The New York Times' Ian Urbina -- who was previously known for his work on fracking -- has cast his eye on the politics and economics of the redefinition of addiction currently taking place in the revision of the psychiatric "bible," the Diagnostic and Statistical Manual of Mental Disorders, or DSM 5, due out in May of 2013.
Urbina focuses primarily on the economic implications of the expansion of the addiction concept. In the first place, "addiction" will replace a differential diagnosis of "dependence" and "abuse." (How many people were aware that the current DSM-IV does not use the word or the concept "addiction"?) One function of this shift is that, since people can now be assessed as being more or less addicted, rather than suffering from a less serious condition like "abuse," more people will receive the addiction label.
In addition, for Urbina, DSM 5 "would expand the list of recognized symptoms for drug and alcohol addiction, while also reducing the number of symptoms required for a diagnosis." This raises for Urbina the concern that there will be an expansion in both "rehab" style and pharmaceutical treatments, a clearly money-making motivation for, and consequence of, the DSM's revision. Urbana indicates in his article's lead paragraph:
In what could prove to be one of their most far-reaching decisions, psychiatrists and other specialists who are rewriting the manual that serves as the nation's arbiter of mental illness have agreed to revise the definition of addiction, which could result in millions more people being diagnosed as addicts and pose huge consequences for health insurers and taxpayers.
Urbina quotes experts who feel that this is both good (since it allows more people to receive help) and bad (since it labels more people with a psychiatric diagnosis requiring treatment) -- the yin and the yang of our always-expanding concern about, and definition of, addiction.
But Urbina's focus on economics is too narrow. The reductive view of addiction and the quick-fix pharmaceutical treatments that currently prevail in American psychiatry stem mostly from a simplistic, wishful belief in straightforward medical solutions for mental illness and whatever else ails us. Writing at the same time in the Times as Urbina, Dr. Allen Francis -- the former chair of psychiatry at Duke who headed the task force that created DSM-IV -- has relentlessly criticized DSM 5 because "it will introduce many new and unproven diagnoses that will medicalize normality and result in a glut of unnecessary and harmful drug prescription." But, according to Francis, "Some critics assume unfairly that D.S.M.-5 is shilling for drug companies. This is not true. The mistakes are rather the result of an intellectual conflict of interest."
In his article, Urbina highlights the role of the central figure in DSM-5's redefinition of addiction, University of Pennsylvania psychiatrist Charles O'Brien, head of the addiction working group. Urbina reports, "Some critics of the new manual have said that it has been tainted by researchers' ties to pharmaceutical companies." But Urbina -- unlike Francis -- seems to support this view. He points out that O'Brien "has been a consultant for several pharmaceutical companies, including Pfizer, GlaxoSmithKline and Sanofi-Aventis, all of which make drugs marketed to combat addiction." (For his part, according to Urbana, O'Brien says "that he had never made any money from the sale of drugs that treat craving.")
My own concern about the addiction task force's efforts and the ultimate categories and criteria it formulates is that these reify the shifting social and historical process of defining addiction into an immutable biological one. Given that addiction researchers and clinicians claim the mantle of science, the highly capricious and ideologically driven nature of the redefinition process is almost stunning. This issue is best represented in the Urbina article by quotes from Dr. Howard B. Moss, of the National Institute on Alcohol Abuse and Alcoholism ("NIAAA"), the federal government's alcohol research agency.
For its part, the NIAAA has recently redefined the course of addiction in the case of alcoholism by pointing out that most people who fit the diagnosis of alcoholic in DSM-IV outgrow the disorder, most without actually ceasing drinking. And this will certainly be the case when the definition of addiction is expanded to include less severe cases of substance abuse. But, then, why define them as addicts? The large majority of this group (close to 90 percent in the NIAAA's research) recover without entering rehab or Alcoholics Anonymous.
So Moss's reactions to these new developments in re addiction take on special meaning. And Moss is highly critical of the role O'Brien has played in adding "craving" to the list of criteria for addiction, one that isn't present in DSM-IV. (Disclosure: I was an adviser in the creation of the substance use disorders section of DSM-IV.) The significance of craving is that DSM-IV focuses on the impact of substance use, measurable changes in behavior and consequences, rather than on subjective states like "craving," which are hard to define and identify.
Moreover, craving carries ideological baggage. It is associated with the disease view that addiction is an uncontrollable force, often permanently present in people's lives, unlike the view the NIAAA's research indicates of addiction as a highly variable syndrome that shifts as people's life circumstances improve, and particularly as they mature.
Urbina ends his article with his interview with Moss:
[Moss] described opposition from many researchers to adding "craving" as a symptom of addiction. He added that he quit the group working on the addiction chapter partly out of frustration with what he described as a lack of scientific basis in the decision making. (emphasis added)
"The more people diagnosed with cravings," Dr. Moss said, "the more sales of anticraving drugs like Vivitrol or naltrexone."
We see here the return to the financial incentives at work in the DSM committee's efforts with which Urbina began his article. But of greater interest to me (as I wrote Urbina in an email about his article):
The whole issue of the centrality of "craving," given "opposition from many researchers to adding 'craving' as a symptom of addiction," indicates the ideological nature of the debate. I would really be curious as to who was in the addiction group and according to what expertise they were selected, given that making a decision to include gambling is such a large, epistemological one.
My comment about gambling is due to DSM 5's expanding the addiction concept beyond substance use -- something I have advocated since my 1975 book Love and Addiction. This expansion is an inexorable trend that will accelerate in the future. And this for me engages the entire debate about the nature of addiction, since the inclusion of gambling addiction in DSM 5 does not seem to sit well with the entire "chronic brain disease" approach in the United States.
As I ended my email to Urbina, "I think it's safe to say, however these matters end up, they'll be just as hotly debated going forward to 2030 or whenever DSM 6 is created."
Researchers and clinicians (those associated particularly with the new medical specialty of addiction, the American Board of Addiction Medicine, led by the head of the National Institute on Drug Abuse, Nora Volkow) claim the mantle of science for their medical initiative in defining and treating addiction. The see-sawing battles and divergences in opinion over the meaning of addiction, however, describe an ideological tussle among warring worldviews, not something we ordinarily think of in association with medical advances. But this conceptual struggle is inescapable when dealing with America's volatile history of, and attitudes towards, substance use.
In other words, the meaning of addiction is a never-ending American, and thus worldwide, cultural debate.
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