ADDICTION IN THE LIGHT OF PSYCHOPHARMACOLOGY
The word 'addiction' that is in general use quite often leads to confusion. Attention lately is focusing more on the 'new' addictions such as bulimia, anorexia, gambling (not to mention sex and work addictions). It is the patterns of behavior which are becoming more and more a part of the 'addiction problem' as perceived by society and which are often being treated according to the AA model. These 'addictions' lead to two exclusive questions: we must ask ourselves whether these behavior patterns really are addictions, or we must ask ourselves whether it is worthwhile to extend the concept of addiction so far beyond addiction to alcohol, tobacco or drugs. The word is obviously too poorly defined to offer clarity in this. Let us look at alcohol addiction. It should be evident that a Frenchman's concept of 'an alcoholic' is different than that of a Sweed. It is only when drug addiction is meant that there seems to be wide consensus as to the interpretation of the concept addiction. But even there we cannot deny that a Dutch person thinks differently about the use of hashish than does a German, let alone a Pakistani farmer. For a Norwegian judge, possession of khat means something quite different than it does for his Yemenite colleague. As you see, the word addiction also has different interpretations when talking about addiction to drugs. There are two approaches that seem to be able to bridge these differences in interpretation.
The relevant keywords are:
dependence and deviation.
Although we speak of addiction to drugs, we mean addiction to substances which have an effect on the human brain.
When psychopharmaca are administered, they reach the synapse by way of the blood, and influence there the stimulus transfer. Some psychopharmaca, e.g. the opiates, directly stimulate the receptors, thus no electrical signal (action potential) is transmitted.
Much larger amounts of (artificial) neurotransmitter are needed for artificial stimulation of the receptors than when a true neurotransmitter is released under influence of an action potential. With artificial stimulation the receptors are flooded. If this occurs only a few times or very occasionally, it is not a problem, however if it happens often, the cells react by making more receptors to be able to process this regularly returning flood. This, in turn, lowers the effect of the dose administered. This phenomenon is called tolerance: the user needs more and more of the substance to achieve the same effect.
In addition, when administration of the substance is stopped, the number of natural neurotransmitters is too small for the sharp rise in the number of receptors. The nerve cells have become used to the administration of large amounts of artificial neurotransmitters, the body has become used to the presence of the substance and can no longer function without it. It needs the substance.
This is called physical dependence. Discontinuing administration, then, also brings on symptoms of illness, withdrawal symptoms, also called the abstinence syndrome. The abstinence syndrome has three characteristics:
- commencement within a definite time span of which the length is dependent on the duration of action of the relevant substance;
- the development of new symptoms during the abstinence syndrome; and
- the symptoms must disappear again after peaking.
Both physical dependence and tolerance are characteristics that depend not so much on the individual in question, but lie in the nature of the substance.
Many different genetic factors can, however, influence the effect of the substance. An example of this is that women are less able to break down alcohol because the alcohol-inactivating enzyme alcohol dehydrogenase is less active in women. Another example is poor transformation of codeine, a derivative of morphine, in people with a special variety of the druginactivating enzyme cytochrome P-450, whereby codeine does not have its usual pain-killing effect. Animal experimental research also shows an interindividual, genetically determined difference in sensitivity to morphine. NOTE 6 Furthermore, Eriksson et al. NOTE 7 shows that paternal morphine use in rats has an effect on first generation offspring (lower birth weight, higher incidence of perinatal death and heightened sensitivity to the analgetic effect of morphine), an effect that was not, however, present in the second generation which means it was not caused by a change in the genome, but by manipulation of the spermatogenase.
But even if we take these kinds of genetically determined differences into account, we can still say that physical dependence and tolerance, in theory, occur in anyone who over a period of time and more or less regularly takes artificial neurotransmitters, as happens when opiates are used as painkillers after serious operations or in cases of illnesses with severe pain as one of the symptoms. Nevertheless, our hospitals are certainly not junkie factories. It is true that doctors never break off the administration of opiates suddenly (the dosage is reduced over a period of days to zero (called weaning off), but, in contrast to junkies after a similar procedure (a reducing course in addiction terminology), these patients do not run straight to a dealer. In short, physical dependence is not determinant for the addiction, something else must also be present.
