Theory of Addiction

Robert West, Jamie Brown

• Publisher: Wiley-Blackwell
• Year: 2013
• ISBN:
  9781118484913
• Edition: 2
• Topic: Psychology
• Subtopic: Addiction in Psychology
• Index: Psychology

The word 'addiction' these days is used to refer to a chronic condition where there is an
unhealthily powerful motivation to engage in a particular behaviour. This can be driven by
many different factors – physiological, psychological, environmental and social. If we say that it
is all about X, we miss V, W, Y and Z. So, some people think addicts are using drugs to escape
from unhappy lives, feelings of anxiety and so on; many are. Some people think drugs become
addictive because they alter the brain chemistry to create powerful urges; that is often true.
Others think that drug taking is about seeking after pleasure; often it is. Some take the view that
addiction is a choice – addicts weigh up the pros and cons of doing what they do and decide
the former outweigh the latter. Yet others believe that addicts suffer from poor impulse control;
that is often true… And so it goes on.

When you look at the evidence, you see that all these positions capture important aspects of
the problem – but they are not complete explanations. Neuroscience can help us delve more
deeply into some of these explanations, while the behavioural and social sciences are better at
exploring others. We need a model that puts all this together in a way that can help us decide
what to do in different cases. Should we prescribe a drug, give the person some 'tender loving
care', put them in prison or what? Theory of Addiction provides this synthesis.

The first edition was well received:

'Throughout the book the reader is exposed to a vast number of useful observations...The
theoretical aims are timely, refreshing, ambitious and above all challenging. It opens up a new
way of looking at addiction and has the potential to move the field of addiction a considerable
leap forward. Thus we wholeheartedly would like to recommend the book for students as well
as scholars. Read and learn!' Nordic Studies on Alcohol and Drugs

'The book provides a comprehensive review of existing theories - over 30 in all - and this
synthesis of theories constitutes an important contribution in and of itself... West is to be
commended for his synthesis of addiction theories that span neurobiology, psychology and
social science and for his insights into what remains unexplained.' Addiction

This new edition of Theory of Addiction builds on the first, including additional theories in
the field, a more developed specification of PRIME theory and analysis of the expanding
evidence base.
With this important new information, Theory of Addiction will continue to be essential reading
for all those working in addiction, from student to experienced practitioner – as urged above,
Read and learn!

Chapter 1
INTRODUCTION: JOURNEY TO THE CENTRE OF ADDICTION

This book aims to take you on a journey. The starting point is the simplest possible common-sense theory of addiction and the destination will be a theory that accounts for the available evidence on how addiction develops, who becomes addicted, what they become addicted to and how some of them recover. The path is traced by exploring with successive versions of the theory how it needs to be extended or changed to take account of the available evidence. The goal is to arrive at a theory that is comprehensive yet parsimonious, coherent, and above all useful. It aims to stimulate research and to guide clinicians and policy makers in coming up with better ways of tackling this global scourge. This is a continuing journey. As new evidence emerges and better ways of explaining the evidence are brought to light, the theory will need updating.

Preparing for the journey

Many theories but not much progress

The field of addiction is not short on theories. There are psychological theories, biological theories, sociological theories, economic theories, biopsychosocial theories and more. Almost all of the theories in the field of addiction capture important elements of the phenomenon. The problem is that each theory seems to stem from an idea or set of ideas that accounts for a part of the problem but does not account for other features that were previously addressed by other theories. They view addiction from a particular perspective and focus on what is immediately visible from that point of view. They neglect key features that are visible from other points of view. This militates against developing an ‘incremental science’ of addiction in which new theoretical principles build on what has gone before, correcting areas where they fail to account for data and creating new avenues for exploration.

Theory and observation

Part of the problem appears to be that we have adopted a model of science that does not quite fit the area of study. In behavioural science, we have developed our methods from the paradigm of the natural sciences; but unfortunately, they have not always served us well. In the prevailing paradigm, the primary source of evidence is the formal study: the survey, the experiment, the semi-structured interview and so forth. Observation of behaviour in the natural habitat is considered ‘anecdotal’. The problem with this is that what one might call the ‘big’ observations about what people do a lot or never do become less important than percentages in surveys, ‘significant differences’ between groups and ‘correlations’ between variables. In many cases, these involve rather trivial behaviours in unrealistic laboratory situations or taking at face value people's reports of their attitudes, beliefs and behaviours on questionnaires or in interviews. Very often this gives us an inaccurate portrayal of real behaviour, thoughts and feelings about things that really matter. The responses are too often a pale shadow of, and bear little relationship to, what happens in the world at large.

