Research paperAddiction screening and diagnostic tools: ‘Refuting’ and ‘unmasking’ claims to legitimacy
Introduction
Human practices of all kinds – substance use, gambling, sex, even eating – are increasingly being reframed through the language of addiction. This ‘addicting’ (Fraser, Moore & Keane, 2014) of contemporary society is achieved, in part, through the standardised screening and diagnostic questionnaires (hereafter referred to as ‘tools’) intended to identify and measure addiction. Critical public health and science studies scholars have argued that diseases, including addiction, are constituted through the scientific knowledge-making processes used to identify, measure and diagnose them (Duffin, 2005, Fraser et al., 2014, Mol, 2002). Addiction screening and diagnostic tools are a key element in the expert knowledge-making through which realities of addiction emerge. Promoted as accurate and objective, the tools are given legitimacy and authority through application of scientific validation techniques. In this article, we critically examine the operations of these validation techniques as applied to substance addiction tools. Doing so is of pressing importance because the knowledges produced via tools carry with them important political implications. They contribute to influential statements about substance users and ‘addicts’, are used to justify public policies and programs and directly inform decisions about resource distribution and service delivery.
We begin with a background section with three parts. First we conduct a brief review of critical literature on addiction tools and on addiction diagnosis, identifying a need for further work in this area. We then outline the objectivity and accuracy claims made about the tools and discuss the statistical techniques of ‘validity’ and ‘reliability’ testing that are deployed to legitimate these claims. This is followed with a discussion of our theoretical approach and methods. The second section of the article presents our analysis of the validation processes applied to the tools, which we structure using Hacking's (1999, pp. 53–4) concepts of ‘refuting’ and ‘unmasking’. Developed by Hacking to perform specific analytical tasks, these two terms have a particular purpose in this article. In the ‘Refuting’ section we consider the validation processes on their own terms, identifying contradictory claims, weak findings and inconsistent application of methodological standards. In the ‘Unmasking’ section we go further, critically analysing validation as a concept in itself. Here we identify two fundamental problems with the validation processes: symptom learning and feedback effects; and circularity and assumptions of independence and objectivity. Our analysis also highlights the extra-theoretical functions and effects of the tools. In concluding, we consider some of the effects of the processes we identify, for the meanings ascribed to addiction, the forms it is said to take and the individuals it is thought to affect. We close by noting that our critique raises pressing questions about the effects of these tools, the politically loaded categories they create and legitimise, and the justifiability of the ‘kinds’ (Hacking, 1998) of persons they produce.
Section snippets
Background
To date the validity and reliability claims made about the tools have received little examination from a critical social science perspective. Room (2006) raises important questions about validity when he points out the differential cross-cultural performance of addiction tools. He draws attention to the cross-cultural variation in interpretations and meanings of individual tool items, as well as in underlying concepts of intoxication, harmful use and addiction. Midanik, Greenfield and Bond
Method
As noted, the analysis in this article proceeds from our broader project examining addiction screening and diagnostic tools (for further detail see Dwyer & Fraser, forthcoming). For this article, we confine our analysis to four key alcohol tools. We focus on alcohol tools in contrast to tools aimed at screening and diagnosing addictions to other substances for several reasons. Firstly, more alcohol tools have been developed. Secondly, the uptake of alcohol screening tools is strongly encouraged
Analysis
The validity and reliability of these tools is widely promoted in the scientific literature aiming to characterise and quantify alcoholism or alcohol addiction. But what precisely is the basis for these claims? In this section, we examine the operations and logics of the validation processes, asking how sound they are. Our argument here is in two parts, representing the two stages of our analysis, refuting and unmasking. In the first part, ‘Refuting’, we assess the validation processes on their
Conclusion
Screening and diagnostic tools for addiction (or alcoholism) have considerable potential to shape subjectivities, introduce or alleviate stigma, and direct resources – in short, to ‘make up’ people, communities and societies. They are fundamental building blocks in the process of ‘addicting’ currently at work in the West (Fraser et al., 2014): in all we know about what constitutes addiction, who experiences addiction problems, where they are located, how they may be engaged, and how widespread
Acknowledgements
The research on which this article was based was supported by an Australian Research Council Future Fellowship (FT120100215). The National Drug Research Institute receives core funding from the Australian Government Department of Health and Ageing. This article was prepared with assistance from Adrian Farrugia, who contributed to the collection of the addiction screening and diagnostic tools and supporting scientific literature.
