research.

Method: Literature review, summary and synthesis of studies examining AA’s MOBC.

Results: While AA’s original main text (‘the Big Book’, 1939) purports that recovery is achieved through quasi-religious/spiritual means (‘spiritual awakening’), findings from studies on MOBC suggest this may be true only for a minority of participants with high addiction severity. AA’s beneficial effects seem to be carried predominantly by social, cognitive and affective mechanisms. These mechanisms are more aligned with the experiences reported by AA’s own larger and more diverse membership as detailed in its later social, cognitive and behaviorally oriented publications (e.g. Living Sober, 1975) written when AA membership numbered more than a million men and women.

Conclusions: Alcoholics Anonymous appears to be an effective clinical and public health ally that aids addiction recovery through its ability to mobilize therapeutic mechanisms similar to those mobilized in formal treatment, but is able to do this for free over the long term in the communities in which people live.


New Dissertation Research: Life “After” Drugs?

Editor’s Note:  These entries are part of an ongoing drug-related dissertation bibliography being compiled by Jonathon Erlen, which was formerly published in the Social History of Alcohol and Drugs journal but is now periodically featured on the Points blog. Contact Dr. Erlen through the link above.

Derailed: Racially Disparate Consequences of Juvenile Drug Arrests on Life Outcomes

Author: Ashtiani, Mariam Tayari

Publication info: University of California, Irvine, ProQuest Dissertations Publishing, 2016.

Abstract: Racial biases in law enforcement over the last three decades are linked to the racialized policies of the War on Drugs, which have given way to controversially aggressive policing tactics, disproportionately focused on minority youth. These policies also pose a serious challenge to race-neutral understandings of inequality: While White youth use and sell drugs at higher rates, Black and Latino youth are more likely to get arrested. What are the consequences of this aggressive and racially biased drug enforcement on the lives of youth? I explore this question by looking at racial differences in the impact of a juvenile drug arrest on two crucial life outcomes: education and employment. Using data from the National Longitudinal Study of Adolescent to Adult Health, I compare the effects of juvenile drug arrests on life outcomes to the effects of other types of arrests, highlighting the unique role that drug arrests play in creating divergent life outcomes along racial lines. Prior research on the impact of juvenile arrests used aggregate measures of arrest, with an underlying assumption that all offenders are uniformly impacted by an arrest, regardless of arrest type or race. In this dissertation, I develop and test Racial Profiling Selection Theory, in which Blacks, and to a lesser extent Latinos, due to racial profiling, are more likely to be arrested for minor drug crimes than Whites. I argue that Blacks and Latinos who are arrested for drugs are often youth who otherwise do not engage in criminal behavior; their pathways towards educational and labor market success are therefore derailed by the arrest. In contrast, Whites who are arrested tend to be those who engage in more criminal and delinquent behaviors. My findings support this theory. I find that drug arrests are unique, relative to other types of arrests, in their negative impacts on the life chances for Blacks and darker-phenotype Latinos. My findings have important theoretical and policy implications since they show that not only do Blacks suffer more from the War on Drugs than Whites because they are more likely to be arrested, they suffer more because the actual arrest is more detrimental to their life chances.Read More »

Substance Use Theory in the Recent Past: Modernization and the Mitchell Report

Editor’s Note:  These entries are part of an ongoing drug-related dissertation bibliography being compiled by Jonathon Erlen, which was formerly published in the Social History of Alcohol and Drugs journal but is now periodically featured on the Points blog. Contact Dr. Erlen through the link above.

It’s a Whole New Ball Game: The Mitchell Report, Performance Enhancing Drugs, and Professional Sports

Author: Schrader, Brian J.

Publication info: University of Denver, ProQuest Dissertations Publishing, 2016.

Abstract: This dissertation investigates the findings of a congressional investigation into the use of performance enhancing drugs (PEDs) in Major League Baseball, known as the Mitchell Report. It analyzes the primary arguments presented in the report, the argument for integrity, role models, and apology specifically, through the lens of governmentality and moral regulation. It argues that the report represents a distinct mode of governance that seeks to condemn PED use in a moralizing way. This mode of governance is characterized by its emergence from a variety of locations as opposed to the relatively simple use of the state and its legal apparatus. Importantly, one of those locations includes the individual subject who is urged to self-govern without the need of external threat or recourse. The dissertation also suggests that this mode of governance is inextricably linked to rhetoric and communication.Read More »

Review: Emily Dufton on Martin Torgoff’s “Bop Apocalypse”

Editor’s Note: This review of Bop Apocalypse: Jazz, Race, The Beats, & Drugs (De Capo Press, 2016) comes courtesy of Emily Dufton, Points managing editor emeritus.

