Posts Tagged ‘Benjamin Rush’

Introduction:

To answer the above question, I am first going to briefly examine what is meant by the terms substance use problem, Criminal Justice Intervention, Public Health Intervention and Harm Reduction. I am going to examine what is meant by contemporary society by the phrase substance use problem, how this concept then defines and drives what are the current thoughts around Criminal Justice Interventions, and public health interventions, and then I will examine what is meant by Harm reduction and how this may or may not compliment public health and criminal justice interventions.

What are Substance Use problems?

The common  contemporary concept of substance use being a social evil, is relatively new, and if you examine social history, and read commentators such as ( Anderson & Berridge 2000),(Barclay et al  2000 ) & (Gossop 2007)  you can see from their research and resultant books, that substance use has been a integral part of society from early times. In many historical pieces, many academics discuss how substances such as cocaine, opium , and alcohol were all used in various commercially available products without any recourse prior to 1820(Anderson & Berridge 2000).

With the advent of the pharmacology act of 1820, the rise of professionalism amongst the new scientific professions such as medicine and pharmacology, the adoption of a new “Medical Model “of viewing substance use issues, or addiction and the rise of temperance, due to the public and social drive against drunkenness and all of its resultant evils, the common concept of what a substance use problem were, gradually began to perfuse into societies psyche. Over the various decades, more prohibitive laws have been passed, each time the laws becoming more prohibitive, until after world war two, the modern landscape of prohibitive legislation was finally developed and ratified by several global position statements by the United Nations. First the 1961 Declaration on narcotics,(UNODC 1961) which ratified the concept of all member nations being drug free, and basing their drug policies on evidence,  and the 1971 convention on Psychotropic  Substances, which called for psychotropic substances to be placed into Schedule one or two dependant on Harm, and banning all use except for medical and research practice. (UN 1971) These two documents also reinforced the concept of the “drugs war”, which had began with the branching out of the enforcement authorities into enforcing social and racial stereotypes based on cultural use of alien substances by ethnic and disenfranchised groups(ref)  which  with the repeal of the Volstead act, which  was the catalyst for the prohibition years from 1920-1932, enabled  the law enforcement apparatus originally set up to enforce prohibition enact a new role as guardians of society  against the insidious march of deviant and immoral drug use as alcohol became a legal substance once more. This new role brought with it the need for a more robust legislative and social framework to control these “immoral substances” and as such a new paradigm acceptable to the public to allow the enforcement and development of new legislation.

This was achieved by not only classifying the sale and use of these substances as illegal acts out with medical and scientific use, but was also fuelled by the development of the scientific model of addiction as a “disease of the will”, an idea first vocalised as early as the 1600’s by men like Trotter, Rush, Levine, & Huss, who all initially discussed alcohol, but the ideas of this “disease model” were quickly applied to all substances. With the advent of the 12 step model, which was “scientifically” endorsed via research and study by E.M Jellinek .published in 1960?

The decision of the United Nations both in 1961, and later in 1971, to endorse these concepts within their individual conventions, introduced this concept of drug use as a form of criminal behaviour perpetrated by criminals to supply clients with substances to ensnare them in a disease process, which then drove them to more crime to facilitate their ever increasing craving for their substance of choice.

Therefore substance use problems can be seen as criminal behaviour caused by the use of illegal substances which by their very nature have medically related problems, such as mental health issues, and physical health issues which are in the long run detrimental to the drug user’s health and social wellbeing.

Criminal justice Interventions:

Within the substance misuse arena, the term Criminal Justice Intervention refers to any of the interventions delivered due to a service user breaking the relevant part of the legislation.  The whole idea of drug interdiction and the reduction of supply all of which are parts of the criminal justice system, as noted above, come from the moral model of addiction, which is based on the belief that the use of drugs and alcohol is morally wrong, and that by preventing use you prevent substance mis use. The most effective example of this was as discussed the Volstead act which ushered in the era of prohibition within the US, strongly supported by the temperance movement, this however is also held up as an example of how the criminal justice approach can cause a rise in criminality, and offers an environment for organised crime to flourish. (Buchanan & Young 2000)

Within the UK we have also had our criminal justice system influenced by this movement, one of the many legislative bills which can be traced to these movements, especially here in Scotland was the 1913 Temperance Act (Scotland) which was an attempt to control licensing, this is sometimes over looked by all of the prohibitions passed with the defence of the realm act, which was intended to control substances, specifically alcohol, and the access troops had to it.

