What Do We Mean When We Talk About Craving?

An essay on drug addiction and need.

For years, craving was represented by the tortured tremors and sweaty nightmares of extreme heroin and alcohol withdrawal. Significantly, however, the one symptom common to all forms of withdrawal and craving is anxiety. This prominent manifestation of craving plays out along a common set of axes: depression/dysphoria, anger/irritability, and anxiety/panic. These biochemical states are the result of the “spiraling distress” (George Koob’s term) and “incomprehensible demoralization” (AA’s term) produced by the addictive cycle. The mechanism driving this distress and demoralization is the progressive dysregulation of brain reward systems, leading to biologically based craving. The chemistry of excess drives the engine of addiction, which in turn drives the body and the brain to seek more of the drug.

Whatever the neuroscientists wanted to call it, addicts know it as “jonesing,” from the verb “to jones,” meaning to go without, to crave, to suffer the rigors of withdrawal. Spiraling distress, to say the least—a spiraling rollercoaster to hell, sometimes. Most doctors don’t get it, and neither do a lot of the therapists, and least of all the public policy makers. Drug craving is ineffable to the outsider.

As most people know, behavior can be conditioned. From maze-running rats to the “brain-washed” prisoners of the Korean War, from hypnotism to trance states and beyond, psychologists have produced a large body of evidence about behavior change—how it is accomplished, how it can be reinforced, and how it is linked to the matter of reward.

It is pointless to maintain that drug craving is “all in the mind,” as if it were some novel form of hypochondria. Hard-core addicts display all the earmarks of the classical behavioral conditioning first highlighted almost a century ago by Ivan Pavlov, the Russian physiologist. Pavlov demonstrated that animals respond in measurable and repeatable ways to the anticipation of stimuli, once they have been conditioned by the stimuli. In his famous experiment, Pavlov rang a bell before feeding a group of dogs. After sufficient conditioning, the dogs would salivate in anticipation of the food whenever Pavlov rang the bell. This conditioned response extended to drugs, as Pavlov showed. When Pavlov sounded a tone before injecting the dogs with morphine, for example, the animals began to exhibit strong physiological signs associated with morphine use at the sound of the tone alone. Over time, if the bell continued to sound, but no food was presented, or no drugs were injected, the conditioned response gradually lost its force. This process is called extinction.

Physical cravings are easy to demonstrate. Abstinent heroin addicts, exposed to pictures of syringes, needles, or spoons, sometimes exhibit withdrawal symptoms such as runny noses, tears, and body aches. Cravings can suddenly assail a person months—or even years—after discontinuing abusive drug use. Drug-seeking behavior is a sobering lesson in the degree to which the human mind can be manipulated by itself. The remarkable tenacity of behavioral conditioning has been demonstrated in recent animal studies as well. When monkeys are injected with morphine while recorded music is played, the music alone will bring on withdrawal symptoms months after the discontinuation of the injections.  When alcoholics get the shakes, when benzodiazepine addicts go into convulsions, when heroin addicts start to sweat and twitch, the body is craving the drug, and there is not much doubt about it. But that is not the end of the matter.

“Craving is a very misunderstood word,” said Dr. Ed Sellers, now with the Centre for Addiction and Mental Health in Toronto. “It’s a shorthand for describing a behavior, but the behavior is more complicated and interesting than that. It’s thought to be some intrinsic property of the individual that drives them in an almost compulsive, mad way. But in fact when you try to pin it down—when you ask people in a general context when they’re exposed to drugs about their desire to use drugs, they generally give rather low assessments of how important it really is.”

While cravings can sometimes drive addicts in an almost autonomic way, drug-seeking urges are often closely related to context, setting, and the expectancy effect. It has become commonplace to hear recovering addicts report that they were sailing through abstinence without major problems, until one day, confronted with a beer commercial on television, or a photograph of a crack pipe, or a pack of rolling papers—or, in one memorable case of cocaine addiction, a small mound of baking powder left on a shelf—they were suddenly overpowered by an onrush of cravings which they could not successfully combat. “If you put them in a setting where the drug is not available, but the cues are,” said Sellers, “it will evoke a conditioned response, and you can show that the desire to use goes up.” Most people have experienced a mild approximation of this phenomenon with regard to appetite. When people are hungry, a picture of a cherry pie, or even the internal picture of food in the mind’s eye, is enough to cause salivation and stomach rumblings. Given the chemical grip which addiction can exert, imagine the inner turmoil that the sight of a beer commercial on television can sometimes elicit in a newly abstinent alcoholic.

