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I I I I I I I I I I I I I I I I I I I Brisish ,jvcrnal of Addiciion ~1990) 85, 1425-1427 COMMENTARY Trivializing dependence JEROME H. JAFFE, M.D. National Ixstiruts on Dr:<g Abuse, Alcohol, Drug Abuse & Merstal Health Administratiort, Rockville, MD 20857, USA Abstract T7urc are a nscMbes of repetirioc behaviot3 which haoc in common what appears to be a dsnease in an individual's capaciry to choose to discontinue t3um 77u taxonomy we select to caugo+yu these behaviors depends on our objectiocs. Broad definiti,m which label as `addresions' both repuitict use of drugs and repetitioc behaviors not related to drug use call atention to the loss of jiesibrliry that the bthavior: have in commo+s. However, such broad definiao+cs may otxsemphasize the value of generol bdcavioral approaches to change and obscure the faa that seemvgly similar behaviors can be dramatically changed by eery diffnau spresc isstrrnentions; (for example, xicodne gscm for eidasrtte smoiEink clomipramine for obsessive compu,isive disorder.) It is also possible that callissg both compulsive lsairpullissg and daily lseroisr use `addicriae disorders' may trioialize the coneept of addirrion and lead to an esotio" of public supponr for research and inurvennon in t1u chemical addie:iorss. English is not unique in using a single word to describe that di.erse category of human behaviors which have as a common fature a uemin= decrease in capacity to freely cbooa to eaia:e in what others perceived to be .olt;ntsry behaviors. Especially in recent years, the word addiction has been applitd to behaviots as different ausing drugs, intestias food, pmbliai, had waahia;, spending mom, ezercia- iag, loving too much, or engaging in aa too frequentll or too indisaiminately. In other lan- suages and sometimes, u:M, in Eniliih, suftes such as 'mania' or 'aucht' may be attached to such behaviors as in tosicomania, n7mphosmaia, motpbi- umsucht or cocainsucht. The cocamon denominator is that the iadiTidual appeus to otbas to have d+'=ini:}ei conQol over the behaviors oc tepOtLt a senae of diuquihbrium, loa, diatresa, a craving when the object or mbennce is unavailable or the behaviors are curtailed Efforts to identifj similari- ties across such diverse beha.ior: have beea at- tempted by a number of workers (Miller, 198o-, Orford, 1985; Peele, 1985; Brewer, 1988; Levison, Gerstein & Maloff, 1985). In hss brief editonal, Iswc Marks has performed a useful service by poiatin; to still additional common features that the chemical addictions appear to ahare with those behaviors that he and others have now labelled "behavioral (aon-chemical) addictions." The pre- sent effort deser.a serious attention, not only because it esamina these commonalities systemati- cally, but also because, drawing upon espenences foc the t;eatment of behavioral addictions, Marks makes a few concrete auggestiona that would require us to change the ways we attempt to intervene in the chemical addicnons. In the limited space allotted for eommeatasy, it is aot possible to discuss the d.mtWa and disad.anta8es of using a broad deSnitioa of addiction to refer to diverse non- cbemical using behaviors. In general, in dealing with behaviors, wanted and unwanted, the taxonomy we select depends on our objecti.es. ju:t as it is sometima useful to think of light in terms of 1425

I I I I I I I I I I I I I I I I I I 1426 J. H. )affe wavelength and at other times in terms of photons, there are times when it i: useful to see compulsive gambling, alcohol dependence and heroin sddiction as kindred phenomena, but there are siso times when it is far less appropriate to do so. In, his paper, Marks makes the ase for a broad definition of addiction and suggests some novel approaches to treatment of drug dependence. For example, rather than ameliorating distressful with- drawal syndromes, we might try having patients experience them in order to learn that they are transient and need not therefore control behavior. Such toleration of distress seems to be useful in dealing with patients with panic disorder and phobia. Some of these ideas will no doubt be subjected to appropriately cont;olled clinical trials. Still others may flow from this very broad generic concept of addiction, even if the specific suggestions