That is not to say that formal studies are not vital to description, and hypothesis generation and testing. Only that it is important not to lose sight of the value of careful naturalistic observation and detective work when trying to find explanations for behaviour. A simple example can illustrate this. People do not get addicted to listening to music, making the bed or taking aspirin. Listening to music can be very pleasurable; making the bed is functional; and taking aspirin provides relief from pain. A theory of addiction has to be able to explain why these pleasurable, functional and self-medicating behaviours are not addictive while gambling, smoking and drinking alcohol are. As we are aware, no formal study has been done on the addictive qualities of the former but the simple observation is potentially illuminating.

Need for a synthetic theory

The theory developed in this book aims to provide a conceptual framework within which the major insights provided by the existing theories can be placed. It is a synthetic theory in the sense that it attempts to pull together the accumulated wisdom. It does not attempt to explain everything there is to explain, but it does seek to explain the ‘big observations’ and provide a conceptual system in which the existing theories can be located. It aims to be as parsimonious as possible: that is to say, it only brings in additional elements if they are needed. It strives for coherence: the ideas should relate naturally to each other and not be just a list of unconnected assertions.

A guiding principle

In attempting this task, we are mindful of the words of Nick Heather (Heather 1998), which we can do no better than to quote verbatim:

‘addiction … is best defined by repeated failures to refrain from drug use despite prior resolutions to do so. This definition is consistent with views of addiction that see decision-making, ambivalence and conflict as central features of the addict's behaviour and experience. On this basis, a three-level framework of required explanation is (needed) consisting of (1) the level of neuroadaptation, (2) the level of desire for drugs and (3) the level of “akrasia” or failures of resolve … explanatory concepts used at the “lower” levels in this framework can never be held to be sufficient as explanations at higher levels, i.e. the postulation of additional determinants is always required at Levels 2 and 3. In particular, it is a failure to address problems at the highest level in the framework that marks the inadequacy of most existing theories of addiction.’ (p. 3)

While addiction as conceived in this book has to be broader than just drug use, Professor Heather's point about the inadequacy of explanations at higher levels seems to us to be well made. Thus, neurophysiological models of the actions of particular addictive drugs on specific brain pathways are important and can help us design medicines to help treat the problem. But it is foolish to imagine that they are theories of addiction given their patent failure to address important observations about social and psychological determinants or indeed other brain mechanisms.

We are also aware of the fact that there already exists in the literature a scholarly and eclectic account in the form of Jim Orford's model ‘Excessive Appetites’ (Orford 2001). The new theory seeks to build on the work of Professor Orford while paying close attention to the admonitions of Professor Heather.

A psychological orientation

We are psychologists by training and our main field of research is tobacco. Both of these things will inevitably affect our approach and the examples we use. It is difficult for theorists to write convincingly in areas that are not their discipline (e.g. neuropharmacologists or economists writing about psychology), and equally difficult for researchers to demonstrate proficiency in areas of addiction that are not their specialty (the alcohol researcher writing about tobacco or the tobacco researcher writing about cocaine) and many do not even try. But we must try because if we do not, we will fail to grasp what addiction is all about. Since the first edition of this book, we have had the opportunity to discuss the ideas with many colleagues studying different forms of addiction and have been heartened by the extent to which those colleagues have considered that the ideas translate well to their areas of study.

In the end

So the book is a journey from the most common sense and simple explanation of addiction to one that is only as complicated as it needs to be. The narrative is punctuated with references to many of the theories that have been proposed, together with comments on these.

These are not just summaries. In any event, it is not possible to do justice to the theories in the space available; some of them take up whole volumes. We attempt to draw out the theories' unique insights or important lessons that may be drawn from them. Where possible, the developing theory uses concepts that already exist in the minds of well-informed non-specialists and use words that serve non-psychologists well in explaining and predicting each other's behaviour. We try to avoid the pitfall of needlessly constructing new terms or making up new meanings for existing ones.

This book uses the device of putting existing theories that it discusses in boxes. In some cases, the theories are described very briefly and in others, they are considered in much more detail. The level of detail is not related to the complexity or importance of the theory but only to what is required to draw out the lessons for the purposes of taking forward the journey to a comprehensive theory of addiction.

The starting definition of addiction

There are many different ways of defining addiction, by which we mean that there are many different things to which the label addiction can be applied. The next chapter will address this issue in more detail but we need to get started on the right foot, so it should be stated here that we will use the term to refer to a chronic condition in which there is a repeated powerful motivation to engage in a rewarding behaviour, acquired as a result of engaging in that behaviour, that has significant potential for unintended harm. It is not all-or-none, but a matter of degree. Its severity can be assessed, amongst other things, by the severity of subjective urges or cravings, a frequency or intensity of behaviour that is causing harm and failure of serious attempts to limit or cease the activity. This definition differs in some respec...