When addicts start to use drugs again after a period of going without, they are able to regain their former level of abuse within a matter of days, or even hours. Some sort of metabolic template in the body, once activated, seems to remain dormant during abstinence, and springs back to life during relapse, allowing addicts to escalate to their former levels of abuse with astonishing speed. This fact, and no other, is behind the 12-Step notion of referring to oneself as a “recovering,” rather than recovered, addict—a semantic twist that infuriates some people, since it seems to imply that an addict is never well, never cured, for a lifetime.

Relapse sometimes seems to happen even before addicts have had a chance to consciously consider the ramifications of what they are about to do. In A.A., this is often referred to as forgetting why you can’t drink. It sounds absurd, but it is a relatively accurate way of viewing relapse. Addiction, as one addict explained, “is the only disease that tells you you ain’t got it.”

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The Strange and Secret Keeley Cure for Addiction

“Drunkenness is a disease and I can cure it.”

In America in the late 1800s, curing alcoholism was a serious business—and for Dr. Leslie Keeley, a very lucrative one. Dozens of clinics and cures already existed, and some treatment centers had even experimented with franchising. For the late 19th Century alcoholic in search of treatment, what most of them had on offer was either outright patent medicine fraud, or else well intentioned if ultimately misguided “opium” cures. None of them, writes William L. White in Slaying the Dragon, “was more famous, more geographically dispersed, more widely utilized, and more controversial than Leslie Keeley’s Double Chloride of Gold Cure for the treatment of alcoholism, drug addiction, and the tobacco habit.”

The Irish-born Dr. Keeley served as a surgeon in the Civil War, and, as family lore would have it, started a treatment program for alcoholism in a Union hospital during the war. We do know that in 1879, he opened the first Keeley Institute in Dwight, Illinois, south of Chicago. His sales pitches were colorful and varied, but boiled down to this pledge: “Drunkenness is a disease and I can cure it.” He could cure it with a secret, specific formula, injected four times daily, about which all he would hint publically was that it contained, as one of its ingredients, gold. This was not so outlandish as it may seem. Gold, silver, strychnine, and other potentially poisonous ingredients were already employed in dozens of standard medicines—and, in many cases, still are. But everything else about Dr. Keeley’s magic elixir was as secret as the ingredients in Coke.

Nonetheless, something seemed to be working. He claimed an outlandish 95% success rate, bolstered by legions of enthusiastic followers who formed proto-AA groups with the catchy title of Bi-Chloride of Gold Clubs, better known as the Keeley Leagues. And Keeley himself employed the largest collection of formerly addicted doctors in the known world. There were no counselors at Keeley clinics. There were enough doctors on staff to go around, even though an estimated total of half a million alcoholics and other addicts eventually took the Keeley Cure.

Treatment consisted of the infamous injections, a liquid cordial every two hours, and, according to White, the following modalities: “daily rest, nutrition, mutual sharing, and alternative diversions worked to improve the patient’s physical and psychological health.” We can assume, from this regimen, that some alcoholics and addicts probably improved, regardless of what was in the medicine. And there was the frequent suggestion that, really, it was probably best not to ask too many questions about what was in the medicine, anyway.

“The atmosphere was informal and friendly at the clinics,” White writes, “with a marked absence of the bars and restraints that were typical in most inebriate asylums of the period.” There were, of course, some very vocal detractors. Dr. T. D. Crothers, a leader in the inebriate asylum movement, said: “There is no gold cure for inebriety. There are no facts to show that gold has any value in this disease. All the assertions and statements concerning gold as a remedy are delusions, and will not bear the test of critical examination.”  Perhaps not. But success was success, and soon, the marketplace saw the introduction of Dr. Haines Golden Remedy, the Geneva Gold Cure, the Boston Bichloride of Gold Company, and many other knockoffs. (Keeley proclaimed that his Double Chloride of Gold cured all forms of inebriety by “speeding up the restoration of poisoned cells to their pre-poisoned condition.”)

