Dichotomies and Digressions About Addiction

By Maria Basualdo 10/04/17

There is no objective definition for addiction, at least not one that suffices to illustrate its complexity. Regardless of the psychological framework; cognitive – behavioral, neuropsychobiological, or psychodynamic, it is key to understand that addiction has a highly complex nature. The question of why people use substances has been raised countless times, yet it has never received a satisfactory answer and perhaps does not admit of one.  Addiction cannot be understood from any single level of analysis and any exegesis about the issue should consider all aspects confluent and involved:  Psychological, biological, social, economic, political, moral, and institutional, among others.

Interestingly, addiction is a fairly modern concept, even though substances have been consumed by humans since the beginning of time. The notion of addiction emerges at the beginning of the Nineteenth Century, when addictive behaviors were categorized as medical nosology. Then, the Soldier's Disease became the earliest example of a documented drug problem, including the first registry of withdrawal symptoms, along with some hypotheses about the cycles of abuse (availability leads to use; use leads to addiction; addiction is long-term process; and addiction becomes a public problem with social consequences). Soldier's Disease refers to a widespread of morphine addiction during and following the Civil War. Some believe the U.S. Drug policy paradigm is based on those bad old days.

Previous attempts to understand addiction can be traced back to ancient Greece. From philosophers and poets theorizing about it, to the etymology of the word pharmakon (forerunner for many substance related words).

Examples abound: Plato scrutinizes the timeless liberal discussion about substance abuse in “The Laws,” asking whether it is a private or a public matter and the role of the estate in those private pleasures, unleashing the discussion about the relation between individual libido and community.  Plato was very concerned about a rigid control of human beings through social institutions, seeing morality more as a matter of shame (that is, socially determined) than of guilt (that is, individually determined). So, he proposed the estate as a regulator of the use of substances, recommending limits in age to drink and other restrictions. Also, in his tale of wine and gods “The Bacchae,” Euripides explores the most basics conflicts between body and mind and the human’s most basic urges, wondering if the evils of abuse are attributable to the individual or the substance.

Intriguingly, the abstruse quality of addiction is expressed within the multiple meanings of the Greek word pharmakon. Greeks thought of pharmakon as a remedy, a poison, and a scapegoat. For them, it could be a noun - drug, poison, charm, spell, or enchantment- calling and implying each other, but also a verb implying the use of such substances. The ambiguity of the term clearly denotes the inherent potential of substances to cure or to kill and their capability to be either a remedy, a cure, or a devastating element. In the context of the analysis of substance abuse, that means more than an issue of translation; the addict can either render the object of his addition as remedy or a poison. And, the addict has that ambiguous love-hate relationship with the substance, in a life and death struggle. Modern psychology calls it self-medication, a model revealing the ambiguity implied when one uses to cope with symptoms paying the high cost of addiction. The analogy may be too remote, but using substances as a coping mechanism sounds like “putting out fire with gasoline.”

Indeed, ancient Greeks sharply grasped the dualistic essence of addiction and its complex and ambivalent nature. Its genealogy evidences a number of contrasting concepts and contradictions, such as:  Is it a public or private matter? Promoting the debate about freedom and prohibition.  Is it a pleasure-seeking or a self-destructive process? Fostering the dilemma about the two-sided essence of a hurtful gratification. Is it a physical or psychological issue? Is it about the body or the psyche? Implying questions such as nature versus nurture and the dangers of biological or psychological reductionisms. Is it about the individual or the substance? A subject-object dialectic involving issues of responsibility and morality, including mystic aspects of abuse and the dichotomy between natural and artificial.

Is it a public or private matter? Promoting the debate about freedom and prohibition.

“I pick my nose, why should anyone be concerned?”

“Well, you don’t affect others by picking your nose...” someone might contend.

The underlying question is: How a matter so intrinsically connected to the most singular human experience -pleasure- becomes public? Certainly, the boundaries between private and public - liberal foundation of the social contract -have always been precarious and debatable. With liberalism, democracy, and laissez faire come the issue of personal rights, the rise of individualism, consumerism, and the foundations of capitalism. In that context, an individual considers himself free to find pleasure in substances, or not.

On the other hand, the necessity of interventionism has many sources. From an historical, religious, and moral condemnation to bodily pleasures, in line with the instrumental conception of the body as a prison of the soul, to a conceptualization of addiction as indissociable from delinquency; the idea is how devices of control emerge to protect society against all the evils associated with addiction.  Prohibition and punishment seem to become legitimated by the preservation of the social bond and the societal system from maladies previously established as connected with addiction, such as irresponsibility, laziness, unemployment, crime, irrationality, unproductivity, sexually transmitted diseases, and social expenses and costs.