 

The main legislation in respect to this in the United Kingdom is the misuse of drugs act 1971, which has tariffs attached to various acts involved in drug use, and has also a classification system based on how harmful the drug is, and each drug is categorised as A, B or C dependant on perceived harm. (http://www.legislation.gov.uk/ukpga/1971/38/contents)

This legislation also gives courts and enforcement agencies the power to hand out custodial sentences, the tariff for which depending on the class of drug, and the part of the legislation the offence is committed under.
In Scotland at this point in time, there are several  criminal justice interventions utilised which can also be linked to Public Health Interventions which are prison based  opiate replacement therapies, Drug Treatment and Testing orders. There are also others, e.g. Probation and community service orders, which may also have public health elements within them.

Within this essay, we are going to focus on two of these interventions, prison based opiate replacement programmes, and drug treatment and testing orders, due to the way they can be linked to public health through the blood borne virus and sexual health framework.

Public Health Intervention

Public health interventions are interventions which look at the health of the general population initially, then specific groups deemed to be vulnerable or at risk specifically within that general population.

As with Criminal Justice Interventions, as outlined above, Public Health Interventions have their  core concepts based within a model of addiction. The model of addiction that public health takes its main concepts and schemas from is the medical model, as briefly discussed previously. This model suggests that addiction is the result of a disease process, and as a result the various issues that are associated to this disease concept such as the cravings, and associated medical problems such as liver damage, blood borne virus and the social issues such as crime and some degree poverty can be abated by people “just saying no” or by facilitating people who use drugs into treatment. The public health model also looks at abstinence, as does the moral model, as the ideal, and to this end most interventions are geared towards a drug free life(Scottish Government 2008,).

Public health interventions rely more on policy than legislation, to guide and facilitate their delivery, and examples of this for substance use  directly related to our two interventions would be the Road to Recovery (Scottish Government 2008) the sexual health & blood borne virus framework (Scottish Government 2011) , both of which discuss in detail substance use/misuse and the governments expectations of what services should offer.

Public Health interventions, especially around blood borne viruses and their prevention, tend to be delivered alongside harm reduction techniques, which are the polar opposite to the models discussed as the focus tends to be on the reduction of harm with abstinence being of secondary concern, this often causes tension between drug services and public health services, as drug services are being seen to condone drug use (Lloyd & Hunt 2007). On the other hand drug services tend to look at harm reduction as one of the many tools on a continuum towards abstinence, but another difference is that drug services are also pragmatic and realise that the concept of abstinence is not suitable for everyone, and with most harm reduction services the role is completed with some clients by just ensuring someone turns up at the clinic is using the correct injecting technique and knows how to react in an overdose situation.

Harm Reduction Approach:

As outlined above, Harm reduction approaches focus on reducing harm, this approach is more centered on thebehaviour change model as described by Prochaska & DiClemente in 1980, but also uses elements from Bandura’s theories around learned behavior, and also to some extent Skinner’s work around operant conditioning. (Ghodse 1995, Rasool 2009)

Harm reductionists believe in facilitating change, by providing choice, and by influencing factors such as mentorship and peer concepts, and this can be seen actively at work in the various peer support models used throughout the current drug services. This idea is at odds with the interventions based on the more traditional viewpoints as outlined previously. These concepts focus on facilitating the service user to enter into treatment and then whilst in treatment, maintain their sobriety, with the ultimate aim to be to facilitate and maintain abstinence. The tension arises with the way that this is done, and how the problems are perceived.

As previously stated, Harm reduction is about choice, with the emphasis being put on personal responsibility, the other two models are about removing choice, the disease model could be said to absolve personal responsibility due to the concrete belief that addiction is a disease, therefore any “addict” or “alcoholic” is at the behest of a disease process which causes the sufferer to have cravings, and ensures that once they use their substance of choice they continue to use until they are intoxicated or causing physical/psychological harm to themselves. Within the Criminal Justice Model, again choice is removed from the service user, as they are either incarcerated, in which case they are removed from their supply, or through DTTO’ given a tariff that also involves forced treatment options on the pain of imprisonment when and if they do not comply(Rasool 2009) there is also the issues around the harm reduction agency facilitating an illegal act by facilitating the use of illegal substances, this argument can be seen in the various papers surrounding the setting up and running of “drug consumption rooms” and introducing needle exchange in a prison environment.