From 1892 through 1900, the Keeley Company pulled in almost $3 million, including mail-order business. There was a Keeley Day at the 1893 World’s Fair in Chicago. Here is an excerpt from the pamphlet, “To the Keeley Graduate,” given to every patient who completed treatment:

You are now numbered among thousands of men and women who have broken the shackles of alcohol and drug addictions by the Keeley method of treatment. Your cure will be as permanent as your life, you will never have any craving for alcohol or other sedative drugs as long as you live, unless you create it by returning to their use, thus re-poisoning your nerve cells.

But by 1900, the bloom was off the Keeley miracle, as insiders fought for financial control, and congressional investigators looked into the affairs of Keeley League president Andrew J. Smith.

Of course, if Keeley had really possessed a specific, replicable formula that took away the craving for alcohol, it would have been monstrously unethical to hold it a secret. And he was constantly accused of using harmful ingredients, such as codeine, strychnine, and cocaine in his magic injections.

Keeley wouldn’t say. And neither did any of his heirs or business partners. The only thing most court records agree on is that the injection didn’t contain any gold—too many possible side effects. According to the testimony of Keeley’s original business partner, “The only patient who ever received Keeley medicine that actually had gold in it almost died.”

The secret ingredient was probably atropine—a powerful compound belonging to a very weird family of plant drugs known collectively as “anticholinergenic deliriants.”  Atropine is the active ingredient in Belladonna, aka Deadly Nightshade. Along with mandrake, henbane, and jimsonweed, the so-called Belladonna alkaloids are among the primary hallucinatory ingredients found in many a witch’s and sorcerer’s brew throughout the ages. Belladonna can cause terrifying hallucinations, feelings of flight or paralysis, blurred vision, impaired motor control, and other side effects usually experienced as highly unpleasant. It was likely Belladonna, not LSD, that served as the basic rocket fuel for the Manson’s family’s horrific activities, according to some accounts. More mundanely, atropine is familiar to armed forces personnel in the form of a self-injection device for serious wounds. Atropine has the ability to speed up a slowing or overworked heart. In ancient times, it was used as an anesthetic for surgery. Atropine is also a poison. (Scopolamine, used medically for motion sickness, is another.)

But one person’s unpleasant side effect is another’s chemical cure. Did the Keeley concoction just terrify the bejesus out of addicts, as some sort of ad hoc version of aversive therapy, or did it sedate his patients into a semi-catatonic, immobile haze, in which they could pass 3 weeks of detox in relative comfort, or at least immobility and minimal disruption? Probably both, depending on drug dosage, drug combination, and patient metabolism. There were widespread reports of Keeley patients who allegedly died or went insane.

“The pulp image of Dr. Leslie Keeley—that of the country physician who had stumbled onto a revolutionary cure for the inebriety problem that had stumped the best medical scientists,” was key to his success, White believes. “Keeley introduced an approach that carried an aura of scientific truth and all the emotional support and intensity of a revival meeting.”

“The likely ingredients of the Double Chloride of Gold remedy and tonics—alcohol, atropine, strychnia, apomorphine —did aid detoxification,” White concludes. And the graduation pamphlet went on to emphasize the importance of “sustaining the new Keeley habits: regular patterns of sleep, regular and balanced meals, regular consumption of water, abstinence from tobacco and caffeinated drinks, healthy recreation, and care in the selection of personal associates.”

If you skip the atropine injections, that series of admonitions remains the bedrock of drug and alcohol treatment programs everywhere.

Photo Credit: http://www.blairhistory.com/

On Chemical Imbalances in the Brain

Maybe it’s not such a bad theory after all.

The brain, as always, bats last. It compensates, reregulates, and adjusts. One of the major ways it accomplishes this is through the neuroadaptive phenomenon called downregulation. When we take drugs continuously, the brain compensates for the artificial flood of, or sensitivity to, serotonin, dopamine, and other neurotransmitters by cutting back on its own production, and the receptors on the cell surfaces ultimately degrade. This is, in fact, what can happen in a case of active addiction, or with the habitual use of any receptor-active drug. The phrase “chemical imbalance,” as a means of describing this process, fell out of favor as soon as Pfizer started using the analogy in its television advertising for zoloft.

