ADDICTION AND ITS SCIENCES

doi:10.1111/j.1360-0443.2011.03723.x

Addiction and the science of history

David T. Courtwright
Department of History, University of North Florida, Jacksonville, FL, USA

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ABSTRACT Aims To discuss the contributions historians have made to the addiction eld, broadly construed to include licit and illicit drug use, drug policy, drug treatment and epidemiological and neuroscientic research. Methods Review of literature, highlighting specic contributions and controversies from recent research on the United States, the United Kingdom, China and world history. Findings and conclusions At the bar of addiction knowledge, historians make for excellent companionsuntil they turn quarrelsome. Historians companionability arises from their ability to tell a particularly rich kind of story, one that blends structure, agency and contingency in a contextualizing narrative. Historians occasional quarrelsomeness arises from their skepticism about the ascendant brain-disease paradigm, the medical and pharmaceutical establishments and the drug war, especially in its US incarnation. These enterprises have put some historians in a polemical frame of mind, raising doubts about the objectivity of their work and questions about the political orientation of historical scholarship (and, more generally, of social science research) in the eld. Keywords Addiction, drug policy, drug treatment, epidemiology, history, neuroscience.

Correspondence to: David T. Courtwright, Department of History, University of North Florida, 3 UNF Drive, Jacksonville, FL 32224-2645, USA. E-mail: dcourtwr@unf.edu Submitted 23 August 2011; initial review completed 17 October 2011; nal version accepted 10 November 2011

INTRODUCTION Historians do not usually think of themselves as scientists, let alone scientists allied to addiction researchers. Even so, history provides data, contextual knowledge and narrative syntheses for those who study addiction in more conventionally scientic disciplines. In some research areas, such as retrospective epidemiology or policy analysis, history is indispensible. Things are the way they are because they got that way, as any evolutionary biologist will attest. Understanding the present state of things requires understanding past events.

WHAT HISTORIANS DO Although historians gain knowledge about the past in many ways, their signature method is the location, close reading and interpretation of primary sources. Why, for example, did the US Supreme Court uphold the federal governments position that the ambiguously worded 1914 Harrison Narcotic Act forbade maintenance, the long-term supply of addicts with prescribed narcotics? Part of the answer can be found by unearthing the briefs government attorneys prepared for two crucial 1919
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cases. Both briefs exaggerated the prevalence of addiction and the threat it posed to the nation. Given that the Harrison Acts extension of federal police power was controversial and constitutionally convoluted; that the Court had previously ruled against government attempts to block maintenance; and that the vote was ve-to-four, it seems likely that the misinformation contributed to the outcome [1]. It seems likely and contributed to are modest and tentative formulations. This is necessarily so, because historians deal in retrodiction rather than prediction. They cannot test their ndings experimentally. No time machine permits us to dial up 1919, substitute amended briefs, and then observe whether the justices votes change. No statistical program can run a regression equation through their minds, calculating causal weights for the many variables in their decision processes. What historians can do, however, is amass enough information to give themselves and their readers an understanding of how historical actors saw evolving situations, with all their peculiarities and ambiguities, and why they acted as they did. The evidence behind such empathic explanations is cumulative and, in an important sense, veriable. How do we know that the justices
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confronted exaggerated claims? What evidence justies that adjective? The answer is that several contemporaneous reports, as well as correspondence between chagrined researchers, showed the government estimates of 750 0001 500 000 addicts to be impossibly high. Prevalence had been declining, rather than increasing, and had been doing so for years [1]. Historical claims may not be experimentally veriable, but they are objective in the sense that they emerge from corroborative evidence that can be conrmed by others. Historians look for patterns. They also look for litigation. Intellectual property lawsuits over amphetamine gave Nicolas Rasmussen the opportunity to show, in rare detail, how medical researchers and pharmaceutical companies developed and marketed the drug, turning quotidian problems into amphetamine-treatable medical conditions [2]. The tobacco litigation discovery process, and convenient internet access, gave Alan Brandt much of the material for The Cigarette Century (2007) [3], his monumental study of how tobacco companies addicted tens of millions of people world-wideand went on doing so after the emergence of damning health evidence. Rather than staring up at the Camel Man, Brandt wrote, I can examine his personal papersthe very contracts, plans, and letters that made him a reality. The Cigarette Century exemplies three of narrative historys cardinal virtues: efciency, readability and range. Efciency seems an odd compliment to bestow on a 600-page book, but Brandt distills thousands of scattered sources, from laboratory reports to marketing studies, into a single, gracefully written narrative that combines technology, culture, science and law with the decisions of key corporate, medical and political actors. His book serves double duty as the chronicle of a conicted, modernizing society and a history of drug usea feat duplicated in Alan Baumlers study of opium in the Chinese Republic and Robert Stephenss account of the Hamburg counterculture, Germans on Drugs [4,5]. In good history, everything is connected to everything else. What makes interwoven accounts possible is hindsight, the one advantage that historians enjoy over deadline-pressed journalists and prediction-oriented scientists. From Thucydides onwards, historians have grasped that the accumulation of evidence from different sources after the fact will reveal processes beyond the control, or even the knowledge, of the historical actors. To those who say that hindsight is always 20/20, the historian responds that there is nothing wrong with excellent vision. Consider again the question of maintenance. In 1880 most US addicts were middle-class women whose narcotic use was medical in origin. By 1920 most were lower- or working-class men whose use was non-medical
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in origin. Because the change occurred gradually and arose from multiple independent causes, contemporaries were not always aware of it; yet it affected policy, in so far as legislators and judges had previously shown no interest in criminalizing drug use by elderly morphine addicts. Junkies were another matter. We can now see that the demographic transformation of the addict population was a necessary, but not a sufcient, condition for the anti-maintenance policy, which also arose from decisions, ill-informed or otherwise, of elite historical actors such as the Supreme Court justices [1].

