The Etymology Addiction and Origins of the Four Pillars Approach
what is addiction and how should we tackle it as a social problem?
ADDICTION
“The question is not why the addiction, but why the pain.”1 Over a decade of working in Vancouver’s Downtown Eastside (DTES) taught Gabor Maté to see addiction not as a disease or a problem, but as a response to painful experience. Lance Dodes, an addiction expert who specialises in substance abuse-psychiatric disorder comorbidity, defines addiction as a compulsive and ritualistic behaviour response to pain or helplessness.2 My mother hooked on benzodiazepines, my crack-addicted alcoholic husband, my hospital patients, and clients I worked with at Insite, all share a commonality—the experience of suffering from which they desire an escape. My own crack addiction began as an escape and metamorphosed into a ravaging compulsion. I had other, socially acceptable addictions before this one—shopping, studies, and my job. Still the reason remained the same—fulfilling a need to escape, numbing the pain than society does not want to recognise or fix. We have deluded ourselves into believing that abstinence ‘cures’ drug addiction. Abstinence certainly does not remedy food addiction, so why would it remedy drug addiction?
Pain is a physiologic phenomenon. “The purpose of all addictions is to create an altered physiological state in the brain,” writes Gabor Maté in his book In the Realm of the Hungry Ghosts.3 In the mythical hungry ghost realm insatiably hungry creatures live—they have big bellies and necks too narrow to ingest food. The hungry ghosts live a liminal, purgatorial existence, in agonising and incurable pain. Addiction is a form of self-medication which itself causes more pain and perpetuates the compulsion to use. What started out as a pleasurable activity metamorphoses into excruciating bondage.
Etymology and History of Addiction
The word addiction has evolved in meaning over time, still it has always been associated with attachment. The word has its roots in the Latin addico, meaning to surrender or enslave. Under Roman law, addiction sentenced a person to debt bondage: indebted individuals unable to pay their debts became the property of their creditors. Addiction meant a life of slavery. Addiction described forced attachment. Shakespeare is widely credited for inventing the word addiction because he was the first to use it in a neutral context. In both Henry V and Othello he used addiction to describe an inclination or predilection: “his addiction was to courses vain,” and “each man to what sport and revels his addiction leads him.”45 Addiction had become a fancy while retaining its association with compulsory devotion.
Having borrowed from the language of Roman morality, Erasmus’s translations of the New Testament utilised the classic notion of servitude to symbolise ecclesiastical salvation. In Paul’s epistle to Titus he uses the word addict as an adjective to describe Paul’s devotion to God: “I Paul, my selfe the addict servant.” George Joye’s use of the word as a verb extends this notion of servile devotion to sinful behaviour, describing as “addicte to these vices,” those who commit any the seven deadly sins. Joye also urged his readers to “addict unto none but to Christ.” Addiction to God required intense piety and one could not achieve it without innate ability, blinding passion, and selfless commitment. The struggle of addiction—a compulsion and a penchant—mirrors the free will conundrum: how much agency do we have in our devotional behaviours?
After the Papacy of Alexander VI, outrage at papal corruption grew, and Luther gave birth to the Reformation by penning The Ninety-Five Theses. Reformers focussed on the evils of idolatry and material devotion, using addiction to describe greed, avarice, gluttony and idolatry—specifically the Catholic adoration of icons. Material devotion insinuated addiction as lustful. In Sonnet 129 Shakespeare provides an apt description of lust: “the heaven that leads men to hell.” Addiction retained its devotional quality, and Reformers continued warning against the evils of devotion to sinful pleasures. Focus remained on agency and personal responsibility, not compulsion or forces beyond control, as the cause of addiction.
The language of tyranny and enslavement to describe addiction implied overindulgence, evil and failure of self-mastery—progressive loss of free will. In Victorian society, drug use was a casual social activity and not condemnable until mid-19th century, when the industrial revolution gave rise to urbanization and mass migrations of people, triggering profound social changes. Drug use was synonymous with crime, violence—especially domestic violence—and most importantly with decreased workplace productivity. In the 1880s The Society for the Study and Cure of Inebriety re-introduced the word addiction to describe a pathological psychological relationship with a drug. The scale and impact of alcoholism gave rise to the temperance movement, which advocated abstinence of spirits. Teetotalism emerged, followed by prohibition—in Canada from 1917 to 1927 and in America from 1920 to 1933.
Narcotic use was criminalised in an effort of prevent and limit drug abuse, further perpetuating the view of addiction as sinful deepening the stigma. Post-prohibition, treatment focused on containment and management of the addicted person—they received the puke and purge treatment or long-term admission to an asylum. Addiction as an illness, or dis-ease, has it’s root in the evangelical thinking of Reformers, who treated sin as a disease. Bill Wilson and Bob Smith founded Alcoholics Anonymous on this premise, employing the principals of the Oxford Christian Group to the development of their 12 step program. According to AA doctrine addicts must surrender themselves to a higher power because they cannot on their own ‘cure’ their addiction. Also according to AA doctrine, if addicts follow the 12 steps they will achieve abstinence and if they fail or relapse it’s due to their failure of self-mastery. Is an addiction ‘fixed’ if the compulsive behaviour has been re-directed to another, more socially acceptable pleasure activity?
