Originally published at The Influence, 2014.
The Addictive Effects of Drugs Are Above All Culturally Determined
Our attitudes, feelings, even our experiences while drinking and taking drugs are determined mainly by our cultural expectations—a fact that we can’t comprehend.
Allan, 29, had been addicted to heroin for more than a decade. He entered a hospital treatment program in New York. As part of his treatment, he and his fellow residents were taken for acupuncture.
Allan soon began looking forward to these sessions eagerly—“like copping some H,” he thought. And when pierced by the therapist’s needles, he nodded out, as did several of his fellow treatment recipients.
How is it scientifically possible that a man with a long addiction to heroin could experience comparable effects from merely having his skin punctured with a needle?
In fact, we have a body of scientific research establishing phenomena like this. We just ignore it—at our jeopardy.
Culture and reality are two different things
Human beings believe their reality is reality, and routinely confuse subjective experience with objective fact. If people do something a particular way in a given place, adherents of that approach routinely mistake their customs for invariable human necessities.
Consider lip plates, which have been used to adorn women in a number of cultures. We might view the process as gross self-mutilation (unlike botox injections, say, or stilettos that damage women’s feet). But an African woman in a tribe that beautifies themselves this way considers the adornment quite natural, essential even to her femininity, while finding our forms of feminine beautification bizarre.
Americans tend not to reflect on what Africans, or people in any other cultures, think. And this holds doubly true in the arena of intoxicants. We — along with other English-speaking and Nordic countries (which Queens College sociology professor Harry Levine groups together as Temperance cultures) — view alcohol and drugs as substances that control our behavior, or even our very beings.
But that idea doesn’t necessarily travel. In a remarkable cross-cultural research project published in 2001, the European Comparative Alcohol Study (ECAS) found that alcohol-related problems were lowest in Southern Europe and highest in the North—despite the much stricter controls imposed in the North and the lower drinking ages and higher consumption levels in the South.
Drinking problems in Temperance cultures occur because of the greater tendency in these countries to drink in heavy bursts, rather than drinking regularly but moderately. This leads to more accidents, violence, suicide and even cirrhosis in Finland, Norway and Sweden—which consume the least alcohol per capita in Europe—than in France, Italy Portugal, Spain and Greece—countries which consume the most.
Italian psychologist Allaman Allamani explained in the ECAS volume the cultural outlooks underlying these differences:
‘‘In the Northern countries, alcohol has to do with the issue of control and with its opposite—‘discontrol’ or transgression. In the Southern countries, alcoholic beverages—mainly wine—are drunk for their taste and smell, and are perceived as intimately related to food, thus as an integral part of meals and family life and are not connected to the topic of control.”
When it comes to addiction, imperialism is alive and well
Despite their poorer performance on drinking health measures, the United States and its colleagues in Scandinavia and other English-speaking nations are intent on imposing their views of alcohol and drugs—and thus their problems—on the world.
The tools we employ for imposing our views of alcoholism, drugs and addiction on others include private enterprise (like pharmaceutical companies marketing drugs to treat mental disorders and addiction, or the Minnesota-model rehabs currently devouring Europe) and research by government agencies (like NIDA and the neuroscientific reductionism of Nora Volkow).
Other primary tools for our psychiatric imperialism are the DSM, US psychiatry’s diagnostic manual, and, more tellingly, the Northern-European centered World Health Organization’s International Classification of Diseases (ICD). The ICD tracks DSM closely, nowhere more so than for mental disorders and substance use and addiction disorders.
We actually have scientific proof that DSM and ICD are culture-bound. A group of World Health Organization epidemiologists investigated the “cross-cultural applicability in international classifications and research on alcohol dependence.”
The group’s confident prediction was that the “subjective” criteria (such as loss of control) would vary from culture to culture, but that the “physical” symptoms of addiction (e.g., withdrawal) would not change from place to place.
But their findings, published in 1999, defied their expectations:
“While descriptions of dependence symptoms were quite similar among key informants from sites that share norms around drinking and drunkenness, they varied significantly in comparisons between sites with markedly different drinking cultures.’’ [My emphasis.]
How is that possible?
