Tuesday, 18.05.2021

Peter R. Martin: Historical Vocabulary of Addiction




        According to the current electronic version of the Oxford English Dictionary (OED), the noun coffee is derived from the Arabic qahwah, pronounced kahveh in Turkish.  This is “the name of the infusion or beverage… said by Arab lexicographers to have originally meant ‘wine’or some kind of wine… Some have conjectured that it is a foreign, perhaps African, word disguised, and have thought it connected with the name of Kaffa in the south Ethiopian highlands, where the plant appears to be native. But of this there is no evidence, and the name qahwah is not given to the berry or plant, which is called bunn, the name in Shoa being būn.  The European languages generally appear to have got the name from Turkish kahveh, about 1600, perhaps through Italian caffè…”  The widspread popularity of this beverage is reflected by the fact that a word closely related to coffee is found in all Western languages and is understood around the world.

        The noun coffee, in an early foreign form, was first used in the English language in a translation of Iohn Hvighen van Linschoten: his discours of voyages into ye Easte & West Indies (Linschoten 1598): “The Turkes holde almost the same manner of drinking of their Chaoua [printed Chaona], which they make of a certaine fruit… by the Egyptians called Bon or Ban.”  The meaning of the word in this quotation is: “A drink made by infusion or decoction from the seeds of a shrub (…a species of Coffea, chiefly C. arabica, a native of Ethiopia and Arabia, but now extensively cultivated throughout the tropics… [bearing] fragrant white flowers… succeeded by red fleshy berries resembling small cherries), roasted and ground or (in the East) pounded; extensively used as a beverage, and acting as a moderate stimulant.”  As demonstrated in The true travels, adventures and observations of Captaine J. Smith (1630) written by John Smith (1580-1631), early Governor of Virgiania,  use of the word in English literature evolved: “Their [Turkes'] best drinke is Coffa of a graine they call Coava.”  Gideon Harvey, the Elder (c1636–1702), a Dutch-educated physician, appointed early in the reign of William and Mary, “their majesties physician of the Tower” despite his open derision of the English College of Physicians, employed the modern version of coffee purporting medicinal value in A Discourse of the Plague… with several waies for purifying the air in houses, streets (1665): “Coffee is recommended against the Contagion.”  There are many mentions of coffee subsequently and not only as a pleasant beverage.  Coffee has played an exceedingly interesting role in world history as a part of the medical pharmacopeia and with mentions in economics and politics, sociology and anthropology, among other disciplines (Pendergrast 2019).    

        Historical accounts of coffee’s health benefits are plentiful. The Islamic physician and astronomer Rhazes (852–932) described the qualities of a plant known as bunn and the beverage buncham in his medical text Al-Haiwi (The Continent) as “hot and dry and very good for the stomach” (Fischer, Victor, Robinson et al. 2019).  Later, the Islamic doctor Avicenna (980–1037) included an entry for buncham in his text Al-Ganum fit-Tebb (The Canon of Medicine) and described coffee as coming from Yemen and, expanding on Rhazes, explained that it “fortifies the members, cleans the skin, and dries up the humidities that are under it, and gives an excellent smell to all the body.”  Coffee use spread widely as a stimulant in this part of the world, in part because Islamic dietary laws strictly forbade the use of alcohol and other intoxicants.  The German physician and botanist Leonhard Rauwolf (1535–1596), who journeyed through the Levant and Mesopotamia in 1573–75 to search for herbal medicines, became the first European to write about coffee.  By the 17th century, coffee was widely seen as the preferred alternative to alcohol and was viewed by many doctors as a viable treatment for a very wide range of ailments.  This dynamic relationship between coffee, considered a gently stimulating component of the refined diet, and alcohol, the primary intoxicant available to the common man, has been a recurring theme in European history.  Nevertheless, medical and moral concerns began to emerge around fears of over-consumption of coffee.  In 1674, women in London called coffee a “drying and enfeebling liquor,” thus protesting the rise in coffee consumption among their men for whom the newly established coffeehouses were popular places of business and social activities, a distraction from duties in the home (Pendergrast 2019).

        Understanding the chemical composition of coffee was necessary to proceed with investigations of its actions in the human body and the putative health benefits and hazards.  The modern characterization of coffee began when the Swedish physician and botanist Carolus Linnaeus (1707–1778), renown for his research on biological taxonomy, named the species Coffea arabica in 1737 (Fischer, Victor, Robinson et al. 2019).  Friedlieb Ferdinand Runge (1794–1867), a German analytic chemist who identified the mydriatic effects of belladonna, determined that caffeine was the major constituent of coffee.  His interest was stimulated by a gift of coffee beans from Wolfgang von Goethe (1749–1832), considered the greatest German literary figure of the modern era, who was a great conoisseur and admirer of the effects of coffee.  This was the beginning of much scientific work on the physiologic effects of coffee, not in the least because of the interest of many of the researchers in the field due to their personal experience with coffee drinking.  The French physician Francois Magendie (1783–1855), a pioneer of experimental physiology, considered coffee as a remedy for infections (Magendie 1835).  Claude Bernard (1813–1878), the French physiologist who laid the foundation for experimental medicine by proposing blinded clinical trials and the notion of the milieu intérieur, conducted some of the earliest experiments to determine the effects of coffee on blood pressure (Bernard, Atlee and Robin 1854).  (Of note, Bernard’s concept of the milieu intérieur is the founding principle upon which the field of addiction is based, evolving into the term homeostasis coined in 1929 (Dale 1947) by the eminent American physiologist Walter Bradford Cannon (1871–1945)  and subsequently, transformed conceptually (Koob and Le Moal 2006) into the idea of allostasis.  The German chemist Emil Fischer (1852–1919) synthesized caffeine in 1895, derived its structural formula in 1897 and for this and related work in chemistry won the 1902 Nobel Prize (Fischer, Victor, Robinson et al. 2019).