Do the two models compliment a harm reduction approach ?:

On initial examination the two models would seem to be at odds to a harm reduction approach, but to answer this question, we need to examine in more depth areas where all three of these concepts intersect, and the easiest topic to do this with is the current delivery of Blood Borne Virus Services within an addiction related context.

Blood Borne Viruses especially Hepatitis C and HIV have been an issue within the drug taking communities and the prisons that are more often than not a main fixture within their existence since the 1980’s.

The topic has been and continues to be an area of  research within academia, and in her book “ Aids in the UK : The making of policy 1981-1994: Virginia Berridge discusses how the issues around this encouraged the prisons within the UK to adopt  Opiate Replacement Therapy as a main tool to fight infection and reduce high risk behavior within the prison system in the 1980’s and 90’s, and the text from this era also indicates that injecting practice, and other high risk behavior was prevalent, which increased the risk of cross infection within the prison estate, with some of the respondents admitting in open questionnaires that they had indulged in risk behaviours whilst incarcerated. (Berridge 1996, WHO,1998).

This research and further discussions with the prison authorities led to Opiate Replacement Therapy being chosen as the main intervention to reduce these risk behaviours.

As with Prisons, and those incarcerated, HCV has also been an issue within the community with the incidence of HCV on the increase, especially within the drug using population. This issue has been deemed a priority by the Scottish Government who have produced two strategies to develop services Hepatitis C Action Plan (Scottish government 2006) which then developed into the Sexual Health and Blood Borne Virus Framework (Scottish Government 2011), which looked at all of the actions needed to deliver containment of what is a growing public health problem (Scottish Government 2006, 2011), inclusive of a section that was specific about Prevention,. In this section, it specifically looked at expectations around provision of services, and the expectation that services should complement each other.

The main thrust of these documents was to decrease risk behaviour in the community and increase access to preventative strategies including needle exchange and related therapies such as Opiate replacement therapy.

To achieve this various strategies were developed, which included the re-orientation of needle exchange to incorporate easier access to sterile equipment, more accessible testing processes, education about the issue and one of the few interventions that has spanned across all three areas without much disagreement has been that of using peers to deliver health, and harm reduction related messages, as well as Opiate replacement therapy.

Recent research has now highlighted that the combination of targeted prevention messages, and information on testing, has reduced transmission rates, and Peer education initiatives (Dolan et al 2004, Allman et al, 2006, Fisher et al, 2013, Moro et al 2013, Lianping et al 2013Weeks et al 2006), has been successful in delivering the relevant messages to target populations and reduced risk behaviour. Opiate Replacement Therapy has also been highlighted as an intervention, with roots in Harm reduction philosophy that has had a major impact on clients in both Public Health, and Criminal Justice environments, as it allows the service users to reduce risk by changing behavior around that risk, e.g.  sharing non-sterile equipment, by eliminating the risk taking.

Recent research suggests that ORT has been so successful in preventing onwards transmission of BBV within the prison environment that in the reports conclusion it suggests that there may be no need for needle exchange programs within Scottish prisons, it also suggests that this result is also due to other harm reduction strategies. (Taylor et al 2013). This trend of ORT and other Harm reduction strategies reducing ongoing transmission through high risk behaviours has also been witnessed in the general community, the NESI study & others indicated that a similar trend in the community of injecting drug users, suggested that ORT was one of the main contributors along with other strategies. (NESI 2012, Turner et al 2011).

Summary:

The question that was to be considered was Do criminal justice and/or public health interventions compliment a harm reduction approach to substance use and problems, and in order to do this we had to examine how and why we as a society view substance use the way we do, how this ultimately affected how we saw the problem , and as a result how this was developed into the conceptual ideas of the moral model and medical model to describe why people with substance use issues behaved in a certain way. We then examined how historically these concepts or models influenced the development of not only two distinct models, the disease model, and the moral model, but also how these models began to influence not only social concepts of addiction/ substance use, but also informed political and policy development in the western world. We then looked at how these historical ideals through globalisation led to the world acceptance of these concepts, and how this acceptance through the United nations conventions and declarations led to not only a prohibitive form on control through the development of legislation like our own Misuse of drugs Act 1971, but also how this “war on drugs” also led to, supported and normalised the continued medicalisation of drug use issues which has led to abstinence based policy statements like the road to recovery(Scottish Government 2008).

