mandag, 25-10-2021

Peter R. Martin: Historical Vocabulary of Addiction

 

Prevention

 

         According to the current electronic version of the Oxford English Dictionary (OED), the noun prevention is a borrowing from Latin and French.  In post-classical Latin, the meaning of praevention-, praeventio is “action of anticipating and forestalling” from late 4th century.  The meaning evolved within French from the Middle French prevention, prevencion and the French prevention: “(planetary) opposition,” an astrological meaning from the 13th century in Old French; “action of coming first” from 1374; “legal privilege of an overlord over other courts,” from 1461; “action of forestalling someone in a course of action,” from 1530; “precaution,” from 1580; and “preconception” from 1637.    There are multiple modern meanings of the word prevention which have been categorized into two broad classes: 1) “Senses related to precluding or hindering something” and 2) “Senses related to preceding or anticipating something.”  The use most relevant to addiction is derived from the first of these classes.

         The noun prevention was first used in the English language in 1447 according to OED (Beckington and Williams 1872):   “I verrely trow…ye wold…stur al tho to whom sholde longe the preuencion and redresse in that behalue, to do and execute thes same truly.”  In this quotation, the word prevention means: “The action of keeping from happening or making impossible an anticipated event or intended act.”  The most appropriate of the meanings of prevention with respect to use in the field of addiction from the first class of definitions mentioned above is: “A means of preventing something; a safeguard; a hindrance, an obstruction.”  The following quotation (Calvin, Pagit and Fetherstone 1584) exemplifies its first such use in the English language: “But this is a preuention wherewith hee shieldeth vs against offences [L. occupatio, qua..praemunit].” 

         An apposite use of the word prevention with respect to addiction is a quotation from Horace Smith (1779-1849), an English poet and novelist, in his book The Tin Trumpet: “Gallows—A cure without being a prevention of crime.”  This quotation alludes to the unfortunate fact that as policymakers try to prevent addiction and detrimental consequences of a drug in the population through legal and other social interventions, there is little guarantee a priori that the desired outcomes will be achieved.  A case in point is the legal status of marijuana, which has been debated for more than a half a century, leaving in its wake a large number of young people criminalized and incarcerated for minor nonviolent crimes or because of racial prejudice during the 1960-70’s (LeDain 1970; Kandel 1975; Joffe and Yancy 2004).  While access to drugs, in theory, should be based in pharmacology (Eddy and Isbell 1959), Erickson has emphasized (1992) that historically, in most societies, legal control of access to substances of abuse has never been consistent with pharmacological understanding of harmfulness:  

         “To inquire about the relationship between drugs and the law, one logical question is: What does knowing a drug’s legal status tell you about its pharmacological properties or its dangers?  If a drug is prohibited, it may be a stimulant, depressant, analgesic or hallucinogen (e.g. cocaine, cannabis, heroin, LSD).  If a drug is legally available, it may also fall into a variety of pharmacological categories (e.g., nicotine, alcohol, codeine).  To reverse the question: What does knowing a drug’s effects on the health of a population tell you about its legal status?  Those drugs whose known long-term effects are harmful to a significant proportion of users are likely to be legal: ‘The drugs carrying the greatest health and safety risks are not, in fact, illegal.’ If a drug’s short-term effects are potentially lethal, it may be medically prescribed (e.g. barbiturates) or illicit (e.g. cocaine, heroin).  Since all the examples thus far cited are addictive drugs, in the sense that they can be used compulsively and destructively, the property of addictive potential is no guide to legal status.  Thus, no apparently straight-forward relationship between a drug’s pharmacological properties and effects, and its position inside or outside the ambit of law, exists. 

         “Nevertheless, the field of addictions is divided into licit and illicit drugs.  Although we tend to take this as a given, it is a phenomenon that originated only in this century.  At different times since 1900, all the drugs that present society with problems today (plus a few newcomers like LSD, amphetamines and steroids) have been variously, and at different times, freely available, medically prescribed, considered a candidate for prohibition, considered a candidate for legalization, banned, re-legalized, aggressively marketed and severely restricted.  If there is one feature that epitomizes the interrelationship between the law and drugs, it is ongoing controversy as to how they should be controlled.” 

         It might be argued that odds of success for prevention strategies may be optimized if interventions are based on etiopathogenesis of the disorder rather than the pharmacology of the drug of abuse or, better still, the interaction between these factors.  Such mechanistic considerations should be grounded in reliable biopsychosocial phenomena rather than misconceptions attributable to the stigma these conditions often carry.  Granville Stanley Hall (1846-1924), a pioneering American psychologist, educator and the first president of the American Psychological Association, whose research focused on childhood development (Thorndike 1925), in 1922 rightly emphasized psychosocial processes as the most meaningful components of prevention: “Far more… deaths and preventions and postponements of death than we know are amenable to mind cure because they are mindmade.”  J.D. Reichard  (1947) also underscores this point:  “Addiction is in itself an important phenomenon; an understanding of it also involves many of our concepts concerning human behavior and misbehavior in general.”  These observations clearly apply to addictive disorders and to co-occurring psychiatric disorders that are their precursors or consequences (Martin 2019).

