Habits: Remaking Addiction

S. Fraser, D. Moore, H. Keane

• Publisher: Palgrave Macmillan
• Year: 2014
• Print ISBN: 9781349338887, 9780230308107
• eBook ISBN: 9781137316776
• Topic: Social Sciences
• Subtopic: Psychiatry & Mental Health
• Index: Social Sciences

What is 'addiction'? What does it say about us, our social arrangements and our political preoccupations? Where is it going as an idea and what is at stake in its ongoing production? Drawing on ethnographic research, interviews and media and policy texts, this book traces the remaking of addiction in contemporary Western societies.

1

Models of Addiction

The use of psychoactive substances in order to alter mood or consciousness, alleviate suffering, improve performance or enhance social relations is characteristic of human cultures. For some individuals, the use of these substances becomes a pattern of habitual and persistent consumption that results in negative physical, emotional, relational and social effects. The range and intensity of these harmful effects is highly varied, depending on the specific substance and the context of use. Frequently, the harms of consumption co-occur with benefits. For example, smokers face the serious health risks and physical problems caused by cigarettes, but may also experience positive effects of relaxation, productivity and sociability. And because nicotine consumption is not generally said to cause intoxication and is a legal although highly regulated practice, tobacco dependence is quite different from illicit drug use and heavy drinking in its social meanings and effects.

Addiction can be understood as a culturally and historically specific set of ideas and practices that shapes the varied problems and predicaments of alcohol and other drug use into a singular and somewhat abstract entity: a disorder of compulsion located in the individual. This, in turn, promotes particular ways of thinking about selfhood. As Kane Race (2009, 15) puts it, addiction produces the self as the moral locus of consumption. But addiction is more than just a concept or field of knowledge; it is a practice, in that it is something that is done in specific contexts. To use the framework of ontological politics developed by John Law and Annemarie Mol in various works (see, for example, Mol 1999; Law 2011), the reality of addiction is brought into being in research labs, clinical encounters, health policy meetings, legal schedules and texts such as the DSM. Addiction is produced in these contexts through the assemblage of certain elements and the exclusion of others. An object of study or target of intervention is stabilised out of the messy, fluid and heterogeneous social worlds of drug use and drug users (see Moore 1992), and various collateral realities are produced along the way.

As with many forms of human behaviour, medical and scientific discourse has become the most influential and authoritative source of knowledge about addiction. Scientific knowledge about addiction is a particularly powerful version of ontological politics because it is ‘believed to reveal the inner workings of brains, minds, and bodies’ (Campbell 2007, 1). It stabilises addiction as an objectively verifiable disorder or disease and employs terms such as ‘symptom’, ‘pathology’, ‘natural history’ and ‘relapse’ to reinforce the medical nature of drug-related experiences. As we show in this book, science valorises the development of a unified and universally applicable account of the nature of compulsive drug use as the goal of addiction research, and constitutes this form of knowledge as the key to solving the problem of drug use.

As an entity which implies the need for some sort of therapeutic intervention, addiction is also enacted as a technology of government. It promotes action on the conduct of others or the conduct of the self, in order to fashion a form of ethical subjectivity based on prudential consumption and responsible citizenship (Valverde 1998; Fraser & valentine 2008). The government of addiction takes many different forms, from court-ordered treatment to the open-ended work on the self fostered by 12-step groups. It can involve the provision of substitute drugs to manage dependence (as in the case of MMT or NRT) or the withdrawal of access to drugs (as can happen to pain patients on opiate therapy who develop ‘aberrant’ drug-seeking behaviour) (Keane & Hamill 2010). The aim may be for the drug user to internalise particular codes of conduct and beliefs about the self, or the goal may be a much more localised shift in appetitive behaviour. It is not just that the kinds of treatment that make sense depend on how addiction is defined; it is that the treatment technique itself constitutes and stabilises the problem of addiction (Bacchi 2009).

The government of addiction as a regulatory project is not simply about self-improvement. It cannot be separated from understandings of drug use, especially illicit drug use, as a pernicious and recalcitrant legal, social and moral problem. The disorder of addiction is not just destructive of the self; it is seen as a threat to social order, family life and the well-being of the nation. As agents of addiction, drugs are themselves enacted as a category of particularly powerful and malevolent substances which are outside normal human existence (despite the historical and cultural ubiquity of their use). This is especially the case when the drug in question is viewed as alien and/or unnatural (Manderson 2011). Therefore, medical models of addiction inevitably interact with policies focused on the control of drug supply and the punishment of offenders. For example, the idea of the addict as an individual who suffers from diminished control over her or his actions can be mobilised to justify coerced treatment as a supplement to, or substitute for, imprisonment.

