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H U M A N PSYCHOPHARMACOLOCY. VOL. 11, S33-S38 (1996)
Failings of the Disease Model of AddictionGI0 BATTA GORIThe Health Policy Center, 6704 Barr Road, Bethesda, M D 20816, U S A
Colloquially, addiction ranges in meaning from addiction to good deeds to addiction to substances of abuse.Especially during the last four decades, addiction in this extreme pejorative meaning has been portrayedalternatively as a disease or a sin, and has been subject to social an d moral sanctions. In an open society of freeindividuals such a coercion cannot bejustified unless the condition is defined precisely by the simultaneous attributesof severe psychotoxicity, severe withdrawal symptoms, and recurrence tied to the loss of self-controland individualvolition. Still, these attributes are open-ended, and an explicit metric of severity at which they may trigger socia]objection has no t been clarified. ASa consequence, addiction allegations are left to elicit emotional, subjective, andvalue-laden responses ready to be exploited. A clamorous example is the claim by US officials that cigarette smokingis equal to the abuse of heroin or cocaine. An unequivocal definition of addiction may restore some sense ofproportion to official normative intervention.KEY wows-addiction; smoking; regulation; substance abuse
I N T R O D U C T I O NWh at addiction is, whether addiction is a disease-and if so, what kind of disease-cannot be deter-mined purely from a medical or behavioural angle,but rather from more basic considerations, giventhe logic and semantic instabilities su rro und ing theterm.I believe it was Voltaire who said that anintelligent discussion beings with a statement ofdialectic premises and assumptions. To do so, Ipropose the following line from Horace, theprom inent Latin poet, who wrote some 2000 yearsago nullius addictus urare in verba mag istri: [I am ]not in the habit of swearing by the words of anymaster (Horace, Epistulcz I, I, 14 (1921)).First, this line gives a fitting description of thegood-natured scepticism that should inform themost optimistic scientific analysis. Second, it is aline in a language th at too k pride in its concisenessand precision, as should be the aim of anyintelligent and logically fair analysis. Third, itmentions addiction as the Latin meant it, namelyto signify a habit, an insistent way to keep doing
* The original Latin meaning was a iegai one. The winner in alegal dispute could be assigned property or even the person ofthe loser. Whatever this assignment, it was said to be addictedto the winner. The word gradually also took the meaning usedby Horace and in current language.
things*. In fact, this has been the meaning of theword down to this day when colloquially wedescribe people addicted to good deeds, tochocolate, t o food, t o sex, to the goo d life, as wella s to gambling, alcohol, hard-drugs, and so on .Such various attributions of addiction imply acontinuum of valuations, from the laudable to thecondemnable. Still, more an d m ore du ring the lastdecades in medical, behavioural, regulatory, andlegal talk addiction has been assigned thepejorative meaning of a syndrome identified withthe abus e of psychotoxic substances. I t is presentedas a repetition of abuses that eventually cancelvolition and personal responsibility, thus generat-ing the need of therapies and other interventions,and leading to social costs and crime. Official andsocial sanctions have been assigned to this syn-dro me , even though assorted interes ts have resisteda defensible definition of precisely why and inwhose eyes addiction becomes objectionable.Because the resulting ambiguities have been leftopen to exploitation and resentment, this essayexplores plausible standards of semantic fairness.A D D I C T I O N D E F I N E DToday-when addiction becomes of medical ornorm ative interest-it invariably carries thepejorative ethical meaning of recurring uncontrol-lable excess. Because the word has moral
CCC 0885-6222/96/S 10833-060 996 by John Wiley & Sons, Ltd.