5114moutnel-_sy344_bo1204203200_Martin Torgoff’s early experiences with drug history began as a family affair: he was first introduced to marijuana by his older sister on November 5, 1968, the night Richard Nixon was elected president. The 16-year-old got supremely stoned and experienced a new kind of ecstasy when his sister placed his head between the speakers of her stereo and played the Beatles’ “Blue Jay Way.” He “felt the music and the lyrics… to the very roots of my soul,” Torgoff explains in the introduction to his new book, Bop Apocalypse: Jazz, Race, The Beats, & Drugs (Da Capo Press, 2016), and this fascination with music and drug use has lasted the rest of Torgoff’s life, transforming itself, successfully, into a writing career.

Torgoff is the author of several previous works about music and drugs, including American Fool: The Roots and Improbable Rise of John “Cougar” Mellencamp and Can’t Find My Way Home: America in the Great Stoned Age, 1945-2000. Indeed, the seeds for Bop Apocalypse were planted in the second chapter of Can’t Find My Way Home (hereafter CFMWH), which carried the same name and explored the early rise of American marijuana and heroin use in Harlem and California from the 1930s to the 1950s. From Herbert Hunke shooting up William Burroughs to Charlie Parker’s saxophone and the rise of the Beats, Torgoff suggests that drug use in the first half of the twentieth century created a kind of secret society among users — a knowing, winking, self-destructive cabal of artists and musicians whose desire to pursue the “wild form” brought powerful elements of improvisation and mysticism to jazz and writing, many of which continue to wield influence today.Read More »

The Points Interview: Benjamin B. Roberts

Editor’s note: Today’s Points Interview is with Benjamin B. Roberts, author of the forthcoming book, Sex, Drugs, and Rock ‘n’ Roll in the Dutch Golden Age, available December 2017. Mark your calendars!

Describe your book in terms your bartender could understand.

The main question of my book is: “What was it like to be a man coming of age in the early seventeenth century at the height of the Dutch Golden Age”. Rembrandt, who was born in 1606, grew up in this period. I wanted to know everything about being an adolescent and teenager in the seventeenth century. What did they think was cool to wear, how did they deal with their sexual urges, at what age did they start drinking alcohol, and what did they do for fun? Ultimately I wanted to find out if being a young man in the seventeenth century was any different than it is now.

One of the main conclusions from my research is that young men rebelled against the older generation with their physical appearance. They let their hair grow long (shoulder length), wore bright-colored clothing, and accessorized with ribbons, silk stockings, and high-heel shoes. Some young men even wore make-up to conceal smallpox marks they had from childhood.Read More »

Smoking Cessation Dissertation Roundup

Editor’s Note: In light of the U.S. Food and Drug Administration’s recent attention to nicotine levels in cigarettes as an anti-smoking measure, today’s post features a selection of relevant dissertations on smoking cessation. These entries are part of an ongoing drug-related dissertation bibliography being compiled by Jonathon Erlen, which was formerly published in the Social History of Alcohol and Drugs journal but is now periodically featured on the Points blog. Contact Dr. Erlen through the link above.

A Unique Tobacco Cessation Service for Cancer Patients at Roswell Park Cancer Institute: Acceptance, Participation and Impact