Case: I went to AA meetings because the recovery house I lived in for 5 months forced all residents to attend. I’d walked into a room filled with self-righteous fundamentalists that had a cultish attachment to AA. Many attended meetings 2 or 3 times in a day and meetings felt like subdued tent revival meetings, or those campy motivational seminars corporations force their employees to attend, with preachiness and slogans like it works if you work it, your best thinking got you here, and let go and let god. I don’t like crowded rooms, particularly when forced. I found AA meetings exhausting and anxiety-producing, and the pathological dependence of every member on AA gave me an uneasy feeling. Once, at a meeting, a women encountered a male who had brutally attacked her at the of 16. No attempts were made to address this situation. AA essentially replaces one addiction with another and ignores causal factors. It reminds me of the Catholic indoctrination that defined my childhood—imposition of a set of rules, and then sanctions for those who disobey, excommunication and threat of damnation.
Contemporary Meaning
In the 1980s, the words addict and addiction became pejorative terms, triggering the move toward more objective terminology., Despite the pre-existence of clinical dependency, the WHO replaced the word addiction with dependence, resulting in widespread conflation of the two phenomena. If addiction had stigma, dependence had an air of moral judgement. The moralisation of addiction impedes any attempt at considering the underlying reasons for the addiction. Relinquishing use of the word addiction for some notion of false virtue upholds the view of addiction as sinful behaviour, and obscures the truth about addiction.
The words addiction, dependance and use have become interchangeable, despite their different meanings. Conflating these three words eclipses the chronicity and harmful compulsive nature of drug addiction. “Patients meeting criteria for substance abuse or substance dependence do not necessarily have tolerance and withdrawal symptoms; moreover, patients using prescribed medication for legitimate medical reasons may show tolerance and withdrawal symptoms despite never having abused the drug(s).”6 Addiction describes a pleasurable behaviour that has become a harmful compulsion; dependence describes a state in which the body’s physiology has become dependent on a drug, the withdrawal of which will produce unpleasant symptoms; use describes casual consumption, such as a glass of wine with dinner.
The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V) defines addiction as “a maladaptive pattern of substance use leading to clinically significant impairment or distress,” and the notion of addiction as a compulsive behaviour in response to pain is gaining scientific and clinical recognition. Addiction is a complex disorder existing at the confluence of factors such as the nature of the drug and addicted person, and environmental factors. It is a persistent maladaptive memory and also a compulsive behaviour.
“The likelihood of developing an addictive disorder is a function of multiple simultaneous, pharmacologic, genetic, and environmental variables, such as the pharmacology of the drug, the route of administration, the personality of the individual, and the availability of the drug. There is increasing evidence that long-lasting changes in the brain result from the progression of casual user to addict. Moreover, the course of the progression of addiction is similar to that of other chronic diseases.”7
Evidence is mounting for the view of addiction as a chronic brain disorder, or altered state of the brain, requiring longterm management. Research has revealed a connection between obsessive compulsive disorder (OCD) and the compulsion—they originate from the same region of the brain. Drug addiction is associated with changes in brain physiology that persist beyond the drug’s clearance from the body, and different drugs differ in their effect on brain chemistry.
Case: I’d wanted to try it for a while. When I did, I instantly loved the exhilarating high and wanted more. Cocaine isn’t like cannabis, you can’t have it around for long, the fleeting high leads to binging. Cocaine dulled the pain. As time passed, maintaining a constant level of relief required increasingly higher doses. The cocaine began damaging my nose, gave me the jitters and caused me to go long periods of time without eating or sleeping. I’m not certain it’s possible to use cocaine on a regular without becoming obsessive and compulsive about using it. I stopped using it for several years. When I decide to stop, I never gave it another though. I loved crack from the moment I met her—the same high for a cheaper price. Smoking it produced an instant high that faded quickly, I spent more and more time procuring crack and getting high. I spent every moment thinking about using crack or using crack, I felt like a slave—this pain relief had become painful and I couldn’t stop.