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s34 G. B. GORlimplications and these qualifiers are prone tosubjective valuation, some questions arise. Forinstance: who appraises addiction: the observer orthe observed? Indeed, it matters if the claimant is adogmatic authority, and if the people branded asaddicted by such an external value judgmentmany not feel unsound at all. Elementary fairnessrequires that when addiction is used to imposesocial or medical labels and sanctions, it should bedefined by objective attributes rather than norma-tive judgments. Fairness further requires that theseattributes not be frivolous. It should not besufficient to rely on the mere recurrences impliedby addiction, nor on pleasurable or therapeuticoutcomes in the subjects iqvolved, nor on medical,physiologic, psychologic, or behavioural markersof contrived ethical implications.A social languagestriving to be equitably normative should explicitlyidentify why, to whom, and by which standardsindividual addiction becomes objectionable andtherefore subject to sanction.For our analysis, uncontrollable excess isdefined in the context of some repetitive actionimplied by addiction. Here, however, recurrence isnecessary but not sufficient because many actionsin life are or must be highly repetitive-someactually carrying risks-without being defined asuncontrollableor addictive. Think, for instance,of keyboard work and metacarpal syndromes,tennis and tennis-elbows, sweets and tooth decay,overeating and longevity loss, and so on. Indeed, inethical, social and normative parlance objection-able addiction has been specifically restricted toconditions involving substance abuse. Therefore,considering the features of these conditions, for-cible intervention seems justified when repetitiveuncontrollable excess leads to objectionable endsor to loss of personal volition on account-forinsta nce -of the lure of psychoactivity or becauseof withdrawal symptoms, both outcomes of sub-stance abuse as commonly understood. Still, inorder to be problematic, psychoactivity may not bea simple pleasurable experience but must bederanged and psychotoxic, while withdrawal mustbe objectively severe. We could propose, therefore,that addiction objectively becomes a repetitiveuncontrollable excess when severe withdrawalsymptoms are soon alleviated by renewing aderanged intoxicating experience, which triggers acontinuing repetition that presumably cannot becontrolled by personal volition. General psycho-toxicity alone may not qualify addiction becausethe occasional abuse and intoxication-by alcohol
or psychoactive substances-does not materializethe recurring loss of volition leading to therepetitiveness of addiction. In turn, the severityof withdrawal must be such that it compelsrepetition by any means. Thus, depersonalizingpsychotoxicity, severe withdrawal, and loss ofpersonal volition seem collectively the necessaryattributes if addiction is to justify social objectionand sanction.These attributes. however, span a domain ofseverity and thus require specific definition of theintensities above which social action is justified.Unfortunately, such metrics have not been definedobjectively, and as a consequence the limits of adefinition are not always respected. Scientists mayuse addiction without ethical implications-avalue-neutral technical term defining a tentativeexperimental model of behavioural and physiologicdescriptors. Healing authorities and professions,on the other hand, often use the same tentativedescriptors and pretend scientific objectivity incalling for social and ethical objections and injustifying sanctions to addiction.In reality, among descriptors of addiction onlypsychotoxicity may be a relatively narrow attri-bute. Severity of withdrawal and loss of personalvolition are concepts open-ended to subjectivevaluation, even though their features could befairly precisely identified for the syndrome ofaddiction to hard-drugs, namely the standard ofobjectionable addiction. Yet, there has beenreluctance-official and otherwise-to adoptmeasures of these features as the legitimate bench-marks of this condition.Behaviour and health scientists have attemptedto seek objective markers for some attributes ofaddiction, but the results have not been persua-sive. The World Health Organization (WHO) andothers have struggled for 40 years with a modeldefinition of addiction. In the 1957 WHOdefinition:Drug Addiction is a state of periodic orchronic intoxication produced by repeatedconsumption of a drug (natural or synthetic).Its characteristics include: (1) an overwhelm-ing desire or need (compulsion) to continuetaking the drug and to obtain it by anymeans; (2) a tendency to increase the dose; (3 )a psychic (Psychological) and generally aphysical dependence on the effects of thedrug; (4) detrimental effect on the individualand on society (WHO, 1957).
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FAILINGS OF THE DISEASE MODEL OF ADDICTION s35In the same 1957 report, W HO experts felt the needto distinguish addiction from habituation. thelatter being thus defined:
Drug Habituation (habit) is a conditionresulting from the repeated consumption ofa drug. Its characteristics include: (1) a desire(but no t a com pulsion) to continue taking thedrug for the sense of well-being it engenders;(2) little or no tendency to increase the dose;(3 ) som e degree of psychic dependence o n theeffect of the drug, but absence of physicaldependence and hence of an abstinencesyndrome; (4) detrimental effect, if any,primarily on the individual (WHO, 1957).
Because of the subjective vagueness of thesedescriptors, WHO experts from 1964 to 1974abandoned both concepts of addiction andhabitu ation in fav our of a unified concept ofdependence.Drug Dependence. A state, psychic andsometimes also physical, resulting from theinteraction between a living organism and adrug , characterized by behavioural and otherresponses that always include a compulsionto take the drug o n a continuous or periodicbasis in order to experience its psychic effects,and sometimes to avoid the discomfort of itsabsence (WHO, 1974).
This earlier definition still did not satisfy, and in1993 dependence was defined in even vaguerterms:A cluster of physiological, behavioural andcognitive phenom ena of variable intensity, inwhich the use of a psychoactive drug (ordrugs) takes on a high priority. The necessarydescriptive characteristics are a preoccupa-tion with a desire to obtain a nd take the dru gand persistent drug-seeking behaviour .The existence of a state of dependence isnot necessarily harmful in itself, but may leadto self-administration of the drug at dosagelevels that produce deleterious physical orbehavioural changes . . (WHO, 1993).
