Sunday, April 15, 2012

Why a volume on addiction now?

The newest (and very rough) installment on draft introduction to Critical Perspectives on Addiction volume in the Advances in Medical Sociology series.

photo by mararie on Flickr

So much has been written about addiction, one can reasonably ask why we need another volume on the subject now. The pieces gathered here take up a number of current trends that make now exactly the right time to take a fresh look at addiction.  These include: debates over the nosology of addiction as part of the revision to the Diagnostic and Statistical Manual of Mental Disorders (DSM); the expansion of addiction’s meaning and spheres of control beyond alcohol and illicit substances; the rise of neuroscience, the increasing “pharmaceuticalization’ of everyday life, and new pharmaceutical treatments for addiction; increasing awareness about the intersection of the drug war and the mass incarceration of people of color; and new theoretical frameworks for understanding the role of addiction a fundamental technique of social control, through the structuring of norms, the promotion of self-governance, and the continued use of overt state power.  These trends are reshaping addiction in both new and not-so-new ways that warrant the study and exposition this volume seeks to provide.

The newest edition of the DSM is due out in May 2013. The DSM is important not only because it is widely used both in the U.S. globally in diagnosing mental “disorders,” including addiction, but also because it reflects the “politics of designation” (Conrad, 1992; see also Widigier in Sadler book on DSM).  Simply put, it exposes both the current political, historical and social context as well as power struggles over how and by whom a given disorder will be defined.  The DSM V is being developed by groups of mental health professionals who draw both on research and discussion among themselves (website).  An enormous amount is at stake in how these groups end up defining a “disorder.”  Often, it is only by taking on a DSM diagnosis (and its attendant stigma) that individuals can access services and providers can access payment.  Increasingly, the DSM is also finding its way into the criminal justice system, both in instances of psychiatric defense and in medico-legal hybrid institutions, such as drug courts.

Importantly, for the first time, the DSM V will include non-substance addictions, specifically gambling.  The inclusion of a host of other “compulsive behaviors” has been also been debated (cite).  This marks a key turning point in the definition of addiction, which has historically focused on “dependence” and “abuse” and tied addiction to psychoactive substances. As the quote below from Peele (2010) suggests, the DSM V debates have further upset addiction’s already ambiguous meaning:

DSM-V proposes to incorporate some non-substance addictions - notably gambling. (Internet addiction is still up in the air - will the Task Force decide if it is addictive by a PET scan or by majority vote?) But DSM-V will call whatever ends up in this category behavioral addictions. So, let's count up. There is hypersexuality, but it is not an addiction. There is gambling, which is a behavioral addiction. Internet fixation may be an addiction, or maybe not. And then there are alcohol and drug addiction, formerly called dependence, in a separate substance addiction category. Clearly, the DSM-V Task Force is confused.[i]

The debates over the expansion of addiction beyond psychoactive substances are rooted, at least in part, in contemporary neuroscience, which is playing an increasingly important role in constructing “addiction.”  Although the science itself has been critiqued (cites), neuroscience has been used successfully to frame addiction as a chronic, relapsing brain disease (cites).  Campbell, for instance, argues that “neuroscience hijacked the field of substance abuse research… and gave substance abuse research the stamp of legitimacy” (2007: 200-1).

Moreover as the debates over the DSM V suggest, addiction neuroscience is being used to substance use to elucidate phenomena beyond substance use.  Specifically, the notion that the brain’s dopamine system is the center of pleasure has been used to explain all manner of behavior, both “pathological” and pleasurable.  Scans of the brain’s pleasure center “have revealed an embarrassment of riches” (Reinarman 2007; see also Vrecko, 2010b).  Gambling, eating, sex, and a host of other activities all “light up” the pleasure center, and scientists are now suggesting a common pathway theory: pleasurable behaviors stimulate the dopamine system and, therefore, tend to be repeated. 

The expansion of addiction to encompass a range of “pleasures” is not just a taxonomic debate; it shifts addiction in ways that reinforce “healthism” and neoliberalism.  The danger is less illicit drugs – though we still demonize many of those – but pleasure more generally, and pleasure is increasingly read as risk (Mackenzie, 2006).  On the one hand, pleasure is at the core of and drives consumer capitalism.  On the other hand, an expanding array of addictions and “diseases” (e.g., obesity) are seen as the result of excess pleasure.  The regulation of pleasure to encourage consumption but avoid becoming “addicted” or “sick” becomes a powerful tool in promoting the self-governance of individuals.  Individuals, with the help of public health messaging, medicine and cultural representations more broadly, are encouraged to police themselves and control their appetites in order to preserve health. 