Author: Amato, Katharine Ann

Abstract: Problem under Investigation: Smoking cessation amongst cancer patients is often thought of as less important because the patient has already developed cancer. However, increasing evidence suggests that continued tobacco use during cancer treatment reduces the effectiveness of treatment, increases negative side effects of the treatment, decreases the quality of life, and increases the risk for tumor recurrence, second primary tumors or death. To date, limited research has been conducted to improve cessation efforts among cancer patients or measure the impact of smoking cessation on survival. Most studies rely on an opt-in randomized control design impacting a limited number of patients or on retrospective chart review with smoking status collected in an inconsistent manner. More data are needed to better understand the impact of smoking cessation among cancer patients. Roswell Park Cancer Institute Tobacco Assessment and Cessation Service: Patients seen in all clinics at Roswell Park Cancer Institute (RPCI), including the thoracic clinic, have tobacco use assessed every thirty days; an automatic electronic referral is generated to a free opt-out telephone based cessation support service for all patients who indicate current or recent (last 30 days) tobacco use, which offers up to eight cessation support telephone calls. Specific Aims: The goal of Specific Aim 1 is to describe the reach and potential impact of the RPCI Tobacco Assessment and Cessation Service (TACS) by describing the patients who participate in the service and by examining the initial quit rates of participants in the current program. The goal of Specific Aim 2 is to conduct a 3-month follow-up of all participants to determine their self-reported quit rates for the previous seven days, as well as patient satisfaction with the RPCI TACS. The goal of Specific Aim 3 is to examine survival rates with relation to smoking status for lung cancer patients referred to the RPCI TACS. Research Methodology: The majority of patient information was extracted from the electronic medical records, finance records, and tumor registry at RPCI for all three specific aims. Mailed surveys, along with follow-up telephone interviews for non-responders or to obtain any missing information, were conducted to obtain self-reported quit status 3-months after the first contact by the RPCI TACS for Specific Aim 2. Univariate and multivariate statistics were used to examine the factors associated with and predictors of quit rates at 1-month and 3-months for Specific Aims 1 and 2. Stratification by patient gender, tobacco use status at referral, disease characteristics, and other health behaviors were explored. Specific Aim 3 was evaluated using univariate and survival analysis statistical methods to determine predictors of other health outcomes associated with thoracic cancer. Results: For Specific Aim 1, 78.3% of 942 thoracic clinic patients referred to RPCI TACS were successfully contacted and participated in the first call; among those who participated in the first call and were called for a follow-up, 88.7% (401/452) participated. Among current users at referral, 26.0% (89/342) reported cessation at follow-up. Among those contacted twice, lung cancer patients were statistically more likely to quit at follow-up compared to other thoracic clinic patients (OR=1.78; 95% CI: 1.02-3.11) and thoracic clinic patients in poorer health (as indicated by a higher ECOG performance score (≥1)) were less likely to quit at follow-up compared to healthier patients (ECOG PS=0; OR=0.43; 95% CI: 0.34-0.77), while controlling for other demographic, health and disease characteristics. For Specific Aim 2, 55.5% (142/256) reported being smoke-free for at least the previous 24 hours at the 3-month follow-up; 86.4% reported being very or mostly satisfied with the service they received from RPCI TACS. For Specific Aim 3, after controlling for age, pack-year history, sex, performance status, time between diagnosis and last contact, tumor histology and clinical stage; a statistically significant increase in survival was associated with quitting compared to continued tobacco use at last contact (HR=1.79; 95% CI: 1.14-2.82), with a median 9 month improvement in overall survival. Conclusions: Thoracic cancer clinic patients are receptive to a free opt-out telephone-based cessation service following a cancer diagnosis, negative biopsy, or participation in a high risk screening program, as indicated by the high participation rates. Patients are interested in participating, are making efforts to quit, and are satisfied with the service they have received. Lung cancer patients who quit show improved survival compared to those who continued using tobacco. Potential Significance: This unique RPCI Tobacco Assessment and Cessation Program will benefit from evaluation and improvement. Results from this dissertation can be applied to making future improvements within RPCI TACS (i.e. by determining optimal timing, frequency, duration, and framing of cessation support messages), can guide the development of a framework to evaluate and improve the cessation service for all other cancer sites, and can offer an example for other comprehensive cancer centers intending to implement a similar program with mandatory tobacco use assessments and automatic referrals to an opt-out cessation support service.Read More »

New History Dissertation Roundup: Marietta Holley, Lyman Beecher, and Drug Addiction on Stage

Editor’s note: In today’s post, we highlight a few recent dissertations on drug use among young people from around the world. These entries are part of an ongoing drug-related dissertation bibliography being compiled by Jonathon Erlen, which was formerly published in the Social History of Alcohol and Drugs journal but is now periodically featured on the Points blog. Contact Dr. Erlen through the link above.