It is apparent that the experts became less andless comfortable with attribu tes of variable inten-sity and ended up with an all-encompassingdefinition lacking specificity. By declaring that... a state of dependence is not necessarilyharmful in itself ... the w ord dependence nowseems to cover the same range of situations as the
generic term of addiction. namely from thelaudable to the objectionable. Sceptics havesurmized that this vagueness might have beendesigned to ease the inclusion of otherwise con-jectura l syndrom es in medical costs reimbursementprogrammes. More likely, it was the outcome ofmounting semantic confusion fostered by multipleand competing professional interests, and by theresulting incapacity or unwillingness to identifyobjectively a specific scientific, medical, social,regulatory, and legal construct as objectionableaddiction.To make matters more complex, an hypothesishas been advanced that the definition of addic-tion might not place overwhelming responsibilityon the substances tha t may be abused, when manypeople use the same substances sporadically andwithout being socially labelled as objectionablyaddicted. Others may chronically use the samesubstances for stress or pain relief, withoutobjectionable or addiction consequences-forinstance, the users of opiates and benzodiazepinesfor pain or mood control. Indeed, and despite thevagueness of the words, only a small fraction ofpeople end up being classified as objectionablyaddicted, even though substances that can beabused are easily available.Thus, the conjecture surmizes that w hat m akesaddicts are addiction-prone personalities--ad-diction being viewed as an endogenous predicatewhile the substances abused are seen as contingentexternal accessories. In this context, the hypothesisof causality has invoked the concept of cognitivedissonance, negative sociocultural influences,devastating family environments. and so on:collectively a multifactorial construct of causation,where the substances that may be abused arecircumstantial complements.In any event, the WHO expert definitions ofaddiction are unsatisfactory both in a semanticand scientific context. A certain routine is notnecessarily objectionable if it shou ld have psycho-active effects-presumably pleasurab le, eup ho r-iant or even hallucinogenic-which reinforce aninsistence to repeat the experience. It is notnecessarily problematic if it should include thedevelopment of tolerance, namely an assuefactionto a substance. For instance, the traditional use ofalcoholic beverages as food or entertainment fitsthese conditions without social offence. Theoccasional drunkenness of otherwise sober indi-viduals or the occasional experience with hard-drugs seem to elicit hardly more than raised
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S36 G. B. GORleyebrows. The occasional loss of volition and freewill is not a controlling determinant of socialdisapproval. Indeed, excluding ever present pur-itanical fringes, ancient and current mores seemlargely indifferent to occasional psycho-intoxica-tions of individuals.Nevertheless, addiction defined by an everrecurring triad of severe psychotoxicity, with-drawal symptoms, and loss of personal volitioncontrol is bound to create personal, social, andmaterial concerns. Still, we have seen how vaguethe medical and behavioural definitions of addic-tion have been made. Addiction can be defineddialectically but apparently not in precisely quan-tifiable scientific terms, ljkely on account of theethical value implications of the word. A legitimateoperational definition would be possible by adopt-ing as benchmarks the intensities of psychotoxicity,severe withdrawal and loss of volition, at the levelsthat characterize the classic addiction to hard-drugs. Yet, this has not happened. Semanticambiguities have been left festering arguably withintention and-given human nature-they seemready-made for exploitation. A clamorous exampleis the 1988 claim by the US Surgeon General thatsmokers are as addicted to cigarettes as others areto heroin and cocaine.CIGARETTE SMOKING, HEROIN, ANDCOCAINEIn an effort to discourage cigarette smoking, theUS Surgeon General in 1988 declared that-behaviourally-cigarette smokers are on the samelevel as heroin or cocaine addicts. On the face of it,this incredible assertion defies common sensebecause the daily experience of everyone tells thatsmokers and hard-drug addicts are not the samepeople. In effect, the Surgeon General trivializedthe pejorative behavioural connotations of heroinand cocaine addiction. Could anyone show thatcigarette smoking comports such an extreme abehaviour as heroin and cocaine addiction? Shouldwe invent other words for substance abuses withtrue objectionable sequelae, when common lan-guage itself separates different habits in differentcategories of intensity? In the context of fairpolicies we should rather demand a precise use ofdefinitions and language, insisting that if a genericaddiction attribute is to be used ubiquitously,then its intensity should be graded in each instance.Official precedent recognizes this need, implicit inthe legal distinction of a 100: 1 ratio for the
