Drug Addiction Dualism is Harmful, Not Just an Interesting Philosophical Navel-Inspection

A recent post from PalMD notes that discontinuation from clinical treatment with modern anti-depressant drugs such as the Selective* Serotonin Reuptake-Inhibitors (SSRIs; Prozac/fluoxetine and the like) can result in unpleasant effects.

When many of the newer classes of antidepressants are abruptly discontinued, there is a constellation of symptoms that many patients experience, including headache, dizziness, muscle aches, and nausea. This isn’t one of those “iffy” adverse drug events, for example when a patient treated with a statin complains of a backache and blames the drug. This is a predictable reaction to stopping or skipping a dose of medication.

PalMD then asks a question that is most fascinating to YHN.

In other words, stopping these medications can cause a withdrawal syndrome. Why don’t we just call it that? What’s with this “discontinuation syndrome” thing?

It all comes back to the stigma associated with dependence on recreational drugs and a persistent misconception that it is all merely “psychological” in nature. The overwhelming connotation of “psychological” in the context of substance dependence is a dualist connotation. In this case the notion expressed quite widely from the average layperson to the medical doctor to certain lay areas of substance dependence treatment (AA for example) that substance dependence is a matter of personal willpower or morality. It follows that all that is wrong with the substance dependent person is a deficit of will or morals and that the solution is to support will-power and moral rectitude.
This is pernicious and harmful nonsense.

scicurious posted an excellent analysis of how we should think about deciding whether or not to call SSRI discontinuation syndromes “addiction” or “withdrawal”. It is her usual excellent communication of brain pharmacology. (Which one would think I would be able to do but consistently fail at. Go figure.) While I disagree with her fundamental conclusion, vis a vis PalMDs post/question

Just because there is a “discontinuation syndrome” associated with a drug does not mean that it is “addictive” in the common sense

this may have to wait for another post. What really (really, really) got me exercised was her expression of the classic physiological/psychological dualist distinction.
Long term readers will recall that I’ve had a go or two at the topic in the past. So I’m kinda primed already, perhaps explaining an impression of being “over the top” on this issue. And I am not really busting on scicurious as hard as she thinks:

Drugmonkey is absolutely right, and Sci considers herself justifiably spanked. So I’m feeling sheepish, and I think I need to try and rectify this situation, and get myself all better in the eyes of Drugmonkey, so I don’t have to cower in his presence the next time I see him

Ha! Hardly. It is really hard to write about this stuff in a way that avoids geekery, leverages the existing knowledge base and yet (gently) corrects misunderstandings of the science. For some reason when it comes to behavioral and so-called psychological phenomena everyone is an expert and feels quite free to aggressively challenge scientific findings in a way only cranks would challenge, say, stem-cell findings. Drug abuse seems to feature this in spades, most usually because of an underlying desire to A) personally use recreational drugs, B) deny there could ever be any harm from same and C) rail about supposedly silly and unjustified legal prohibitions. So it’s difficult to walk an informative line when blogging sciC, I get it.

return to huntNevertheless, supporting or continuing the convenient shorthand distinction physiological/psychological to describe lasting consequences of sustained drug (recreational or clinical) exposure has negative consequences when it comes to avoiding or treating those medically, personally and socially significant symptoms. A comment from D. C. Sessions gives us a start:

It took me freaking forever to figure out that those miserable days-long headaches were the result of caffeine withdrawal. The coffee didn’t do anything for me except taste good, you see, but if I went without I was wide-awake but the day after I did without coffee I had a killer headache.

