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K. KLAUE
Researcher, Institut universitaire de médecine sociale et préventive,
Lausanne, Switzerland
Abstract
Drugs
Addiction and dependence
Deviance
Disease
Dichotomies
References
Footnotes
ABSTRACT
In the present article, an attempt is made to deconstruct some common categories widely used in the literature on substance abuse. First, the occurrence of a drug problem in western societies is analysed within a historical perspective and in the context of the category of addiction. This is followed by an examination of the way that substance use is ideologically sanctioned and classified into deviance and/or disease in either biological or societal terms. The drug issue does not appear to be a static, objective reality but changes in different historical contexts. By the same token, the social labelling of substance abuse in terms of deviance and disease is sometimes ideologically driven. Any approach to these questions should be sensitive as to context and explanations should go beyond exclusively internal or external causes.
At first sight, substance-related literature deals with a straightforward terminology. Categories such as drugs, addiction, dependence and, more generally, deviance and disease are often used uncritically. They function as accepted a priori conjectures which do not need to be discussed. Such a reification of concepts then implies that they map an objective reality which is decontextualized and not historical. This epistemological stance of naive realism contrasts with a long tradition in the social sciences, showing that reality itself is a social construct embedded in changing cultural and historical contexts [1-4]. For example, social research has shown the changing concepts of childhood through the ages, throwing new light on what was previously regarded as a naturalized category [5-6]. Even a biological fact such as gender has been shown to have no counterpart in the way societies construct and redefine its presumed characteristics [7-8]. The study of pain, which is particularly relevant to drugs, can also be understood better in a temporal cultural dimension [9-10]. Hence, any substance-related issue leading to so-called social problems needs to be placed in its sociological, economic, historical, cultural and political context. Taking a theoretical perspective on the literature should accompany any meaningful review by situating it in its cultural environment and taking account of the author's intellectual background.
Along these lines, careful attention should be given to the history of substance in order to grasp the meaningful changes in attitudes towards their consumption. Without attempting an exhaustive review of such work, a few significant studies and events are detailed below to illustrate this theoretical position.
In the context of American history, dramatic shifts in attitude towards drugs have been documented by authors involved in public health work in the United States of America. Buchanan [11] shows that drug-taking habits are deeply embedded in social dynamics which have, in turn, promoted or inhibited their use. He identifies three cycles marked by major national conflicts: the American Revolution, the Civil War and the decade of the 1960s, with its civil rights movement and the war in Viet Nam. Buchanan stresses what he calls the country's intense love-hate relationship with drugs, revealing a deep-rooted ambivalence between feelings of liberty and duty. After each of the national crises mentioned, drug use increased dramatically and was followed by phases of public disapproval and intolerance. He argues that these cycles symbolize a shift between a commitment to societal institutions and commonwealth to the expression of individualism in a reaction against society. Thus, drug use is interpreted as having deeper meanings than a mere desire for intoxication.
Musto [12] also describes dramatic historical swings over the past two centuries in the United States of America. During the nineteenth century, the use of opiates and cocaine was widespread. Around the turn of the century, this attitude started to change. Drugs were considered dangerous and harmful until the 1940s, followed again by more relaxed societal attitudes in the 1960s and 1970s. Nowadays, there is a clear resurgence of strong negative reactions to drug use. He notes that the periodicity of these cycles, alternating between enthusiasm and abstinence, are roughly a lifetime apart, favouring a kind of social amnesia which wipes out the historical memory of these phenomena. As a consequence, like Sisyphus, society confronts the problem each time as if it were new, with the risk of repeating past errors, and often in a very passionate climate. It should be noted that extreme positions in such ideologically loaded debates tend to negate historical facts in order to increase the weight of their arguments and to legitimize their polarized positions on the basis of fixed categories. Musto explains the cyclical nature of drug use by a kind of learning curve followed by social amnesia. Usually the elite first experiments with drugs; then their use becomes popular and more people are confronted with their negative consequences; as a result, their use declines and people forget how bad they can be. After some time the process starts all over again [13].
