This collection is a snapshot from 2007 of 27 points of view regarding addiction in short papers. It starts off with an introduction from C. Everett Koop, who takes a very definite stand in favor of strong medicalization of addiction, including not only street drugs and alcohol, but also tobacco, although he does not mention "addictions" to food, gambling or sex. He insists that we must show addicts the same compassion as we do for others who are sick and injured. He quotes himself approvingly in his statement about AIDS that "We are fighting a disease and not the people who have it," and he says this equally applies to addicts. He argues for a comprehensive public health approach to addiction that makes effective treatment widely available, and he believes that those who profit from selling drugs, alcohol and tobacco should be discouraged to the full extent possible. While he does not deny that people have a personal responsibility to avoid disease, his focus is on the forces that lead people to take drugs.
Some of the other papers directly address Koop's views. Alan Leshner, the previous director of the National Institute on Drug Abuse builds the scientific case for the disease model. He published a widely quoted paper, "Addiction Is a Brain Disease, and It Matters," and here he waxes even more lyrical in praise of the work of neuroscience in addiction. He says that addiction causes changing in the structure of the brain making drug craving, seeking and use all compulsive and typically uncontrollable. He gives high praise to drug addiction research, saying it sets high standards and that brain-imaging has been especially productive. He laments the high stigma attached to addiction, saying that according to popular myth, addicts have control over their actions and could quit if they really wanted. He argues this is fuelled by people who know very little about addiction believing that they are experts and being driven by ideology. He concludes that it is the responsibility of scientists to do more education of the public, and this will enable science to replace ideology.
In direct opposition to Koop and Leshner are Stanton Peele and Sally Satel. Peele is well known as a long-standing critic of the disease model of addiction, and Satel is known for her conservative views in medicine. Peele makes a perceptive comment: "There are two worlds of addiction: the one glimpsed through clinical dealings with addicts and the one viewed through broad population, epidemiologic studies ... At times, these two worlds are unrecognizably different." (154). He goes on to make similar arguments to Heyman in his recent book Addiction: A Disorder of Choice that the epidemiology shows only a quarter of those with alcohol dependence ever seek treatment, and that those who do not seek treatment have a higher recovery rate than those who do. He also uses the data to argue that there is no need for most former alcoholics to be abstinent, since most people who had substance dependence manage to return to light drinking without returning to alcoholism. He further argues that cultural differences make a large difference to alcohol use, and that everyday use such as found in southern European countries led to less alcoholism than the binge drinking more typical of northern countries, even though the southern countries tended to consume more alcohol overall. He particularly warns that the disease model of alcoholism may make the problem worse. He argues that treatments that emphasize individual responsibility tend to be more successful than those that depict alcoholism as a disease over which we have no control. He concludes that we should completely abandon the disease model.
Satel's arguments are the most provocative of the book, since she is in favor of the stigma of addiction. She argues that it is bad behavior and we risk causing more problems by removing the stigma attached to it. She makes her argument mainly by attacking the claims in favor of eliminating stigma; for example, contrary to them, she argues that the stigma of addiction probably makes people seek treatment, and that we should not boost the self-esteem of addicts, but instead we should encourage them to stop being addicts. She ends that her view is compatible with being compassionate towards addicts and we should provide care for them. Unfortunately her argument is not buttressed by a careful scrutiny of social science on stigma, so it is entirely speculative.
In an attempt to bridge the gap between the disease model and the personal responsibility model, William Miller argues that all can agree that motivational factors are essential to addictions and recovery; since Miller is the author of Motivational Interviewing: Preparing People for Change (Second Edition, Guilford, 2002) it is no surprise that he emphasizes the benefits of MI, but he also mentioned brief interventions, the community reinforcement approach, and contingency management. He emphasizes that punishment is ineffective as a means of ending addiction and that confrontational counseling is "abysmally ineffective." Trying to take away someone's choice or to use shame do not stop addictions. If the data backs up Miller, then this gives us good reason to question Satel's endorsement of stigma.
Robert West outlines his PRIME theory of addiction (plans, responses, impulses/inhibitory forces, motives and evaluations) (set out in his Theory of Addiction) which synthesizes a variety of different approaches and factors. It's an impressive contribution, because the synthesis is systematic and principled rather than the usual mess associated with a biopsychosocial model. His most intriguing comment comes at the end, when he writes "We are seeking to reshape the addict's motivational system--to change the addict as a person." This is one of the most explicit acknowledgments by addiction researchers that addiction can change one's character, and that recovery requires not just self-control but a further change in character.
Most of the other contributions are not at the high theoretical level, but instead address more practical issues. One particularly interesting piece is from Larry Gentilello, on alcohol screening in trauma centers. He says that between 40 and 50% of patients admitted to a trauma center are under the influence of alcohol. When patients who are screened and test positive for alcohol receive a brief intervention soon after their accident, they are much more likely to reduce their alcohol intake. The likely explanation is that they were probably scared by their injury and are much more receptive to changing their ways. The danger of injury recurrence is reduced by about 50% when patients receive interventions. Yet due to legislation passed in most states, if people test positive for alcohol, then their treatment for their injury will not be covered by health insurance. This policy, which was designed to cut costs of healthcare, turns out to do no good because it is easy to circumvent, since trauma surgeons simply avoid screening patients. If patients are charged for their treatment when it is not covered by insurance, they often have to declare bankruptcy, so the treatment center then has to absorb the expense. Gentilello ends by saying that there is a trend starting to forbid denying payment by insurers on the basis of alcohol intoxication, and this will make it easier to give patients interventions and get them to reduce their alcohol use.
Other papers in the collection address a wide variety of issues, including addiction and HIV infection, addiction and pregnancy, stimulant abuse, tobacco abuse, addiction treatments in prisons, marketing of alcohol to youth, confidentiality in treatment, and art by addicts. Since the chapters are short, they cannot provide a comprehensive discussion of any of the issues, but most of them include a good number of references, and allow one to follow up in researching the topics. While the collection is short on work by active neuroscientists, it does include some prominent scientists as well as some well-known commentators, and it gives one a better sense of the variety of research and treatments being tried in the USA. This makes it a valuable contribution to the literature.
© 2009 Christian Perring
Christian Perring, Associate Professor of Philosophy, Dowling College, New York.