This other aspect is psychological dependence. Psychological dependence, in contrast to physical dependence, depends less on the substance than on the user. Psychological dependence has to do with 'pleasurable'. Something can be so pleasurable that you can almost not do without it. But whether or not you find something pleasurable depends on you, not on it. One person likes sweets, another savories. So, although you cannot say that a substance causes psychological dependence, you can observe the fact that many more people like sweets than like savories. The chance then that someone who has never tried anything sweet will like it after tasting it is great. To be able to examine the basis of this phenomenon we will take a closer look at the effects of that psychopharmaca classified as addictive.
When covering the subject of subcortical centers, attention was given to the nucleus accumbens. We have already seen that this group of cells functions as a kind of punishment/reward center. Experiments in animals give us an indication of the extent to which a substance is addictive. The animals are provided with a permanently implanted infusion, administration of which they can control by pressing a button. If the substance has 'addictive' qualities, the animals administer it to an increasing degree. This is called self-injection behavior.
The behavior of animals (generally rats or monkeys) here may not be regarded as identical to that of humans, although this is often the case with 'addiction'.
Firstly because these experimental animals are always in isolation: there is no social interaction, thus no other rewarding stimuli can be received. There is little other than administering a 'chemical' reward. Think here also about the use of drugs by people in prison. When the environment also offers other rewarding stimuli, the chemical reward is less important.
The second difference is that humans have a much more complicated repertoire of behavior patterns, in other words the human cortex allows many more possibilities of modifying behavior. Psychologically dependent behavior in humans is present only when neither the internal environment (e.g. in psychiatric disorders), nor the external environment (social and family situations) offer sufficient rewarding stimuli. Only then do we see the occurrence of psychological dependence. Psychological dependence in humans does not necessarily come only from substances that stimulate the reward system. Humans can also become psychologically dependent on other rewarding activities. The best example of this is gambling. The excitement that gambling evokes is for some just as rewarding, and brings on 'gambling fever'. In a similar way, people talk of bulemia, or its antithesis, anorexia.
This, of course does not disregard the fact that some substances stimulate the human reward center more than others, thereby evoking dependent behavior quicker.
The question can still be asked whether 'addiction' uses and understands language symbols. According to Lindesmith NOTE 8 it does, and chimpanzees e.g. cannot become addicted. He regards chimpanzees that demonstrate cravings NOTE 9 no different from patients who, not knowing they are getting morphine, demonstrate cravings, but then directed towards pain-killing or even more directly towards getting an injection. He says they are 'not addictions', in contrast to Spraggs who considers both to be examples of addiction.
A totally different aspect, the aspect of standards and surpassing these standards is however also clear: the more behavior deviates from the local standard, the sooner we tend to define it as addiction.
This social normalization is qualifying if the prevailing standards of behavior condemn use of the substance.
The behavior of junkies is, rightly, condemned. But does this have to do with 'drugs' or with a special situation of dependence, a situation in which the object of the dependence is 'scarce'?
As we saw above, the behavior we call addictive is the behavior that results if a substance causes physical dependence, thus is necessary; lowers stress, thus is pleasurable and is also forbidden, thus scarce, this behavior takes on the pattern of junkie behavior.
The same outline can be applied to all other psychoactlve substances whether they are legal such as alcohol and tobacco, semi-legal such as the tranquilizers and sleep-inducing drugs or illegal such as the substances we then suddenly classify as drugs. All these substances cause effects by interfering in one way or the other with the stimulus transfer mechanism between nerve cells. The different effects are due to the differences between the activity of the neurotransmitters involved and their different properties.
By using the word 'addiction', we get a variable cocktail of the concepts physical dependence, psychological dependence and 'trouble', the degree in which the ultimate resulting behavior deviates from our standard. With this we leave the concept dependence and go over to the earlier mentioned other concept 'deviation. With regard to each factor, in human behavior we see a division; according to Gauss, the bel-curve. In the middle we have the prevailing standard. It does not matter which that is. On each side we have deviations. The first deviation from the standard has no meaning. The second is already 'oh, that's just the way he/she is'. Deviant, but not seriously so. It is only after we pass the second deviation of the standard that it becomes difficult. We have different methods of dealing with it. However, all of these methods must satisfy one requirement: they must be stripped of threatening behavior. After all, society is not just a lot of separate individuals, no, society is defined as a collection of people who more or less agree with each other on a number of things. And what we more or less agree about are our values and the rules of behavior, our standards which are based on those values.
Extreme deviation from these standards is fundamentally threatening for the society. So, we must avert the threat. This we do by medicalizing, pathologizing this behavior: we create the drug-related disease. The stand taken by the medical world around the turn of the century was highly instrumental in this. NOTE 10