Cravings make for one of the most challenging, baffling and terrifying aspects of addiction: no matter how devastating the consequences of ongoing drug use become for someone, as well as for those who love and care for them, no matter whether their addiction is no longer pleasurable, and no matter how adamantly they want and try to manage or stop their drug use, their attempts are continually overwhelmed by intensely motivating desires to engage in the addiction.
Moreover, not only do cravings play this intrusive role in active drug use, but these unwanted desires can arise and be highly motivating even years into recovery from addiction.A lot of medical and clinical thinking about addictive craving is driven by a certain neuroscientific picture that explains cravings in terms of the effects of drugs on the production of dopamine in the brain.
On this picture, the object of a craving is a drug itself or the pleasurable effects that getting high is expected to produce.
But, by focusing narrowly on the brain, this view misidentifies the object of craving in addiction, or at least puts too much emphasis on the chemical component.
When we look at the social and psychological factors that correlate with addiction, the real object of craving is made salient.
Understanding the object of addictive craving in this way helps to explain why cravings in addiction are so hard to resist.
As a result of the long-term effects of this learning process, drug cues can continue to trigger cravings even years after active drug use has stopped, thus the link between craving and relapse.
On this view, addictive cravings are desires for the high produced by drug ingestion.
Most drug use does not lead to addiction, even the drugs that are often considered ‘highly addictive’, such as cocaine.
Rates of recovery suggest that addictive cravings either stop or become easier to resist, given the correlation between drug craving and use as well as relapse.
We need to look beyond biological factors to find a complete answer to the questions at hand: why don’t addictive cravings impact all people who use drugs equally, and why do cravings seem to weaken or desist over time for many addicted people?To understand the puzzle of addictive craving, we need to think about what cravings are for.
A clue is that research shows the distinction between those who are most vulnerable and those who are least vulnerable to addiction strongly correlates with a range of social, economic and psychological factors.
These include structural factors such as poverty, unemployment, housing instability, incarceration, and lack of access to physical and mental healthcare services; and there are social factors as well, including adverse childhood experiences, mental health issues, stigma, prejudice, discrimination, and social exclusion.
Many factors are both social and structural, such as colonial violence, transphobia and homophobia.So how do these factors contribute to understanding addictive craving.
Ostensibly, the object of craving is a drug or the expected pleasurable effects of intoxication, but the desires driving ongoing addiction run deeper.
These emotional experiences themselves can become the objects of the desires driving addiction, and drugs are a vehicle to satisfy them, at least temporarily.
The desires to attain them through drug use, even in the face of consequences, reveal the social and structural conditions that characterise their absence.
Social factors (stigma and lack of supportive social relationships) and structural factors (discrimination and lack of access to mental healthcare services) constrain a person’s options for coping with the symptoms of mental illness, that is, for fulfilling the desires to alter these psychological states.A particularly devastating feature of addiction is that, while drug use can become a way of addressing psychological needs, addiction can simultaneously increase life instability and exacerbate barriers to social inclusion and access to services, as people who use drugs face stigma, community exclusion and institutional discrimination.From a social and structural perspective, addictive craving is not an involuntary switch but a strategy for coping with highly specific life experiences and conditions.
Which drugs and particular experiences of intoxication become enticing, the initial reasons for trying them out, the roles they play in social interactions, all reflect cultural context, social norms and personal history.
The powerful motivation of craving is determined not only by how drugs affect the dopaminergic system, but also by the social and structural conditions that inform these desires in an individual’s life.
According to the US National Institute on Drug Abuse, approximately 40-60 per cent of the variation in the population in risk factors for addiction can be accounted for by genetics.
Environmental factors play an important role in controlling the expression of genes, meaning that individuals’ genetic vulnerability to addiction depends on their circumstances.
Even where heritability is at play, this leaves open how genetics influence the unequal distribution of addictive cravings.
A social explanation of craving is not incompatible with evidence that genetics are a risk factor for addiction.How we think about addictive craving has impacts on how we think about addiction research, treatment and recovery, as well as how we think about the meaning of cravings beyond addiction.
What follows from viewing addictive craving through a social and structural lens.The neurobiological explanation of craving on its own is unequipped to answer questions about why the desires driving addiction in key moments manifest unequally across individuals, and why they are so hard to resist.
But more fruitful addiction neuroscience must do more than concede that social factors impact vulnerability to addiction.
Social factors need to be integrated into research on addictive craving.Given the role cravings play in addiction and relapse, craving can be a crucial target for addiction treatment and intervention?
If we view the strength of addictive cravings as primarily the result of how drugs affect an individual’s brain, then the most promising avenues for treatment would seem to be pharmacological interventions aimed at abstinence-based recovery, and therapies focused on individual strategies for coping with cravings.A more socially integrated explanation of craving affirms that treating addictive craving requires addressing the socioeconomic, structural and emotional conditions of individuals experiencing addiction?
Focusing narrowly on the brain to explain craving also misses the ways that the modern world is perfectly built for the desires driving addiction: capitalism, poverty, inaccessible healthcare, colonialism, the prison industrial complex, child abuse, an increasingly socially disconnected way of life.
A social view of craving promotes the perspective that addiction recovery isn’t just a personal health journey, it’s a collective struggle for social transformation.
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