The Clinical Concept of Opioid Addiction Since 1877: Still Wanting After All These Years

In 1877, the psychiatrist Edward Levinstein authored the first monograph on opioid addiction. The prevalence of opioid addiction prior to his publication had risen in several countries including England, France and Germany. He was the first to call it an illness, but doubted that it was a mental illness because the impairment of volition appeared to be restricted to opioid use: it was not pervasive, since it did not extend to other aspects of the individuals' life. While there has been huge progress in understanding the underlying neurobiological mechanisms, there has been little progress in the clinical psychopathology of addiction and in understanding how it relates to these neurobiological mechanisms. A focus on cravings has limited the exploration of other important aspects such as anosognosia and addiction-related behaviors like smuggling opioids into treatment and supporting the continued provision of co-patients. These behaviors are usually considered secondary reactions, but in clinical practice they appear to be central to addiction, indicating that an improved understanding of the complexity of the disorder is needed. We propose to consider an approach that takes into account the embodied, situated, dynamic, and phenomenological aspects of mental processes. Addiction in this context can be conceptualized as a habit, understood as a distributed network of mental, behavioral, and social processes, which not only shapes the addict's perceptions and actions, but also has a tendency to self-maintain. Such an approach may help to develop and integrate psychopathological and neurobiological research and practice of addictions.