The rise of addiction neuroscience has also led to the promotion of medications to help those who may fail at controlling their appetites through the assertion of will powere by targeting the biochemical processes of their brains.  The advent of new addiction pharmaceuticals can be seen as part of the increasing pharmaceuticalization of society more broadly, wherein pharmaceuticals are seen as the solution to ever-expanding array of personal and social problems. Between1980 and 2003 the average annual amount spent by Americans on prescription drugs rose from $12 billion to $197 billion (Petersen, 2010).  The rise of neuroscience means that behavior that deviates from the norm is more and more likely to be understood in biological terms as some sort of dysfunction of the brain.  Treatment with medication inevitably follows: “if the problem is neurologically based, it should be treated with a drug” (Diller: 1998: 110).  Medications have played an important role in attempts to to advance the medicalization of addiction (see Courtwright).  The development of one such drug, buprenorphine, in fact, was used to justify a remarkable legislative change in 2000 that permitted physicians to prescribe a narcotic (buprenorphine is an opioid) for the treatment of addiction in an office-based setting (i.e., not a methadone clinic) for the first time since 1914. 

Despite these efforts to frame and treat addiction as a medical disorder amenable to pharmaceutical intervention, behavioral, punitive, and morally-inflected responses to addiction continue to dominate drug policy and drug treatment. Indeed, programs focused on helping individuals achieve “abstinence” through behavior change still make up the majority of treatment in the U.S.  (SAMHSA 2010).  Gowan (2012) has noted the peculiar melding of the medical and moral in our contemporary approaches to drug treatment:

The current impulse toward reform and rehabilitation also has its new and peculiar specificities. At once medicalized and deeply authoritarian, riven with anxiety about self-control and ‘choice’ – the rise of drug courts and strong-arm rehab reflects the peculiar prominence of addiction within the current American Zeitgeist (71).”

Alongside our medical and behavioral treatments for addiction stands the real and present danger of incarceration. Drug offenses accounted for two-thirds of the rise in the federal inmate population and more than half of the rise in state prisoners between 1985 and 2000 (Alexander, 2010).  In her highly acclaimed and popular book, The New Jim Crow, Alexander argues that the war on drugs has undermined fundamental civil liberties and created a new system of racial oppression:

The fact that more than half of the young black men in many large American cities are currently under the control of the criminal justice system (or saddled with criminal records) is not—as many argue—just a symptom of poverty or poor choices, but rather evidence of a new racial caste system at work. 

Work like hers has reinvigorate the debates over the criminalization of addiction and heightened awareness about how racialized our attitudes about and responses to addiction are.

This volume, then, emerges at curious time in the history of addiction.  The very meaning of the word is in dispute (again), and yet the confusion over its meaning has done little to slow addiction’s growing dominion over a host of behaviors ranging from eating to online gaming.  The popularization and influence of neuroscience and the development of addiction pharmaceuticals, which have undergirded the expansion of addiction, seem poised to finalize the accomplishment of addiction as a disease and, as such, the appropriate province of medicine.  And yet, addiction remains inextricably bound with morality and stigma and linked with the exercise of racial oppression through the mass incarceration of people of color on drug charges.  Whether through reinforcing neoliberal desires for self-governance and control, placing “addicts” under the authority of a doctor, or locking up “criminals,” addiction has become one of our most expansive and influential systems of social control.

These responses to addiction and the hybrid versions of them that seem to be emerging are contained with a larger sociopolitical context that is highly stratified, particularly by gender, race and class.  There is no singular Truth about addiction, and because there is not, it can be deployed differentially in ways that reflect existing gender, racial and social stratifications.  It is these deployments and the ways they reflect our contemporary society that this volume addresses.

Saturday, April 14, 2012

Sociology and the Addiction Kaleidoscope

Snippets from the draft introduction to "Critical Perspectives on Addiction" for the series, Advances in Medical Sociology.

photo by Lucy Nieto on Flickr
“Addiction” is increasingly being used to explain all manner of human behavior.  Just a few recent headlines from the New York Times reveal how varied and expansive our ideas about addiction have become. 

“When is gambling an addiction?”
“A wave of crime and addiction with the medicine cabinet to blame”
“Miss G.: a case of internet addiction”
“When tanning turns into addiction”
“In the cave: philosophy and addiction”
“Is sex addiction an excuse?”
“Can food be as addictive as a drug?”

