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Monday, December 26, 2011

The Meaning of Addiction in Flux (again)

The concept of ‘addict’ is relatively new in its present usage.  Here’s an interesting history of this word, which clearly starts off as a strong interest rather than an uncontrollable obsession:

From a historical perspective as well, we can see that ‘addict’ as a concept was not really present in alcohol usage until the distilling of spirits in the 18th century and the coincidence of industrialization and urbanization:

Addicts have probably always existed, though not in any noticeable number until the last few hundred years.  Then, as the number of alcoholics grew, so did the need for a term or category to assign to this troubled cohort.

The meanings of ‘addict’ and ‘addiction’ have been boiled down to a loss of control over a behavior.  This loss of will-power has frustrated modern medicine, which has exclusively relied on the human will-power to overcome mental illness or its utter sedation.  Hence, we either think our way out of our problems, or anesthetize them into oblivion.

The advent of Alcoholics Anonymous in the mid-20th century meant that addiction could be treated through a spiritually-based program which replicated many of the spiritual traditions of ancient Christianity.  AA was soon recognized by the world of psychological professionals as the only effective treatment they observed results in.

The medical world was beaten back in the 1930’s, when alcoholics and other addicts were often locked up in insane asylums due to their inability to control their drinking.  AA did away with this need, though the medic al profession has not entirely left the field.  Professional counseling, prescribed anti-anxiety medications, and various other services have been continuously offered to recovering (and not-so-recovering) addicts and alcoholics.  Counselors try to use individual and group therapies to help addicts overcome contributing psychological phenomenon (anger management, grief therapy, etc.).

But, in the end, the backbone of treatment still remained with 12 Step groups.  What is fascinating is that the medical world even deferred to AA’s separation of alcohol-abusers (often referred to as ‘heavy drinkers’) versus the person who has lost the ability to control his drinking, the alcoholic.
For AA, the issue is control.

However, the medical profession has never entirely been happy with this definition, in large part because it has had so little success with managing loss-of-control issues, and the results of AA are hard to medically measure.  Now, the medical world is preparing for the new Diagnostics Statistics Manual V (DSM-5), which is preparing to redefine addiction is a more confusing way:

“The DSM-5 will—after a review process already in its closing stages—do away with the long-established distinction between “abuse” and “dependence.” In the DSM-IV, abuse was the harmful or excessive use of a substance, dependence the habitual harmful use of a substance. All addicts were understood to move from abuse to dependence, although not all abusers became dependent (or addicted), so the two conditions were different problems with different diagnostic criteria that demanded a different treatment. Starting with the release of the DSM-5, abuse and dependence will be collapsed into a single diagnosis—“substance use disorder”—specified by 11 “criteria.” You will have to meet only two of these 11 criteria to merit a “moderate” diagnosis—a relatively low threshold that has raised the hackles of some addiction specialists. In the DSM-IV, patients had to meet three criteria out of seven to qualify for a diagnosis of “dependence.”

For addiction to get the official DSM stamp of “disorder” means that entire realms of human behavior will be newly medicalized—or at least newly diagnosed—which will undoubtedly result in more diagnoses, and therefore more business for psychiatrists themselves. In theory, the changes will promote earlier intervention and better outcomes with the national health care system paying out more in the short term but saving in the long run because of fewer serious complications and expensive hospitalizations. Again in theory, former, current and future addicts should benefit, too, but only if they have access to affordable treatment and care….

This change is also based on statistical studies showing that essential difference between abuse and dependence is one of degree rather than kind. The old AA truism that “You can’t be partly alcoholic any more than you can be partly pregnant” will no longer hold. Under the DSM-5 diagnosis for “alcohol use disorder,” you can be “moderately” or “severely” addicted.

Taken together, the introduction of the word addiction with both the increase from seven to 11 of the possible criteria and the decrease from three to two in the required number to meet a diagnosis will have one already-certain result: More of us will be “addicts” than ever before. The implications of this fact, however, are anything but certain.

Thomas Babor, an expert in psychiatric epidemiology at the University of Connecticut and an editor of the international journal Addiction, told The Fix, “If [the  DSM-5] is published as currently proposed, you’re likely to see an explosion or an epidemic of addiction in the United States which is attributable to the fact that instead of three symptoms out of the current seven, you how have to have two symptoms out of eleven. The chances of getting a diagnosis are going to be much greater, which is artificially going to inflate the statistics even further. It could be an embarrassment.”…

So, the changes will allow psychologists and psychiatrists to treat more people for ‘problem drinking’ by choice.  Obviously, those who abuse drugs or alcohol who are not addicted are going to respond much better to treatment than a hard-core addict.  Yes, more people will be categorized, but they will surely point to their numbers and say, “Look at all the people we are helping!”

This new definition is also meant to undercut the centrality of the spiritual experience to recovery.  Sure, there are plenty of people who want recovery without the spiritual element.  That’s been noted.

The problem here is that the medical community and the courts (who turn to the medical community for professional advice in such venues as ‘drug courts’ and ‘substance abuse programs’) still rely on 12 Step groups for their patients.  You will see more and more people being ordered to groups who are able to quit but don’t want to.  More and more unwilling people will be forced to attend meetings to please their probation officers, parole agents, or judges.  What this also means is that 12 Step meetings will become more and more of a ‘turn off’ to more and more people who are ill-prepared.

This also means that meetings will be filled with more and more people who will ‘chill’ the overall honesty that groups need in order to function.  This problem has created an underground community of ‘private’ 12-Step meetings that are held because the regularly posted meetings have become carnivals.

The 12 Steps require willingness, yet more and more unwilling people are going to fall under the expanded definition of the DSM-5.  Whereas the medical community and 12 Steps groups have lived symbiotically for over 70 years, this proposed change might bring all that to a crashing halt.  The main organizations like AA might have to decide to no longer sign ‘court cards,’ thus undermining the highly-flawed attendance system in use.

What’s more, we in the Church are likely to see an increased number of our parishioners falling under this newly-expanded guidelines and wondering if they really have a problem or not.  Clergy will need to prepare themselves now more than ever.

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