It is well known but often ignored in mainstream discourses on drug use that psychoactive substances have been consumed throughout history. Opium use, for instance, can be traced across civilizations for about 8,000 years [14]. The permanency of this fact does not of course imply that the epidemiology and significance of these phenomena are unchanging and constant. A more comprehensive account stretching across different civilizations is, unfortunately, beyond the scope of the present review. It is, however, the nineteenth century that is the most interesting, because it saw significant innovations which made drugs available in new forms. It marked the advent of organic chemistry, allowing for the synthesis of morphine, cocaine and heroin. The invention of the hypodermic syringe in 1850 opened new routes of substance administration. The rapidly growing pharmaceutical industry made mass production and global distribution of drugs possible, thus making a significant quantitative change in drug availability and consumption. Not surprisingly, the nineteenth century coincided with the onset of the systematic study of substance abuse based on new scientific paradigms [15]. The social problems linked to drug use also began around this time. Most historical studies focus on this period, as with the literature mentioned above.
In Europe, changes of attitude concerning drug use can be observed during the past century but clearly defined cycles of tolerance and repression tied to specific events cannot be identified easily. For example, in France [16], drugs in general were not considered a problem before 1970, mainly because they were closely linked to a medical use. In particular, morphine serves as a model for the elaboration of a sociological discourse of the drug phenomenon. A German chemist, Friedrich Sertuerner, discovered this psychoactive constituent of opium in 1817 and called it morphine because of its hypnotic properties. Its powerful analgesic characteristics were much appreciated by physicians to relieve the pain of their patients. Prior to the nineteenth century, social, religious and stoical philosophical attitudes considered that pain was sent by God. The right not to suffer became progressively a human right and the discovery of anaesthesia was a key moment in this evolution. Under medical control, morphine was administered to alleviate the psychological pain of unsteady nervous states. 1 Many persons who were prescribed morphine by physicians continued to self-administer it so as to benefit from the psychological well-being it brought them. During that time, there was no distinction between such iatrogenic intoxications and hedonistic purposes. Together with the transformation of societal attitudes towards pain another transformation of mentalities emerged regarding the rapport to one's own psyche. This shift first became visible through the accounts of aesthetic experiences of writers and artists. The artificial paradises described by authors such as Baudelaire or de Quincey showed the greater public how drugs could open doors to the imagination. Substances were taken to cure moroseness and sustain creation. In the century of Freud, dreams served as new methods by which to reveal the unconscious. Similar states could be induced by psychoactive drugs. Reflecting this evolution, the first groups of morphine users were to be found in the medical world of physicians, dentists, nurses and pharmacists, as well as in the artistic world. It was a drug of the upper classes and only spread to other strata of society in the latter part of the century. This democratization marked an increase of production, diffusion and consumption of substances. As a consequence of this development, the discourse related to drugs changed radically. By the 1870s morphine was denounced as a social peril, linking it to the then popular concept of degeneration. Drug users were identified as driven by perverse, egotistical, immoral, remorseless, morbid tendencies that were thought to be hereditary. It is interesting to note that these disqualifying descriptions were never applied to upper class users but reserved for the lower classes. Ideas of the corruption of race based on genetic explanations led Darwin's cousin, Sir Francis Galton, to advocate eugenic sterilization of people with inferior degenerate genes. On this ideological ground there was a gradual differentiation between "good" users who were victims of the prescriptions of their physicians, and "bad" users who were responsible for their predicament and therefore unworthy of compassion.