        With a recorded history spanning centuries documenting the health benefits and medical uses of coffee, the notion that this beverage was addictive and harmful emerged and became widespread.  An editorial in Science, entitled “Coffee Inebriety,” exemplifies a common viewpoint at the turn of the 20th century (Anonymous 1890):

        “Dr. Mendel of Berlin has lately published a clinical study of this neurosis, his observations being made upon the women of the working population in and about Essen. He found large numbers of women who consumed over a pound of coffee in a week; and some men drank considerably more, besides beer and wine. The leading symptoms were profound depression of spirits, and frequent headaches, with insomnia. A strong dose of coffee would relieve this for a time, then it would return. The muscles would become weak and trembling, and the hands would tremble when at rest. An increasing aversion to labor and any steady work was noticeable. The heart's action was rapid and irregular, and palpitations and a heavy feeling in the precordial region were present. Dyspepsia of an extreme nervous type was also present.  Acute rosacea was common in these cases. These symptoms constantly grow worse, and are only relieved by large quantities of coffee…The victims suffer so seriously that they dare not abandon it, for fear of death. Where brandy is taken, only temporary relief follows. The face becomes sallow, and the hands and feet cold; and an expression of dread and agony settles over the countenance, only relieved by using strong doses of coffee… Melancholy and hysteria are present in all cases.  Coffee inebriates are more common among the neurasthenics, and are more concealed because the effects of excessive doses of coffee are obscure and largely unknown.  A very wide field for future study opens up in this direction.”  

        This clinical description of coffee inebriety shares many features of addiction (Martin, Weinberg and Bealer 2007).  For example, individuals who drink very large quantities of coffee, are a priori considered to have a mental disorder, termed a “neurosis.”  The magnitude of drinking is portrayed as out-of-control use, which is readily combined “with beer and wine,” indicating a co-occurring alcohol use disorder, as often occurs with many other drugs of abuse.  Interestingly, coffee is portrayed as a gateway drug for other drug use disorders, with “neuresthenics” being particularly predisposed to its use. “Many opium and alcoholic cases have an early history of excessive use of coffee, and are always more degenerate and difficult to treat.”  A withdrawal syndrome from coffee drinking is described as “profound depression of spirits, and frequent headaches, with insomnia…[t]hese symptoms constantly grow worse, and are only relieved by large quantities of coffee…”  The complications of harmful coffee drinking include: “muscles… become weak and trembling… the hands… tremble when at rest… increasing aversion to labor… heart's action was rapid and irregular… palpitations and a heavy feeling in the precordial region… dyspepsia of an extreme nervous type...”  The editorial emphasizes how coffee drinking is initially characterized by self-medication to assuage neuresthenia and eventually becomes toxic to health and well-being.

        Presumbably the association between coffee inebriety and neurasthenia may be related to the pharmacological actions of caffeine, as suggested by Lewis Lewin (1850–1929), a German pharmacologist, known for systematically classifying the psychoactive actions of plants based on their pharmacological and toxicological effects.  He suggested in his Phantastica: Narcotic and Stimulating Drugs (1931) that coffee is a stimulant, causing: “…an excessive state of brain-excitation which becomes manifest by a remarkable loquaciousness sometimes accompanied by accelerated association of ideas.”  So, in addition to the social and moral fears about caffeism (addiction to coffee/caffeine), and beyond the psychopharmacological effects of caffeine, early studies of coffee's effects on humans up to the last decades of the 20th century, focused on its impact as an addictive drug and its proclivity for concurrent use with other drugs of abuse, primarily alcohol or tobacco.  In fact, concurrent coffee and alcohol drinking and cigarette smoking are likely due to pharmacological and social reasons and alcoholics have been found to increase their coffee intake to cope with alcohol abstinence (Aubin, Laureaux, Tilikete and Barrucand 1999).  One notion that has emerged in a study of Alcoholics Anonymous members who have been in recovery for variable durations of time is that coffee drinking may assist abstinent alcoholics remain sober (Reich, Dietrich, Finlayson et al. 2008).