The next step of our exploration of the question examined how these two models viewed the harm reduction approach, and this concept and what it means in relation to the prohibitive and moral stance point of the medical and moral models, we also looked at how their is inherent tension between the traditional models and harm reduction due to the focus of harm reduction being on and this was explored looking at the issue of blood borne viruses, and how certain harm reduction approaches have been identified and utilised to control the spread of this condition, within the paradigms of the two traditional models, and their related interventions. We also briefly examined the research that has suggested that these identified harm reduction approaches, namely Opiate replacement therapy, and targeted prevention education utilising peer educators, has been seen to be as effective inside the criminal justice intervention that is incarceration, and also within public health where they are targeting substance use sub populations to facilitate total abstinence.

Conclusion:

Therefore when considering the question Do criminal justice and/or public health interventions compliment a harm reduction approach to substance use and problems, we have to suggest that in some cases these two  forms of intervention can complement the harm reduction approach, as outlined above, however we also have to concede that the two approaches that advocate criminal justice interventions and public health interventions i.e. the medical model and moral model, although fundamentally trying to do the same thing as harm reduction approaches, that is to protect the population from harm, are fundamentally different in outlook and design. We also have to concede that the two abstinence based models also in their own ways remove responsibility from people who use drug, and therefore by default remove ownership and responsibility for actions and behaviours as well. This again is a major difference that can only add to the tensions previously discussed, and this is evident when you examine the current debates around the introduction of drug consumption rooms in the community,( Lloyd & Godfrey 2010,Lloyd & Hunt 2007, Patel, 2007, McKeagney 2006, Rhodes et al 2006) or needle exchange programs within the prison (Taylor et al 2013). Therefore in conclusion it can be strongly suggested that some harm reduction approaches are complimented by Criminal Justice and Public Health Interventions, with the caveat that these harm reduction approaches can be effectively said to be within the letter of the law, i.e. are not encouraging the illicit injecting of illegal substances, or are not condoning use of illegal substances.

This discourse is well represented in research literature, (Lloyd & Godfrey 2010, Lloyd & Hunt 2007, Patel, 2007, McKeagney 2006, Rhodes et al 2006) and most famously was commented on by the Joseph rowntree trust in their 2006   paper “The Report of the Independent Working Group on Drug Consumption Rooms”

References

Anderson S. and Berridge V. (2000): Opium in 20th Century Britain: Pharmacist’s regulation & the people, Addiction Vol.95 (1)

Barclay et al, Royal College of Surgeons ( 2000) Drugs, Dilemmas and Choices, London Gaskell

 

Berridge V (1996) Aids in the UK: The Making of policy 1981-1994: Oxford University Press

 

Bloor M and Wood F. (1998) Addictions and Problem Drug Use: Issues in Behaviour, Policy and Practice,  London, Jessica Kingsley Publishers.

 

Buchanan J and Young L ( 2000): The War on Drugs-A war on drug users?. Drugs :education, prevention & policy Vol.7 No4

Department of Health(England) and The Devolved Administrations(2007):Drug Misuse and dependence: UK Guidelines on Clinical Management London: The Department of Health (England),the Scottish Government, Welsh Assembly Government, and Northern Ireland Executive.

Ghodse H.  (1995): Drugs and Addictive Behaviour : A guide to treatment  2nd  Edition London Blackwell Science Ltd

Gossop  M. (2007): Living with Drugs 6th EditionAldershot, : Ashgate Publishing Ltd.

Hunt N. And Stevens A. (2004): Who’s Harm? Harm Reduction and the Shift to Coercion in UK Drug Policy, Social Policy & Society Vol 3 . (4) pp333-342

Independent Working Group (2006) : Drug Consumption Rooms, summary report of the Independent Working Group, Joseph Rowntree Foundation

Jellinek, E. M. (1960). The disease concept of alcoholism. New Brunswick, NJ: Hillhouse Press

King R.S and Mauer M. (2006): The war on marijuana: The transformation of the war on drugs in the 1990’s: Harm Reduction Journal Vol 3 (6)

Lloyd C, Godfrey C (2010): Commentary on Pinkerton(2010): Drug consumption rooms-time to accept their worth: Addiction, 105 p1437-1438

Lloyd c, Hunt N, (2007)  : Drug consumption rooms: An overdue extension to harm reduction policy in the UK?: International Journal of Drug Policy  18  p 5-9

McKeganey N, (2006): Safe Injecting rooms and evidence based drug policy: Drugs: education, prevention, and  policy   Vol.13,No1, P1-3