Call it a receptor imbalance, then. Call it neuronal dysregulation, if that helps. The concern with downregulation is that, over time, chronic use of serotonin reuptake blockers or dopamine-active drugs of abuse can lead to both a decrease in the number of receptors and a desensitization of existing receptors. The brain does not stay idle during these artificial rains of neurotransmitters. As explained by Peter Kramer in Listening to Prozac: “The chronic, constant, reliable presence of high levels of neurotransmitter causes the cell to downregulate—reducing the number of receptors, by drawing them back into the cell membrane, where they become inactive, or by otherwise uncoupling them from further events.”

The brain adjusts to the constant bombardment of addictive drugs. Downregulation and upregulation are not well understood. If significant downregulation takes place, then conceivably, there could be a rebound effect. Even withdrawal from non-addictive drugs can be difficult and stressful, as the brain upregulates to account for the new biochemical dispensation. Drugs of abuse, and the drugs used against them, share one important trait—they both illustrate the adage that too much of a good thing is a bad thing.

The entire field of addiction medicine has its detractors, of course. In particular, the SSRI medications have been a prominent target since their inception. Dr. Peter Breggen, Dr. Joseph Glenmullen, and other critics have been particularly vocal in their objections to the use of serotonin-active drugs. They argue that psychoactive drugs cause assorted brain dysfunctions, and that such medications do far more harm than good. But these jeremiads aside, there are legitimate issues surrounding the use of many of the receptor-active drugs that addicts and alcoholics may encounter, or may request—whether treatment consists of a formal in-patient clinic or an informal arrangement with a family practitioner. Since addiction and mental illness overlap, a percentage of addicts are likely to encounter antidepressant and other psychoactive drugs during treatment. Drawing on work by Robins, Kessler, and Regier, Dr. Lance Longo, Medical Director of Addiction Psychiatry at Sinai Samaritan Medical Center, wrote as far back as 2001: “Approximately half of individuals with bipolar disorder or schizophrenia and approximately one third of those with panic disorder or major depression have a lifetime substance use disorder. In general, among patients with alcoholism, nearly half have a lifetime history of coexisting mood, anxiety, and/or personality disorders.”

The optimistic view of anti-addiction drugs says that depressive and addictive episodes feed on themselves. The more you get that way, the more you get that way, so if you can somehow give the brain a giant holiday from being serotonin- and dopamine-impaired, it will naturally adjust, compensate, rewire. It will teach itself. It will learn how not to be addicted and depressed all the time. In this view, what the addict/depressive needs is normalcy, a period of feeling better, a chance to sort things out, adjust behavior, become productive, and build confidence. While all of this is happening, under the influence of an antidepressant or an anti-craving drug, the patient learns to experience a different kind of world on a daily, even minute-to-minute basis. Like training wheels, the medications give the brain its first chance in a long time, possibly ever, to operate within the normal parameters of serotonin, dopamine, norepinephrine, and GABA metabolism.

Okay, “chemical imbalance” is a very imprecise description of all this. But branding it as a “myth” has the potential of doing far more damage, by discouraging active addicts from seeking medical treatment.

Adapted from The Chemical Carousel: What Science Tells Us About Beating Addiction by Dirk Hanson.

Graphics Credit: http://bentobjects.blogspot.com/2007/11/slight-chemical-imbalance.html

Addiction Specialist Kicks Off A3 Academy in L.A.

Filling the void between “doing nothing and formal treatment.”

Good news for recovering addicts and addiction experts in Los Angeles: Dr. Adi Jaffe, a well-known addiction psychologist from UCLA and a longtime friend of Addiction Inbox, is kicking off a new venture: the A3 Academy.

 Dr. Jaffe, who runs the All About Addiction website, and writes a column for Psychology Today, knows whereof he speaks, having spent 8 years as a meth addict and drug dealer in a former lifetime. “The A3 Academy is specifically formulated to fill the void between doing nothing about addiction and formal addiction treatment,” Dr. Jaffe said. The inaugural academy will be held on Tuesday, September 6th, in West Los Angeles (2001 Barrington Ave.) at 6:00 PM, and is intended to become a weekly event. Information, tickets, and details of online participation are available HERE. Or you can email for information at academy@allaboutaddiction.com.

