Wednesday, 9 April 2014

What is Addiction?

A recent paper has been published in Frontiers of Psychiatry which attempts to rebuke the supposedly dominant view of addiction as a brain disease. I think it’s a decent paper - it gives a good account of the problems with the “disease” view, and also covers evidence for both sides of the debate – brain disease versus choice – in a balanced, well-structured fashion. However, I think the authors’ conclusion and suggestions for future perceptions of addiction are a little vague and, ultimately, unhelpful, so I thought I’d try and clarify things a little further. I say this not because I think that they’re wrong, but because they offer no structured way of viewing addiction which others can draw from.

Addiction appears to be a nebulous concept in society, being used in everyday discourse to denote something generally absorbing, or even just somewhat appealing. Even some “experts” seem to have been drawn into the haze of confusion regarding the reality of addiction, with this psychiatrist comparing the “Trojan horse” of excessive texting to drink and drug abuse (warning, stupidity may be contagious)*. Such confusion is one of the reasons I’m writing this post – another is that, even when confident of what something is not, it is still pertinent to clarify what it is. Hopefully, this is what this post will achieve. So without further ado, if addiction isn’t the propensity to eat more than one (or eight) Ferrero Roche in one sitting, or the continuation of watching the always looming next episode of your favourite show on Netflix (until you suddenly realise it’s time for work), what exactly is it? The point of this piece is to lay out a robust way in which addiction can be viewed in everyday terms.

Theoretically, contemporary models generally pose addiction as a power struggle between a strong motivation to use the drug, and a limited capacity to constrain such motivation. Practically, the Diagnostic and Statistical Manual of Mental Disorders - 5th Edition (DSM-V) has melded the previously distinct categories of substance abuse and substance dependence into a unitary substance use disorder (SUD) with which to diagnose addiction-related problems. Each substance-specific problem is granted its own SUD type (e.g. alcohol use disorder, stimulant use disorder etc.), with each measured on a continuum from mild to severe. In addition, the “behavioural addiction” of pathological gambling has now been recognised as a disorder possessing similar clinical manifestations and even neural correlates to that of drug addiction.

Essentially, addiction is a concept used to denote a set of states, behaviours and consequences which centre around particular substances or actions, and which are conducive to a problematic life. That’s it. Addiction can principally be viewed as a set of behaviours that encumber much more negative consequences than they do positive, but which the individual continues to perform anyway (though as alluded to above, addiction also possesses biological and cognitive components). That’s fine, but how about the all-important label? Is it a biological disorder, or a disease, or a choice? And also, what about sex, internet and “selfie” addictions – are these things real? We’ll start with the latter.

Might as well face it, we’re addicted to… everything:
As we know, drugs are not the only things people have suggested can be addictive. We’ve already seen how people somehow allowed on TV have termed the very act of texting addictive; well, such claims stretch far and wide. Sex, exercise, the internet and videogames are just some of the behavioural normalities accused of enticing some of us to the point of dependence. Could these things ever be considered truly addictive? Well, why not? Many objections to such a proposal seem to rest upon arguments from incredulity, that there’s no way a videogame could ever be that enjoyable or satisfying – but a lack of imagination as to how gratifying someone else may find something is not in itself an argument. 

Take a recent example. The Mirror recently reported that a teenager had become addicted to taking selfies – something which conjures up images of older readers shaking their heads and muttering “this country…” But if their report is accurate, this case was extreme and the person in question undoubtedly needed help. This individual dropped out of school, didn’t leave his house in six months and lost two stone due to his obsession of taking the perfect picture. When he realised his goal was unattainable, he attempted suicide. This spiralling out of control due to fixation on one particular thing is reminiscent of addiction, and so it’s plausible to see why the connection has been made.