Throughout the ages, opium was entered into various therapeutic preparations and was variously considered as a panacea for cholera, insomnia, syphilis, tuberculosis and mental disturbances. A general cure-all for body and mind, it was used by the elite for pleasure, especially in the form of laudanum, a mixture of opium, wine, saffron, cinnamon and cloves, which was invented by the English physician Thomas Sydenham in the seventeenth century. These ingredients strongly evoke the Orient which always served the Occident as a theatre for its representations, as described by Edward Said [17] under the term "Orientalism". The multiplication of travel opportunities in the nineteenth century to the strongholds of the European colonial powers contributed to the spread of opium parlours, where opium was smoked à la Chinoise. Known as the "black idol", opiomania was never a lower-class intoxication. It was a leisure drug that induced dream-like and meditative states of mind. It was the drug most frequently used by artists, and smoking it involved complex rituals. In spite of its medical uses, no iatrogenic intoxications were observed and clinical problem cases were extremely rare. Its consumption became a problem only when it was assimilated into the morphine problem model around the 1870s.
Unlike the traditional opium substance, cocaine and heroin were new fin de siècle drugs in a synthesized form. The alkaloid contained in the coca leaf was isolated by Albert Niemann, a German chemist in 1859. By 1880, its anaesthetic effects were well-known and first applied in the field of ophthalmology, followed by a widening of its therapeutic indications. It was observed to be very efficient against throat diseases, infections of the mucous membrane and asthma [18]. At the same time, it was found that cocaine was a powerful psycho-stimulant praised in particular by Freud. In his book, Über Coca, published in 1884, he suggested prescribing cocaine to cure people from morphinism (morphine addiction). Hence the adverse effects of both substances became cumulative, increasing the risk of accidents such as seizures or heart attacks.
Heroin was obtained from a diacetylation of morphine in 1874 by C.R.A. Wright and further studied by a chemist from the pharmaceutical company, Bayer, who introduced it as a remedy in 1898. This time, physicians thought to dispense a miracle cure especially recommended for respiratory diseases. The same error that had been committed with cocaine was made with heroin, that is, it was used to treat morphinism, which meant substituting one substance with an even more potent one.
By the turn of the century, the drug problem existed in the collective representations of European society. There was a clear change in the general attitude towards substance users. From considering morphinism as a consequence or symptom of a disease, the attitude moved towards disqualification of the users via aetiology. The portrait of the user emphasized a neuropathological hereditary constitution. The popular imagery saw him or her as a deviant inferior being. This shift from disease to deviance destabilized the medical world, especially since many of its members were involved in the problem: for them, it was a question of treatment or exclusion. Treatment attempts aimed at full abstinence which was equated with recovery. Discussions turned on the timing of the withdrawal process: abrupt stoppage or gradual reduction of dosage. The uncertainties about therapeutic approaches revealed the doubts about the psychogenetic, biological or psycho-sociological origins of toxicomania which were to persist into the twentieth century.
The historical examples of opium, morphine, heroin and cocaine show how the category of drug was constructed during the nineteenth century. They have in common the blurring of the idea of a remedy that was intended to cure with its opposite, the latter being a substance which turned out to be hazardous to the user's health. This ambiguity continues to be embedded in language (droguerie, droguiste, drugstore etc.), revealing that these issues still rest on shaky ground. The generic category of drugs goes well beyond the definition of a substance forbidden by law, since the extent of its prohibition has varied greatly over time. Drugs have much to do with human behaviour and experience, involving the self and the other on a continuum between pain and pleasure.
Probably the most cited in attempts to characterize substance-related problems, the term drug is often accompanied by the term addictive as if the latter were an inherent quality of the product itself. How can addiction or its related concepts of dependence and tolerance be defined? The task seems difficult; Akers [19] calls addiction a troublesome concept that has been widely misunderstood and misused. Alexander and Hadway [20] judge the literature on opiate addiction chaotic and bewildering. The World Health Organization (WHO) has preferred to use the term dependence which is defined as a psychic, sometimes a physical state resulting from the interaction between a living organism and a substance, characterized by behavioural modifications and other reactions which always comprise a need to repeat the consumption of the product in order to re-experience its psychic effects and sometimes avoid the discomfort of frustration. According to WHO, this state may be paralleled or not by tolerance, and the same individual might be dependent on several products. Such a definition underlines the importance of the interaction between a user and the substance, which means that the drug is not to be considered a mere stimulus, encapsulating precise intoxicating effects, but that the person taking it is an important part of the process. Substances, however, are classified by WHO as a function of their intrinsic addictive characteristics, using a less useful distinction between physical and psychological dependence. The separation of mind from body in trying to understand drug use seems particularly irrelevant if one considers that drugs are psychoactive, mind-altering substances in constant interaction with bodily processes. At best, the distinction between the physical and psychological can indicate the levels of phenomena involved. Physical effects are linked to tolerance and withdrawal effects, that is, the need to increase the dose or the frequency of drug intake and the somatic reactions of stomach cramps, muscle spasms, chills, fever, diarrhoea, nausea etc., linked to the abrupt stoppage of use. Such pain cannot, however, be classified as a purely physical phenomenon but has to be considered in its psychological dimension. The classic examples of substances that have these effects are heroin and alcohol.