“If it has to do with addiction,” we’ll probably cover it,” Dr. Jaffe said. He plans to integrate “informational sessions, process groups, life planning, mindfulness, nutrition, and expert consultation with leading addiction experts from the Los Angeles area and beyond.”

Dr. Adi told Addiction Inbox that “local LA people can attend the event, and others can stream and watch, and the cost is purposefully low. It's going to be an educational/empowerment sort of thing that will adapt to the needs of the specific group attending.”

Judging by his blog postings at All About Addiction, Dr. Jaffe brings a wealth of information and experience to the task—as well as being an accomplished public speaker. “I’ve learned a lot about the genetic, behavioral, and environmental influences on addiction and drug-abuse,” he says. “Whatever you’re comfortable calling addiction, there’s no doubt that it’s having a great, negative, impact on those it affects. More than 500,000 deaths and a burden of more than $500 million dollars are attributed to substance abuse every year in the United States alone. I think it's time we get real about the problem and stop using stigma and misinformation to hide behind.”

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Is Shoplifting the Opiate of the Masses?

Another look at "behavioral addictions" and the DSM-V.

The DSM-V, when it debuts it 2012, is set to replace the category of “Substance-Related Disorders” with a new category entitled "Addiction and Related Disorders."  Gambling is the only behavioral addiction currently recommended for inclusion, but some experts have set their sights on shoplifting—an activity that is even more difficult to picture as a legitimate addiction than gambling. Or is it?

Long before gambling was widely looked upon as an addictive disorder, compulsive shoplifting already had a name: kleptomania. The National Association for Shoplifting Prevention claims that about 9-10% of the population show a “lifetime prevalence” for shoplifting. This is remarkably similar to the percentages commonly bandied about for alcoholics, drug addicts, unipolar depressives,  compulsive gamblers, and compulsive overeaters.

A recent University of Florida survey pegged shoplifting losses, or “shrink,” in 2009 at more $11 billion annually. Plato, in The Republic, wanted to know whether thieves are made or born. It’s a good question. Curiously, the stealing doesn’t seem to be about money: The most recent study measuring income and shoplifting shows that Americans with incomes over $70,000 shoplift 30% more more than their fellow citizens earning less than $20,000 a year. And the actual items stolen by compulsive shoplifters often seem nonsensical, or even surreal. As director John Waters said of Pink Flamingos’ star and compulsive shoplifter Divine: “I saw him walk out of a store once with a chain saw and a TV.”

There is a definite “rush” to the act of stealing, writes Rachel Shteir in The Steal, her informative book about shoplifting. One shoplifter said it was equal to drugs but only lasted a few minutes—“And you’re back to yourself again. In your mind, you think, It was all for a stupid blouse, or stupid soap. For this, I risked everything.” Another source quoted in the book says, “I shoplifted every day, like someone with a drug addiction.”  Seconds before another women is arrested, she quizzes herself: “All she needs in the world is one crummy formal dress so why is there a blue silk jacket, one that she doesn’t particularly like, in her camera bag?” And a shoplifting Lee Grant says in the movie Detective Story: “I didn’t need it. I didn’t even like it.” The objects seem to lose their intrinsic value once they have been stolen, and the shoplifter must get high again with another theft.

If, as some neurobiological researchers insist, addictive disorders are not independent disorders, but outward manifestations of an underlying disease pathology called addiction syndrome, then the definition might be stretched to include gambling, shoplifting, and certain other “activity-based expressions of addiction.” Sometimes the alcoholic, the drug addict, the depressive, the compulsive gambler, and the obsessive overeater are all one and the same person. And drug addicts show a remarkably ability to substitute one drug for another. Perhaps a recovering cocaine addict might hope to assuage that sense of craving, of inchoate need, through excessive gambling. Or a shoplifter might use alcohol as a means of dampening the impulse to steal compulsively. While we don’t use the term kleptomania anymore, “shoplifting crops up as a symptom of many types of mental illnesses—bipolar disorders and anxiety disorders as well as substance abuse, eating disorders, and depression,” writes Shteir. Compulsive shoplifting, Shteir concludes, is “as difficult to stamp out as oil spills or alcoholism.”