However, despite such similarities some caveats need to be made. First, it might be the case that “technology addictions” actually exist and that such addicts can be categorised alongside drug addicts (or perhaps more reasonably alongside the only recognised behavioural addiction, gambling), but we need to be sure that these are in fact the same disorders. It is plausible, for example, that this case in particular was just an unusual manifestation of obsessive compulsive disorder (OCD) and body dysmorphia – two underlying conditions which gave rise to behaviour eerily similar to addiction. If this is the case with the other suggested “addictions” mentioned above – that sufferers are in fact just showing an unusual presentation of symptoms of already established disorders – then there is no reason for the creation of “new” addictions. To clear up such confusion we only need ask a single, but broad, question: are the profiles of such addictions similar to “classic” addiction? We can take “profiles” to mean clinical manifestations, environmental and biological causes, underlying dysfunctions of the cognitive system and so on. If these things are the same (or very similar) in these new age addictions, then there’s no reason not to classify them as such. If they’re not then they must either be classified as unusual manifestations of already-established disorders or something completely new – either way, the important thing is to find the right diagnosis for the right treatment.

The second caveat is that, even if we do eventually classify sex and videogames as being potentially addictive, this does not mean that we have to recognise them as having the same level of addictiveness as drugs. It also, crucially, does not mean that we have to grant that such addictions confer the same potential for harm (particularly in health terms). Even between drug classes, we recognise that some are potentially more addictive and harmful than others – the same could be done between different classes of addictions. For example, gambling may confer similar negative social consequences to addictive drugs (loss of money, falling out with friends), but it does not possess the same potential to deteriorate one’s health. Some addictions, it would seem, are simply worse than others.

The Choice versus Disease debate:
Scenario: You’re at a dinner party and after the initial merriment which a few glasses of wine delivers conversation turns thoughtful and, once the obligatory topics of politics and religion have been navigated, talk turns to problems in society, including addiction. Some suggest that addiction is an excuse, a way out for the weak-willed and the morally bankrupt – after all, most of us enjoy a few drinks on occasion, but we suck it up and turn in for work the next day. We take responsibility. Others rebuke such claims with anecdotes of perfectly respectable family members or friends who have succumbed to addiction – something which they describe as a disease. You – who now can’t remember why you ever agreed to attend a party with such dull people – are at a loss. On the one hand drug-taking is a choice, isn’t it? On the other, why would people choose such a life – and aren’t there addicts who want to recover, but can’t?

These are reasonable questions, and even researchers in the field are having similar discussions. Nora Volkow – head of the National Institute on Drug Abuse (NIDA) – is in the “addiction as brain disease” camp, while Gene Heyman – a psychologist at Harvard University – sees addiction as a problem of choice. So which is it? Well, a “disease” is defined as a “disorder in structure or function… that produces specific symptoms or that affects a specific location”. Now, presentations of the evidence show that addiction can certainly fit the criteria of disease; chronic use of drugs for example can significantly alter the “reward pathways” of the brain over time. However, as Heyman points out in his book “Addiction: a disorder of choice”, many addicts can and do quit when the stakes are raised high enough – something not possible for “real” diseases such as cancer and diabetes.

The problem with debates of this kind is that the opposing sides can force each other into ever more extreme positions, leading to a false dichotomy – the positions of which nobody wants to side with. It is true that drugs can change the brain; it is also true that it is inevitably choice which initiates and maintains recovery. If both are true, we have no need to distinguish between disorder and choice – instead of choice versus disorder, how about disordered choice? This is not a new concept, Mark Lewis – a “former”** drug addict and current psychologist and neuroscientist – espoused just such a view a number of years ago in response to Heyman’s book. Though not a simple disorder, our conception of it can be simple. We don’t need to quibble about choice versus, well, anything, because choice is a part of addiction. As long as we include all the components in our explanation, we’re doing okay.

