Views and Models About Addiction: Differences Between Treatments for Alcohol-Dependent People and for Illicit Drug Consumers in Italy

Abstract

Treatment of people who are alcohol-dependent and treatment of users of illicit drugs differ remarkably in Italy, in keeping with the perception of the general public that drinking alcoholic beverages is a time-honored behavior, while consumption of illicit drugs is a deviant behavior. From a clinical perspective, the treatment for alcoholism essentially stands on the principle of free choice, motivation to change, and a family approach, while the treatment of people who are illicit drug users is characterized by control, pharmacotherapy, and individual therapy approaches. From a socio-political viewpoint both were established in the 1970s, the former being a “bottom-up” movement that started as “spontaneous” responses that mutual help groups and a few clinicians and institutions gave to alcoholics and their families; while the latter was provided “top-down” as a political response of the Government confronting the increase of illegal drug consumption among youngsters.

Keywords:

• addiction
• alcohol addiction programs
• illegal drug addiction units
• cultural viewpoints
• mutual help groups

Acknowledgments

Thanks to editors, Alexandra Laudet and Shlomo Einstein for their patience and competence in reading the manuscript and suggesting many appropriate changes. This article is therefore luckily affected by a challenging dialogue with the editors, while its weakness is entirely due to the author. Also, thanks to Donald Bathgate for his support in the English translation, and to Ivana Pili for her help in plotting the figures.

Notes

¹ Treatment can be briefly and usefully defined as a planned, goal-directed change process, of adequate quality and appropriateness, which is bounded (culture, place, time, etc.) and can be categorized into professional-based, tradition-based, mutual-help-based (AA, NA, etc.), and self-help (natural recovery) models. There are no unique models or techniques used with substance users—of whatever types—and non-substance users. In the West, with the relatively new ideology of “harm reduction” and even the newer quality of life (QOL) treatment-driven model, there are now a new set of goals in addition to those derived from/associated with the older tradition of abstinence-driven models. Editor's note.

² The journal's style utilizes the category substance abuse as a diagnostic category. Substances are used or misused; living organisms are and can be abused. Editor's note.

³ Sir Bradford Hill published the following nine criteria in 1965 to help assist researchers and clinicians determine whether risk factors were causes of a particular disease or were outcomes or merely associated. The nine criteria include: strength of association, consistency between studies, temporality, biological gradient, biological plausibility, coherence, specificity, experimental evidence, and analogy. and are defined below (Hill, 1965). Editor's note.

⁴ One or few trials learning, in humans, is quite rare complex, dynamic, multidimensional, phase/level-structured, nonlinear processes/phenomenon—which are also bounded (culture, time, place, etc.). Thus a “lapse” or “relapse” may be a necessary dimension for initiating, sustaining, and integrating a change process. Editor's note.

⁵ The effects of psychoactive substances in humans have been categorized as being due to the “drugs” chemical action (which has to do with a chemically active substance entering an organism, getting to a receptor, being metabolized, and then being excreted) and what has been coded a “drug experience”, which is the outcome of the interactions between the human and his expectations, the active chemical, and where this complex process is taking place. Humans do and have described “drug experiences” from nonpharmacological “drugs”. Editor's note.

⁶ Any diagnosis is a data gathering process designed to help make needed decisions and is based, medically, upon at least three bits of information: etiology, process, and prognosis of that which is being diagnosed. Whereas a “diagnosis” is part of a nosological system all nosologies are not diagnostic. The relatively recent diagnosis “substance use disorder” can easily be understood by “labeling theories” given its limitations of evidence-based etiology, process, and prognosis. Editor's note.

⁷ Readers interested in either of these processes are referred to Brandt, A. M. and Rozin, P. (1997) Morality and Health Routledge NYC, particularly to their concept of secular morality as well as to the recent literature about “disease mongering” which is easily found on Google. Editor's note.

⁸ This concept is often noted in the literature, without in any way helping the reader to adequately understand its dimensions (linear, nonlinear), its “demands,” the critical necessary conditions which are necessary for it to operate (begin, continue, become anchored and integrate, change as de facto realities change, cease, etc.) or not to and whether its underpinnings are theory-driven, empirically based, individual and/or systemic stake holder-bound, based upon “principles of faith” or what. What is necessary—endogenously as well as exogenously—for the posited process to happen? This is necessary to clarify if the term is not to remain as yet another shibboleth in a field of many stereotypes. Editor's note.

⁹ The interested reader is referred to the large “moral panic” and “moral entrepreneur” literature as well as to books such as Bullen, R. J. et al. (eds.), Ideas into Politics (London: Croom Helm, 1984) and Brandt A. M. and Rozin, P. (1997) Morality and Health Routledge NYC; MacCoun, R. J. and Reuter, P. Drug War Heresies: Learning from Other Vices, Times and Places. (2001) London, Cambridge University Press. Editor's note.

¹⁰ Franco Basaglia (1924–1980) was an italian psychiatrist and an innovator of an important italian mental health system (reform Law N.180, in 1978) which established the abolition of the mental health facilities.

¹¹ Drug supply and demand reduction continues to be the underpinning for drug control efforts in many parts of the world and is exemplified by the U.S. “War on Drugs” and the ideology for United Nations intervention, among others. It is noteworthy to consider that notwithstanding increases in illegal drug seizures there also continues to be an increase in drug users of various types and ages and decreases in the prices of “street drugs.” It is useful to consider that the “supply and demand reduction” model is linear in its dimensions albeit its use to effectively intervene with processes which are dynamic, complex, nonlinear, multidimensional, and bounded (time, place, culture, etc.). Editor's note.

¹² In a manner similar to what the General Semanticists posited that the map is not territory; incidence and prevalence (of substance use–misuse-dependency-addiction) is not “the PROBLEM”. Editor's note.

* This figure is adjusted by adding 808 full time professionals to 736 (total of 3,680) part-time professionals hypothetically working in the alcohol addiction treatment program one day per week.

¹³ The reader is referred to Hills's criteria for causation which were developed in order to help assist researchers and clinicians determine whether risk factors were causes of a particular disease or were outcomes or merely associated (Hill, 1965). Editor's note.