Tuesday, 31 January 2012

The Role of Addictions in Human Culture

In this exclusive interview, we speak to Professor Griffith Edwards, CBE (A world expert in alcohol and drug addiction) who founded the National Addiction Centre, served as Editor in Chief of the Addiction journal and is Professor Emeritus of Addiction Behaviour at Kings College London. We discuss the role of drugs in society, and examine the social, economic and political implications of drugs use for the future of our world.

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Vikas Shah, Thought Economics, January 2012

In hypothetical-land, global corporations and criminal organisations used (often subversive) techniques to hook individuals onto dangerous substances which would alter their minds and bodies, often killing them. Together, these organisations (conservatively) generated over USD 2 trillion in revenues and were (again, conservatively) linked to the deaths of almost 9 million people every single year (of which 8.5 million deaths were caused by the legally sanctioned products of corporations).

The above paragraph is not science fiction, but a reflection on part of the global market for addiction. The 'corporations' in our tale refer to the tobacco and alcohol companies, while the 'criminal organisations' refer to the estimated supply participants in the global market for illicit drugs.

In their 2000 book, "A Critique of Nicotine Addiction", Reuven Dar and Hanan Frenk note that, "... many psychoactive drugs have been used by humans for hundreds and even thousands of years, the term drug addiction was a creation of the twentieth century. Originally the word ‘addiction’ (from the Latin source, addicere) was used for a strong inclination towards any kind of conduct, good or bad. Only towards the end of the nineteenth century did ‘addiction’ begin to be used to describe a preoccupation with drugs, but it still did not have the connotations that the term would receive later. Thus, when the German physician Levinstein wrote the first detailed description of opium addiction in 1877, he still saw addiction as a human passion, such as smoking, gambling, greediness for profit, sexual excesses, etc. This may be related to the fact that opium and its derivatives, the opiates (e.g., heroin, morphine, and codeine), were openly and legally used in the USA until the beginning of the twentieth century and were considered by many less offensive than cigarette smoking. The observation that opium caused less health damage than alcohol even led physicians in the USA to prescribe opium and morphine for alcoholics as a substitute for alcohol. Thus, until the end of the 19th century, 'most physicians regarded addiction as a morbid appetite, a habit, or a vice .' In fact, caffeine drew nearly as much concern as the opiates during that period. The twentieth century gave the word ‘addiction’ a new meaning, that of an uncontrollable disease..."

That 'disease' (which the World Health Organisation refer to as 'dependence') is characterised by, "...the state of needing or depending on something or someone for support or to function or survive...." and presents as, "...a cluster of cognitive, behavioural and physiologic symptoms that indicate a person has impaired control of psychoactive substance use and continues use of the substance despite adverse consequences..."

The adverse consequences to which that rhetoric refers are not limited to the individual who is dependent, but create negative effects for their immediate families and wider society. Each year, tens of thousands are killed and hundreds of thousands subjected to violence and inhumane conditions in the licit and illicit supply chains for these substances. For the communities their users inhabit, the situation is different- albeit hardly an improvement. Edward M. Brecher (in his 1972 Consumers Union Report on Licit and Illicit Drugs) noted that "...Alcohol is by a wide margin the biggest law-enforcement problem in the United States today..." The economic impacts are no less staggering, with addictions. Alcohol alone is estimated to have cost the global economy up-to USD 665billion in 2002 alone. So why have addictions become such a big part of human culture?

In this exclusive interview, we speak to Professor Griffith Edwards, CBE (A world expert in alcohol and drug addiction) who founded the National Addiction Centre, served as Editor in Chief of the Addiction journal and is Professor Emeritus of Addiction Behaviour at Kings College London. We discuss the role of drugs in society, and examine the social, economic and political implications of drugs use for the future of our world.