But, such procedures denote normative concepts, institutional evaluations, and prescriptions about the pathologization and criminalization of addiction which must be pre-existing to punitive practices. The regulatory and receptive nature of these measures, consequently deployed, may have the purpose of maintaining security, health, and the good functioning of institutions, yet are not designed to protect us from ourselves but to protect others from us. And, they presume a fabrication of subjectivity, a definition of what an addict is. An addict is always subject to marginalization because of a pre-existing pathologization and subjectivization.

So, is it addiction deplored per se, at the individual and private pleasure level or because of how it affects society?   It looks like that private and solitary satisfaction is forbidden, precisely, because it de-socializes and contaminates the social bond. That enjoyment, which pretends to be purely intimate, as if the addict was using his sacred right to a private property -in this case his own body- would instantaneously make that pleasure licit.  Possibly not, since the addict is never an isolated being. A priori, addiction implies buying and consuming. Therefore, the addict participates in the public market of substances. And, an addict, with his behavioral repertoires, has relationships and activities, passively or actively affecting others (e.g., an alcoholic is censured because he might attempt against vial security, can be a dangerous driver, or dangerously impulsive).

So here comes the notorious issue of prohibition, legalization, or criminalization. It is a common belief that forbidden things are most sought after, such as the Eighteenth Amendment to the U.S. Constitution, 13 years raising illicit manufacturing and smuggling, or the Chinese, who used opium for centuries, but it’s use only became a problem after the English colonizers forbade it.   Prohibition seems to have a paradoxical effect, promoting abuse more than restricting it. Adding to ambiguity, there is a befuddling and disloyal institutional discourse, in which one is expected to indulge in alcohol and drug use during most celebrations and gatherings, but at the same time, condemned and punished for it. Paradoxical sanctions and subliminal messages proliferate, from do not smoke signs and restrictions to public drinking, covert and/or overt advertisement of substances, to medical prescriptions. Perhaps, at the subjective level, the addict’s behaviors are triggered as if they unconsciously seek to live marginalized, either as a sign of transgression or a cry for attention. Or, by means of prohibition and pathologization, the addict is sent back onto the ego and its consequent creation of guilt, which expresses itself as a need for punishment.

Anti and pro legalization arguments settle in the issue about rising potency of abuse, notwithstanding many research leaning towards the idea that legalization would not increase addiction per se. And, we should not lose sight of the underlying obscure gains around substances’ legalization or criminalization, which don’t have the addict’s best interests in mind.

On the other hand, freedom is no stranger to most disciplines and aspects of our lives. Isn’t’ it everyone’s goal to increase (even if only slightly) individual freedom? Addiction brings about a crucial aspect of choice, confronting the addict with both, internal and external constrictions.  Restrictions cut both way. Either there is a harsh internal authority which subdues and punishes him, not only for incorrect actions but for sinful pleasure, wishes and intentions; or there is an external one, forming and imposing. And, the issue of freedom, of course, borders with questions about individualism, selfishness and, why not? Hedonism. After all, I am free to do what I want, to be a cantankerous misanthrope, a hedonist, or a dope fiend programmed by the pleasure principle, in the strictest sense, shunning others and isolating in self pleasure. Still more, shouldn’t I be free to self-destroy? Should it be my private issue? These are the same conundrums pose by issues of euthanasia and the right to die.

Is it a pleasure-seeking or a self-destructive process? Fostering the dilemma about the two-sided essence of a hurtful gratification.

“Must it so be that whatever makes man happy must later become the source of his misery?”  pondered Goethe.

Aren’t’ those the precepts of self-medication?  Truly, the use of a pharmakon seems to be one of the greatest paradox of the addict: How self-destruction can stem from the attempt to self-cure, preservation, or even salvation by chasing consolation, or take refuge in the yield of chronic intoxication.  But, satisfaction comes with a price, sometimes very high, in this gain/loss dialectic.
For the addict, Epicurus got some things right; pleasure and pain are at the center of human morality and are the only drives to produce any kind of action. So did the psychoanalytical-Greek myth of Eros and Thanatos, that metaphor which remarkably grasps the core oxymoron of substance abuse. In the psychoanalytic doctrine, Eros represents the life and pleasure drive, following the Greek god Eros of Empedocles of Agrigentum, who discussed two of his fundamental principles, love and discord, and Plato’s conception of Eros as a relentless seeker of what he lacks. Eros -the life drive- thrives to integration and unification, to create networks, relations, and closeness.  Thanatos symbolizes the death drive, leading ourselves inwards, with a self-destructive element, or outwards, in the form of aggression, destruction, and even criminal behaviors. Death here, has a literal and a symbolic meaning:  Obliteration of dreams, plans, self-esteem, health, and relationships, also respond to the dynamic of Thanatos. When there is abuse, something always dies.