made in Mark's paper are not found to be useful. But, there is also a very different view: even drug syndromes that seem to have so much in common and to which we now apply a single set of criteria for determiain8 the degree to which dependence is present (DSM-III-R) may themselves be diverse and similarities along several dimensions as de- scribed by Marks may mask important etiolopcal differences that have profound impliations for tnatment. When I was a medical student more than 30 years ago, we were taught that despite virtually identical clinical presentations, hemophilia was not a single entity and that two distinct defects in control of blood clottin` had been found. Now medical science recosaizes at leau niae dininct mbtypes of here- ditary bleeding tendency based on the specific biochemical defect iavol.ed. O.er the same interval additional distinet ansea of hypertension and several varieties of elevated blood lipids have been elucidated, and the knowled=e of the specific mechani:ms has opened new possibilities for intervention. Accepting such mechanistic di.ersity does not mean that we should disregard more general interventions for hypateaaioa or beart disease such as sensible diet, esercis e, and saas reduction. There ia no fundamental ia=paibility between the search for specific mec•++im and treatmeatt and the recofnition that some general procedures may have value across a Roup of problems that involve a very different weighting of the etaolopal facton. Similarly, we should not let otu ur=e to find commonalities among repetitive behaviors and drug using behaviors interfere with our obligation to search for etiological specificities and mechaaisms. Some specificities have already been demonstnted and tanslated into useful interventions. For example, some regular tobacco users are sigaifi- aatly helped by nicotine gum or a nicotine patch (Mulligan, er al. 1990; Rose n al. 1990), adjuncts to tnatment which are unlikely to be useful for gambling, hair-pulling or obsessive-compulsive dis- orders. On the other hand, some smokers do not find nicotine gum effective and respond better to general behavioral interventions. Daily doses of methadone seem to be very helpful for some who are dependent on opioids, but this is not a treatment that one would recommend for 'compulsive' joggers. Despite Marks's comments on behavioral approaches that are useful for obsessive-compulsive disorders, those who have struggled for years to deal with this difficult to treat sPndrome have been gratified by the prottess made in finding useful pharmacoloeical interventions such as clomipramine (Leonud et al., 1989). Quite apart from a concern that a broad definition might de-emphasize the importance of searching for specific mechanisms, there are other reasons to be cautious about such definitional shifts. Aay taxo- nomy that places unwanted repetitive behaviors not involving reinforcing drugs in some super-category along with behaviors which do, does more than suggest that the two subcategories are related; it also tends to m++++m+=e any imporant distinctions that esist between them. 'There are some who would see this as an advance in thinking. For example, Peele (1990) has asserted that the "modera 'acientific' .iew of addiction has acrually caused addictive behaviors to grow [because] it excuses uncontrolled behaviors and prediaposes people to interpret their lack of control as the expression of a disease that they an do nothing about." Peele suggests that there an ao fundamental differences between chemical addictions and many other behaviors which require people to choose among alternatives, and sees the very concept of sddictive diseases as `p~etido-scieace' aatithetial to an emphaau on willpower, self control, and values. Admittedly, there is a tendency, especially by the laity, to interpret the notion of an addictive disorder u implying a total loss of control; Alcoholics Anony- mous and other self-help pnnps do require mem- bers to concede that they are 'powerless ova alcohol' (or mme other substance). However, to assert that all acientists see drug dependence disorders as implying a total loss of control over drug intake is to set up a convenient 'straw man', a