PROGRESS AND RECOGNITION Historical knowledge is thus cumulative. The perspective that comes with time, the opening of new archives and the growth of secondary literature adds continuously to the store of insight, making possible ambitious books such as Brandts or the international drug history and policy studies by Rudi Matthee, Kathryn Meyer and Terry Parssinen, William McAllister, Richard Davenport-Hines and Grifth Edwards [610]. The emergence of English as a common academic language has facilitated access to the secondary literature, as has the translation of such important works as Wolfgang Schivelbuschs Das Paradies, der Geschmack und die Vernunft [Tastes of Paradise: A Social History of Spices, Stimulants, and Intoxicants] and Pierre-Arnaud Chouvys Les Territoires de lOpium [Opium: Uncovering the Politics of the Poppy] [11,12]. It is now possible for an English-uent graduate student in any discipline, anywhere in the world, to gain, in a semesters reading, knowledge of the history of addictive substances beyond all but the most sophisticated scholars of a generation ago. The same graduate student would also learn something about addiction science. Although historians do not usually test theories in a formal way, their research often applies, and sometimes corroborates, ndings of social and natural scientists. Why, for example, did addiction become much more widespread during the 19th century, to the point that political elites began imposing market restrictions? The answer is complex, but would minimally include the expanded production and export of cheap spirits; the isolation and non-medical use of psychoactive alkaloids (morphine, cocaine); new means of consuming drugs (injecting narcotics, smoking cigarettes); and global migrations, such as those of indentured Indian and Chinese laborers, who introduced cannabis and smoking opium to new lands. What is striking about this list is how well it corresponds to the ndings of epidemiologists, economists and clinicians, namely, that exposure, price and mode of administration are crucial variables in the addiction process [13].
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HistoriansI include all serious researchers who apply the methods and insights of the discipline, not only history PhDshave also turned their attention to addiction research and treatment. They have given us classic accounts of the origins of the concept of alcoholism [14,15]. They have described the development of alcohol and drug treatment [16,17]. They have proled such seminal gures as Marie Nyswander and Jerry Jaffe [18,19]. They have described the rise of addiction as a medical and scientic eld [20,21]. They have recorded, transcribed and provided internet access to interviews with many of the elds leading gures [22]. Attention from historians is, like imitation, a sincere form of attery. The College on Problems of Drug Dependence (CPDD) has returned the attery in the form of media awards for Nancy Campbell, Brandt and other academic historians. CPDD has also honored journalist Michael Massing and economist Peter Reuter, both of whose works are deeply informed by history. All this prize-giving is of little moment to bench scientists working in wet laboratories and imaging centers. Like research into consciousness, pain or mental illness (broadly considered), the great intellectual divide in the addiction eld is between the reductivists and the nonreductivists. Those who are concerned only with nomothetic brain research, such as receptor pharmacology in experimental animals, will have little or no immediate use for the idiographic history that sociologists, ethnographers, economists and other social scientists nd valuable; yet the trend towards preserving and articulating the history of addiction science and treatment shows that there are at least some areas of common interest and potential collaboration between those in white coats and those in tweed.