Griffith Edwards, CBE was born in India, and received his M.D. from Oxford University. He has spent his life focussing on the study and treatment of alcohol and other drug dependencies and has advised governments around the world in these areas. He was Director of the Medical Research Council's Addiction Research Unit from 1968 till his retirement. He also established the UK National Addiction Centre in London, and served as Editor in Chief of the journal "Addiction". He wrote the original description of alcohol dependence and the terminology of dependence has become the global term adopted in international disease classification systems including the DSM and ICD classifications. Edwards has published a wide range of original scientific studies on alcohol and other drugs and has also written several well-respected books on the subject including Alcohol, The World's Favourite Drug, Matters Of Substance: Drugs, and Why Everyone is a User.

Q: Why do we use drugs?

[Prof. Griffith Edwards] There are as many answers as you can think of... and one more. We don't use drugs for one reason, it's a mix. What's special about it as a science subject is that it is so awkward, it doesn't lend itself to easy solutions. It's a multi-factorial problem, very different to- for example- the question of what causes influenza?

In terms of what drugs do to our bodies and how we get addicted... Different drugs are all unique in their action. It's a family of disorders, with families of very different drugs. How we get addicted is actually rather simple, it's the fact that we're exposed to drugs! You can't get addicted to drugs unless you're exposed to them. You have to be exposed in situation where you can determine the dose. If you take the drug long enough and in a high-enough dose... most drugs which are addictive, will give you withdrawal symptom... making you feel rotten, and giving you another reason to take more (albeit this is at a later stage).

Q: What is the relationship between drugs (and their usage) with human culture?

[Prof. Griffith Edwards] There's a litter of clich├ęs in this regard. What is obvious is that the first reason people use drugs is that they're there. You can't use drugs unless they're there, and they're cheap for your pocket or for the fruits of your stealing! For that reason, we need to get a deeper understanding of the fundamental question of why drugs are available on our streets.

In the country as well as towns now, drugs are very available and reasonably cheap. Economics comes in as a big deterrent. Concern with the economic and legal aspects of drug use, in the last twenty years of the science, has largely replaced the anthropological questions which is perhaps a pity....

The next person I see with a heroin problem will probably be working class. They will probably have gone to the sort of school which is itself tragedy, and will have come from a family environment, such as a run-down council estate, which is a sink-hole. There's a very strong relationship between depravation and drug use in many western cultures. It's not the sole reason- you do get the rich and mega-privileged using drugs... You can't go shouting from the rooftops that it's all about depravation... a lot of it is... but there are other social factors, personal factors, genetic factors and economic factors - all mixed into the pot.

I went to Jamaica for research, and found that the Rastafarians had a deep symbolic valuation of cannabis. They know some people get very nasty symptoms from cannabis and they will tell them not to use it... and they won't! The Rastafarian culture is a strong one. If I go to Thailand, to the northern areas, there are people in villages growing heroin instead of cucumbers but they have strong rules against using it themselves. If someone is found using heroin they will be seen as a social pariah and nobody will want to marry them.

There was some fascinating research in Judaism which showed that as an individual moved from being orthodox, to conservative and eventually liberal.. there was a steep rise in the prevalence of drug use and drunkenness in society. It's not because the Jewish faith, at an orthodox level, derides drugs or drinking- but more that it derides letting yourself down publically.

Q: Why are tobacco and alcohol treated differently to other addictive substances?

[Prof. Griffith Edwards] When I first became interested in this field, it was understood that smokers smoked because they enjoyed holding a cigarette in their hand, and it was a social habit- and wasn't an addiction. It's only in the last thirty years, that we've had overwhelming evidence that it is the nicotine which hooks you. It is fortunate that there is a readily available substitute for the smoker which are nicotine patches and so forth. You have in that, a very safe substitute available which also forms a substantive treatment. Strange to say, with alcohol there is no safe substitute drug. If you start giving valium as a substitute drug, you will very soon get a person hooked on that [valium] instead. For that reason, psychologists have a big role to play in treatment- and the advance of psychology as a clinical subject has, in my opinion, been led by alcohol problems.

Q: Do you think caffeine is an addictive substance?

[Prof. Griffith Edwards] I think that is the case. Far more often than people realise, caffeine does produce anxiety, headaches and so on. It's not a harmless drug, but doesn't kill people with the frequency of heroin for example.