Eros and Thanatos are at the core of addiction, dwelling within and underneath. Picture the face of an addict infusing heroin in his veins. See how in that precise instant, his face reflects both, pleasure and death -a pharmakon-. Eros commands the massive pleasure, flooding the brain with an elixir of chemicals. Perhaps the most common answer and addict gives when asked about why he uses is: “Because I like it.” Truly, they feel pleasure, boundless bodily gratification. The pleasure-seeking compulsion is basic and conscious and Eros seems overt, usually hedonistically and cogently saved. Thanatos is hidden, silent, unconscious, but fatal, bringing the addict closer to death and to the end of all true relationships, as he began substituting them by the investiture of his object of addiction, creating as-if-relationships, object relations, fake connections, and loneliness.  With his repetitive characteristic, as it connected with a compulsion -the compulsion to repeat- addiction spreads with a self-destructive drive. These gods’ manifestations are not always ostensible; they can express in subtle and reticence ways. For instance, when someone diabetic eats sweets, when one recklessly drives, or when one procrastinates. All those, and many more, can be self-destructive impulses, propelled by transient pleasure.

Like the strange case of Dr. Jekyll and Mr. Hyde, the addict inherently personifies two aspects of addiction, deliverance and the dynamics of self-sabotage. And, the discrepancy between thoughts, emotions, and behaviors is so wide and their desires are so many-sided that a door becomes opened for addiction to start eroding whatever certainty lingered. There are many everyday examples: “I want to get fit, but I don’t exercise,” “I want a healthy relationship but I found myself in toxic relationships, over and over,” “I love animals, but I want that steak,” etc.

Is it a physical or a psychological issue? Is it about the body or the psyche? Implying questions such as nature versus nature and the dangers of biological or psychological reductionisms.

Neurobiology’s explanations about addiction are based on the study of the brain and its role, neurotransmitters, their biochemical - functional properties, reuptake mechanisms ingrained emotional memories, the reward pathway, and homeostatic responses, among many other biological processes. Because the understanding of the brain can explain so many things about the process of addiction from a hardcore scientific and tangible perspective, it became a very popular conceptualization. Explanations flourish: From the impulse control disorder model, posing either neurobiological or genetic deficiencies which make a person unable to control and regulate impulsive behaviors, or the reward deficiency and neurophysiological adaptation model, assuming a chemical imbalance in the brain areas are linked to pleasure-seeking behaviors, to the genetic model, alleging genetic predispositions,  the biomedical model, proposing that using drugs repeatedly over time changes brain structure and function, or the cognitive deficit model, assuming with addictive disorders have abnormalities in the prefrontal cortex (judgment, planning, other executive functions), to the diathesis stress model, combining pre-dispositional vulnerability together with stress, the biological substrate standpoint is rated very highly.

There is also the infamous concept of immediate gratification, the evil of the century, burgeoning beyond addiction. The ability brought about by technologies that surpass our sense of astonishment by allowing us to have things Now –with a capital N- abolish the virtue of patience. Once just a camera needing a film to be developed, is now a picture taken instantly and indefinitely stored. Before, research required a book to be found in a library and later read, to find a chapter or a quote, now it is as simple as copying and pasting from a google search. From cellphones, to internet, to video stream; our brain ceased to understand the notion of waiting or the notion of process, and the ability to enjoy, not suffer it. Time and space become redefined as it is all here and now; immediate gratification turned postponing into sacrifice. And, speed and availability are detrimental to value and appreciation; because it is fast and easy, it is less cherished. Immediate gratification is incarnated in the addict, who dives into the substance, without delay or deferment, without foreplay with the world around. Some say the addict’s emotional logic can be summarized in the phrase “I want what I want and I want it now.” Yet, it seems to be more “I don’t know what I want but I still want it now.”