addictive power of crack versus powdered cocaine(US Code). By all measurable evidence,if cigarettesmoking-or chocolate craving, for that matter-is to be called addictive, it should be accorded acomparatively more extreme reduction of intensitywhen compared to powdered cocaine.An explicit gradient of intensity is apparent inthe definitions of addiction and habit advancedby the healing professions. In fact, the WorldHealth Organization has characterized smoking asa habit, not an addiction, and even statements byprevious Surgeon Generals in the US also qualifiedsmoking as a habit. For instance, the original 1964Surgeon Generals report reads:The tobacco habit should be characterizedas an habituation rather than an addiction, inconformity with accepted World HealthOrganization definitions, since once estab-lished there is little tendency to increase thedose; psychic but not physical dependence isdeveloped . No characteristic abstinencesyndrome is developed upon withdrawal .Discontinuation of smoking . . is accomp-lished best by reinforcing factors whichinterrupt the psychogenic drives. Nicotinesubstitutes or supplementary medicationhave not been proven of major benefit inbreaking the habit (USSG, 1964, p. 354).The overwhelming evidence points to theconclusion that smoking-its beginning, hab-ituation, and occasional discontinuation-isto a large extent psychologically and sociallydetermined (USSG, 1964 p. 40).To smokers, smoking is pleasant in many waysand therefore it could be expected to be mildlyreinforcing as any pleasant experience tends to be.There is no good evidence of tolerance in smokers.A certain dose is attained early when people startsmoking and that dose is not exceeded becauseexceeding it makes smoking unpleasant. Un-controllable, compulsive use is not apparent insmokers: the Surgeon General acknowledges thatover 40 million smokers quit on their own in theUnited State alone, in a climate where cigarettesare legally and readily available. The all importantqualifier of psychotoxicity is absent in smokers.Finally, there is no evidence of physical depen-dence: withdrawal symptoms are usually absent,transient and mild at best when present, and lessnoticeable than the withdrawal symptoms experi-enced by people on strict diets. Jack Henningfield,a principal architect of the US Surgeon Generals
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FAILINGS OF TH E DISEASE MODEL OF ADDICTION s37claim o f smoking addiction, himself wrote a fewyears ago that:
The following constraints and inconsisten-cies should be noted when considering theevidence for a tobacco withdrawal syndrom e.First, a syndrome of reliable physiologicsigns ... has not been described .. . w i t hthe exception of the desire to smok e . otherphenom ena typically occur only in a fractionof all subjects abstinent from cigarettes . .For instance . . . weight gain, gastrointestinaldisturbances, or anxiety may each occur inless than one-third of all subjects; and up toone-half of abstinent subjects may report nosymptoms a t all.The second major issue is that whiletobacco withdrawal is commonly equatedwith nicotine withdrawal, there is little evi-dence that nicotine produces physiologicdependence . Administration of nicotine-receptor antagonists . has not been shownto evoke a withdrawal syndrome . Plrovid-ing abstinent smokers with a nicotine-containing chewing gum only partiallyattenuates physical complaints . [and] inanimal studies, abrupt abstinence is notfollowed by .. a withdrawal syndrome.These inconsistencies . impose constraintson the com parison . .of tobacco withdrawalwith that of withdrawal from opioids, seda-tives, and ethanol ... The relevance of thispoint goes beyond semantic issues of classi-fication .. [because] when withdrawal isconsidered in the context of drug dependenceit generally connotes a more narrowlyspecified set of conditions (viz. a reliablesyndrome of behavioural and physiologicchanges) (Henningfield, 1984, pp. 147-148).