Currently, the dominant scientific paradigm is of addiction as a ‘chronic relapsing brain disease’ caused by drug-induced dysfunction in neurochemical reward systems. Advocates of the brain disease model assert that it will undermine moralised and punitive beliefs about addiction and usher in an era of enlightened policy responses and treatment (National Institute on Drug Abuse 2007). Medical models of addiction are often contrasted with moralistic perspectives in this way. But as we suggest in this chapter, medical models are themselves hybrid medical-ethical assemblages, built on culturally specific ideals such as self-control and autonomy and inevitably involving normative judgements about how to live and how to prioritise pleasures. And while the narrative of scientific progress presents the most recent models as replacing superseded and outmoded knowledge, elements of these earlier governing discourses remain in circulation (Room 2001).

So far, we have discussed addiction as if it is a problem restricted to the consumption of psychoactive substances. It is certainly the case that medical concern about addiction has focused on alcohol and other drugs, and the first medical models of addiction that developed in the 18th and 19th centuries were based on problems of heavy drinking and opiate use (Levine 1978; Berridge 1999). However, as our discussions of the DSM in this chapter, binge drinking in Chapter 2 and overeating and obesity in Chapter 6 demonstrate, addiction science and medicine are currently in an expansionary mode in relation to the scope of addiction. Forms of habitual behaviour previously excluded from the frame of genuine addiction because they did not involve psychoactive substances are now being incorporated through the enrolment of neuroscientific explanations. Compulsive patterns of gambling, internet use, eating, sex and shopping are understood to involve the same neural substrate as drug use. This expansion in the potential agents of addiction is significant in part because addiction designates more than a dysfunctional pattern of behaviour. In both medical and popular discourses it produces an identity, a type of person – the addict – who is defined in terms of pathological desires. Characterised as lacking control over their consumption, their behaviour and their lives, addicted subjects have been easily read as ‘other’ to the ideal of the rational, autonomous and self-regulating individual (Fraser 2006; Moore & Fraser 2006). The effect of this expansionary mode on the marginalised and stigmatised identity of ‘addict’ remains an open question. Some recent prevalence research suggests that where addiction is defined as an intense preoccupation with a behaviour that produces negative consequences, it becomes a problem of the majority rather than a minority. Does this mean that addiction should be understood not as an aberration but as ‘a natural state of affairs as a human being’ (Sussman et al. 2011, 46)?

In this chapter we critically examine two influential contemporary models of addiction: the mental disorder identified in the DSM of the American Psychiatric Association (APA) and, more briefly, the already-mentioned brain disease model. The chapter begins with a general discussion of the DSM and its constitution of substance-related disorders. This is followed by three sections which examine different aspects of the DSM-5¹: (1) its model of Substance Use Disorder (SUD); (2) its redefining of addiction to include non-substance-related disorders; (3) the commentary and criticism that followed its publication. These three sections necessarily refer to the brain disease model of addiction as neuroscience was invoked both as a justification for changes to the DSM and as a reason to question its scientific validity. A more systematic and detailed critique of addiction neuroscience and the brain disease model is presented in the final two sections of the chapter.

While both DSM and brain disease models have the institutional and epistemological authority of medicine and science, they are the product of distinct histories and as such have different purposes. They thus bring into being different realities and different types of problem. The DSM model was developed as a diagnostic tool and is based on a list of observable or reportable symptoms. It is a category embedded in a system of nosological classification. It reflects a clinical tradition of thinking about addiction in relation to harm, as well as contemporary psychiatry’s demand for operationalisation. However, its influence goes far beyond the clinical as it provides the standard definition of addiction used in medical, epidemiological and psychological research.² Thus when psychopharmacologists study the effect of a certain treatment on cocaine addicts, the research subjects have usually qualified as addicts through the application of the DSM criteria. Or when epidemiologists study the prevalence of alcohol dependence on college campuses, they use the DSM criteria to determine who is counted in this category.

The fifth edition of the DSM, the DSM-5, was published in May 2013. It is the first new edition of the manual in two decades and its creation was a ‘massive undertaking’ which, according to the APA, involved evaluating all the diagnostic criteria and considering every aspect of the manual’s organisation (APA 2013a, 5). Thirteen expert work groups undertook the task of proposing revisions, including a group devoted to substance-related disorders headed by Charles O’Brien. O’Brien is one of the most prominent addiction researchers in the United States, whose work encompasses the neurobiological and clinical aspects of addiction, including pharmacotherapy. A draft of the new manual was released in 2010 for professional and public comment, and 13,000 responses were received via the dedicated website (APA 2013a, 8). The final version of the DSM-5 contains significant changes to several categories of disorder, including those related to substance use, as well as some important organisational changes. However, there is also a great deal of continuity between DSM-5 and DSM-IV.

Unlike the DSM, the brain disease model is a causal explanation rather than a list of symptoms designed for clinical use. Although it stabilises addiction as an organic and observable neurobiological condition, it cannot be used to determine who is or is not addicted in the way the DSM can. It is a product of technoscientific research and offers a neurochemical and molecular account of the underlying process that produces the disordered behaviour of the addict. This is not to suggest that there are no connections or interactions between the models and the styles of thought they represent. One of the stated aims of the DSM-5 revision was the incorporation of new knowledge from neuroscience, brain imaging and genetics into psychiatric nosology. As we will see, however, this aim has remained largely unfulfilled.

