Consumption and Dependence: Inextricable Link or Cultural/Subjective Connection? Stanton Peele...

Consumption and Dependence: Inextricable Link or

Cultural/Subjective Connection?

Stanton Peele

Presentation at Kettil Bruun Society Meeting at Skarpö, Stockholm, on Measurement of Drinking Patterns and Problems

The Stanton Peele Addiction Web Site http://www.peele.net

What is addiction?

• Inexorable physiological process– leaves out so much– doesn't explain use of heroin– so much of addictive behavior common


What is addiction?

• Meaning of Addiction (Peele 1985/1998) – experiential model of

addiction

– individual and social interpretation

– psychic/physical dependence split illogical


Consumption Dependence

• Limits of Consumption Models

(Peele, 1987)– misapplication of pharmacological model



• Room (1987) Response:

"As dependence concepts shift to . . . physiological aspects, they become . . .

another name for sustained heavy

alcohol use."



• Studies:

"The greater the craving of the addict and the severity of the withdrawal symptoms the better are the chances of substituting a hypodermic injection of sterile water"

(Light & Torrance, 1929)


Clinical Controlled Drinking

• The Context– war on controlled drinking – British studies of mid-1980s



• Outcome Studies– Heather, Rollnick, and Winton (1983) –

SADQ v. CD beliefs– Miller et al. (1992) – severity + views + goals



• Quasi-Experimental / Choice Studies– Elal-Lawrence, Slade, and Dewey (1986) – Orford and Keddie (1986) – subjective dependence objective dependence


Conclusion: CD Research

• Expectations/Experience– in the context of choice– more important than dependence


Conclusion: CD Research

• Sample Qs (Heather et al., 1983): – Do you have a drinking problem? – Are you "hooked" on alcohol?– Do you believe, one drink/one drunk?– Can you control your drinking?– Have you controlled your drinking?– Have you attended AA?


Epidemiology

• Problem Drinking Among American Men – "symptomatic drinking –– physiological consequences of heavy drinking" – not more consistent than loss-of-control – highest r with "psychic dependence" (.41) – higher than with heavy intake (r = .34) – preceded heavy intake in 68 percent of cases


Epidemiology

• Dawson (2000) on Dependence – Life and death

• dependent light/moderate drinkers have no advantage over abstainers

• nondependent heavy/very heavy drinkers not worse off than abstainers

• consumption-dependence related but not exhaustive (NLAES)


NAS: Measuring Dependence 1967-1984

• Tangible Consequences (Social Problems) • 4 Dependence Symptoms

– skipping meals while drinking– waking up in the morning after [drinking] unable

to remember the night before – having been unable to stop drinking until

intoxicated – having stayed drunk or high for more than a day

at a time


NAS: Measuring Dependence 1984-1995 13 Symptoms

• Withdrawal – I have often taken a strong drink the first

thing... in the morning – my hands shook a lot the morning after

drinking – sometimes I awakened during the night…

sweating all over...


NAS: Measuring Dependence 1984-1995 13 Symptoms

• Tolerance – I needed more alcohol than I used to, to get the

same effect as before

• Craving – sometimes I have needed a drink so badly that I

couldn’t think of anything else

• 3+ symptoms the prior year


ARG National Alcohol Surveys Heavey Drinking & Dependence

1967-1984

5+ drinks / weekly +25%

dependence symptom +114%

tangible consequence +33%

• Room (1989)


ARG National Alcohol Surveys Heavey Drinking & Dependence

• Midanik / Clark (1994/1995)

1984-1990

Total 5+ drinks/weekly -36%

3+ symptoms +13%

18-29 5+ drinks/weekly -38%

3+ symptoms +50%

Unemployed 5+ drinks/weekly -12%

3+ symptoms +118%


NAS: Heavy Drinking Dependence

• Trends in Heavy Drinking – leveling off – dependence increasing– especially among some groups


Models of Heavy Drinking Dependence

• Hilton (1991) Dependence (%) Among Drinkers Who Consume 5+ Drinks at Least Once a Week

Demographic Categories Moderate Dependence High Dependence

Age 18-29 29 19

Age 50-59 19 7

Married 14 10

Single 32 22

Not HS Grad 27 15

College Grad 6 3

< $10,000 38 28

> $40,000 11 8



• Harford et al. (1991)

3+ Dependence Symptoms, by Frequency of Intoxication

Frequency of Intoxication %

< 2/year 16

3-11/year 21

1-3/month 24

1-2+/week 39



• Consumption x Age – For twenty year olds, the risk for dependence is

estimate to increase by 0.51 for each additional ounce of ethanol consumed daily while the corresponding increase in risk is 0.19 for sixty year olds.


WHO/NIH Cross-Cultural Applicability Project

• Schmidt, Room, et al. (1999) – Key Informants – Nine Sites – Predict: Physical symptoms vary less by culture – Found: Cultural applicability is as problematic

for them as for psychological symptoms


WHO/NIH Cross-Cultural Applicability Project

"even though physical dependence criteria involve more objective, observable phenomena, cultural applicability is as problematic for them as for the psychological symptoms" . . . .

