According to the editors of Addiction Trajectories, ‘Addiction is particularly relevant as an object of anthropological inquiry because it sits at the crossroads of some of the issues that most define the world today’ (p. 1). The issues to which the editors refer are the role of scientific knowledge in the shaping of identity, new medical technologies and their cultural settings, and confluence of biology, psychology, and various social systems. It is this multi-faceted nature of addiction that is often overlooked by those who attempt to prevent and treat the condition. To address its nebulous nature, Eugene Raikhel and William Garriott have collected ten chapters written by anthropologists who have focused their ethnographic lenses on addiction. As a result, the book gives personal and culturally historical reasoning for why a particular addiction is prevalent among a certain population, and why treatment methods may either work or fail.
The chapters of the book track the path of addiction from three perspectives: epistemic, therapeutic, and experiential/experimental. By looking at the epistemic trajectory, the authors ‘seek to understand how scientific and other [related] expert framings of addiction are implicated in lived experience’ (p. 11). The section covering the therapeutic trajectories examines and discusses the wide variety of treatment options that are available for addicts struggling to recover. These range from various faith-based recovery systems, 12-step programs, psychology-based therapies (cognitive behavioural therapies, family counselling), and pharmaceutical treatments. When discussing the experimental and experiential trajectories, the editors say, ‘addiction is revealed to be deeply implicated in questions of human vitality and what has come to be called “the politics of life itself”’ (p. 26).
The editors claim this perspective on addiction is unique as it does not rely on substance categories. The various authors have instead studied ‘”addiction” as an object of anthropological study in its own right, all the while insisting on its contingency as a category of human experience’ (p. 6).
The various chapters of the book are wide-ranging and well-balanced. The topics discussed often seem quite disparate. As Helena Hanson’s fourth chapter examines coping with neurological changes brought about to protracted heroin use, the eighth chapter shows how William Garriott charted the interconnectedness of methamphetamine use and the justice system in a rural American town. In between is chapter 5 by Anne M. Lovell, who discusses ‘a new type of drug user,’ referred to as ‘elusive travellers,’ who misuse a French ‘methadone program as a way to gain access to health and other services’ (p. 127).
The chapters might appear mismatched on the surface, as the focus shifts between topics as varied as the criminalisation of addiction and the ritualization of therapy. However, there are common themes that continuously arise throughout the book. The most striking of these is a modern revisitation of the nature vs. nurture argument. In this volume, it isn’t one’s personal nature, but rather a form of biological determinism that is being compared to the nature of free will. This struggle is alluded to in the first chapter, where Angela Garcia tells of the increasingly common view of addiction as a chronic disease in a Spanish-speaking community in New Mexico. In Chapter Four, Helena Hanson gives evidence for this view in her examination of buprenorphine (an opiate blocker) used to treat heroin addiction in a Kentucky prison:
‘As one prescribing psychiatrist says many times a day to her buprenorphine patients, “When you bang on your endorphin receptors – your natural opiate receptors – over and over again over the years with high doses of heroin, your body produces fewer and fewer receptors, they wither , and even if you stop using heroin they may never come back. So the “bupe” is like insulin for a diabetic; it just replaces what was naturally there”’ (p. 119).
Other evidence for this sort of biological determinism is later explored by Nancy D. Campbell in chapter 9. A neuroscientist using functional magnetic resonance imaging (fMRI) to study the brain of a methamphetamine addict finds evidence of ‘an uncontrollable reflex that happens very quickly in the brain. The person does not have the ability to stop it’ (p. 241). This ‘reflex’ is easily created within the brain due to aspects of evolution. The drug has confused the user’s brain into believing that it is necessary, like food. As a result, a function of the brain that is very important to our very survival becomes subverted, making addiction a much more difficult burden to overcome. This hypothesis supports the need to medicalise addiction, and also lends credence to the notion that addicts are misunderstood – that choosing to quit goes beyond mere will power.