Such a stateme nt amounts to an admission that-by comparison to withdrawal from hard-drugabuse-smoking withdrawal simply does not exist.Most smokers quit without consequence whatso-ever. A few ma y experience some discomforts thatquickly disappear spontaneously or are curable bythe mildest intervention. Severe cases are said toexist, but are undocumented in the scientificliterature, even at the anecdotal level. If anything,it can be argued that at present smokers may besomewhat less comfortable about quitting becausethe addiction label and the proliferation ofcessation clinics and devices makes them think-consciously or not-that quitting has become a
difficult ordeal-a view supp orted by prom inen tanti-smoking advocates (Chapman, 1995).Smoking may be a habit comp orting some risks,but d oes not qualify as addiction under the termsdiscussed above. In fact, if persistent abuse ofhard-drugs exemplifies the uncontrollable excessthat includes psychotoxicity, severe withdrawal,an d loss of volition-then the use of the term inconnection with smoking is improper, loses forceand impact, and must descend at the level of ahabit, as earlier Surgeon Generals in the US haverecognized (USSG, 1964). Other than in jest,addiction cannot apply to common pleasanthabits, without generating semantic confusion.IS ADDICTION A DISEASE?A true addiction syndrome with its attendingsocial costs indeed poses som e crucial questions. Isit th at a proliferation of addictions is inevitable inan age of plenty and relative idleness? Is crimina-Iization of addiction likely to rem edy o r to w orsenthe situation? Is it Utop ian to think of medical an dbehaviou ral fixes? Wh at m ay be t he useful psycho-logic, sociologic an d educational remedies?Despite much th at has been written a nd argued,answers to these and other questions are by nomeans clear, although it may be fair to concludetha t contro l of socially costly addiction problemsmay not be attained without new social structures,In this co ntex t, if addiction is a disease, it is more asocial than a medical disease. Sociology andpsychology may hold the key to its control,although not likely to its eradication-giveninevitable human frailties. To begin with, it maybe necessary to remedy the anarchic decay ofwestern civility at the hands of laissez-faire NewAge sociologists (Adorno ef af., 1950; Memmi,1968; Ryan, 1971). Und er their influence in the lastfour decades, traditional virtues of individual self-control and accountability have been spumed tothe point of contempt (Sykes, 1992). How muchthis has contributed to the proliferation of addic-tions may be difficult to measure, but a return ofindividual responsibility could only presageimprovement.Our analysis also raises broader concerns.Addiction is a value-laden perception with ethicalimplications. In the absence of defensible intensityqualifiers of recurring psychotoxicity, withdraw al,loss of volition, and social cost, addiction isambiguously defined and open to semantic manip-ulatio ns by special interests-the healing-ind ustry
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S38 G . B. GORlinterest in fostering victimization syndromes; theregulatory-industry interest in creating phantomhealth and safety hazards; the funding interests ofthe research establishment. Lewis Carroll hadHumpty Dumpty saying that: When I use aword, it means just what I choose it to mean-neither more no r less. If addiction might be asocial disease, we unquestionab ly have a disease ofwords in current public discourse, a disease ofrhetoric and semantic ambiguities. In this context,addiction has rightfully become an abuse oflanguage.Here, a s always, the cavea t emptor admonition-buyer beware-is para mo unt. We undoubtedlybuy government and regulations, and healthservices: bo th essential$ unregulated businesses.Th e perennial and still unresolved questio n is: wh ocontrols the controllers? Beware of contrivedambiguities. Is it ethical to intervene on the basisof heuristic hypotheses and of subjective-andlikely interested-ethical judgments? Can a freesociety survive deceptive public policies even ifallegedly issued with good intentions? I think not:straight public talk should be a minimum require-men t of social fairness. Until tha t may be achieved,Horace still offers excellent advice to the commonm an and to the scientist: nullius add ic tus jurare inverba magistr i .R E F E R E N C E SAdorno, T. W. et al . (1950). The Authoritarian Person-ality. Harper & Brothers, New Yo rk.
Chapman, S. 1995). Smokers: why do they start-andcontinue? World Health Forum ( W H O ), 16, 1-9.Henningfield, J. E. (1984). Behavioral pharmacology ofcigarette smoking. In: Advances in Behavioral Pliarma-cology. Thompson, T .. Dews, P. B. and Barrett, J. E.(Eds), Academ ic Press, New Y ork, pp. 147-148.Horace, Q. Horati Flacci Opera, Heinze. R. (Curator).Insel Verlag, Leipzig, 1921.Memmi, A. (1968). Dominated Man. Beacon Press,Boston.Ryan, W. (1971). Blaming the Victim. Vintage Books,New York.Sykes, C. J. (1992). A Nation of Victims: The Decay ofthe American Chnracter. St. Martins Press, NewYork.US Code. 21 United States Code Q 841(b).USSG (1964). Smoking and Health Report of theAdvisory Committee to the Surgeon General of hePublic Health Service. US Department of Health,Education, and Welfare, Public Health Service,Publication No. 1103, Washington, DC.USSG ( I 988). The Health Consequences of Smoking:Nicotine Addiction. R eport of the Surgeon General. U SDepartment of Health and Hum an Services, PublicHealth Service, Publication N o. 88-8046, Was hington ,DC.WH O (1957). Expert Committee on Addiction-ProducingDrugs. Seventh Report. World Health Organization,Geneva.WHO (1974). Expert Committee on Drug Dependence.Twentieth Report. World Health Organization,Geneva.WHO (1993). Expert Committee on Drug Dependence.Twentyeighth Report. World Health Organization,Geneva.