I I I I I I I I I I I I I I I I I useful debating device, but hardly a means to advance understanding. Most of those who view themselves as behavioral scientists recognize that all behaviors, including repetitive drug-using beha- viors, have multiple determinants: history, genetics, biology, beliefs and current circumstances all play a role. It is not a denial of the importance of willpower, values, or beliefs to suggest that, other things being equal, a very thirsty man may need far more willpower to resist consuming a glass of water placed before him than a man who is not at all thirsty. The core idea common to the chemical addictions as used by scientists is not that the individual is `powerless' over the drug, but that as a iesult of a number of possible factors the im r- tance of wich vary across drug categories and among individuals, the individual's freedom to choose is diminished, relative to that freedom at some prior point. iven sufficient motivation, even those who are thirsty can refrain from drinking;, drug users can and do elect to stop using substances (or ask others to help them do so) even as they report that they feel out of control. Recogaizing that there is something about the interaction between certain drugs and people that leads some people, at least temporarily, to exhibit a diminished freedom to choose to continue to use, and to set out criteria about when such a condition might merit clinical attention, is to describe a common human situation, not to explain it. In addition to the role of learning and habit formation, the ezplaaations for diminished Sezibil- ity or freedom to use a drug may sometimes include an inabiliry . or an un..illiagness to tolerate with- drawal. Other factors may include drug induced chan es in the .M dieci:ion-making apparatus itself, the brain; inherent ' erenca in the way effects or in some sense of distress that is alleviated by the drug. Whik tbese actori alone are nsually not sufficient to explain why some continue and otbez3 stop, to attribute the behavior to inadequate motivation, an bseau of willpower, or inappropriate values is to abandon the effort to understand how drugs can come to play such important roles in the lives of so many people. Tnasalir:ng depende=e 1427 Looking 'for commonalities across cbeaucal and non-chemical addictions can be heuristic. However, to the degree that seeing these behaviors as members of a supercategory suggests that they are all amenable to behavioral interventions, inspirauon, or changes in values and beliefs, we risk the trivialixa- tion of some of the commonest and most destructive of humaa problems. The task for those seriously interested in advanc- ing knowledge in this field is to take the best of ideas and remedies that are uncovered by each of these very different perspectives on hu.man problems, test them in the furnace of well designed clinical tnals, and keep and use those which emerge unscathed (or only a little singed) from the fire. What terminology we use is secondary as long as it does not cloud our vision. References BRZs'E3t, C. (1988) The mana;ement of opiate abuse: Learning from other addictions, Jorsrnal of Drut Jssues, 18, pp. 679-697. LsON,uta, H. L., Svao, S. E., Rr+rotoRT, J. L., KoL.tY, E., LsxAxg, M. C., CHEStow, D. L. & HtiwtRGfx, S. D. (1989) Treatment of obsessive-compuls,ve disorder with clovupramme and desipraauae sa children and adolescents, Archzas of Geseral Prychiarn, 46, pp. 1088-1092. Lswx, P. K., GsxsTErx, D. R. &'yiuoty, D. R. (1985) Commonalisus :n Subssance Abus4 and Xalnss<sl Behs- flior (Lesiaiton, LeiiaBton Books, D. C. Heath). Mu.L.Ex, m. R. (1980) The addictive behaviors, in: Q' R. MmLe7t (Ed.) The Addurm Behaosors, pp. 3-7 (Os- ford, Pergamon Press). Mtlu.twuv, S. C., rlUTEasou, J. G., DtvA..E, J. G. & KEi.i.1t, J. G. (1990) Clsascal and pharmacokineuc propcrties of a transdermal tucoune patch, Clinual Pkarw<ocoloV axd T7ierapeLncs 47, pp. 331-337. ORfORa, J. (1985) Esussive Appersus: a prycholojual vim ojaddiason: (Chichester, John Wiley). PiaLa, S. (1985) T4 Meanirrj oJAddicnm Co+tzpLLrirr Faptriew ased lu luerpreraston (Le==ton, Leuagton Press). PEiLE,, S. (1990) Editorial, The addict's values, Bainmore Srs; March 27. ltosa, J. E., LEVtx, E. D., Bnim, F. M., Aarni, C. & ScNUR, C. (1990) Transdermal nscotsne facihues smok- ini eessation, CJixical PharmacoloV and Theraprruus, 47, pp. 323-330. I