But what about the treatment and care addicts get? If it’s a choice should we really be spending taxpayers’ money “helping” them? Well, it’s important to note that “choice” does not equal “free”. Our choices are swayed All. The. Time. And though you may think yourself immune, this is plausibly just the result of another cognitive bias (which ironically indicates just how influenced we are by things of which we’re not aware). Though, clearly, some influences are more compelling than others. This brings us back to spectral thinking – it is not a case of choice versus no choice, but how compelling one choice is compared with another. In the case of addiction, the “choice” to keep using is far more gripping than the “choice” to turn your life around and abstain. Consider the scenario below:

Imagine a favourite reward of yours, a reward which – though enjoyable – impacts negatively on some aspect of your life. On occasion you feel the urge to obtain that reward, but you keep these cravings at bay with minimal effort and only indulge every now and then. You fill in the majority of your time doing other things you love – maintaining other hobbies, obtaining other rewards. Now imagine that – relative to everything else – the reward has become five times, ten times more valuable. The urge to indulge has become far greater than it ever was before – your thoughts continue to cascade onto the same track again and again, with the reward always meeting you at the end of the line. Alongside the increase in craving, in wanting, there’s a decline in liking. You no longer enjoy the reward the way you used to – but you no longer enjoy anything the way you used to. Work, hobbies, social occasions – none make you feel the way they should. But the reward takes the edge off. Sure, it’s not as good as it used to be, but it’s as good as it gets. So you have a choice, you can muster all the effort and willpower you can, for as long as you can and reject the only thing that now offers any relief from the constant psychological and physical craving – or you can accept that not having that reward in your life is no longer an option. You want it. You need it. Life without it is unbearable.

Based on descriptions from addicts themselves, this would seem to be not too far from what it’s like to be dependent on highly addictive drugs like heroin. Notice that the more one uses the substance the worse one’s life becomes, but that the major source of relief is also the substance itself. It’s an ever-escalating drama, with the substance playing both villain and hero. Addiction is neither a complete disease, nor a complete choice; rather, it contains aspects of both.

Addiction’s Grasp:

Much of Heyman’s and others’ arguments centre on the fact that, when offered a great enough incentive, many addicts do turn their life around and give up drugs. For example, the paper I mentioned at the very start of this post cites numerous examples where addicts have gotten clean after threatened with unemployment, jail time or them being declared unfit to raise their children. However, a crucial thing to notice is that they need such significant incentives in the first place – slowly killing themselves and gradually worsening their quality of life isn’t reason enough. If that isn’t disordered choice I don’t know what is. It’s also worth noting that not all addicts can be dissuaded of their drug habit – NIDA estimates that around 50% of those receiving treatment still relapse. Further, it seems some addicts never fully recover and remain addicted for life regardless of their loss of earnings, partners, friends and even loss of their own children. These would be regarded as the most severe cases on our spectrum; those for which incentives – no matter how great – will not work.
Such instances do not disrupt our view of addiction as a disorder in need of treatment. Disordered thinking, which leads to disordered decision-making and therefore distorted choice, needs to be rectified if people are to live happy, productive lives free from drug abuse. This is better not only for individuals themselves, but also for society at large. Furthermore, treatments of various “levels” of the addiction landscape can be considered, something Satel and Lilienfeld discuss in the paper which initiated this post. They argue that one reason for discounting addiction as a brain disease is that it is not the most useful way to view addiction, given that other factors (social, economic, geographical etc.) play a more significant role. Leaving aside any discussion of the fact that such factors exert their influence by affecting the brain (something which the authors do address briefly but which I won’t bother with here), this seems like a sensible argument. This also means that there must be many “levels” at which to treat addiction: social, economic, cognitive and others.
Such a “levelled” approach to treatment is likely to prove most effective overall, compared with any approach which attempts to “cure” addiction via some pharmaceutical wizardry alone. It may also be the case that different treatment levels or types correspond optimally to certain parts of the spectrum. For example, small incentives (e.g. monetary rewards) and cognitive training may be helpful for persons located on a part of the spectrum labelled hazardous; however, such approaches may be futile for those deemed to be at the more extreme end, who more so resemble what we picture when we hear words like “addict”. For these individuals large incentives (e.g. loss of job, family) or pharmacotherapy may be needed while, further still, the group who seem immune to any kind of treatment may need to be subjected to multiple approaches simultaneously. Again this is not new, it’s just that this seems to me to be the most reasonable way to structure our discussions of addiction – to view it as a problematic extreme of normal human behaviour, rather than an abnormal category reserved only for those suffering from either biological or moral disease. 