         Prevention strategies for alcohol and drug use disorders can be conceptualized in terms of two broad classes of interventions.  Demand reduction refers to efforts aimed at reducing the desire for alcohol/drugs among individuals in the population.  Such approaches typically include altering the public health or expectations through media or education, addiction treatment and re-integrating those in recovery into the community and reducing poverty through economic opportunities.   In contrast, supply reduction policies are intended to reduce availability of these substances to the population by limiting access by taxation, changing age for legal access, destruction or substitution of crops from which drugs are derived, limiting availability of precursor chemicals required for illicit synthesis of drugs like methamphetamine and policing drug trafficking within a country and across national borders.  Although such approaches have typically referred to reducing the demand and/or supply of illegal or illicit drugs (Tennyson 1953), there is, in fact, a long history of significant societal gains obtained by legislation to contain use of legally available psychoactive substances with abuse liability, such as alcohol (Vingilis and Smart 1981; Waller 2002) or tobacco (DiFranza, Norwood, Garner and Tye 1987).   As suggested, one of the greatest difficulties in crafting policies to moderate the harms to society and to the individual from alcohol/drugs is to determine the appropriate balance between these two forms of interventions, succintly summarized (Ramsey 1986) as follows:  

         “While encouraged… to continue efforts directed toward demand reduction  endeavors, some of the unanswered  questions troubling the mind… include:

1. Are there community-wide, supply-reduction, focused drug abuse prevention strategies which through evaluation have been shown to be effective and portable to other communities? 

2. Should funding agencies support prevention strategies that include a mixture of demand and supply initiatives?

3. Does evidence exist which suggests that demand reduction strategies should proceed or follow supply strategies?

         “The answers to these and other questions can assist us in the search for successful prevention programs.  It is useful to consider each of these strategies separately.  However, doing so should not imply that a combination of them cannot be forged, as in the case of impaired driving counter-responses, to culminate into one macro-prevention initiative.  Nor presently is there available access to any definitive or rigorous scientific studies that compare strategies.  Given this, we  are left with some knowledge, experience, data and common sense upon which to base decisions for the purpose of allocating scarce resources on an ethical and cost-effective basis… given the evolution and development of new prevention strategies, common sense suggests that future substance abuse counter-responses should not be preferentially limited to one approach, resulting solely from the demand reduction side of the prevention  equation.”

         While the debate over drug policy in the U.S. has focused on choices and combinations of demand and supply reduction, the Dutch have pioneered an alternative strategy of harm reduction (Duncan and Nicholson 1997). The philosophy of harm reduction is to encourage alcohol/drug users to progress towards reducing harm from their drug/alcohol use and thereby improve health at a speed which is acceptable and realistic for them. This strategy dovetails very nicely with motivational treatment approaches but less well with abstinence-focused philosophy which has been predominant in North America (Martin 2020).  The aim of harm reduction is to keep alcohol/drug users alive, well and as productive as possible until they are able or willing to attain recovery and can be reintegrated into society (Ritter and Cameron 2006).  Harm reduction involves multiple strategies including drug substitution programs (methadone, buprenorphine and medically supervised self-administered heroin); outreach programs and peer education typically in the addicts’ own environment rather than in the clinc; and needle and syringe exchange programs to reduce spreading of infectious diseases (HIV/AIDS, Hepatitis B and Hepatitis C) among intravenous drug users.  Harm reduction has recently been recognized to offer an increasingly advantageous perspective on treatment benefits of pharmacotherapy of alcohol use disorder (Witkiewitz, Falk DE, Litten et al. 2019). 

         The prevention strategies discussed, to this point, have some value for moderating the toll of addiction in the population, but are not easily applicable to treatment of individuals.  For a physician who encounters a youngster with unique clinical characteristics that might put him/her at risk for addiction, it is not readily apparent how results from prevention studies conducted in populations can be extrapolated to the clinical situation.  Nevertheless, there are increasingly recognized opportunities to apply lessons learned from the population to the clinic and vice versa.  This is ideally accomplished in controlled prospective prevention studies in moderate size samples, such as school classrooms that allow careful evaluation and longitudinal follow-up.  Kellam, Ensminger and Simon (1980) were able to identify predictive factors for development of drug use disorder among a sample of elementary school students — higher IQ, male sex and aggressiveness.   Subsequently, these investigators demonstrated significant improvements in behavior through middle school, among the males who were more aggressive in first grade, in a prospective two-year classroom‐based randomized preventive intervention (Kellam, Rebok, Ialongo and Mayer 1994). The ultimate test of prospectively altering such predictive factors is to actually modify these characteristics and demonstrate they significantly influence development of drug use many years later (Wang, Storr, Green et al. 2012). Once ascertained, such cohorts can be valuable to translate epidemiological observations to the clinic and also to retrospectively investigate modifying factors in the efficacy of the intervention, such as genetic characteristics (Musci, Fairman, Masyn et al. 2018), so as to provide insight into genetic-environmental interactions in addiction prevention.

 

References:

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Calvin J, Pagit E, Fetherstone C. A harmonie vpon the three euangelists, Matthew, Mark and Luke with the commentarie of M. Iohn Caluine. Londini: Impensis G. Bishop. 1584.

DiFranza JR, Norwood BD, Garner DW, Tye JB. Legislative efforts to protect children from tobacco. JAMA. 1987; 257(24):3387-9.

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Witkiewitz K, Falk DE, Litten RZ, Hasin DS, Kranzler HR, Mann KF, O’Malley SS, Anton RF. Maintenance of World Health Organization risk drinking level reductions and posttreatment functioning following a large alcohol use disorder clinical trial. Alcohol Clin Exp Res. 2019; 43(5):979-87.

 

December 10, 2020