Thursday, April 29, 2010

Addiction as Cultural Pathology?

I use an addiction model to understand the nature of human relationships, I employ a comparative philosophical perspective to investigate this addiction model. Philosophy, at its best, is the tool for reconceptualizing how we understand the world. In my research, funded by NIDA and as a researcher for Kennesaw State University, I noticed that the addiction science literature tends to operate with a particular model of how humans can define themselves and so how they interact. This assumption tends to guide the research and experiments toward a certain range of responses and perhaps outcomes.

Culture is a recursive patterning of human behavior in relating to the world. Like a fractal, if we can get a sense of the overall pattern, we can begin to understand how the system works at a micro and macro level. Addiction, it seems to me, is above all a pathological recursive patterning of one's behavior. But addiction does not happen only in an individual, contrary to our primary methods for treating and “dealing with” addictions (prison, a strict pharmacological intervention). Because human beings are defined by this recursive patterning of behavior that we call culture, if we are to properly understand this phenomenon called addiction, we must examine the interactions between the person addicted (or with the problematic use of a substance) and their environments. The guiding question became for me, what insights might a focus on the relational dynamics of selfhood provide to understanding how methamphetamine practices are negotiated throughout the drug-use career?

There are two predominant strategies for the treatment of addiction – pharmacological interventions and psycho-social interventions and most commonly employed is the incorporation of both dimensions when treating those afflicted. Following Volkow and Li (2004), the term addiction is employed so as to distinguish between chemical dependence (defined by the DSM-IV) and the broader phenomenon encountered while documenting the respondents' meth-using practices which can be characterized as repeated drug use resulting in an intense desire for methamphetamine and an impaired ability to control their urges to use methamphetamine. My aim is not to conflate chemical dependence with addiction, nor do I use the term without an acute awareness of the historical and philosophical problems associated with it (Berringer, 1979; Buhler, 2005; Davies, 1998; Hammersly, 2002; May, 2001). The pharmacological interventions developed to date (methadone for opiates, disulfiram for alcohol, the TA-CD vaccine for cocaine and perhaps methamphetamine), as the developers themselves are quick to point out, are not preventative and cannot act as stand-alone treatments: the effectiveness of these interventions are attenuated if the patient simply begins taking larger doses of the drugs. Thus, the central problematic in addiction science right now is managing relapse, a phenomenon that seems to be intimately related to drug use initiation and reiteration. It is here argued that these are primarily social processes and as such require a properly social intervention.

The success of therapeutic group dynamics as found in Alcoholics Anonymous-style twelve step programs seem to be based on the insight that an individual who changes not only their individual behaviors but also their social context is more likely to abstain from problematic use of drugs. This process of recovering in groups such as AA is possible through the many interpersonal interactions of the members themselves (Kitchin, 2002). Adams (2008) has argued that addiction is the gradual foregrounding of the person's relationship to the substance of abuse and so he calls for an increase in the intimacy among individuals' relationships as a means to both attenuate the individual's susceptibility to addictions as well as a means to overcoming addictions. Where Adams' model assumes externalized relationality, I am suggesting the primacy of internalized relationality in identity formation, as Hughes, Valentine, & Kenten (2009) have stated, our identities are, “inevitably socially and historically, constituted...always embodied, material; and so subject to embodied social and material constraints.” (10)

Culture is a recursive patterning of interactions. How we understand ourselves is subject to a long process of identity creation and negotiation within a social milieu. The identity migration model (Hughes, 2007; Hughes, Valentine, & Kenten, 2009) is a three-step process that assumes that people are fundamentally developed and come to define themselves in their relationships to their environments and their social worlds. Central to understanding both how one creates an idea of oneself (identity creation) as well as understanding how one changes one's identity over time (identity migration) is recognizing the performative nature of social life. We seek to produce an identity within what our social contexts allow and, given this pallet from which to choose, we then evoke this sense of self as frequently as is possible. With frequent evocations of this constructed self we are able to say that we are “being true to ourselves.” Because repetition is central to how we understand “who we are” at the fundamental level, we can to discuss problematic usage of substances of abuse without already having to concede to the language of volition or chemical overdetermination. In this way the identity migration model presents an understanding of addictions that eschews the classical dilemmas that have been well-documented in the literature (Bailey, 2005; Berringer, 1979; Davies, 1998; Graham, 2008; Hammersley, 2002) enabling us to generate novel understandings of the initiation into problematic behaviors as well as routes to cessation by illuminating the fundamentally relational nature of problematic behavior. The identity migration model also bolsters a renewed vision of risk in the addiction literature, as Pilkington (2007) has demonstrated what is at risk in drug-use is not necessarily the assumed legal or health implications, but must be expanded to include the traumatic loss of one's identity-affirming position within a group.

There is neurophysiological evidence (Volkow and Li, 2004) to suggest that the brain itself, without the learned cues from external phenomena will function differently as it unlearns the methamphetamine habit. While Hughes (2007) prefers to eschew, “a positivistic preoccupation with causality,” as well as avoiding a, “clinical search for the 'mechanism' of addiction,” (674) I would suggest that employing this apprenticeship language succeeds in her goal of reorienting addiction as an object of social theory and also jibes well with what the neuroscience of learning seems to be indicating (Schultz, 1998, 2000; Tripp and Wickens, 2008). Addictive behavior seems to be the result of a hijacking of the brain's inherent reward system corrupting how the brain naturally processes salience (Robinson and Berridge, 2000; Everitt and Robbins, 2005). The identity migration model, understood in the manner I've described suggests that the reward of methamphetamine is not only found in the surge of dopamine that accompanies the metabolism of methamphetamine, but this model also fits within the model of learning as a process of the dopaminergic system. These modes of understanding addictions are extremely powerful in identifying pharmacological interventions that will facilitate the social interventions that are necessary to reinforce methamphetamine cessation.

My data demonstrates the identity migration model is a process with three distinct moments: 1) an apprenticeship to methamphetamine use in a meth-practicing community, 2) an archaeological “bottoming-out” that the performative utterance announces so that gains entry into a community of recovery and thus 3) one may perform recovery at given opportunities. Key to understanding this process is the fundamentally social nature of methamphetamine use. With this analytic we are provided a lens for reconciling both pharmacological and psycho-social addiction interventions. With future studies employing the analytic here described and with other substances of abuse it is hoped that the community will be able to shift our understanding of addiction from an individual's pathology to an understanding of the primacy of social relations in how we understand ourselves.

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