* If, like me, you too have a masochistic penchant for viewing media sources presenting baffling levels of scientific ignorance, The O’Reilly Factor is your holy grail. Enjoy.
** I’ve placed “former” in quotation marks here as it’s arguable that no one ever fully recovers from addiction.


Monday, 2 December 2013

Culture eats strategy for breakfast, but maybe strategy will have more luck over dinner: A review of the North West Alcohol Conference 2013

We recently attended the North West Alcohol Conference in Liverpool. I, along with Natasha Clarke and Inge Kersbergen summarise the highlights. (A slightly different version of this blog can be found at the University of Liverpool's Addiction Group Blog.)

Natasha Clarke

Professor David Walker, Deputy Chief Medical Officer of the NHS, gave the first talk. This focussed on The National Alcohol Strategy; the proposal put forward by the government to tackle our society’s harmful use of alcohol. The key issue raised was the disappointment of Public Health England with the government’s reluctance to introduce minimum unit pricing (MUP), despite initial plans to implement it. Evidence from Canada and the Sheffield Alcohol Policy Model indicate the implementation of a 45p MUP may decrease alcohol consumption and reduce hospital admissions, yet the strategy states that more evidence is needed. The sudden backtrack is suggested to be due to intense lobbying from the alcohol industry; for example, the Wine and Spirit Trade Association (WTSA) launched a campaign against the proposal and claim that MUP would unfairly penalise the majority of responsible consumers. Previous research has shown that the industry can use evidence to support policies that are in line with their commercial interests and WHO stress that industry should have no role in forming alcohol policy.

So what is being done? The government has committed to a ban of “below cost sales”, with cost being duty + VAT. This is equal to roughly 21p per unit for beer and 28p per unit for spirits, prices significantly lower than the original proposed MUP. It is estimated that only 1.3% of all units of alcohol would be affected by this and that a threshold of 45p would have a considerably larger impact. The government also mentions a pledge through the responsibility deal to take 1 billion units out of the market by 2015; the Health Committee doesn’t think this will have any significant impact. A further emphasis was placed on education campaigns, despite evidence showing their ineffectiveness in reducing alcohol-related harm.

What was clear is that the government are not doing enough. Words and promises (especially ones that are broken) will not produce changes in the nations’ health. An audience member asked David Walker… “Can you change culture?” The answer was “Yes, we can”. Using smoking and driving behaviours as previous examples he explained that these are health aspects to which our outlook as a nation has changed. Smoking attitudes took decades to alter and faced similar pressure from the industry. The verdict was that we must continue to fight for better policy, but an equal match of input from public health and industry is continuing to prove difficult.

Inge Kersbergen

Discussions then continued in different breakout sessions. Colin Shevills and Ali Wheeler made a compelling case for changing licensing regulations. Licensed premises are popping up everywhere in the country. You can now buy alcohol in a large variety of places: in cinemas, indoor playgrounds, and even hairdressers’. And the more traditional licensed premises keep growing in number as well. All whilst we know from research that the density of licensed premises is related to more alcohol-related harm and crime. The licensing act is still operating under the premise that licenses are granted where possible, even if licensing committees and communities want to limit the amount of licensed premises in an area.  Licensing committees have very limited power when it comes to restricting licenses in high density areas or taking licenses away. However, they do possess two powerful tools to limit alcohol availability: Early Morning Alcohol Restriction Orders (EMROs) and Late Night Levys (LNLs).  