Patel K, (2007): Research note: Drug Consumption Rooms and Needle and Syringe  Exchange programs: Journal of Drugs Issues 37: 737

Rhodes T, Kimber J, Small W, Fitzgerald J, Kerr T, Hickman M, Holloway G, (2006): Public Injecting and the need for “safer environment interventions” in reduction of drug-related harm: Addiction 101, 1384-1393

Runciman R,  Lloyd C, Hunt N, Fortson R, Green K, Hayman A, McKeganey N, Stimson G, Strang J, Wright N, (2006): The Report of the Independent Working Group on Drug Consumption Rooms: Joseph Rowntree Foundation

Rassool G.H., (2009): Alcohol & Drug Misuse: A handbook for Students and Health

Professionals,  Abingdon: Routledge

Scottish Government (2008) The Road to Recovery: A new Approach to tackling Scotland’s Drug Problem, The Scottish Government Edinburgh

Stimson G, Des Jarlais D.C, Ball A (editors) (1998): Drug Injecting and HIV Infection: World Health Organisation UCL Press London.

Turner, K et al. (2011) The impact of needle and syringe provision and opiate substitution therapy on the incidence of hepatitis C virus in injecting drug users: pooling of UK evidence. Addiction, 106, 1978-88

University West of Scotland et al. (2012) Needle Exchange Surveillance Initiative (NESI): prevalence of HCV and injecting risk behaviours among people who inject drugs attending injecting equipment provision services in Scotland, 2008/2009 & 2010.

United Nations : Convention on Psychotropic Substances1971, United Nations New York.

United Nations Office on Drugs and Crime (UNODC) (1961): Single Convention on Narcotic Drugs 1961(amended in 1972), United Nations New York

http://www.legislation.gov.uk/ukpga/1971/38/contents  Accessed on  8th May 2014 @ 20.13

Introduction:

Within this essay I am going to critically examine the evidence supporting the concept of the disease model, and I am also going to examine the research which counter acts this evidence. I am going to initially explore the development of the disease model of Addiction , then examine the process which allowed this model to dominate the area of drug use, and explore some of the arguments, social control, social construct, and the discourse that enforces these concepts which have been used to counter and discredit this model and how one of the most important factors “Spontaneous Recovery” calls the core concepts of this model into question.

Addiction: The Definition of a Disease.
For the purposes of this essay I am going to use the definition of Addiction as first muted by Benjamin Rush (1745-1813) and Thomas Trotter (1760-1832) who suggested that “alcoholism” & Substance Use could be viewed as a disease rather than as an issue which had its roots in loose moral fibre and weakness as the previous moral model of addiction had suggested.
Rush and Trotter suggested that drunkenness was a process of disease, a mental illness and as such displayed specific symptoms and was not a character flaw. Further weight was added to this concept of a disease of the will by Magnus Huss (1807-1890) in his book Alcoholismus Chronicus, or Chronic Alcohol Illness. A Contribution to the Study of Dyscrasias Based on my Personal Experience and the Experience of Others, in which the phrase alcoholism was first used, when in it he also highlighted symptoms of this new disease. According to the model “inebriety” (Courtwright 2005) has several main characteristic of this “disease of the will” and these were “loss of control”, or “craving”, and a progression of the disease, leading to an irreversibility of the problem which led to the person becoming addicted to a substance which made them an addict with a chronic condition that once treated, would always run risk of re-occurring. This model also suggested that the addict was different from the normal person, in a way that was reminiscent of the moral weakness that afflicted the drunkard of the moral model. Rush suggested abstinence was the only realistic cure to this disease, and this Disease concept, also relied on the “alcoholic” to see the need for change, and embrace the abstinence that would allow this change to happen. Rush suggested this could be achieved in “Sober Houses” or institutions where alcohol was banned.

The Development of the Disease Model
To understand the development of the disease model, we have to step backwards and briefly explore the moral model, and the influence it had on society.
This moral model perpetrated by the church suggested that alcohol was directly responsible for the ills of society, and the movement which grew out of this model, the temperance movement, advocated abstinence as the main treatment for this issue. This model also gave birth to the concept of the “Work Ethic” which was pushed by the church and the newly developing industrialists as the ideal, and that those in society should aspire to achieve this, stigmatising those who drank or used other drugs to extreme. Those who drank too much or utilised other substances, were deemed to be criminals and deviants and were treated as such. This work ethic which was the result of a redefinition of the traditional social order which had existed pre industrial revolution, where the relationship between society and substances was less prohibited acted as a social control on the use of substances, and the stigma around drunkenness, and in turn this social control also served as a social enforcement. The treatment with regards to this model was to repent the behaviour and the cause of it alcohol and embrace total temperance whilst promising not to drink again, on the pain of eternal damnation.