In cultures like Greece, as Allamani explained, the entire experience of consuming alcohol differs from the experience of drinking in English-speaking and Northern European countries. But the latter countries formulate DSM and ICD. The divergent addiction-related experiences in these different cultures are simply incommensurate with, unrelatable to, one another.
The WHO group concluded:
“Findings on dependence should be interpreted in light of what is known about the drinking cultures and norms of the societies involved. Future nosologies and diagnostic interview schedules should take into account a broad base of cultural experiences in conceptualizing alcohol dependence.”
Too bad the DSM and WHO have done nothing of the sort—and actually the opposite. They simply can’t imagine doing otherwise.
Hypocrisy at the highest level of world health
Perhaps most surprising, WHO and the epidemiologists who made the discovery of the relativity of “physical” symptoms of addiction, as well as conducting the ECAS, happily disregard their own findings. Instead, they spread through their policy recommendations their own biases about mental illness and addictive disorders and treatment.
And how’s that going? Are we eliminating addiction from the face of the earth? The consensus tends in the opposite direction.
Adopting the American Minnesota-model treatment model and neuroscientific claims won’t make the world a better place—although it will make it more like us! Back in 1988, WHO’s leading alcohol epidemiologist (he was a principal investigator in the cross-cultural applicability and ECAS studies), Robin Room, noted:
In comparing Scotland and the United States, on the one hand, with developing countries like Mexico and Zambia, on the other hand, in the World Health Organization Community Response Study, we were struck with how much more responsibility Mexicans and Zambians gave to family and friends in dealing with alcohol problems, and how ready Americans and Scots were to cede responsibility for these human problems to official agencies or to professionals ... Studying the period since 1950 in seven industrialized countries (including California), we were struck by the concomitant growth of treatment provision in all these countries. The provision of treatment, we felt, became a societal alibi for the dismantling of long-standing structures of control of drinking behavior, both formal and informal.
Yet Room is now the leader of a group of epidemiologists whose stated aim is to impose strict alcohol controls characteristic of Scandinavia and North America on those Southern European countries, like Greece and Italy, that, thanks to culturally embedded social control mechanisms, have lower levels of alcohol problems and alcohol-related mortality!
Room isn’t alone. German-born, now Canadian-residing epidemiologist Jürgen Rehm, for example, travels to Italy to lecture authorities there to raise the drinking age from 16. He does this confidently, even though Nordic and English-speaking countries with higher drinking ages have higher rates of drinking problems and alcohol-related deaths than Italy and other Southern European countries.
Talk about chutzpah!
The Camba people of Bolivia
But Greece and Italy bear far more resemblance to US culture than many of the more far-flung cultures of the world. The extremely divergent views of substances among Indigenous South American peoples can be even more instructive.
In 2010, Malcolm Gladwell described in the New Yorker, under the sub-headline “How much people drink may matter less than how they drink it,” one remarkable example of how other cultures drink in a way American researchers insist biology makes impossible.
Gladwell interviewed anthropologist Dwight Heath, who in the 1950s flew into the most remote region of Bolivia to study the Camba, a mestizo people with indigenous and Spanish ancestors. After returning, while walking on the Yale campus where he attended graduate school, Heath ran into E. M. Jellinek (who created the disease theory of alcoholism) and Mark Keller.
When the two men noticed Dwight’s tan, and discovered he had been in Bolivia, one grabbed him and said, “Well, can you tell me how they drink?”
Here is what Dwight, a good friend of mine, told them: Every weekend Dwight and his wife were invited to a party where everyone sat in a circle and drank an intense variety of alcohol that, when Dwight brought it back to Yale, was measured to be 180 proof. The Yale alcoholism school researchers refused to believe that human beings even consumed the beverage—until Dwight drank a large quantity in their presence.
Everyone in the Camba group drank all weekend, drinking again when they woke up after passing out. Yet, as Dwight noted:*
There was no social pathology—none. No arguments, no disputes, no sexual aggression, no verbal aggression. There was pleasant conversation or silence. The drinking didn’t interfere with work. It didn’t bring in the police. And there was no alcoholism, either.