An EMRO restricts sales of alcohol in a specific area at a set time between midnight and 6am. Premises that are in violation of this order will receive a fine. The LNL is an additional fee for licensed premises if they want to sell alcohol between midnight and 6am. At first glance these policies seem very similar. The difference lies in how voluntarily businesses restrict their selling times. At the start of November 2013 a LNL has been introduced in the city of Newcastle.  So far, it seems like this levy has the effect of an EMRO, as many businesses voluntarily decided not to pay the additional fee, but to stop selling alcohol at midnight instead. The proposed EMRO in Blackpool, on the other hand, was met with a lot of resistance from the business owners. The speakers argue that it is therefore important that businesses do not feel forced into restricting their selling hours to get their full cooperation. Local licensing committees should make more use of the tools they have, get more freedom to limit licensed premises in their area and be able to involve the local community in their decision making.

Jay Duckworth

Further suggestions for policy change came from Mark Gilman, Strategic Recovery Lead at Public Health England and the National Treatment Agency for Substance Misuse. Gilman, a man who speaks with an almost paradoxical sense of passion and levity, offered advice which he concedes many see as “unscientific, folky [and] quirky”. His idea is that we need to place more emphasis on 12-step programs in which addicts are forced to confront matters of “spirituality”. Initiatives such as Alcoholics Anonymous (AA) are of this breed, asking addicts to admit they are “powerless over alcohol” and to recognise that a “Power greater than they can restore their sanity”. As Gilman admits, this may be a difficult pill to swallow for many. First, non-spiritual individuals will find it problematic to attain the “spiritual awakening” necessary for success in many 12-step approaches. Additionally, though AA is effective at reducing rates of drinking there are many equally effective treatments available which come without the mystical baggage.

That being said, there is an essential feature of 12-step programs which Gilman is right to say should be an active focus of substance dependence treatments across the country: social networks. Social support provided in 12-step programs appears to be one of the primary mechanisms of action, accounting for as much as 1/3 of treatment effects in reducing harmful use. In fact, one study’s authors even remarked that “The addition of just one abstinent person to a social network increased the probability of abstinence for the next year by 27%”. Clearly, emphasis on social change is vital.

The subsequent speaker was Wim van den Brink, Professor of Psychiatry and Addiction at the Academic Medical Centre of the University of Amsterdam. Taking advantage of the passionate but light-hearted tone set by Gilman, van den Brink lamented a presentimental partial rebuke to his predecessor, “I agreed with almost everything you said, but I’m going to disagree on some points just to make it interesting…” And so he did. He focused on his own recently published research which tested the efficacy of the drug Nalmefene on an alcohol-dependent population (though patients were simultaneously given a motivational and adherence-enhancing intervention).

Two clinical trials had shown that Nalmefene reduced drinking significantly in patients relative to placebo. However, what’s really interesting about these results is van den Brink’s post hoc analyses of the data. These analyses were directly relevant to the previous presentation as they show us what can be done for patients who may not respond so favourably to social intervention. The analyses compared the effects of the drug on those whose drinking improved between screening and randomization and those whose did not. This latter subpopulation of the original studies – labeled “non-reducers” – was categorized as excessive drinkers who remained as such despite minimal interventions; contrarily, the former – labeled “reducers” – were those patients whose drinking reduced simply after the assessment of their problem by clinicians. To put it simply, Nalmefene works, but it works so much better in patients whose drinking patterns are not reduced by initial clinical assessment.

At this point, van den Brink highlighted the main flaw in viewing social networking and cultural change as a panacea (not that this was necessarily the viewpoint of any of the aforementioned speakers) – substance dependence is not merely cultural, it’s biological too. “For those patients who don’t respond to programs like AA, what shall we say to them… shall we tell them to f**k off?!” I believe was his gentle phrasing. The important take-home message it seems is that for improvements to be seen with regards to substance dependence, governments need to pay attention to the evidence, and advances in policy and research – both cultural and psychopharmacological – need to be made.

About Me

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Liverpool, United Kingdom
I'm a PhD student in experimental psychology at the University of Liverpool. My research is focused on automatic versus deliberative processes in general drug use and addiction. Here I blog about my research as well as casting a critical eye over new - and sometimes old - news in the world of psychology.