scientist exhibit any awareness at all that the historical claims they were making were, at best, simplistic? [23] Or, at worst, erroneous. At some point the number and casualness of historical misstatements in a purportedly scientic book, such as Solomon Snyders Brainstorming, crosses the line from irritation to unconscious disciplinary insult [24]. The problem has a time-honored solution: hard work and accuracy. To avoid appearing foolish, scientists need to understand that history is the fruit of disciplined research, not something cobbled together from memory, oral tradition and prefaces from old journal articles. Historians, for their part, will gain credibility and insight by adding the new language of addiction neuroscience to the familiar languages of paradigms past. Historians, who are interested in the diachronic development of multiple scientic approaches, are multi-lingual in the classical languages of addiction; laboratory researchers, who are interested mainly in the synchronic elaboration of the current paradigm, are monolingual in their modern languageand blissfully unaware that it, too, will pass into the classics under the pressure of revision. Even so, historians should do their best to understand the latest dispensation. Veteran researchers such as Michael Kuhar have simplied the task by providing, in interdisciplinary conferences and journals, lucid surveys of basic science in the eld [25]. Such surveys are especially useful in addiction, where developments are occurring rapidly and issues of etiology and treatment remain tangled and complex. The words etiology and treatment connote disease, which raises another fundamental difference between historians and scientists: addiction as a pathological frame. Like most social scientists, historians study alcohol and other drugs in contexts other than those of addiction or disease. Tellingly, the name of their international association makes no mention of addiction. Founded in 1979 as the Alcohol and Temperance History Group (ATHG), the organization grew from a renaissance of historical studies of alcohol, which was itself part of a larger wave of new social history in the late 1960s and 1970s. There was a smaller but near-simultaneous revival of the historical study of narcotics and street drugs such as cannabis and cocaine. The informal alliance between the two groups of researchers became formal in 2004, when the ATHG renamed itself the Alcohol and Drugs History Society (ADHS). Specialists in licit psychoactive drugs, such as historian David Herzberg [26], have since become active in ADHS, whose 2011 conference was expansively entitled The Pub, the Street, and the Medicine Cabinet. ADHS members are concerned with addiction, in that addicts have long accounted for a disproportionate share
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TENSIONS Whatever common ground historians and addiction scientists have found, there are still some signicant tensions. One involves an unspoken double standard, which historian Joseph Gabriel described with unusual candor: Scientists often feel free to make historical claimsand in fact they often feel somewhat compelled tobut, at least in my experience, they really dont like it when historians try to make scientic ones. Historians, for our part, generally dont feel comfortable making scientic claims at all, and when we do we generally do so with a lot of apologiesdisqualiers of the now, Im not a neuroscientist . . . type. But when was the last time you heard a scientist apologize for not being a historian? When was the last time you saw a