Marietta Holley on Temperance and Women’s Rights: Framing and Interpreting a Legacy of Social Reform

Author: LaCoss, Joan Harkin

Abstract: The values of historical figures may be misconstrued when later scholars view the past through a perspective of newer facts and beliefs. Such revisionist research can apply new values to reshape understanding, but in the process may inadvertently marginalize or invalidate the original values at stake. Consequently, the interpretation of past events and cultural trends can be very different from the intended meaning of the principals involved. An examination of the life, work, and legacy of Marietta Holley exemplifies this type of skewed interpretation. As a writer, supporter of political rights for women, and advocate of social reforms in late nineteenth and early twentieth century America, Holley had ample opportunity both to express her personal values and to influence American society. Holley became a focus of twentieth century feminist scholars who framed her work to further a specific interpretation of feminist history – in the process these scholars displaced Holley’s values and the meaning of her legacy and niche in American culture. Studying Holley illuminates the creative ways through which a group can exercise freedom within a restrictive social environment, using that very creativity to challenge that environment. This thesis will address two major questions: how Holley constructed a unique personal legacy through the use of language and actions as a humorist, temperance and women’s rights proponent, and social reformer; and how a number of twentieth and twenty-first century researchers distorted her intended impact on American social and cultural development. The Holley analysts placed her within a frame of women’s rights and distanced the scholarship from an alternative interpretation that temperance was her main reform cause and the impetus behind her women’s rights stance. As this thesis will reveal, both life and literature reflected values that found expression in female involvement in the temperance and women’s rights movements. Holley believed in political and social empowerment for women, especially as that female power could be used constructively toward reform. With Holley as a focal point for the convergence of women’s history, culture, and literature, this study will explore her place in popular fiction and find alternative interpretations for the influence she hoped to have on society.Read More »

Big Nicotine, Part I: Big Tobacco’s Drug Problem

Just over a week ago, the United States Food and Drug Administration announced what new FDA chief Dr. Scott Gottileb called “a cornerstone of our new and more comprehensive approach to effective tobacco regulation”: an initiative to reduce the nicotine content in cigarettes to “minimally or nonaddictive” levels. The 2009 Tobacco Control Act gave FDA authority to reduce any “additives, constituents…, or other component of a tobacco product.”

Obama Tobacco
President Barack Obama signing the Tobacco Control Act

Public health historian Robert Proctor was thrilled. “This is exceptionally good news for tobacco control, and for human health,” he wrote last week in the New York Times. Not so for companies like Altria and British American Tobacco, whose stock value fell within an hour of the statement (and recovered somewhat before the closing bell).

Big Tobacco was reeling for good reason: nicotine is the primary addictive component of cigarette smoking, not incidentally the leading cause of preventable deaths in the U.S. The addictive capacity of nicotine is now practically indisputable. For over sixty years, government regulators, independent researchers, and tobacco company scientists have investigated the extent of that capacity and the danger it poses when delivered via tar-laden cigarettes.Read More »

Dissertation Roundup: Drug Use and Young People, International Edition

Editor’s note: In today’s post, we highlight a few recent dissertations on drug use among young people from around the world. These entries are part of an ongoing drug-related dissertation bibliography being compiled by Jonathon Erlen, which was formerly published in the Social History of Alcohol and Drugs journal but is now periodically featured on the Points blog. Contact Dr. Erlen through the link above. Stay tuned for original content, coming soon!

The Development of Health Risk Behaviors by Mexican-Origin Youth

Author: Bacher, Kelly Beaumont

Abstract: This dissertation investigates the development of risky health behaviors by Mexican-origin youth. The two papers comprising this dissertation utilize data from a community sample of Mexican-origin adolescents participating in a prospective, longitudinal research study. Paper 1 examines the longitudinal relationship between ethnic discrimination and adolescent substance use behaviors. This study extends previous work by examining these processes in children of Mexican origin, who are often neglected in research on discrimination. Findings reveal that ethnic discrimination from peers at school predicts increases in substance use across a five-year period of adolescence. Paper 1 also assesses supportive parenting as a source of resilience by investigating potential compensatory and buffering effects on adolescent drug and alcohol use. Paper 2 examines the extent to which, during the transition from late childhood into adolescence, individual and contextual characteristics of female youth predict engagement in risky sexual behavior. This paper addresses a need in the current literature on sexual risk-taking by investigating predictors of this behavior for girls of Mexican origin, who often report higher levels of risky sexual behavior than other ethnic groups. Results indicate that early pubertal development and affiliating with deviant peers are important direct predictors of later sexual behavior. This study also examines indirect and transactional relationships between study variables. Together, these papers enhance our understanding of the family, peer, and personal characteristics of minority children that influence the development of health risk behaviors.Read More »

#ADHS2017 Field Reports: Friday, June 23 by Richard Robinson

Editor’s Note: Between June 22 and June 25, the Alcohol and Drugs History Society organized its biennial conference in Utrecht, The Netherlands. In three day-by-day reports, some attendees will reflect upon the proceedings and their highlights.  Today’s post was provided by Richard Robinson, urban historian at the University of Helsinki.