Yeah. Except coffee doesn’t even taste good, my friend. Coffee and beer objectively taste terrible and smell bad to boot. You have learned to associate those bad tastes and smells with a highly desirable subjective drug effect. This is why you think coffee and beer taste really great, my friends! The brain is really quite a fascinating organ.
Drug addiction dualism poses a problem at the outset in getting the individual simply to recognize that problems that are causing them distress may indeed stem from neurological alterations that are a direct result of their drug exposure. If they do not recognize this, they go for years continuing to use without recognizing that they are drug dependent. They may try to reduce their use or stop altogether without success, leading to feeling dismal about personal failings of will. Family members may reinforce these notions of personal failings and disappointment if they fail to see a substance dependence problem for what it is. It may occasionally be the case that collective ignorance about drug dependence and neuronal plasticity has the most tragic of consequences.
Now, don’t get me wrong. I’m not a complete drug-science-Nazi. There are very, very good reasons for the state of common, layperson understanding of dependence. Starting with the central fact that it is only a minority of individuals who sample a given drug that will go on to develop dependence. Reinforced by the fact that some people who consume enough drug over long enough periods of time to cause dependence in majority fractions of the subpopulation (probably) may NOT develop a clinically significant dependence. And cemented by the fact that a dependence problem and withdrawal/craving symptoms not at all obvious to the external observer leading to a lot of denial of the seriousness of the dependence among friends and acquaintances.
The less obvious the symptoms of the characteristic withdrawal syndrome, the less likely a drug is to be taken seriously as causing addiction. This can be because the symptoms are almost entirely covert (limited to subjective craving) or because continued use is cheap, easy and socially encouraged (see caffeine). Despite these facts, dependence on these substances is still a significant lifestyle or health issue for some users of which some fraction can be helped with clinical (not necessarily pharmaceutical) intervention.
There is a familiar and tired history to this which is perhaps not obvious to all. Caffeine and cannabis are addictive substances that cause brain and other changes that result in adverse symptoms when acutely discontinued. Withdrawal symptoms. Remember the seventies and eighties? People thought cocaine wasn’t “physically addictive”. Harder for me to draw population level descriptions but probably through the fifties, ditto for cigarettes. Patent medicine era of the late nineteenth century? You bet. So for those of you who think that, duh, of course heroin and cigarettes produce dependence of a physiological and medical nature but aren’t so sure about the caffeine and cannabis….well, check your history lessons along with the current science.

So what?

Back to the essential point in my objection to drug abuse dualism there are four obvious problems.
First, people who are uninformed about dependence risk/potential will not modulate their exposure so as to minimize dependence in the first place. Here you can think about the sordid history of cigarette dependence. Those of us raised post-sixties scoff about how anyone could have failed to recognize that cigarettes were addictive (particularly when reading the “I didn’t know” testimony in those big tort cases of the eighties and nineties) but this is naive. They really didn’t know. Lots of people now are unaware that cannabis and caffeine are addictive, the comparison may be helpful.
Second, people who are dependent will not seek out available treatment options. Instead they will try to exert willpower to cut down or quit, only to fail repeatedly. Thereby feeling depressed and helpless and generally bad about themselves….guess what makes ’em feel better?
Third, that people who do attempt to seek care may not be taken seriously by their medical care provider. If such a person believes that the lack of directly observable symptoms like seizure, vomiting, shaking or the like excludes the complaint from further consideration, well, that doctor is not going to be all that up on current pharmacotherapy and behavioral/talk therapy options, now, is s/he?
Fourth, medical insurance will not cover such treatments if it is not commonly accepted that dependence is 1) a medically treatable problem and 2) should receive care like any other** acquired medical problem.
Of course this latter requires legislation to insist that insurance companies comport with logic and science when it comes to parity of coverage for the so-called behavioral and mental disorders. Legislation, of course, requires very overt understanding on the part of the relevant legislators to overcome insurance industry and morality-warrior lobbying. Understanding which is greatly assisted by general understanding of the constituents in that legislator’s district. Which means the general public.
This is the very long answer to commenter joe over at Neurotopia :

What barrier to getting “medical help” does making the distinction between 2 different classes of effects, one on the reward centers vs. one that just trashes your body for a time?

UPDATE 1/06/09: leigh has quite a nice description of pharmacological mechanisms that are related to much of the neural alterations associated with chronic drug exposure.
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*That is a relative concept since almost all compounds which interact with any of the dopaminergic, serotonergic or noradrenergic re-uptake mechanisms (“transporters”) have the capability of interacting with all three. The relative affinity and activity to inhibit (or reverse) the function can differ to the extent that we consider the activity of the drug to be “selective” even though it really is not totally exclusive.
**Does the medical care insurance industry refuse to cover traumatic accident care even though we choose voluntarily to put ourselves at risk with recreational vehicles or other pursuits?