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of alcohol and drug consumption, prots, taxes and social costs. Without addictions pathos and urgency, alcohol and drug history probably would not have coalesced into a specialty with its own organization and journal. However, in absolute terms, compulsive users never made up more than a minority of all users. Alcohol and other drugs played multiple, often positive social rolesas markers of identity, occasions of conviviality, talismans of faiththat had little to do with addiction. ADHS members, whose meetings are conspicuously catholic affairs, assume neither a common interest in addiction nor, for that matter, common training. They lack the equivalent of a fellowship in addiction medicine. They also lack allegiance to the NIDA paradigm, shorthand for the scientic model of addiction as a chronic, relapsing brain disease with a social and genetic component, signicant comorbidity with other mental and physical disorders, long-term changes in brain structure and function visible in imaging studies, and a dening loss of control over drug craving, seeking and use despite adverse consequences. Emanating from researchers at the National Institute on Drug Abuse (NIDA), this paradigm currently dominates, and may one day unify, scientic work in the addiction eld. Researchers, and journalists who popularize their ndings, now routinely describe compulsive behaviors involving gambling, sex, shopping and eating as addictions. These claims are more than metaphorical. Imaging studies have shown that drug and behavioral addictions activate the same neural pathways. Epidemiological and genetic studies have found that compulsive gamblers are more prone to alcohol and drug abuse. Clinical studies have revealed that narcotic antagonists can reduce compulsive gambling and viewing of pornography, evidently by limiting these activities capacity to augment dopamine release. In the NIDA paradigm all addiction is, in the words of psychiatrists Michael Bostwick and Jeffrey Bucci, an acquired malfunctioning of the brains reward center [27,28]. Historians have found much evidence that vices, as they were once called, were linked spatially and conceptually. Gamblers ocked to bars. Prostitutes and their customers drank liquor and snorted cocaine. Chinatown revelers found opium dens, brothels and gambling parlors in the same teeming quarter, a stones throw from the pawnbrokers. Victorian reformers regarded vices as a constellation of ruinous behaviors, all of which they sought to discourage or suppress [29]. However, historians are loath to concede the neural and genetic commonalities of these same behaviors. The brain-disease paradigm appears to be an oldfashioned monistic pathology wearing the fashionable garb of neuroscience [30]. It strikes them (and many other social scientists) as crudely reductive because it
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ignores that which cannot be illumined with positrons or studied in neurons. It seems irrelevant because it sheds no light on culturally specic phenomena. It seems threatening because it gains all the funding and media attention. It seems intellectually reactionary because it evokes biological essentialism and naive positivism. It may even be politically reactionary because it lends, inadvertently and despite the medicalizing intentions of its proponents, the prestige of science to supply-side drug warriors bent on keeping everyones fragile brains out of the sizzling drug grease [27]. In The Cult of Pharmacology, Richard DeGrandpre marshals these grievances and more in his retelling of the story of how America became the worlds most troubled drug culture. Drawing selectively on history, as well as on such critics as psychologist Bruce Alexander and physician-ethnobotanist Andrew Weil, DeGrandpre indicts the brain-disease model as a prop of pharmacologicalism. This is his term for the largely arbitrary, socially clueless and highly protable division of the pharmacopeia into angel drugs on which we spend billions for prescriptions and devil drugs on which we spend billions for futile suppression. Among former NIDA directors, DeGrandpre has some angels and devils of his own. The late Bob Schuster has wings. Alan Leschner has horns [31].