A key point of the neurobiology of addiction is the evidence that the use of a drug, with a certain dose and frequency, produces long-term changes in brain functioning. Those drug-induced changes in brain function are then conceptualized as the cause of addiction. Neurobiology then seems to be confined to the causality dilemma of the chicken or the egg. During the past decades, neuropsychology has centered the discussion about addiction on the study of neurotransmitters in the brain; dopamine and serotonin can thoroughly explain the status quo of an addict’s brain, explaining how things are, but failing to account for its genealogy. Neurotransmitters, excess or lack thereof, can explain many things, from infatuation to depression, from anxiety, to addiction. Yet, there is a potentially damaging fudging of an important issue: Namely the issue of the extent to which human beings are not just driven by biological dispositions but also by complex psychological and social needs. The biological reductionism, undermining the social and psychological fabric, attempts to see everything through the brain prism, playing down other components of human life, stressing brain functions rather than social needs or psychological grounds, making the dynamics of the neurotransmitters more fundamental than the individual’s psyche and group interactions.

Reductionisms are at the root of the eternal debate between nature or nurture, currently resolved by the gracious standpoint of balance. Nature or nurture, also known as neither fish nor fowl (nor good red herring). Without quantifying, things seem to be better explained by both approaches because no reductionism can contain the human complexity. There is a biological component, a gene, an inheritance, a predisposition, but there are also environmental aspects, intrapsychic motivations, and structural personality aspects.

Is it about the individual or the substance? A subject - object dialectic involving issues of responsibility and morality, including mystic aspects of abuse, and the dichotomy between natural and artificial.

The entire issue of substance abuse boils down to whether addiction is attributable to the substance or the individual. Theories considering addiction as a brain disease would focus more on the neurological level, attributing brain changes to the effects of the substance, more than subjective psychological factors. Truly, addiction disrupts the normal and healthy functioning of brain, bringing serious harmful consequences. But, it is crucial to recognize that there is an interaction between the substance and the individual, which surpasses the disease model. Addiction has an essential subjective nature, expressed in a unique and unrepeatable relationship an individual develops with a certain object, whatever it may be, legal or illegal, psychoactive or not. And, it is precisely that relationship between the subject and the object that becomes pathological. One turns out to be addicted to that very relationship, like a gambler, who is addicted to the godlike sensation of mastering games, becoming addicted to his own sensations, not gambling per se. Or like a social network addict, who becomes addicted to the effect of what a like or a share, or lack thereof, produces and means to her. An addict becomes addicted to the subjective meaning of the object, which may symbolize approval or even affection, a self-esteem-boost, a narcissistic reward, or many others addictive stuffs. That intimate experience is the ultimate subjective experience. Any object, activity, or event can become an object of addiction and a compulsive need, precisely because it is not the object, but how the addict relates to it. Food, games, social networks, work, sex, shopping, substances, anything can be attempt to fulfill the addict’s need or desire.

Thenceforth, the addict departs from normal and healthy relationships with people and objects and develops an abnormal relationship with his addictive fads. The individual to individual relationships -with a normal emotional intimacy- gets replaced by an individual-object relation. Indeed, the most pervasive aspect of addiction is the continuing replacement of people by objects, which become the addicts’ partenaire. And, because objects are manageable and provide pleasure, addicts tend to seek them for emotional fulfillment. Consequently, people became insufficient and disappointing because they are not as dependable and manageable pleasure-providers as that object. In the long term, the substance also fails, bringing about an added factor of disappointment. Then, addiction backfires when one can get no satisfaction, neither from the substance nor from people. The addict becomes isolated, with nothing to hold on to, enduring a shattered self with his own brand or loneliness and damnation.

The Trojan war developed after Helene eloped with Paris, yet both expressed: “It wasn’t me, it was Aphrodite.”  Actually, pre-Socratics had a feeble sense of responsibility as they attributed behaviors to a divine act. Olympus was the name of their external locus of control. The same is true for some addicts when they act contrite; uttering “it wasn’t me, it was the substance.” Such attribution of power to the substance erodes subjective responsibility and, ultimately, identity. And, this is not only about internal accountability, it is also about who is the real you.  Is it the sober or the drunk? Echoing the belief that only alcoholics and children tell the truth. An addict’s significant other usually ponders who the real one is. She might ask: Is it the one who hits and aggrieves or who clumsily cloys, “I love you”?  Identity and relationships shouldn’t be a time adverb, or the result of an inhibited inhibition center. The truth of the matter is that people have the tendency to blame the substance and minimize the subjective role of the addict. Holding yourself accountable is the first step to understand the process of addition, or any other one for that matter. It is more than a moral issue, it is confronting denial and initiating a healing path. It was not Aphrodite, it was you; it is not the substance, it is the substance in you.

“Who am I?” is the ultimate existential question and conditio sine qua non for relationships.