One shared feature of the two approaches is an attempt to produce a generic and generalisable model applicable whatever the substance, its effects, its legal and social status or route of administration. In the DSM-IV, the seven diagnostic criteria of substance dependence (see Table 1.1) were applicable to the self-administration of any ‘class of substances except caffeine’. The manual also stated that ‘the symptoms of dependence are similar across the various categories of substances’, although it is noted that some symptoms are less salient for some classes of drugs and in a few instances not all of the symptoms are applicable (APA 2000, 192).

In the DSM-5, 11 diagnostic criteria make up the general model of ‘substance use disorder’, although not all are applied to every class of drug. Table 1.2 shows these 11 criteria as they appear in the specific diagnostic category opioid use disorder. The production of a general category of addiction requires that differences between substances, such as the absence of withdrawal with hallucinogens and inhalants, are classified as exceptions to a general rule (APA 2013a, 483). It also rests on the generic nature of symptoms listed in the DSM, for example, ‘the individual may spend a great deal of time obtaining the substance, using the substance or recovering from its effects’ (2013a, 197). This is not a single symptom but rather a cluster of experiences related to time and its use. Presenting these different experiences as a single criterion allows behaviours as disparate as ‘visiting multiple doctors or driving long distances’ and ‘chain-smoking’ to be examples of the same symptom.

Table 1.1 DSM-IV substance dependence criteria

A. A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

1) Tolerance, as defined by either of the following:

a) A need for markedly increased amounts of the substance to achieve intoxication or desired effect

b) Markedly diminished effect with continued use of the same amount of the substance

2) Withdrawal, as manifested by either of the following:

a) The characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for withdrawal from the specific substances)

b) The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms

3) The substance is often taken in larger amounts or over a longer period than was intended.

4) There is a persistent desire or unsuccessful efforts to cut down or control substance use.

5) A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects.

6) Important social, occupational, or recreational activities are given up or reduced because of substance use.

7) The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption).

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (Copyright © 2000). American Psychiatric Association. All rights reserved.

Table 1.2 DSM-5 opioid use disorder criteria

A. A problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

1) Opioids are often taken in larger amounts or over a longer period than was intended.

2) There is a persistent desire or unsuccessful efforts to cut down or control opioid use.

3) A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.

4) Craving or a strong desire or urge to use opiods.

5) Recurrent opiod use resulting in a failure to fulfill major role obligations at work, school, or home.

6) Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.

7) Important social, occupational, or recreational activities are given up or reduced because of opioid use.

8) Recurrent opioid use in situations in which it is physically hazardous.

9) Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.

10) Tolerance, as defined by either of the following:

a. A need for markedly increased amounts of opioids to achieve intoxication or desired effect.

b. A markedly diminished effect with continued use of the same amount of the opioid.

Note: This criterion is not considered to be met for those taking opioids solely under appropriate medical supervision.

11) Withdrawal, as manifested by either of the following:

a. The characteristic opioid withdrawal syndrome (refer to Criteria A and B of the criteria set for opioid withdrawal).

b. Opioids (or a closely related) substance are taken to relieve or avoid withdrawal symptoms.

Note: This criterion is not considered to be met for those individuals taking opioids solely under appropriate medical supervision.

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright © 2013). American Psychiatric Association. All rights reserved.

In the case of the brain disease model, whatever the subjective effects of different ‘drugs of abuse’, they are hypothesised to occur through the action of the neurotransmitter dopamine on a common neural pathway. This generalising approach enables the production of a coherent and robust assemblage ‘addictive disorder’ which incorporates psychological and social elements and exists beyond the specific consequences of drinking, smoking, using opiates and so on. Addictive disorder becomes an expansive category that can include rewarding non-drug activities such as gambling, eating and sex. However, this generalising approach ex...

Table of contents

• Cover
• Title Page
• Copyright
• Contents
• List of Figures and Tables
• Acknowledgements
• List of Abbreviations
• Introduction
• 1. Models of Addiction
• 2. Stabilising Stimulants: Amphetamine Dependence and Methamphetamine Addiction
• 3. Making Methamphetamine in Drug Policy and Consumer Accounts
• 4. A Field in Disarray? The Constitution of Alcohol Addiction in Expert Debates
• 5. Assembling Alcohol Problems: Young People and Drinking
• 6. Junk: The Neuroscience of Food Addiction and Obesity
• 7. Stepping to the Side of Addiction: Everyday Realities of Overeating and Obesity
• Conclusion: A Multiverse of Habits: ‘Addicting’ Science, Policy and Experience
• Appendix: Interview Data Collection Methods
• Notes
• Bibliography
• Index