OPPOSITIONAL SCHOLARSHIP The Cult of Pharmacology exemplies what historiographers call oppositional histories, works that are highly critical of the status quo and that favor radical change. They occupy the left end of an ideological spectrum that runs from oppositional to accommodationist (i.e. mildly reformist) to dominant (i.e. conservative) views [32]. In a discipline in which left-liberal views are commonplace, virtually any political or social subject can prompt an oppositional response; but they arise most often when the subject involves morally charged policy questions or claims about the biological determinants of behavior. Americas punitive drug policy and high-prole addiction research programs have made for especially tempting targets. For much of the mid-20th century, authors such as Alfred Lindesmith, Rufus King and Edward Brecher treated history as a sort of munitions dump where they might nd the means of exploding prejudicial ideas and unjust policies [3335]. Then, beginning in the 1970s, historians such as David Musto, Wayne Morgan, Jill Jonnes, Joseph Spillane, Timothy Hickman and Eric Schneider published new, conspicuously professional histories [3641]. Although these works were accommodationist to a lesser or greater degree, they provided empathic narratives based on primary sources. Their authors, all of whom had graduate training in history,
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ground no axes, or none so conspicuous that readers might doubt their selection and handling of evidence. (Social psychologist Robert MacCoun and economist Peter Reuter displayed similar circumspection in Drug War Heresies: Learning from Other Vices, Times, and Places, a widely read hybrid of comparative policy analysis and history that used past experience of vice regulation to guardedly support such heresies as cannabis depenalization [42].) The new accommodationist scholarship merely counterbalanced the older polemical tradition. It did not replace it, as books such as those of DeGrandpre [31] or Arthur Benavie [43] continued to roll off the presses. Recent drug-history literature in the United Kingdom follows a similar pattern. Virginia Berridges Opium and the People [44] and Alex Molds Heroin [45] are straightforward narratives, measured in tone. Grifth Edwardss Matters of Substance [10], a medical and historical tour dhorizon with a coda of policy suggestions, is more explicitly accommodationist. Davenport-Hiness The Pursuit of Oblivion [9], Gargi Bhattacharyyas Trafck [46] and Toby Seddons Foucauldian A History of Drugs [47] are all frankly oppositional works. The same spectrum runs throughout Chinese drug history. Here the stakes are particularly high, as all historians agree that the Chinese opium situation motivated international efforts to curtail the drug trafc in the late 19th and early 20th centuries. Historians do not, however, agree on how serious the Chinese problem was or whether it warranted strong prohibitory medicine. Carl Trocki [48], who uses words such as plague or bane to describe the drugs impact in China and other Asian lands, argues that opium enabled Europeans to create a vast empire and to exploit Asian consumers and laborers. Although he concedes that Qing China had many underlying problems, his damage narrative is consistent with that of the nationalists, missionaries, physicians and diplomats who sought to suppress the trafc. The same could not be said of Frank Diktter, Lars Laamann and Zhou Xun, who deny that China was Patient Zero in a global drug plague [49,50]. They condemn as counterproductive (and sometimes murderous) the 20th-century drug wars inicted within and without China. Opium was, if not quite harmless, then a popular, multi-purpose drug used in social contexts other than compulsion and degradationan interpretation consistent with work by Richard Newman [51] and Zheng Yangwen [52]. Broadly speaking, the more a historian doubts or qualies the extent of past addiction and other drug-related harms, the more likely he or she is to criticize prohibitionist regimes. The same is true of social scientists, save that oppositional scholars in disciplines such as sociology or criminology argue typically that current drug problems are
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exaggerated and/or by-products of suppression. Thus Tom Decorte writes that captive samples in prisons and treatment programs blind authorities to the extent of controlled drug use, which is made more difcult by their imposition of prohibition regimes [53]. Anthropologist Phillipe Bourgois describes vividly the self-destructive behavior of homeless street addicts, but presents them as victims of social neglect and structural change whose lives are worsened, not improved, by law enforcement [54]. Unsurprisingly, when oppositional social scientists evoke history, they most often cite the works of oppositional historians with whom they are simpatico. As in Middle Eastern politics, the enemy of my enemy is my friend. If it is natural for controversial subjects such as drug policy to produce oppositional scholarship, it is also natural for such scholarship to breed a measure of distrust and confusion. While a single polemic can be bracing, a dozen can color the perception of an entire eld: guilt by association. The value of history to policy analysts and addiction scientistsor even the likelihood that they will bother to read itdiminishes in proportion to their perception that it is politicized or dismissive of cutting-edge research. The danger is that the addiction eld will become a grotesque caricature of C. P. Snows two cultures [55]. Neuroscientists will dismiss historiansin fact, all non-quantitative social scientistsas naive leftists and neurochemical Luddites. The compliment will be returned in renewed charges of scientic arrogance and indifference to the addictions real-world contexts. While we have not yet reached such an impasse, I worry that mutual distrust and incomprehension will end the tenuous cross-fertilization between scientists and historians concerned with addiction. That would be an irony as well as a shame, forthis is the nub of my essayboth of their enterprises have ourished in the last four decades. We know more than ever about addictive processes that occur inside the brain. We know more than ever about addictive processes, past and present, that occur outside the brain. The chance to put that knowledge together represents, perhaps more for historians and social scientists than for bench-bound researchers, an ungrasped intellectual opportunity. Declaration of interests None. Acknowledgements The author thanks Nancy Campbell, Claire Clark, Andrew Courtwright, Shelby Miller, Joseph Spillane and Nicolas Rasmussen for commenting on a preliminary draft.
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