Of course, even if you believe culture impacts drinking and reactions to alcohol, down to disinhibitory behavior+, you won’t believe the same principles apply to heroin. Yet, as I noted in The Meaning of Addiction:
“Neither traumatic drug withdrawal nor a person’s craving for a drug is exclusively determined by physiology. Rather, the experience both of a felt need (or craving) for and of withdrawal from an object or involvement engages a person’s expectations, values and self-concept, as well as the person’s sense of alternative opportunities for gratification.”
Two Philadelphia physicians, Arthur Light and Edward Torrance, studied a total of 861 street narcotics addicts at Jefferson Hospital in the early part of the last century. Even though their subjects used far higher doses than most contemporary street users, and had on average been addicted for many years, Light and Torrance were unable to identify any reliable physiological measure of withdrawal.
For example, their subjects had their withdrawal symptoms relieved by “the single prick of a needle” or a “hypodermic injection of sterile water.” The doctors noted:
“...paradoxic as it may seem, we believe that 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 to obtain temporary relief.”
The “worst addict,” the person most insistent on receiving his injection before schedule, was injected with such a saline solution and immediately drifted off into sleep.++
Light and Torrance likened withdrawal to "a university football team just prior to the playing of a so-called 'important game'...yet, when the whistle starting the game is blown, all fatigue quickly disappears."
Today, the typical response to Light and Torrance is that, despite their careful clinical and biometric observations of hundreds of men using 20-30 times today’s typical street doses, these benighted physicians completely misunderstood addiction and withdrawal.
Unlike well-informed us! After all, we’ve seen Jamie Foxx undergo withdrawal in the biopic Ray (or, for the older among us, Frank Sinatra in The Man with the Golden Arm).
We have learned via movies, rumor and scare stories to view addiction in a way that rarely occurs in nature—except to the extent that people have come to learn our cultural formula for enacting it.
Does Light and Torrance’s work have therapeutic implications? It did for Allan, whose story we heard at the beginning of this article. Allan, for all of his drug jones, was a reflective person. After noticing the effects of acupuncture, he thought: “You mean I can get the essence of my addictive experience from simply putting needles in my arm without drugs?”
With that awareness, what could he do but quit? Allan has been off heroin longer now than the dozen years he was on it. And when he confides his past addiction to people, and they ask him how he was able to quit, he answers with a sly grin, “acupuncture.”
But the real answer is mindfulness, a process that Ilse Thompson and I investigate and detail in Recover!
Most people nonetheless refuse to believe that heavey narcotics users like Allan—or Light and Torrance’s subjects—can simply power through withdrawal.
Our cultural assumptions blind us to reality, making us that much more susceptible to addiction. We can never fathom the degree to which cultural and individual beliefs impact our drug experiences. And our ignorance places us in peril, even as we congratulate ourselves on our advanced neuroscientific thinking.
In our drug and alcohol policies and how we define and deal with addiction, we elevate our prejudices into universal laws of nature. By doing so, we not only disrespect people whose cultural experiences differ from ours, but also create dysfunctional and useless drug and alcohol policies. It is as if we were punishing both ourselves and those in other cultures, the latter for not sharing our problematic views.
A far better alternative is to recognize the pliability of drug and alcohol experiences, so that we can better help people to change their views of the indelibility of their addictions in order to escape them.
There are many empowering and life-enriching ways to do this, and I will explore them in my next Substance.com column.
* Dwight B. Heath, “Drinking Patterns of the Bolivian Camba,” Quarterly Journal of Studies on Alcohol 19:491-508, 1958.
+ The classic work of culture and alcohol disinhibition, by Craig MacAndrew and Robert Edgerton, is Drunken Comportment: A Social Explanation. MacAndrew and Edgerton showed that how people reacted to being drunk takes vastly different forms, and that even when extremely intoxicated, people observe their culture’s norms for drunken behavior.
++ Arthur B. Light & Edward G. Torrance, “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, 1929.
Stanton Peele, a columnist for Substance.com, has been at the cutting-edge of addiction theory and practice, including uncovering natural recovery, identifying addiction as being not essentially linked to drugs, and focusing on social forces and individual choice in addiction since writing (with Archie Brodsky) Love and Addiction in 1975. He has since written numerous other books and developed the online Life Process Program. His latest book, with Ilse Thompson, is Recover! Stop Thinking Like an Addict. His website is Peele.net.