For some, shoplifting brings a rush “similar to a cocaine or heroin high,” according to psychiatist Jon Grant at the University of Minnesota School of Medicine. To find out just how similar, psychiatrists there tried treating shoplifters with naltrexone, a drug that blocks opioid receptors and is used to treat alcoholism and heroin addiction. In 2009, in an article for the April issue of Biological Psychiatry, Grant and colleagues at the University of Minnesota School of Medicine recorded the results of their work with 25 kleptomaniacs, most of them women. All of the participants had been arrested for shoplifting at least once, and spent at least one hour per week stealing. The 8-week study is believed to be the first placebo-controlled trial of a drug for the treatment of shoplifting. In the April 10 issue of Science, Grant said that “Two-thirds of those on naltrexone had complete remission of their symptoms.”

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7 Myths the Alcohol Industry Wants You to Believe

Staying on message in the liquor biz. 

“Our national drug is alcohol,” wrote William S. Burroughs. “We tend to regard the use of any other drug with special horror.” This emotional loophole in the psyche has been skillfully manipulated by the alcohol and tobacco industries ever since modern advertising was invented.

 Recently, the European Alcohol Policy Alliance, known as EuroCare, put together a brochure addressing the common messages the liquor industry attempts to drive home through its heavy spending on advertising. The messages are not just designed to sell product, but also to influence alcohol policy at the political level as well. (Eurocare is a network of more than 50 voluntary non-governmental organizations working on the prevention and reduction of alcohol-related harm in 20 European countries.) According to the group, the “industry”—the alcohol and tobacco companies—“has traditionally worked closely together, sharing information and concerns about regulation. They have used similar arguments to defend their products in order to prevent or delay restrictions being placed on them (Bond, et al. 2010).”

EuroCare offers this introduction: “The intention of this brochure is to inform professionals about the attempts made by the alcohol industry to influence alcohol policy globally and to subsequently arm them against the industry’s methods to prevent effective policies from being made…. For politicians and health experts it is important that they reveal to the public the subversive messaging of the alcohol industry and do not fall prey to the industry’s half-truths—or worse—outright lies.”

Message 1: Consuming alcohol is normal, common, healthy, and very responsible.

Explanation: To bring this message home, alcohol advertisements nearly always associate alcohol consumption with health, sportsmanship, physical beauty, romanticism, having friends and leisure activities.

I note here that it’s left to the social service agencies and non-profits to attempt to convey the opposite side of the coin: a dramatically heightened risk for health problems, traffic fatalities, domestic violence, loss of job, loss of marriage, suicide—you name it.

Message 2: The damage done by alcohol is caused by a small group of deviants who cannot handle alcohol.

Explanation: Indeed, the message of the industry is that ordinary citizens drink responsibly and that ‘bad’ citizens drink irresponsibly and are the cause of any and all problems associated with high alcohol consumption.

This one is insidious and unscientific. There is no evidence that alcoholics are “bad people,” or simply unwilling to stop engaging in bad behavior. For the industry, irresponsible drinkers are a major revenue source—the dream customer— even though alcohol manufacturers continue to insist that their advertising is primarily about driving home the message of responsible alcohol consumption and brand choice.

Message 3: Normal adult non-drinkers do not, in fact, exist.

Explanation: Only children under 16 years of age, pregnant women and motorists are recognized by the industry as non-drinkers.

My personal favorite, this one. The existence of non-drinkers is seen by the industry as a threat. Accordingly, they have subtly reinforced the message that moderate drinking is not only normal, but also good for you. Never mind that the real profits come from excessive drinking and pricing strategies that encourage it. Estimates vary, but recent studies  at UCLA show that “the top 5% of drinkers account for 42%of the nation’s total alcohol consumption.” If 5% of all drinkers account for nearly half of total alcohol sales, it would be folly for the alcohol industry to get serious about encouraging moderation. It’s not too far off the mark to say that the alcohol industry’s quarterly statements hinge on the success they have in encouraging alcoholics to believe that everything’s okay, everybody drinks that way. The message becomes clearer: Drinking is mandatory—unless you’re a deviant.