Within my lifetime the science of addiction and the awareness of its dangers has advanced significantly. The evidence is that 50% of young heroin users who are under 19 will die by the age of 50. It's a terrible danger. People with alcohol problems have got a full 400% increase in expectation of death, than people without alcohol problems.... and so on. Advances in epidemiology have been very important too- to help us find cases, do long-term follow-up studies.

Q: Why are drugs are considered a taboo or unacceptable?

[Prof. Griffith Edwards] The idea of the cycle of harm was only really established around 1880. In 19th century England, there was no law against opium use until something like the 1890's. It was freely available, people didn't talk about addiction but rather about "bad use of opium" (prevalent in mill towns). Mothers used to dope their babies, mills gave a reward of opium dissolved in alcohol.... People in the Fenlands, when Malaria was common, used to control the symptoms using opium.... Charles Dickens used to use it extensively! It wasn't always banned!

Alcohol attracted legal concerns far before what we now call 'illicit drugs'. Alcohol has a long-history of involvement in the western world. In the Christian church, you can find books of penances which are very interesting in historical record. In these records you can find what punishment was accepted for what rank of person, and for what sort of drunkenness. Bishops had the hardest time... They would have to leave as soon as it was darkness if they started getting drunk. A village priest would simply have to say a number of "Ave Marias". In Germany, they used to cut off the ears of drunkards.... In some areas of South America, they would kill anyone who was publically drunk. As you can see, there were extreme efforts to control it....

Q: In the developed world, what are the social, political and economic outcomes of drug use for society?

[Prof. Griffith Edwards] I think, if I had grown up in a grim council-estate... with not got much going for me... without good school exam results... I might, even as underprivileged as I am, get into work... find some way forward and have a happy, productive and social life. But then, if I started using heroin... I would not keep any job for long, and then would have to steal to pay for my heroin. I think it's a fact that one of the troubles we have is that there isn't really much in the way of culture. People may 'hang out' together, but they don't share values, loyalty and so on. There is a void of culture. I don't think culture itself will protect someone, but the fact that it's OK to use drugs is bad news. In the developed world, the problems of drug-use are predominantly, therefore, social and economic- it's hard to attribute them to being purely cultural.

If we look at richer parts of society. You see that there is still a prevalence of drug-use, but it doesn't occur as frequently as other groups. If you've got yourself a good O-Level, you will probably want a good A-Level, and you'll find that at university, a lot of students may smoke cannabis, but you won't find many shooting heroin.

There was some very good research from Liverpool looking at different towns around the Wirral peninsula. There was a straight line relationship between indicators of depravation and prevalence of heroin use. In the poorest areas, 10% of people by the age of 20 used heroin. In the wealthy areas and affluent suburbs, by the age of 20, 0 - 0.001% of people use heroin.

Q: How do you see addictions impacting the developing world?

[Prof. Griffith Edwards] The biggest problem affecting the developing world is alcohol. I once undertook some research in Zambia with the World Health Organisation. We wanted to see how an emerging culture dealt with drinking problems. At the time, drink was only available when it was brewed by the village women. It was a thick, stodgy pudding-like beer which was drunk by the men sitting under a banyan tree. It could only be drunk by men of good standing - and supplies were soon gone. It was very ritualised, very ceremonial. We went back a few years later, when beer-halls were opening- and they didn't even have time to put labels on the beer bottles because they had to produce them so quick. People were falling into the road drunk, there were many frightful car smashes, increases in violence and knives drawn. The rules of culture can even change with socioeconomic development in these parts of the world. What then really hit me was the actions of the international drinks industry, who exploit what they describe as these "emerging markets".

Q: How do drug economies impact the third world?

[Prof. Griffith Edwards] I once went on a mission to Bolivia, where I sent by an English Foreign Minister who had been out there and was appalled by the site of children who were chewing their fingers off under the influence of cocaine. The government wanted someone to go out and tell them where to send the money to show their sympathy.