The Aetiology of the Disease Model

The disease model concept was developed when Physicians like Rush Trotter and Huss, began to feel that the traditional Moral Model and the concept of alcoholism being a sin perpetrated by the devil was not the answer. They also felt if alcoholism/addiction was a disease then it could be treated, and if it could be treated then and also as with other diseases it could be understood, and prevented. The new professionals utilised the process of scientific enquiry, to look at this issue, and identify what were the factors causing the disease, Huss being a good example of the use of this process, by utilising his research and observations from other physicians to coin the phrase alcoholism, and publish his work, All of this research identifying the core characteristics outlined above with all of the theorists suggesting the only treatment for the disease process of “inebriety” was abstinence, because the alcoholic would always be at the mercy of the need to drink, and the inability to control this drinking behaviour.

With the acceptance of the Disease Model the 19th and 20th centuries heralded the adoption of stricter prohibitionist legislation, which utilised this idea of an incurable illness to forward the introduction of the said legislation, and develop the concept of the drunk as being deviant and in need of treatment. This legitimised medical treatment, and also allowed the substance misuse to abdicate personal responsibility as they suffered a disease and as such any behaviour or misdemeanours were as a result of this disease process and not the person themselves. By the very nature of their social standing and the existing class system the new medical professions were inevitably supporters of the temperance message along with the temperance ideal and embraced this condition and used the spectre of addiction and “loss of control” to target other substances and ensure that their professions were the only ones qualified to treat this disease. The new medical based professions, Pharmacists and Physicians also used this new disease and the introduction of the dangerous drug acts (1920) for example which targeted the sale and prescription of opium ( Berridge 1999) to professionalise the concept of addiction, and introduce the idea that substance misuse, and the resulting bad behaviour could only be treated legally by them, in effect beginning medicalization of this issue, a concept of addiction which society still uses today. Whilst in Britain the temperance influence produced strict regulatory apparatus, in the United States the temperance movement used this model to forward the Temperance cause so successfully that in 1920 the use of alcohol was banned nationally in the US resulting in the prohibition of alcohol from 1920 To 1933.This period allowed the concept of the disease of addiction to be further ingrained into the general populations psyche, by the demonisation of addiction, alcohol in particular and its use, although the concept of addiction being a disease, and the idea of drug induced addiction was beginning to take on a more racist base, with cannabis(marihuana) and opium in the US and UK respectively, being linked with immigrants , and the spectre of drug use and addiction being used to demonize and marginalize immigrant populations. This process was also used as a vehicle to to introduce more prohibitionist legislation, the Harrison Act (1914) and the Defence of the Realm Acts (1915) (Gossop 2007) The media was also used to reinforce and further disperse the desired image of the addict as being a diseased person who can’t control their behaviour when confronted with their choice of drug by creating a moral panic utilizing the press and film industry, publishing story lines playing on the fears of the WASP majority, scape- goating the targeted populations and making films which added to the already growing myth around addiction as a disease which afflicted those who were different.
In Britain, stories were rife in the press suggesting that Chinese immigrants were responsible for the corruption of single females, and the proliferation of “opium dens”, a topic backed up by “Fu Man Chu “ stories, which were incidentally made into films in the fifties and sixties , with the undercurrent of the “yellow peril” still unaltered in the modern adaptations.

With the repeal of Prohibition in 1932, and the resumption of normal drinking patterns, but without the increase in “Alcoholics”, The temperance movement were forced to re evaluate the disease model, and EM Jellinek with funding from Marti Mann and the help of members of Alcoholics Anonymous carried out research in 1946 which resulted in his book in 1960“The Disease Concept of Alcoholism” in which he further reinforced the concept of alcoholism as a disease by his classification of the types of alcoholic identified in his 1946 study. This book also started to separate Alcohol as a substance from that of other drugs (Ref) and slowly began the process of moving the 12 step process into the realm of treatment provision, and began to perpetrate the modern concept and discourse of what addiction is, but more importantly what the concept of recovery within addiction was.