The concept of physical dependence implies a deterministic outlook which limits seriously any therapeutic hope. It predicts that once a user has taken a dangerous drug he or she will be hooked, with little chance to gain control. It also implies a social policy advocating total prohibition, since the drug itself is seen as the cause of addiction. The person is seen as passive and helpless in front of the pernicious substance. Alexander and Hadway [20] have called such a view the exposure orientation on addiction. They contrast it with an adaptive view of addiction which suggests that drug use is an attempt to reduce the distress that existed before it was first taken. Opiate users thus are at risk of addiction only under special circumstances, that is, when they are confronting difficult situations and trying to cope by turning to drugs. The problem lies in the persons's psychological deficiencies and not in the drug itself. Thus, drug prohibition would be of no effect since the individual would still have to confront his or her stress and deal with it. In this view, the user has the choice of finding alternatives, searching for help and ultimately abandoning his or her dangerous habit.
A number of facts show that there is no universal and exclusive connection between such drugs as opiates and physical addiction. Any person using drugs does not necessarily become an addict. The effects of psychoactive substances are extremely variable from person to person and are relative to a number of factors among which are prior history of drug use, genetic susceptibility, cognitive factors, such as expectancy and attributions, environmental stresses, personality and opportunities for exposure [22]. People who have come to use drugs by accident, such as hospital residents who were given regular doses of morphine for pain relief, have not demonstrated an irresistible craving for such substances after release. It is estimated that about one quarter of the American soldiers in Viet Nam took heroin. Most of them, once back home, were able to quit without major difficulties. Similar observations hold for the period of the American Civil War. The case of controlled users, of which physicians are the best known group, shows that regular intakes of opiates over decades do not lead to tolerance or to withdrawal symptoms during abstinence. Heroin can be used on a regular but infrequent basis without dependence or catastrophic consequence [23]. It has also been found that former heroin addicts can completely stop using it or shift to casual use. Epidemiological studies have established that many heroin users are adolescents who grow out of their addiction and become abstinent later in life. People can experience withdrawal symptoms from much milder substances than opiates, such as sedatives, tranquillizers, laxatives, nicotine and caffeine. This evidence shows that no deterministic physiological mechanism can explain physical addiction exclusively.
If at the level of physical dependence there are fairly clear indicators, this is much less so with psychological dependence. It is defined by WHO as a psychic impulse to absorb periodically or continuously a substance in order to derive pleasure from it or to avoid a sensation of unease. The terms of this definition are much more difficult to put into operation than the physical syndrome discussed above. The psychological symptoms of drug dependence, such as craving and the compulsive necessity to take the substance regularly, go beyond the issue of toxicomania and can appear whenever the absence of a person, an object, a place or a situation creates a feeling of anxiety, stress or serious discomfort often coupled with psychosomatic signs. A number of behavioural patterns are very similar to psychological dependence linked to drugs but are not caused by any pharmacological substance. Lovers have been described as addicted [24]. Overwhelming involvement in sex and/or food resembles the compulsiveness that is classically associated with drugs. Activities such as gambling, shopping, jogging and working also fit into the category of addictions. Such an extension of the use of the concept of addiction is indeed puzzling and does not contribute to the understanding of the underlying processes.