When I got there, I sat around with some lovely people in a very distant village in the jungle and got them to talk about their experiences. I don't like reading books and journals, but I do like listening to people! These people told me that when cocoa leaves come down from the mountain, schools close and schoolteachers take time off to help prepare these leaves for processing. They will get paid as much for a nights work doing this, as a month of work in school. Economics determine outcomes in these (and many other) societies. It's clear that to do well in this trade, you want to have more than the villages to sell your cocaine- so you export it.

In Afghanistan, you have no computer industry, no real industry... you have poor farmers. If these farmers can grow opium, they will. We can get understandably worried about it, these pose very real dangers for the rich world.

Q: Do you think drug economies have any impact on global security?

[Prof. Griffith Edwards] They talk about it as 'narco-terrorism'. Certainly in Latin America and Mexico, you see it manifesting as terrorism or, at the very least, anti-state movements on a large scale. You also, in this regard, see a huge amount of violence from gang wars. We recently had a governmental conference on this topic in London, and noted that a lot of the terrorism aimed at us in this sense was due to the perception these individuals have that the western world simply does not care about them.

Q: What do you see as the future of drug-use?

[Prof. Griffith Edwards] I have learned that when people ask me to predict the future, I tend not to answer..... I simply can't do it! History teaches this....

In the United States, during the 1880's towards 1912... there was a very serious problem with morphine and cocaine. Why? because clever chemists in Germany had pulled opium out of the poppy as a pure and dangerous chemical. They then did the same for cocaine and doctors, who were after a reasonably fast buck, were using these drugs promiscuously as cure-alls. They were prescribing opium as a hay fever remedy! I could not have predicted in 1820 that this would happen.

I think I can only ever have a five-year perspective on what I'm dealing with. In this sense, I think a lot of what the future holds will be influenced by changes in society. Will it be more equal? Will we have different personal values? Will we be more supportive to individuals? I think drug use may considerably reduce if these conditions are met.

Meanwhile... for policy-makers, research shows that if you price alcohol or cigarettes higher, less people will use them and less will be harmed. Whereas... civil remedies such as education simply doesn't work at all. This is something which science has repeatedly shown, in very good quality research from many different countries, specifically that alcohol is price elastic. By setting a minimum price for alcohol, you could save the national health service millions every year. With drugs, I don't think it's at all easy to do research on pricing. Prices vary so much from case to case and week to week.

There are also questions for evolutionary science to understand in this regard. We are still in the process of social evolution. Even the very idea of what a family is has changed dramatically from Victorian times. The idea of love is very different. Sexual revolutions also have an impact on human culture. Society is in flux... it is changing.

Q: How do you think drugs are currently handled by the criminal justice system?

[Prof. Griffith Edwards] I have seen some very fine research done on this topic. Drugs are, for the state, a convenient enemy. So far as I can understand in a science policy context, if you were to legalise all drugs- I would expect the industry to become heavily commercialised, heavily promoted, branded and advertised. In a free-market world, if you legalise a subject, you can't half legalise it... You will find today that people have already patented the names of potential brands of drugs against the happy day when drugs are legalised!

I think you have got to keep measure of control for the more dangerous sorts of drugs, but I think drug-laws in general are radically in need of overhaul.

It's a bit of a false-dawn to think that we'll see a day when all drugs will be freely available and the world will be a better place.

Q: What do you see as the most effective treatment and care modalities for addictions?

[Prof. Griffith Edwards] The history of treatment is fascinating. Right up till the 1850's and 60's in the United States, there was no strong treatment movement anywhere. This meant setting up asylums! In Britain, we did the same and there was a cry for "...more asylums for more drugs!" You even found lovely little nursing homes in the country with a little piano maybe and other activities for middle-class persons with addictions. Even primitive research showed these approaches were useless. This strategy centred on shutting people out of society for a long time. There is even medical research which shows evidence of brain surgery done on alcoholics and drug-addicts, along with promiscuous use of electric-shock therapy.