Message 4: Ignore the fact that alcohol is a harmful and addictive chemical substance (ethanol) for the body.

Explanation: The industry does not draw attention to the fact that alcohol (ethanol) is a detrimental, toxic, carcinogenic and addictive substance that is foreign to the body.

Naturally, pointing out the neuroscientific parallels between alcoholism and heroin addiction is not part of the message. Alcohol is a hard drug—ask any addiction expert. Alcoholism can kill you quick. But so far, the labeling mania that struck opponents of Big Tobacco has not played out in a major way in the battle against deceptive alcohol advertising.

Message 5: Alcohol problems can only be solved when all parties work together.

Explanation: Good, effective policies to combat alcohol consumption would require a higher excise-duty, no marketing or sponsoring, an increase in the drinking age to 18, a prohibition of the illegitimate sale of alcohol, and an increase, through a campaign, in the public’s awareness of the damages that alcohol can cause (Babor et al, 2010; WHO, 2009).

Obviously, these bullet points are not high on the alcohol industry’s agenda.

Message 6: "Alcohol marketing is not harmful. It is simply intended to assist the consumer in selecting a certain product or brand."

Explanation: Meanwhile, research has indisputably demonstrated that alcohol advertisements are both attractive to young people and stimulate their drinking behavior (Anderson et al., 2009: Science Group of the Alcohol and Health Forum; 2009). Yet the industry continues to flatly and publicly deny that advertising stimulates alcohol consumption (Bond et al; 2009).

Stuffed with attractive young people meeting and mating over alcohol, it seems fair to suggest that alcohol ads had better stimulate increased drinking, i.e., a boost in quarterly sales, or else the industry is wasting a lot of money fighting over pieces of a pie that isn’t getting any bigger. These days, slow growth is no growth.


Message 7: “Education about responsible use is the best method to protect society from alcohol problems.”

Explanation: Effective measures such as a higher alcohol excise-duty, establishing minimum prices, higher age limits and advertisement restrictions can reduce alcohol related harm and will therefore decrease the profits of the industry (Babor, 2003; Babor, 2010). The industry therefore does its best to persuade governments, politicians, and policy makers that the above mentioned measures would have no effect, are only symbolic in nature or are illegitimate.

A truly great dodge, because the strategy being advertised sounds so imminently sensible. Who could be against the promotion of responsible alcohol use? Irresponsible zealots and deviants, that’s who. Why should all of us happy drinkers be made to suffer for the sins of a few rotten apples?

Indeed, all of the messages, overtly or covertly, send the same signal: You should drink more. It’s good for you.

Photo Credit: http://www.frankwbaker.com

What Does Harm Reduction Mean?

A rift in the addiction treatment community over abstinence.

What is harm reduction? How does it differ from the approaches traditionally associated with drug recovery and rehab?

Originally, I became interested in harm reduction because its advocates were highlighting the folly of prison terms over treatment for drug addicts—a sentiment with which I wholeheartedly agree. Also, the various harm reduction organizations worldwide were fastened tenaciously to the issue of clean needle exchanges as a means of reducing HIV transmission—another approach I heartily support. And at its core, harm reduction has always been about reducing the number of deaths by drug overdose. At its essence, harm reduction is sensible and necessary, given the failures of the drug war, and the inability to make a significant dent in addiction statistics by traditional socioeconomic approaches.

Harm reduction, as formally defined by Harm Reduction International, concerns itself with “policies, programs and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption. Harm reduction benefits people who use drugs, their families, and the community.” It’s a hopeful mission statement. But reducing harm without necessarily reducing drug consumption? What does that mean, exactly?

Lately, activists in the harm reduction movement have been leaning hard on the notion that abstinence is just so much humbug; an archaic admonition that need not be automatically imposed on addicts. Who said addicts have to become abstinent for the rest of their lives? Are we forever hostage to the religious zealotry of the Cambridge Group and it’s successor, Alcoholics Anonymous? If an alcoholic drinks one drink less today than yesterday, or a junkie shoots up a bit less junk today than yesterday, that is harm reduction in action.