There was once a collection cars aficionado, who wanted to buy a very special car. He made a deal with the seller who before delivering the car, decided to have it re upholstered, did some painting touch ups, and replace a few parts. At the time of delivery, the buyer noticed those changes and claimed, “this is not the real car.” A frenzy debate started about what made the car to be what it was, an issue that ended in Oxford University for resolution. What makes the person to be what she or he is? Regarding addiction, it results in the question “why?” Asking why someone uses is the very same than asking why you are who you are. That “why” is so intrinsically connected to identity that becomes, somehow, inscrutable.  In the context of such subjective venture, why is the answer.

Another issue involving this dichotomy is how most anti substance stances use the argument of artificiality, claiming a fix is not natural. Like the nose, the breasts, the hair color, the contact lenses, or many other things. Addiction is then morally condemned because it cheats truth and reality and deceives nature. And, such moral standpoint, historically bounded and seeped broadly into the culture, poses the addict’s experiences to be deemed unreal, de legitimized, and ultimately, an act of cowardice. It is not the pleasure itself; the condemnation to hedonism comes from a moral stance as their experiences are deemed to be unauthentic. The addict becomes a man of the simulacrum, an impostor, clandestinely and unspeakably relishing and savoring, and emotionally seduced into believing that he or she can be happy.

The artificial-natural, reality-fiction dichotomies are essential to understand the substance abuse process. The addict is reproached for exiling from reality, from real emotions, and relationships by using artificial fixes. He is accused of escaping to a make-believe world, a fictional illusion, losing sense of the truth and reality, resonating the old tension between Enlightenment and Romanticism, involving questions such as nature versus invention and a natural essence versus a tamed existence.

Our contemporary life brings about a new way of relating to objects, in general. Concerning substances, there has been a shift in the appropriation and function of the environment, with pleasure at the epicenter of life. Yet, some claim substances reflect a reunion with oneself and If we look at history, we can see there has always been a relationship between substances and metaphysics. Substances can be a rite of passage, part of a revolutionary social movement, or an inspirational muse, like the green fairy. From LCD to ecstasy, to the rather esoteric or spiritual mind-altering Indian mushrooms, ritualistically taking you through a healing path or revealing the true self; these alternative conceptualizations redeem substances in the name of a higher good and a function of the field of transcendence.

Rastafarianism and cannabis, Judeo- Christianism and alcohol, South-American shamanism and the idea of emancipation and alienation, Chinese and their aphrodisiac opium, or the hippies and their road to new dimensions of the self. Interestingly, some marijuana or mushroom users would wield the nature argument (e.g., it is natural) in favor of their substance of choice, as if some sacred order granted authenticity and rightfulness, or as if nature couldn’t harm or kill you.

“Sometimes a Cigar is just a Cigar,” Sigmund Freud

But most of the times, it is not. Often, a cigar –or any substance- means something else, serves some other purpose, has some peculiar secondary gain, fills some void, or replaces someone. It is not just a substance; addiction is a metaphor to desire or a metonymy to angst. And, desire is craving for what one does not have, a tale that begins with Plato’s Eros, the son of "Contrivance" (father) and "Scarcity" (mother). That is the very nature of an addict; in his pessimism lies a compulsive hope and a further incentive of possible happiness, at the expense of a disengagement with the world. Pursuing relief, addiction promotes an intensification of angst; by enhancing desire, it heightens dissatisfaction, by anesthetizing suffering, it turns the addict insensitive to his or her own emotions.

How has it happened that so many people have taken up this strange attitude of abusing substances?  The basis seems to stem from a deep and long-standing dissatisfaction. Once an isolated event is now a generalized consumerism, yet addiction remains the most subjective of the psychological disorders. Nothing is more subjective that the underlying reasons why one abuses and no rule is valid for everyone, as each person seeks happiness in his or her own terms. Coping mechanism, escape of boredom, emptiness, pain reliever against the unbearable lightness of being, crutches, aids, distraction, or a deleterious enjoyment, leaving you stagnant and comfortably numb. Some use to forget, others to remember, to fall in love, or to be lonely.

Paradoxically, addiction appears to be a symptom, but don’t get fooled; it is not. If the symptom is the tip of the iceberg of underlying issues and traumas -the smoke of the fire-  then the substance is the tip of that tip. And, perhaps that is the most detrimental aspect of addiction; it masks the symptom, that peculiar thing that could indicate there is something that needs to be addressed and resolved. And we are no Titanic. If the symptom is a question, one that could open doors to underlying keys, for the addict, the substance becomes an answer, one temporary and fallacious, insufficient and misleading. Only to later discover that substances not only are not the answer, but make them forget about the question.