Peter R. Martin: Historical Vocabulary of Addiction
The term self-medication was formed in English, as noted in the electronic version of the Oxford English Dictionary (OED),by a combination of the noun medication, meaning “The action of treating medically; treatment with a medicinal substance,” and the prefix self-, which is in objective relation to the second element. In the OED, self-medication is defined as: “Administration of a drug or other remedy to oneself without advice from a medical practitioner; (also) use of narcotics, alcohol, etc., in an attempt to alleviate depression, anxiety, or another condition.” The term initially denoted compliance with self-administration of medications that a treating physician recommended the patient take strictly according to prescription but could not directly oversee, e.g., antibiotics that must not be skipped so as to avoid emergence of highly resistant infections as in tuberculosis and more recently human immunodeficiency virus (Anonymous 1958). However, the meaning of the term that is most relevant to addiction, namely the ingestion of psychoactive agents at will and without medical guidance to relieve distressing mental symptoms, is the topic for discussion here.
According to the OED, the first use of self-medication in the English language with the relevant meaning of alleviating mental suffering by administration of a psychoactive substance like alcohol appeared in an editorial in The British Medical Journal (1886). The initial precept underpinning self-medication was noted as recognition by an individual of “being ‘below par’.” Self-medication becomes the choice if one does not fully appreciate or accept that “…the proper treatment is, undoubtedly, not to stifle the feeling by injudicious blending of the effects of alcohol, tobacco, and excitement, but to afford an opportunity for the recuperative powers of the system to assert themselves, and so restore the mental tone which is wanting.” In modern psychiatry, this has come to mean that it is preferable to enhance functioning through various forms of lifestyle improvements including diet, exercise or mindfulness techniques such as yoga, meditation and relaxation techniques as well as formal psychotherapy from an expert practitioner than to self-medicate (Martin, Weinberg and Bealer 2007). The editorial discussion proceeds: “In the excellent little work on Digestion, recently published by Sir William Roberts, he suggests, with great plausibility, that, although the effect of habitual alcoholic indulgence is, beyond question, injurious to the average constitution, yet it may, under circumstances of intense and passing worry, save the individual whose mental equilibrium is menaced from positive mental aberration, by rendering him simply insusceptible of the violent emotions which unhinge and deprave the intellect. The idea is, doubtless, correct in a limited number of cases, but, from its nature, it is very undesirable that it should be generally accepted.” The editorial concludes: “People are very partial to self-medication as it is, and rush to alcohol as a panacea for the ills to which flesh is heir.”
The notion that a self-administered psychoactive agent can alleviate emotional suffering over the long term is hardly realistic — most agree that such “self-treatment” will not resolve the problem and, more often than not, can lead to a pattern of out-of-control and self-destructive use characteristic of a drug use disorder as a result of rewarding effects of the drug (Martin 2016). This conceptualization of self-medication has become the cornerstone for both behavioral pharmacologic (Tatum, Seevers and Collins 1929; Schuster and Thompson 1969) and psychodynamic (Radó 1957; Khantzian, Mack and Schatzberg 1974) understanding of the pathogenesis of drug use disorders or addiction. There is, however, an alternate argument, namely, that drugs of abuse themselves actually produce specific psychiatric disorders over time in individuals who use these agents based on their preference for specific classes of pharmacologic agents (McLellan, Woody and O’Brien 1979) or that neurotoxicity of drugs of abuse lead to psychopathological syndromes of impairment (Martin, Adinoff, Weingartner et al. 1986). Therefore, despite the fact that drug use disorders are epidemiologically associated with specific other psychiatric disorders, as persuasively documented in the National Institute of Mental Health Epidemiologic Catchment Area Program (Regier, Farmer, Rae et al. 1990), the direction of the path that undeniably links drugs of abuse with psychopathologic conditions remains controversial.
Although a syndrome of self-destructive and out-of-control use of neuropsychopharmacological agents has been accepted among psychiatric disorders for the better part of a century (Nathan, Conrad and Skinstad 2016), it is still widely held that drug use disorders are actually complications of underlying other psychiatric disorders, developing predominantly due to self-medication to alleviate emotional suffering. Stated otherwise, anxiety, depression, mania or schizophrenia were considered the primary causes of addiction. It seems completely justified and understandable why humans self-administer drugs because “one of the intrinsic evils of man's neurobiological make up is that a prime motive of the brain seems to be to bring comfort, security and pleasure for itself. Therefore, it is not surprising that drugs - notably the barbiturates and more recently the benzodiazepines (tranquillizers) - have been prescribed to give to the brain that peace of mind that it seeks” (Grahame-Smith 1975). Along the way between evolution of behavioral pharmacologic and psychodynamic constructs of the pathogenic role of self-medication in addiction, the polemic of “self-medication as a fundamental right” of an individual rather than a medical problem emerged (Szasz 1971). It was not until elucidation of reward mechanisms in the brain that could shape behavior did it became feasible to conceptualize addiction as a psychiatric disorder in its own right (Olds 1958). All the same, it is far too easy to invoke primary symptoms of anxiety, depression, pain, insomnia, desire for cognitive enhancement as primary motivating factors via conditioning for problematic use of neuropharmacological agents (Wikler 1948). However, the ultimate question may well be why stimulation of brain reward centers by self-administration of drugs of abuse leads to development of neuroadaptation and addiction in some but not all individuals.
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November 14, 2019