Theoretical difficulties with the term "addiction" does not mean that it does not exist. It is not a unitary construct but a multidimensional concept. As noted above, there is no definition in terms of the intrinsic pharmacological properties of a drug. While such a reductionist description has been widely used, it is nowadays recognized that addiction is not merely a chemical reaction but also an experience, most often one of physical or psychological pain relief [25]. The shift from drug to person is necessary to account for the variability of the effects of different drugs in different cultures and on different individuals. Hence, if physical dependence is not to be equated to psychological dependence, they cannot at the same time be considered separately. By the same token, substance use cannot be analysed independently of a person's cultural context and cognitive, emotional and social functioning.
Hess [14] notes that, during much of opium's long history, addiction appears to have been unknown or at least not recognized and described as such. Addiction became progressively an issue during the nineteenth century along with the discrediting of drug use as a degenerate activity. Taken beyond the threshold of facts, addiction is a stigmatizing label. If substance use is described as a disease or a crime, the loss of control attributed to the state of addiction is considered deviant behaviour outside societal norms. The declared addictive property of a drug also serves to induce fear as means of prevention. Labelling a drug as addictive is intended to discredit it; the opposite is considered to signify downplaying the seriousness of the problem. The loaded ideological undertones of this apparently semantic point are often very pronounced in the literature and obstruct efforts to comprehend the complexity of the issues involved.
The temptation to reify categories like drugs, addiction and dependence can be understood in reference to the biological process involved. Whenever a phenomenon can be ascribed to nature, it appears to gain in objectivity, reality and transparency and therefore exclude historical and cultural relativity. The concept of deviance, which apparently is more remote from a biological cause, has been attached to heredity. During the nineteenth century, deviance was thought to originate in a person's genes. Subsequently, but on the same level of analysis, that of the individual, deviance was explained by the characteristics of the person and his or her personality, cognitive abilities or behavioural skills. It was only in the 1960s that sociologists from the Chicago School argued that deviance was not part of an individual's actions but is defined by society and the person who internalized it. Deviance is co-constructed by society and the individual whether he or she accepts or refuses the label. The normal and the stigmatized are not absolutes but viewpoints [26-28]. From the perspective of the excluded, one observes a recomposition of the social fabric with different norms, forming alternative worlds to society. The task of the researcher is to understand the viewpoints of this otherness which are often invisible from the outside. The war on drugs and, more surreptitiously, on users seems to be based on the absolute paradigm of the outsider. Drugs have been systematically linked to the unwanted foreigner and urban poor ghetto dweller who are considered a threat to society. There have been spectacular shifts in history in the public concern about drugs. At times it has created moral panics, a phrase coined by Cohen [29] to describe the reactions of the media, police, public, politicians and action groups as
"... [a] condition, episode, person or group of persons emerges to become defined as a threat to societal values and interest; its nature is presented in a stylized and stereotypical fashion by the mass media ... . Socially accredited experts pronounce their diagnoses and solutions; the condition then disappears, submerges or deteriorates and becomes more visible. Sometimes the panic passes over and is forgotten, except in folklore and collective memory, at other times it has more serious and long-lasting repercussions and might produce such changes as those in legal and social policy or even in the way society conceives itself."
There are several explanations for this complex phenomenon [30-31]. From such a constructionist stance, the existence of the drug problem as a purely objective condition can be questioned: what characterizes the problem is largely the attitude of the majority of the public. This becomes evident with the category of deviance.
