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Addiction: a brief history of an idea

When the Archbishop of Canterbury says in Shakespeare’s The Life of Henry the Fifth, ‘his addiction was to courses vain’, he implied penchant for, or inclination to indulge in activities of little or no importance. The connotation was for the behavior to be entirely voluntary. The word addict is derived from its Latin root addicere: to favor, adjudge. Concepts change and words’ meanings alter over the passage of time in a living language (Williams, 1976); the word addict is no exception. It is widely used, and there is no general agreement about its meaning: ‘Medical men stress its physical aspects and sociologists its social aspects and lawyers its legal aspects’ (Leigh et al. 1977). Despite attempts to use putatively less pejorative terms such as substance misuse or dependence, the term addict is proving to be resilient and continues to be widely used. The American Society of Addiction Medicine (2017) defines the term as follows: ‘A primary chronic disease of brain reward, motivation, memory and related circuitry,’ and that dysfunction in these circuits leads to ‘characteristic biological, psychological, social and spiritual manifestations’. Psychoactive substances are ubiquitous and have been known to humankind since time immemorial. One can, therefore, assume that a certain percentage of the population misused substances historically. Early medical texts appear to recognize the deleterious effects of these substances, such as alcohol, but are silent on labeling the person abusing as suffering from a disorder and requiring treatment. For instance, Hippocrates noted that high levels of drinking alcohol cause tremors; Aristotle noted that drinking could be injurious during pregnancy (Madden, 1995).Similarly, ancient Indian medical practitioners were cognizant of the deleterious effects of alcohol but were silent on addiction as a problem to be addressed (Haldipur, 1989). In the first half of the nineteenth century, with the publication by Thomas Trotter (1988) of his 1804 An Essay, Medical, Philosophical, and Chemical, on Drunkenness and Its Effects on the Human Body, it was generally accepted that heavy and persistent alcohol consumption ‘was itself a disease in its own right, or at least a key symptom of some underlying disease’ (Porter, 1988, p. xii). Here the focus of attention was the person misusing – the addict, rather than the condition (Lewis, 1979), and this was, arguably, a paradigm shift (Levin, 1978, p. 493). The notion that alcoholism is a progressive disease – the chief symptom of which is a loss of control over drinking behavior is now about 175 years old, but no older (Levine, 1978) (italics are mine). To answer the question as to when addiction was recognized as a problem to be addressed, one may have to turn not to extant medical texts but to a treatise on statecraft, economic policy and military strategy, The Arthashastra (Kautilya, 2016), written sometime between 300 and 100 BC (Olivelle 2013; Doniger, 2014). Addiction was considered to be a hindrance to good governance – a notion redolent of the present-day interest among lawmakers the world over to enact laws governing the manufacture, sale, and use of various psychoactive substances. The treatise has a stark warning to rulers: Spies ‘may allure the prince toward hunting, gambling, alcohol and sex and thus instigate him to attack his own father’ (Kautilya, 2016, p. 27). Kautilya, or Chanakya as he is also known, the putative author of the treatise, suggests that ignorance and lack of discipline are the root causes of addiction (p. 238). The treatise lists four addictions: hunting, gambling, sex, and drinking. There is also a hierarchy of addictions: Gambling, the author suggests, is worse than an addiction to sex. For each addiction, adverse effects are adumbrated. Excessive drinking causes ‘loss of money, lunacy in a sensate man, corpselike appearance while living, nakedness, the loss of knowledge of the Vedas, loss of life, wealth, friends, dissociation with the good, suffering from pain....’ (p. 239). Most modernday clinicians are likely to recognize many, though not all, of the adverse effects listed. In addition, as for the inveterate gamblers, ‘they play even at night by lamp light, and even when the mother of one of the player’s has died’ (p. 239). The treatise also suggests remedies: ‘when fond of liquor, he shall be terrified by making him drink such liquor as is adulterated with narcotics’. This may well be the earliest known version of aversive therapy for alcoholism. Similar aversive treatment is recommended for sex addicts: ‘impure women under the guise shall at night and in lonely places, terrify him’ (p. 27). There is no mention of the involvement of physicians in the treatise. It will remain a matter of speculation as to who, if anyone, used treatment modalities described in the text. The publication of Trotter’s book in 1804 marked the start of the inexorable move toward the disease concept of