THE FOUR PILLARS
The Four Pillars approach to substance abuse emerged from the AIDS/HIV crisis of the 1980s and a need to provide a coordinated multi-dimensional approach to substance abuse. Drug use steadily increased throughout the 1950s and 60s, reaching peak levels in the early 1970s. The Swiss government adopted an abstinence and enforcement-based drug policy. Drug use continued unabated and transmission of HIV/HCV, as well as overdose deaths, rose dramatically. The government sought to revamp drug policy, and in 1998 proposed two drug policy initiatives to the Swiss people: the abstinence-based Youth Without Drugs, and the decriminalization-based For a Reasonable Drug Policy. They overwhelmingly rejected both options, forcing the government to reconsider their approach to addiction and drug use. Annie Mino, Director of the Substance Abuse Service in Geneva at the time, described the progression of drug policy ideology:
“The suffering that we imposed on our patients by reducing their choices to either painful, inefficient treatments or a return to their illegal, marginal lifestyle was in no way shocking in a ‘sacrosanct’ context. After all, he who ventures beyond the pale must always pay the price for his folly by suffering and the access to freedom is justified on the day of victory. That was our attitude and we didn’t worry about knowing whether or not our patients felt the same way. We literally gave up being doctors, as we gave up on alleviating human suffering. There was indeed an ethical question at the heart of the matter, but it wasn’t where we saw it to be. AIDS opened my eyes.”8
We cannot consider The Four Pillars in isolation from Switzerland’s unique political landscape—a bottom-up, ideologically-neutral, consensus-based system of governance in which citizens have the final word on legislation and policy via referenda. There are 26 diverse cantons and the entire federal cabinet is collective head of state—the president is chair of the council, first among equals and the presidency rotates on a yearly basis. Development of a new drug policy took an ideologically neutral approach involved coordinating input and expertise from medicine/science, NGOs, community-based organizations, cities, and drug users themselves as well as establishing consensus among the 26 cantons, to ensure a coordinated and balanced national approach to addiction. The Swiss people rejected an executive order that legalised heroin-assisted treatment—the public wanted a drug policy with a broader scope.
The Four Pillars emerged with a view to:
1. stabilize and reduce the numbers of hard drug-addiction
2. address the negative medical and social effects of drug addiction.
The strength of the Swiss Four Pillars approach lies in it’s freedom from the influences of dogma or ideology, bringing together both proponents of harm reduction and abstinence, and focussing on communication between all four pillars, as well as continuous re-evaluation. “The Four Pillars must not be considered as so many isolated intervention methods, as there are multiple interactions between them. These diverse measures should hence be further considered from the vantage points of the various pillars and adapted in the most efficient way possible, taking into account different objectives.”9
Vancouver’s Four Pillars Drug Policy also began at the grassroots level. Methadone treatment (MT) was established on the late 60s and early 70s. Cumbersome administration reduced the scope and efficacy of the program until physicians themselves took control of MT. Following Switzerland’s lead, Vancouver established a needle exchange program in 1989. Harm Reduction emerged on the Vancouver scene, based on the success of both the Swiss and Merseyside drug policies. In reaction to the overdose and HIV/HCV crisis, DTES activists opened an unsanctioned injection site in 1995.
Bud Osborn and Ann Livingston created the Vancouver Area Network of Drug Users (VANDU) in 1997 to provide peer-based support and education for drug users as well as to lobby for decriminalisation as well as a harm reduction approach to drug use and addiction. VANDU focussed on teaching infection control and safe injection techniques to drug users. In 2001 Vancouver adopted their own Four Pillars Policy, the focus of which is harm reduction, with a the objective of reducing overdose deaths and disease transmission of IV drug users. In 2002 needle distribution replaced needle exchange and in 2003 the province opened Insite, the first official safe injection facility in North America.
The North American Opiate Medication Initiative (NAOMI) had proved successful, taking place between 2005 and 2008 and yielding a high retention rate and reduced illicit heroin use and illegal activity. However Canada lacked the political will to extend harm reduction to medically-prescribed heroin or other alternatives to MT. When we did finally implement decriminalisation it failed miserably and the province reversed it. When the province began its safe supply policy, that too failed to achieve a constructive and sustainable end, with so-called the “safe supply” ending up on the street, in the illicit drug market.
The introduction of Fentanyl on the street has revealed to policymakers and harm reduction advocates that there is no “safe supply”: it’s an illusion to think there can be a “safe supply” of brain bending, life devouring drugs. The only truly “safe supply” is no supply.
Gabor Maté, In The Realm of the Hungry Ghosts
Henry V, Act 1, Scene 1
Othello, Act 2, Scene 2
Charles P. O’Brien, M.D., Ph.D. Research Advances in the Understanding and Treatment of Addiction, in American Journal Addiction 2003;12[Suppl 2]:S36-S47
Charles P. O’Brien, M.D., Ph.D. Research Advances in the Understanding and Treatment of Addiction, in American Journal Addiction 2003;12[Suppl 2]:S36-S47
Mino Annie, Arsever Sylvie, 1996, J’accuse : les mensonges qui tuent les drogués , Paris, CalmannLévy
Swiss Federal Office of Public Health (BAG), 2005, Troisième programme de mesures de la Confédération en vue de réduire les problèmes de drogue (ProMeDro III) 2006−2011. Bern : BAG