Disease or illness 2 as a category bears a close similarity to the category of deviance. Indeed, disease is a deviance from the normative yardstick of health. It connotes a disorder that has been widely fantasized. Diseases have, throughout history, served as symbols and representations for something else. In Greek antiquity, disease was the expression of the god's wrath; for the church, it was often a punishment for the sins of the patient. Such projections always disqualified the sick person, implying that, in one way or the other, he or she was responsible for it. On the collective scale, the imagery concerning the great epidemics such as leprosy, cholera, syphilis and, above all, plague, exemplify the stigmatizing of illness. On a more individual level, diseases such as tuberculosis and cancer, described by Sontag [32], have been interpreted as reflecting the particular predisposition or temperament of the person. There has been an invariant link established between biological and moral defects even if the diseases themselves have changed. More recently, the case of acquired immunodeficiency syndrome (AIDS) has shown the way in which those who are ill are viewed as dangerous untouchables, a view enhanced by an association with deviant, excessive and/or abnormal sexuality. The reification of the concept of disease appears particularly inappropriate for AIDS. As Sontag [33] notes, AIDS is not the name of an illness but a clinical construction, an inference describing a terrain for a spectrum of conditions that are often lethal after a period of latency. Adding an ostracizing societal attitude to the severeness of an illness seriously increases the sufferings of the patients.
The disease concept has been applied mainly to alcoholism, less often to drug use. Such medical models emphasize the role of physiological addiction anchored in genetic factors and leave aside the psycho-social aspects of the problem [34-35]. Thus, the future alcoholic is considered to have an innate predisposition to drink excessively even before the problem is manifest. Such a reductionist view treats alcoholism as a unitary and discrete category instead of seeing it as a complex multidimensional pattern of behaviour. Using the disease model oversimplifies the issue in a purely medical perspective [36]. Neuhaus [37] notes some logical inconsistencies in this trend of thought. Indeed, there is a circularity in reasoning by labelling someone an alcoholic because he or she drinks too much and explaining that he or she drinks too much because he or she has the disease of alcoholism. There is another inconsistency to note. The purely biomedical model sees people as not responsible either for the problem or the solution [38]. The claim that treatment must be complete abstinence, inherent in the belief that alcoholism is a medical condition, has, however, been made by Alcoholics Anonymous. This organization functions according to an enlightenment model which states that people are not responsible for the solution of their predicament but are blamed for causing their own problem. This again shows the shift from a biological defect to a moral defect. The disease model of alcoholism has been applied to drug issues but with less research effort to ground it on an empirical basis (even though findings on the hereditary origins of alcoholism have not been solidly established). Whenever theorists stress physical addiction exclusively, they operate within the same framework.
The theoretical background of the social sciences in general and the approaches concerning drug issues in particular rest upon traditional dichotomies. Going back to Locke and Descartes, the opposition involved empiricism versus nativism (i.e., acquired or innate determinants of a person's cognizance and behaviour). Subsequently, these polarized views were renamed the nature-nurture debate, contrasting the role of biological and cultural factors. In different times, the emphasis on one at the expense of the other shifted like the swinging of a pendulum. Ideological and political interests are clearly involved in explanations referring to internal versus external causes. Whichever side is chosen in terms of these dichotomies, the result remains the same: the person and the environment are viewed as separate entities without considering their interwoven connections. Biological and cultural processes mutually constitute each other so that, as Cole put it, "the form of our nurturing is our nature" [39].
The paradigm of separating the individual from the environment has been transposed to the terrain of toxicomania. The drug abuser, the addict, the deviant and the ill person are rarely considered as subjects embedded in their historical sociocultural contexts [40]. The internal defect model is a perfect example of this way of thinking. The origin of a person's problem is unilaterally located within the subject without any reference to his or her surroundings. It is of interest to note that the causal processes invoked are not exclusively biological. The abuser can also be found guilty because of his or her moral or psychological flaws owing to severe personality disorders, independent of any contextual factor [31]. Explanations other than the internal defect model have, however, advocated the role of the environment but left it largely unspecified or limited it to immediate external conditions, such as family constellations or peer influences. In order to grasp the complexities of the drug issues, a comprehensive framework is needed in which cultural, social, psychological and biological levels are taken into account.
1 The adverse effects became evident only after 1850 when the new technique of injection produced much stronger effects with accompanying signs of dependence.
2
The two terms are not synonymous. A disease is strictly a biological entity, that is, an alteration in structure or function of the organism. An illness is a reaction to a change in one's physical state bearing social, psychological and cultural connotations.
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