Again as with Rush and Trotters concept, within this version of the model Abstinence was the only true treatment, but this time with the use of the added support of peers, as provided by AA, the AA movement also suggested that the “alcoholic “ would always be an alcoholic, and this very statement began the discourse, and reinforced the construct of Alcoholism being a disease with its own specific mysticism, and process that only alcoholics could understand, further reinforcing the concept of the alcoholic being different from other “normal people “adding to the already common belief that the disease was an entity in its own right.
There was also a more concerted move by the authorities, towards the inclusion of other substances into the model, and the concept of drug induced addiction, or the one hit and your addicted concept began to gain more acceptances in the eyes of the general public. This move by the apparatus that originally was set up to police prohibition, mainly driven by Henry Anslinger also began to utilise the concept of ethnic minorities and the relationship of these populations with certain drugs to perpetrate the concept of race related addiction , with the stereo types already mentioned previously, and this became a form of covert social control, utilising a similar process of demonization,and the resulting moral panic to force further prohibition as the moral model had used religion and the threat damnation to advance social control centuries earlier. With the added development of the expert addict, and the discourse that this provided to the public backing up the ideas of Jellinek and the disease model as a whole was beginning to resemble what today we see as the condition of Addiction.

As outlined in the brief history above, the concept of addiction as a disease arose at the beginning of the 19th century, and can trace it’s routes through to E M Jellinek in the 1940’s as well as the research into discovering a genetic cause for addiction, which could be said to be the modern arm of the existing disease model.
These differing versions of the model, all have one major factor in common, and that is the main core concepts of the model, which subscribe the process of addiction being caused from within the addicted person. They also all suggest that addiction is a discrete commodity, as previously touched on and I would suggest that the modern day compulsion to explore the human G-Nome for genetic markers for all sorts of diseases, inclusive of the search for a definitive causal gene for addiction is a direct extension of this centuries old concept of an addiction disease process. This eugenic approach, is very similar to the older concept of inebriety in such that, it aspires to remove the locus of control from the addiction sufferer, and put it squarely in the realms of medicalised treatment, in effect removing all emphasis from the actions of the substance user, and laying the blame for their subsequent actions and behaviours onto a disease process, which they are susceptible to because of their genes, which has predisposed them to suffering from, or caused them to become addicted. So is it any different from the disease of inebriety, and moral weakness?

Addiction as a Disease : Proof of a Myth

There are many factors which have led to this concept being one of the most popular explanations, and we can also see that over the years, many agendas and professions have spawned from the concept of addiction being a disease. These concepts with some revision have becoming all encompassing, Initially the research from the 18th & 19th centuries, which posed the concept of inebriation, and Rush’s disease of the will, backed up by the writings of Huss and then E M Jellinek and his research in the 1940,s all produced a more scientific explanation for the disease of Addiction by utilising research practice to identify the progressive nature of the disease. This concept of an internal disease process, backed up all of the thoughts and reductionist ideals of 18th, 19th and early 20th century medicine as the scientific inquiries focused on finding a central cure for the problem of substance misuse. The expert patient, testimonies backed up by the recovering “alcoholics” and substance misusers from Alcoholics anonymous, and other peer support/12 step based groups only added weight to these scientific inquiries. This is the basic concept on which modern disease theory is based, it portrays alcoholism, as a chronic disease, ideas that are backed up by researchers such as White et al (2008), and policy documents such as the road to recovery( Scottish Government 2008) all of which in their own ways reinforce this idea within the public domain. These ideas have very close resemblance to the original ideas of the 12 step movement, and preach abstinence as the only solution, the document “Road to Recovery” actually talks about “moving towards an approach to tackling problem drug use in Scotland based firmly on recovery.” and about guiding substance users “towards a drug-free life” phrases that hint towards the ultimate goal of a drug free society, which can only be achieved through abstinence.

The concept of abstinence being the only cure for addiction, and the equally popular concept of drug induced addiction, are the disease models down fall.
The disease model relies on the core elements as highlighted at the beginning of the essay which are “loss of control”, “craving”, the progression of the disease, leading to an irreversibility of the disease, and the idea of addiction in some way being intrinsic to the sufferer. All factors whose validity has come under scrutiny from behaviourists and sociologists who suggest that the disease model is more myth than fact (Peele,1998 Szaz 1996, Alexander,2002, Schaler 1991 , MacAndrew & Edgerton 1969 & Gori 1996).They all in fact suggest that this model is no more than a social construct, or a form of Social Control.