As a result, diagnostic criteria for dependence "do not easily cross particular kinds of cultural boundaries."


Is This New Information?

• Peele (1987):– "Cross-cultural research defies the idea that

dependence or addiction is the natural consequence of overimbibing."



• Peele (1987):– "The most remarkable evidence for this is

Heath's (1958) investigation of the Bolivian Camba, a group with among the highest recorded rates of alcohol consumption in the world."



• Peele (1987):– "People in this culture drink a beverage

containing 89% alcohol. Although the drinkers typically blacked out, Heath observed no cases of antisocial aggression, alcohol withdrawal, solitary drinking or job problems due to drinking."



• Peele (1987):– "Thus it appears that alcohol dependence is not

a syndrome that can be removed from a cultural context."


Conclusions

• Individual clinical measurements – belief in loss of control models – accept relevance to themselves

• Understanding social group differences – social resources – drinking experiences – belief in addictive models – belief/experience of efficacy


Conclusions

• Cultural Differences – view of the nature of drinking experiences – definitions of addiction – existence and likelihood of loss-of-control


A Theory of Addictive Knowledge

• "To say that overdrinking creates dependence—rather than comprising some objective description of the nature of addiction—is to describe a particular societal drinking milieu."

(Peele, 1987)


A Theory of Addictive Knowledge

• "Addiction, at its extreme, is an overwhelming pathological involvement. The object of addiction is the addicted person's experience of the combined physical, emotional, and environmental elements that make up the involvement for that person. Addiction is often characterized by a traumatic withdrawal reaction to the deprivation of this state or experience. Tolerance—or the increasingly high level of need for the experience—and craving are measured by how willing the person is to sacrifice other rewards or sources of well-being in life to the pursuit of the involvement" (The Meaning of Addiction, p. 26).


ReferencesCahalan D., and Room, R. (1974). Problem drinking among American men. New Brunswick, NJ: Rutgers Center of Alcohol Studies.Dawson, D.A. (2000). Alcohol consumption, alcohol dependence, and all-cause mortality. Alcoholism: Clinical and Experimental Research, 24, 72-81.Elal-Lawrence, G., Slade, P.D., and Dewey, M.E. (1986). Predictors of outcome type in treated problem drinkers. Journal of Studies on Alcohol, 47, 41-47.Harford, T.C., Grant, B.F., Hasin, D.S. (1991). The effect of average daily consumption and frequency of intoxication on the occurrence of dependence symptoms and alcohol-related problems. In W.B. Clark and M.E. Hilton (Eds.), Alcohol in America: Drinking practices and problems (pp. 213-237). Albany, NY: SUNY.Heath, D.B. (1958). Drinking patterns of the Bolivian Camba. Quarterly Journal of Studies on Alcohol, 19, 491-508.Heather, N., Rollnick, S., and Winton, M. (1983). A comparison of objective and subjective measures of alcohol dependence as predictors of relapse following treatment. British Journal of Clinical Psychology, 22, 11-17.Hilton, M.E. (1991). Demographic characteristics and the frequency of heavy drinking as predictors of self-reported drinking problems. In W.B. Clark and M.E. Hilton (Eds.), Alcohol in America: Drinking practices and problems (pp. 194-212). Albany, NY: SUNY.Light, A.B., and Torrance, E.G. (1929). Opiate addiction VI: The effects of abrupt withdrawal followed by readministration of morphine in human addicts, with special reference to the composition of the blood, the circulation and the metabolism. Archives of Internal Medicine, 44, 1-16.Midanik, L.T., and Clark, W.B. (1994). The demographic distribution of U.S. drinking patterns in 1990: Description and trends from 1984. American Journal of Public Health, 84, 1218-1222.Midanik, L.T., and Clark, W.B. (1995). Drinking-related problems in the United States: Description and trends, 1984-1990. Journal of Studies on Alcohol, 56, 395-402.Miller, W.R., Leckman, A.L., Delaney, H.D., and Tinkcom, M. (1992). Long-term follow-up of behavioral self-control training. Journal of Studies on Alcohol, 53, 249-261.Orford, J., and Keddie, A. (1986). Abstinence or controlled drinking: A test of the dependence and persuasion hypothesis. British Journal of Addiction, 81, 495-504.Peele, S. (1985/1998). The meaning of addiction. San Francisco: Jossey-Bass.Peele, S. (1987). The limitations of control-of-supply models for explaining and preventing alcoholism and drug addiction. Journal of Studies on Alcohol, 48, 61-77.Room, R. (1987). Alcohol control, addiction and processes of change: Comment on "The limitations of control-of-supply models for explaining and preventing alcoholism and drug addiction." Journal of Studies on Alcohol, 48, 78-83.Room, R. (1989). Cultural changes in drinking and trends in alcohol problem indicators: Recent U.S. experience. Alcologia, 1, 83-89.Schmidt, L., Room, R., and collaborators. (1999). Cross-cultural applicability in international classifications and research in alcohol dependence. Journal of Studies on Alcohol, 60, 448-462.

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