But now that harm reduction has become intimately associated with the abstinence debate, egged on by activists like Stanton Peele and Jack Trimpey, the ground underneath the movement has shifted. Many harm reductionists are becoming wary, and sometimes completely hostile, to the notion of addiction as a disease syndrome with a distinct, lifelong, and incurable timeline beyond the reach of notions like “Rational” or “Smart” recovery. “Your best thinking got you here,” AA likes to say, reminding alcoholics that “being smart” or feeling full of “will power” often have less to do with recovery than one might suppose.

But in order to free themselves of the need for abstinence, extreme harm reductionists often deny that addiction is in any meaningful way a medical disorder. This has created a rift in the treatment community, and complicated the mission of recovery programs based on abstinence. Kenneth Anderson, a harm reduction advocate and the author of How to Change Your Drinking, framed it this way for me in an email exchange: “The more alcohol related problems you have, the more you need to practice harm reduction by planning safe drinking strategies, until you resolve your alcohol related problems by quitting or developing a non-problematic drinking pattern.” Like many harm reductionists, Anderson is no fan of Alcoholics Anonymous. One of the book’s sections is headed: “Everything You Always Wanted to Know About Alcohol—But you got told to go to AA and not ask.”

Anderson said that the National Institute on Alcohol Abuse and Alcoholism (NIAAA) “tells us that about half of people who overcome alcohol dependence do so by quitting, the other half overcome it by cutting back.” If even the nation’s premier scientific agency for researching alcoholism doesn’t seem so sure about whether alcoholics need to strive for abstinence, why should abstinence be a stated goal at the outset of treatment at all? Said Anderson: "When abstinence is forced on people against their will, it often backfires and leads to more drug or alcohol use."
 
A few weeks ago, on Denise Krochta’s excellent podcast, Addicted to Addicts, I suggested that part of the argument over abstinence vs. controlled drinking stemmed from a confused bundling of “problem drinkers” and “alcoholics”—a move that the National Institute on Alcohol Abuse and Alcoholism, whose very name is a testimony to the institute’s fundamental ambivalence, has been championing lately. This has helped harm reductionists center the battle precisely where the definitions are fuzziest: at the point on the spectrum where “problem drinking” becomes “alcoholism.” Nonetheless, by focusing on this imprecise edge, harm reductionists make a legitimate point: Culture and environment are major influences on the course of heavy drinking.

“I do not use the word alcoholism [in the book], because it has no scientific definition in the current day and is not found in the DSM IV” Anderson told me. “Although there is some heritability of alcohol dependence, it is a great error to overlook the importance of environmental factors. Alcohol dependence is not located on a single gene--currently there are dozens of genes implicated in alcohol dependence.” And he’s right. These are legitimate caveats that apply to many of the disease models of addiction now at play in the scientific community.

The counter-argument here is that genuine alcoholics do not have, and cannot develop, a “non-problematic drinking pattern,” any more than a serious diabetic is likely to develop a non-problematic sugar doughnut strategy. What alcoholic hasn’t tried controlled drinking? Again and again? And failed? Where are the legions of former drunk-tank alcoholics who have rationally transformed themselves into social drinkers?

These are some of the terms of the current debate in the addiction recovery community. But we do a disservice by concentrating solely on points of departure. The harm reduction movement, at street level, has some very sound contributions to make regarding addiction and public policy. Anderson, in his book, drives home the overlooked but essential point that there is no one-size-fits-all treatment for destructive drinking:

• “Harm reduction never forces people to change in ways which they do not choose for themselves.”
• “Harm reduction recognizes that each of us is a unique human being different from all others.”
• “Harm reduction recognizes the need for ‘different strokes for different folks.’”
• “Harm reduction supports every positive change.”

I fervently hope that 12-Step Groups and Harm Reduction Groups can work their way toward a rapprochement. And so does Kenneth Anderson. But what stands in the way of this is, I fear, is the disease model of addiction—and medical addiction researchers aren’t likely to turn their backs on that premise any time soon. Still, we cannot say what future research will reveal. And I agree with harm reductionists that the best attitude we can bring to the subject of addiction and recovery is open-mindedness, and a willingness to treat each case as unique, in order to forestall “metabolic chauvinism.”

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