The humanising influence was alcoholics anonymous. It's about people themselves discovering what can be done about their problems. It's about people getting together, showing each other humanity. I've been privileged to attend some AA meetings now and again. What is so lovely is the laughter- they are very funny! There are so many stories, so much encouragement. It's astonishing what AA can do, and it leads on to asking what psychiatry and psychiatry really are.... It's not about giving things to people, but enabling them to do things for themselves.

We are going through a radical change in the understanding of treatment.

Q: What can be done at the prevention stage?

[Prof. Griffith Edwards] Education doesn't work in this regard. There is very good research to show that education, however expensive, doesn't work.... It's therefore the favoured remedy proposed by the drinks industry who put millions every year into promoting education as a solution. I don't want to demonise this industry, but it's not a credible solution.

Ultimately, when you look at prevention, the key is to keep drugs as far from society as possible. This means trying to keep the prices up!

Q: What are your views on the attitude of national and international policy-makers toward drugs use?

[Prof. Griffith Edwards] I think that many of the people involved do. There is a wonderful man of Iranian origin who has worked in this field for many years, Hamid Ghodse. Just before the terrible attacks on New York, he was negotiating with the Taliban in Afghanistan. They came back and said they wanted to present him with a scroll to say that they had agreed to ban opium in perpetuity. He has travelled the world and has an acute understanding of the issues and WH0 has an important role.

While such individuals can do great work, it's important to remember that can't have inflated expectations about what a government or even a UN agency can do. The need for more political awareness is real. It's very important to foster the relationship, in this regard, between science and policy. It's a long-haul.

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Understanding addiction reveals one of the great hypocrisies of the current iteration of society. Specifically the cultural context which defines what is and isn't a drug, and the social context which defines whether that drug is good or bad.

There is little to suggest that either alcohol or tobacco (two largely domesticated drugs) are any less harmful than their illicit counterparts. The overwhelming majority of users know the dangers these substances cause, but as they are culturally accepted and socially contextualised, it's close to impossible to change behaviours towards them. To put it another way, they are not seen as a problem.

David E. Schoen in his 2009 book, 'The War of the Gods in Addiction' wrote, "...If everything is an addiction, then nothing is an addiction, and the term becomes so overused, generalized and watered down it becomes meaningless and of no use in a clinical sense to help describe and understand that phenomenon..." he continues, "...my definition of psychological addiction has two key components. First, the addictive substance, activity, or behaviour must ultimately take over complete and total control of the individual, psychologically. That is, it must take over control of normal ego functioning... And the second part of this definition is crucial: the addiction takes over control in an inherently destructive and ultimately life threatening way. It is not an addiction unless it is a death sentence..."

Even using this very clear definition, it is hard for us to deny that many 'accepted' human behaviours can be seen as addictions. Capitalism and the pursuit of profit, our engagement with brands and celebrity, our relationship with food, technology and so many more aspects of human life can "take over complete and total control of the individual" and can often become "destructive and life threatening.."; we need only to see the levels of poverty and inequality around the world to understand the negative impact of our pursuit of wealth... we need only to see rates of eating disorders to understand the destructive impact of addictions to food, or addictions to the pursuit of self image... the list goes on. Some would even argue that many of our world's policy makers and political institutions are addicted to conflict. The story isn't all negative. From arts to science and most every discipline of human endeavour, our greatest achievements have come from individuals and groups for whom their passion was an addiction.

Perhaps it is more accurate, therefore, to state that our species has the habit of becoming addicted. To understand that as a characteristic rather than a disease may change our attitudes and ultimately help us to become more human.

We are all addicts, it's what makes us who we are.

1 comment:

Tryn Rose said...

As one who leans towards addictions that are detrimental to my life, and who avoids these choices because I believe my life is better lived without this detrimental dynamic, I find this article very interesting. Professor Edwards says *education doesn't work, but *high prices prevents access to legal drugs (caffeine, alcohol) therefore harming fewer people. I hope people can be educated as they aspire to change for the better; Alcoholics Anonymous has helped so many on the premise, as I understand it, that one *can decide to change, put efforts towards this goal, and have a better life because of this process. Thank you for posting this article.