“The interdisciplinary spirit of enthusiastic curiosity in classrooms doubling up as impromptu saunas”
By Richard Robinson


At 8.45 AM on a fine Friday morning, the opening sessions of the Alcohol and Drugs History Society conference feel very far away indeed. Our party has left its hotel on the outskirts of Utrecht to walk to the university, but we have naively strolled straight onto a bike superhighway during rush hour. This is no place for the humble pedestrian: hundreds of cyclists stream past as we stumble along the grass verge, scouring the foliage in vain for an exit route. The sole geographer in our party is visibly flummoxed, and the day’s panels disappear in a whirl of spokes and fixed gears. Our destiny, it seems, is to be a very Dutch form of road kill.

Thankfully, two English literature scholars emerged as the unlikely heroes, navigating us successfully over a two-tiered canal to the comparative safety of a residential road. Breathing a sigh of relief, the one thing I really needed at that moment was a strong drink-and-drugs-themed conference. Luckily, Friday’s papers did not disappoint: fascinating new research was introduced and old narratives were undermined in an atmosphere that exuded bonhomie and warmth, a result of both an interdisciplinary spirit of enthusiastic curiosity and classrooms that doubled up as impromptu saunas.

Given the subject matter and conference title, it is perhaps redundant to observe that regulation was one of the recurring themes of the day, but those presentations that considered its porosity and cultural form were particularly enlightening. Focusing on seventeenth-century England, Alex Taylor adeptly demonstrated how the illicit trade in bulk tobacco by the very sailors responsible for its transportation meant that attempts to license and restrict the good largely went up in smoke. Ryosuke Yokoe traced the shifting medical conception of cirrhosis in Britain – from alcoholic’s disease in the Edwardian period to a consequence of poor nutrition in the 1940s – and argued convincingly that this was due to a softening of the political climate surrounding drink. Finally, Rachel McErlain considered the soft regulation of moral suasion, immersing the audience in the melodramas of mid-nineteenth-century temperance tracts and assessing the ways in which they depicted drinking as anathema to feminine respectability.

McErlain’s paper was also one of a clutch that addressed the significant roles of women in drink history: as victims, as sellers and as reformers. Showing that a lack of extant source material does not preclude comprehensive analysis, Jenni Lares used lower court records and Judith Bennett’s seminal work on England to examine the status and rights of female publicans in early modern Finland. Victoria Afanasyeva discussed the increasing prominence of women in the French temperance movement from the late nineteenth century, and reminded us that such campaigns did gain traction in countries beyond the traditional temperance cultures.

Indeed, throughout the day established truths of drink history were called into question. Richard Yntema’s meticulous account of the development of the distilling industry in Holland went against the grain of conventional wisdom by demonstrating that spirits were being commercially produced already in the late sixteenth century. In her expansive discussion of transatlantic temperance connections, Annemarie McAllister stressed that, in spite of the two-way cultural transfer that clearly took place, the British movement always remained on the fringes of mainstream society, in contrast to its US counterpart. And in the keynote lecture, Phil Withington confronted his 2010 economic-history-seminar demons in style, roundly – or perhaps rather trigonally – disabusing the notion that per capita consumption should be the pre-eminent means of understanding intoxicant use. Railing, too, against presentist historiography, and drawing on theory by Elizabeth Shove, amongst others, he outlined the premise of his multidisciplinary consumption triangle, which puts the study of the production, control and representation of social practice firmly at the palpitating heart of alcohol and drug history.

Post-plenary, it was resolved to put social practice theory to the test, and we meandered along the riverside into a park for a Dutch festival. Unlike Dutch courage and Dutch uncles, it should be noted that this is intended as an entirely positive epithet: not every country can combine large-scale public drinking and good cheer so easily. With pockets full of munten (a cardboard currency of indeterminate value) and power in numbers, we occupied a coveted picnic table and began to explore the multitude of food stalls and beer tents in the vicinity. Sadly, I was not party to the astonishing debauchery that no doubt occurred as the night progressed: ever the professional, I left early to prepare for my presentation. However, lacking the advanced orientation skills of literary scholars, I proceeded to finish the day as I began it, by getting hopelessly lost.