Although addiction appears to be becoming a dominant interpretive framework, what we mean by “addiction” if far from clear.  Sociologists have characterized attempts to classify and define “addiction” variously as a “shifting kaleidoscope” (Room, 1997), “taxonomic unruliness” (Keane, 2002), and “conceptual acrobatics” (Reinerman, 2005).  Lindesmith, widely considered to be the founder of the sociology of addiction wrote in 1938: “The problem of drug addiction has been an important one in this country for several decades and has proved to be a difficult one to handle from a theoretical as well as from a therapeutic standpoint (593).”

Unfortunately, it appears that neither the passage of time nor the advent of new technologies and scientific frameworks have done much to clarify theories of addiction.  In 1980, the National Institute of Medicine published a monograph that included 43 separate theories of addiction from a range of disciplines.  Ever malleable, addiction takes on the latest scientific theories of the day; just in the past 50 years it has been described as a metabolic, genetic, and, most recently, a neuroscientific problem.  As this volume will demonstrate, the malleability and chameleon-like qualities of addiction give it a conceptual elasticity that allows it to be deployed strategically to not only explain an ever-widening array of behavior, but also as a targeted tool of social coercion and control.

From a sociological standpoint, addiction is important because it engages a number of core theoretical issues – each of which is taken up in this volume.  First, addiction– often defined by a loss of control -- troubles issues of structure, agency, and free will.  Second, drug use – or at least some drug use -- remains stigmatized and criminalized, and thus addiction plays an important role in our systems of social control and racial segregation.  Third, addiction, especially as its meaning has expanded, engages key questions about pleasure, rationality, and self-control in ways that reinforce new forms governance and neoliberal citizenship.  Fourth, there is an ongoing and vigorous debate over whether addiction exists purely as a cultural, social and representational phenomenon (a social construction) or has some “real,” material, or biological basis – a key tension in sociology more broadly.

Finally and related, addiction has long been understood as having both medical and moral component making it an especially interesting and important topic for a series on medical sociology. There has been no graceful arc from deviance to medicalization – from badness to sickness -- in the case of addiction.  Although the medical model of addiction has gained in prominence in the U.S. over the past thirty years, scholars have noted neither alcoholism (Appleton 1995; Valverde 1998) nor drug dependence (Smart 1984) fit easily into the medicalization model. The slippage between medicine and morality, a characteristic of many medicalized conditions, has been especially pronounced and problematic throughout the history of addiction and has contributed to the ambiguity in how we understand addiction and addicts.   This ambiguity plays out in real, materials ways that have shaped an often chaotic and inconsistent approach to drug policy, specifically, and response to addiction more broadly.

While the medical and the moral are often pitted against one another rhetorically, our responses to addiction often contains elements of both.  As May (2001) explains “clinical constructions of addiction still engage a set of moral questions” (386).  These moral questions are often directly built into addiction treatment programs, many of which have explicit crime control functions (Fox 1999) but rely on medical language to describe addiction. Medical and moral views of addiction have also increasingly blurred through criminal justice practices such as drug courts, where defendants with drug-related offenses are mandated to drug treatment (Tiger 2008).

Even when addiction is understood as a disease, because it is a disease that involves the “loss of control,” it often used to justify extreme forms and systems of coercion and social control. As Reinerman (2005) puts it:

[T]he disease concept sometimes serves as a human warrant for the right of access to services, but is also serves, paradoxically, as the key justification for punitive prohibition…. It is a weapon that helps justify – ‘for their own good’—the suspension of the Bill of Rights … and the mass incarceration of the powerless (317).

Indeed, even as disease models of addiction have gained traction, criminalized approaches to drug use have continued to play a large role in drug control policy, especially in the U.S.  The increasing criminalization of drug use over the past thirty years, as evidenced by lengthy mandatory sentences for drug convictions and dramatic increases in federal funding for the “War on Drugs,” has had a significant impact on the number of people incarcerated in the U.S., now exceeding 2,000,000 (Glaze and Palla 2004) and has become a firmly entrenched and powerful tool of racial control (Alexander, 2010).  Although Black Americans are no more likely than whites to use illicit drugs, they are for more likely to be incarcerated for drug offenses (Rich et al. 2011).  Black men in the U.S. are more likely to have been in prison than to have graduated from college or joined the military by middle age (Rich et al 2011).