The first of the many areas of research that have cast doubt on the model was the studies of MacAndrew and Edgerton into drunken comportment in 1961. This study was a large scale study, which looked at drinking culture across a number of societies, inclusive of primitive and industrialised ones. The study concentrated on how a society interpreted the concept of intoxication, and how they acted whilst being drunk. This study suggested that the common perception of the drunk being seen as a deviant, and alcohol being responsible for criminality within society was proven not to be as common as was indicated by the disease model. MacAndrew and Edgerton observed that the behaviour of the intoxicated person was governed by how society expected them to behave, and inevitably in society where expectations were negative, then the resulting behaviour was negative, it was also noted by the study, that in most societies the expectation of the society and the resultant acceptable behaviour when intoxicated fell within that societies idea of normal drinking behaviour. So the idea of intoxication and addiction through drug use, was deemed to be an exception rather than a norm. Stanton Peele has also suggested in many articles that addiction rather than being a disease was more to do with the persons experiences and life themes, which also included the ability to spontaneously recover from excessive substance use and maintain controlled drinking which indicates the usefulness of harm reduction within addiction, concepts which are totally at odds with the core concepts of the disease model, irreversibility and uncontrollable drinking as advocated across the previous three hundred years by addiction treatments. His work also discusses the validity of denial as part of the overall disease model, and likens it to “a web” (Peele 1996) which only acts as a reinforcement of the model, which suggests that the very discourse involved in the disease model, as touched on earlier, which is specific to twelve step models is self fulfilling in that it “brainwashes” the subject into believing that they are incapable of dealing with their addiction without the support of the other “brothers” in recovery.
Davies in his book The Myth of Addiction (2009) also discusses the use of discourse within the disease model of addiction , suggesting that the very nature of this discourse, and the way it is used between practitioners and clients, reinforces the specific roles of the of the two opposing groups. He suggested that substance users learn the specific language of the disease model, and they also learn how to manipulate this language to maintain their identity as addicts. This is supported by the practitioners who prime the substance users by asking specific questions, expecting the learned responses from the user, which then adds validity to the whole exchange. This suggests that the whole disease model of addiction is a construct between two individual groups, which legitamises the treatment and stigmatisation endured by one of the groups, and reinforces the concept of the addicted person being different from the general population, the suggested discrete entity of addiction, which is part of the core concept of the disease model.
The idea of professional constructs has also been voiced and championed by Thomas Szasz,(1920-2012) who consistently suggested that the idea of the disease of addiction as part of the trend for the medicalisation of bad habits, suggesting that the concept of a disease that is addiction is a way of utilising social control, and that the disease concept basically allows governments to enforce treatment , and this treatment paradigm allows for the creation and support of the treatment industry. He also suggests that addiction is a form of scapegoating utilised to maintain social control, a similar idea to the use of peer support to maintain the concept of recovery amongst 12 step societies. He also constantly refers to the inability of researchers to identify the cause of the uncontrollable excessive use an idea which has been explored by Gori (1996) in a paper which looked specifically at the failures of the disease model. Within this paper Gori discusses the ambiguity of the definitions as used by the world health organisation, and the moral attachment of the language in the definitions from WHO and how this allows treatment to be loosely prescribed, which in turn can be “subject to Social & moral Sanctions,” hinting at the religious overtones of treatment, and the disease model itself.

Conclusion:

Within this essay I have explored the idea of addiction as a disease, exploring the model from its beginning through to its modern incarnation. From the ideals of forward thinking professionals, to the voices of a few of the many critics of the idea of addiction as a disease. I have attempted to show how the ideas of commentators like Szasz , Peele and others have attempted to highlight inconsistencies, and dangerous assumptions within the model, and how the core concepts can be explained by other means. The one idea that has been constant through out this essay has been the idea that the disease model is a construct utilised to explain the condition of addiction. We have seen how traditionalist medical model users such as Trotter, Rush and Huss utilised it to try and explain addiction in a more understandable way than the previous moral model had. I also feel that they were trying to de stigmatise the idea of addiction and find a way to help those afflicted. We then saw how this model then developed into a tool for social control, with the use of scientific enquiry and the perpetration of the myth around the core concepts of the model and how organisations and governments manipulated the ideas of society towards addiction, and the resultant stigmatisation of those who become addicted high lighting how the disease model is in deed a modernised version of the moral model, with a new lexicon allowing a new set of professionals to take over from the original perpetrators of social control, the churches and the industrial complex.

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