That is not to say that people don’t try – and succeed – in escaping the clutches of addiction. However, there is a wide variety of treatment options, and individual response varies greatly. Several chapters in the book compare certain types of addiction treatment, and give a good account of the broad spectrum of responses to such interventions.
In chapter four, ‘Pharmaceutical Evangelism and Spiritual Capital,’ Hanson compares a faith-based treatment programme in Puerto Rico and a drug-replacement programme in Maine that uses buprenorphine to help heroin addicts curb their cravings. In this article, not only are the treatment methods wildly different – the patients are, as well. The Puerto Rican individuals are represented as destitute and desperate, whereas the comparative group from Maine are shown to be White middle-class, educated and relatively higher socioeconomic status. At first glance, the disparities between the treatment methods and those they cater to seem vast. But Hanson does a brilliant job of showing the similarities between the two. She states that both religious and biomedical institutions claim to have custodianship of knowledge, which they intend to use to alter the behaviour of those in need. Both are reinforced through ritual – the religious institutions use the Bible, whereas ‘buprenorphine is the ritual object around which an institutional realignment and a reweaving of the social fabric of care is performed’ (p. 120).
Other forms of treatment that are discussed are often inextricably intertwined with the criminal justice system. While several chapters mention the effect that the criminalization of addiction has on its treatment, William Garriott’s eighth chapter goes into great detail on the subject. Studying the relationship between crime and methamphetamine addiction in rural West Virginia, Garriott discovered that certain addicts would actively attempt to get arrested in order to detoxify themselves for a few days due to a lack of other options. Also, the only treatment programme available in the area was one run out of the county jail, so the only way to be admitted was to be arrested. Garriott comes to the conclusion that ‘the association between drugs, crime, and addiction, though itself an artefact of U.S. drug control policies, has become a social fact in the United States’ (p. 215). Garriott discusses the inadequate efforts of the U.S. criminal justice system to properly address addiction, which ‘is often the root cause of many drug offenders’ criminality’ (p. 215).
Another rather surprising drug treatment methodology is outlined in Raikhel’s seventh chapter, ‘Placebos or Protheses for the Will: Trajectories of Alcoholism Treatment in Russia.’ The treatment plan and the ethical dilemma it presents seem to be uniquely Russian. In an effort to quell the rampant prevalence of alcoholism, patients are given an injection, pill, or implant of disulfiram (locally referred to as khimzashchita, which translates to ‘chemical protection’). While this chemical is present in the bloodstream, the body is unable to process alcohol. This can lead to violent illness and possibly death should the person imbibe during the treatment course. However, a good percentage of the people receiving this treatment are given a placebo instead of the active chemical. Many Russian psychiatrists remain under the shadow of their Soviet predecessors and their adherence to Pavlovian theories of behavioural modification.
Breaking with convention, Addiction Trajectories uses relevant ethnographic material to contextualise a wide range of addictive behaviours and (il)legal substances [if you think necessary add the following] rather than narrowly relying on a single example of addictive behaviour or substance (mis)use. Whereas many volumes will deal with addiction to only one class of substances or behaviours, Addiction Trajectories breaks away by discussing addiction to a wide range of illicit and legal substances, and even gambling. This book also does great credit to the field of medical anthropology by highlighting why a holistic, multi-layered perspective approach is important if health and wellbeing providers hope to understand, and thereby treat, addiction.
That’s not to say that the book is perfect. While alcoholism and drug abuse are the obvious choice, a wider range of discussion topics would have been welcome. Given the growing rates of obesity in the UK, US, and on the European continent, articles about compulsive eating would have been welcomed. Other sorts of behavioural addictions (sex addiction, compulsive shopping) were also conspicuously absent from this book. Perhaps the editors are planning a second volume. Such a book would be a welcome addition to a conversation that is fraught with political and social contentions.
Reviewed by Kyle W. West, a medical anthropologist and research assistant at UT Southwestern Medical Center in Dallas, TX. He is currently working on a study investigating clinical depression in patients with chronic kidney disease. He holds two degrees in anthropology (BA, MS) from the University of North Texas.
Correspondence to Kyle W. West.