        Until recently, the terms coffee and caffeine were used almost interchangeably.  There was considerable controversy about whether caffeine was an addictive psychoactive agent like recognized drugs of abuse (e.g., alcohol, nicotine, opioids, stimulants, etc.) or had some unique characteristics that made it somehow different.  In a genetic epidemiologic study of caffeine intake among women in the Virginia Twin Registry, Kendler and Prescott (1999) reported: “Caffeine is an addictive psychoactive substance. Similar to previous findings with other licit and illicit psychoactive drugs, individual differences in caffeine use, intoxication, tolerance, and withdrawal are substantially influenced by genetic factors.”  In contrast, in an extensive review of neuroscience research related to caffeine dependence, tolerance, reinforcement and withdrawal, Nehlig (1999) concluded: “…it appears that although caffeine fulfils some of the criteria for drug dependence and shares with amphetamines and cocaine a certain specificity of action on the cerebral dopaminergic system, the methylxanthine does not act on the dopaminergic structures related to reward, motivation and addiction.”  Swanson, Lee and Hopp (1994) reported: “A review of 86 studies of nicotine withdrawal, caffeine withdrawal, and caffeine toxicity suggests that the symptoms are similar enough to be confused, and that reported nicotine withdrawal symptoms may be a mixture of nicotine withdrawal and caffeine toxicity.”  Therefore, whether or not coffee drinking per se is addictive or harmful, it is so closely linked in the behavioral repertoire with use of other addictive agents, namely smoking cigarettes (nicotine) and drinking alcohol, which each have very harmful effects on health, that it has been far too easy to blame coffee along with its “co-travelers.” 

        Two research directions eventually settled these unresolved issues about the putative detrimental effects of coffee on health.  First, research into the chemistry of coffee has progressed beyond the study of caffeine.  Many other compounds have been identified in relatively high concentrations within this complex plant, each with independent bioactivity (Farah, de Paulis, Moreira et al. 2006).  Of particular relevance to the field of addiction, has been determination that chlorogenic acids in coffee specifically bind to the mu-opioid receptor (Boublik, Quinn, Clements et al. 1983) and can reverse the antinocipetive actions of morphine in vivo (de Paulis, Schmidt, Bruchey et al. 2002).  Modifying activation of this receptor has become a major pharmacological strategy to treat alcoholism (Altshuler, Phillips and Feinhandler 1980; Sinclair 1990) and opioid use disorder (Dole and Nyswander 1965; Jasinski, Pevnick and Griffith 1978) and supports the benefits of coffee in recovering alcoholics mentioned above (Reich, Dietrich, Finlayson et al. 2008). 

        The second research direction has consisted of re-examining the presumed negative effects of coffee consumption identified in the mid-20th century using imperfect epidemiologic approaches. By parsing out the effects of concurrent smoking, drinking and other harmful lifestyle factors in consumers of coffee, it has become possible, not only to reverse earlier conclusions of harmful effects of coffee (MacMahon, Yen, Trichopoulos et al. 1981; Gordis 1990), but also to identify real health benefits.  Demonstration of reduced rates of cirrhosis, especially in alcoholics, specifically associated with increasing coffee consumption has furthered the notion that coffee drinking has protective effects against a major complication of alcoholism (Klatsky and Armstrong 1992).  Another relevant factor concerning the role of coffee in addiction has been studying the chronological initiation of alcohol drinking, cigarette smoking and coffee drinking.  Among recoverying alcoholics, coffee drinking was the last intiated of these concurrently used psychoactive drugs, starting in the late teens, which is inconsistent with coffee being a gateway drug as proposed above for coffee inebriety (Reich, Dietrich and Martin 2011).

        Coffee is now considered a healthy component of the diet and consumption has been demonstrated to be significantly associated with reduced all-cause mortality (Freedman, Park, Abnet et al. 2012).  Additionally, many beneficial health effects of coffee have been documented in the medical literature in the last three decades using advanced statistical techniques that have allowed parsing out of the effects of the co-travellers, showing a significant inverse relationship between daily coffee consumption and rates of many specific disorders; of note, the majority of these beneficial effects are still present in those consuming decaffeinated coffee.  Conditions for which protective effects of coffee consumption have most consistently been demonstrated include: Type 2 diabetes mellitus and obesity, suicide, cirrhosis, various types of cancer, cardiovascular mortality and neurodegenerative disorders (Farah 2019).  Of note, there are clinically meaningful potential connections of a number of these with beneficial outcomes in addiction which remain to be as well investigated as the protective effect of coffee consumption on alcoholic cirrhosis.  For example, reduced rates of suicide associated with coffee consumption is quite relevant to addiction because of the high rates of suicide in this patient population.  However, it might be difficult to explain how coffee might reduce suicide risk via any antidepressant/anxiolytic effects of caffeine alone – caffeine is highly anxiogenic due to antagonism of adenosine receptors.  Discovery that chlorogenic acids in coffee inhibit reuptake of adenosine (de Paulis, Commers, Farah et al. 2004) provides a feasible mechanism whereby coffee drinking may actually enhance mood and anxiety (Marangos and Boulenger 1985).  Finally, obesity can be conceptualized as an addictive process characterized by over-eating (Martin, Weinberg and Bealer 2007).  The protective effects of coffee consumption with respect to obesity and type 2 diabetes mellitus may have tremendous implications, as the highest projected increases in obesity and diabetes are in those parts of the world that have traditionally not been drinkers of coffee (Seidell 2000). 



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December 24, 2020