Conflict of interest
We wish to confirm that there are no known
References (66)
- et al.
Conjoint screening questionnaires for alcohol and drug abuse
Wisconsin Medical Journal
(1995) - et al.
Psychometric properties of alcohol screening tests in the emergency department in Argentina
Mexico and the United States. Addictive Behaviors
(2010) Validity and reliability of the Michigan Alcoholism Screening Test: A review
Drug and Alcohol Dependence
(1983)- et al.
Relative performance of the MAST, VAST, and CAGE versus DSM-III-R criteria for alcohol dependence
Journal of Clinical Epidemiology
(1993) The drug abuse screening test
Addictive Behaviors
(1982)- et al.
Screening properties of questionnaires and laboratory tests for the detection of alcohol abuse or dependence in a general practice population
British Journal of General Practice
(2001) - et al.
Assessing alcohol problems. A guide for clinicians and researchers
(2003) - et al.
Statistics notes: Diagnostic tests 1: Sensitivity and specificity
British Medical Journal
(1994) - et al.
Statistics notes: Diagnostics tests 2: Predictive values
British Medical Journal
(1994) Diagnostic and Statistical Manual of mental disorders DSM-IV-TR
(2000)
The psychometric properties of the composite international diagnostic interview
Social Psychiatry and Psychiatric Epidemiology
AUDIT. The Alcohol Use Disorders Identification Test. Guidelines for use in primary care
Evaluation of the Drug Use Disorders Identification Test (DUDIT) in criminal justice and detoxification settings and in a Swedish population sample
European Addiction Research
The Alcohol Use Disorders Identification Test for detecting at-risk drinking: A systematic review and meta-analysis
Journal of Studies on Alcohol and Drugs
Scripting addiction: The politics of therapeutic talk and American sobriety
Brief screening instruments for alcoholism
Alcohol Health & Research World
A critical evaluation of several alcohol screening instruments using the CIDI-SAM as a criterion measure
Alcoholism: Clinical and Experimental Research
Alcohol Use Disorders Identification Test (AUDIT): An updated systematic review of psychometric properties
Psychology & Neuroscience
Systematic reviews of evaluations of diagnostic and screening tests
BMJ
Alcohol and drug treatment services. Fact sheet: Screening for complexity
The CAGE questionnaire for alcohol misuse. A review of reliability and validity studies
Clinical and Investigative Medicine
Lovers and livers. Disease concepts in history. The 2002 Joanne Goodman lectures
Making addiction in screening and diagnostic tools used in AOD and other health settings
Detecting alcoholism. The CAGE questionnaire
JAMA
Screening for alcohol problems in primary care: A systematic review
Archives of Internal Medicine
Beyond the ‘potsherd’. The role of injecting drug use-related stigma in shaping hepatitis C
A thousand contradictory ways: Addiction, neuroscience, and expert autobiography
Contemporary Drug Problems
Habits: Remaking addiction
Making disease, making citizens. The politics of hepatitis C
Substance and substitution: Methadone subjects in liberal societies
Social constructionist contributions to critiques of psychiatric diagnosis and classification
Feminism and Psychology
Guidelines for the treatment of alcohol problems
Cited by (14)
Making multiple ‘online counsellings’ through policy practice: an evidence-making intervention approach
2018, International Journal of Drug PolicyCitation Excerpt :Such discourses assume that an intervention will have a singular, predictable effect if implemented correctly, such that promises can be made about an intervention’s likely effectiveness prior to its implementation on the basis of evidence generated in other intervention contexts. However, several scholars have critiqued the assertion that AOD clinical tools and interventions are stable objects with predictable effects through critically-informed empirical analyses of, for instance, the implementation and use of AOD diagnostic and outcome monitoring tools (Dwyer & Fraser, 2015; Dwyer & Fraser, 2017; Savic & Fomiatti, 2016), online AOD screening and automated feedback interventions (Savic, Barker, Hunter & Lubman, 2016), and methadone (Rhodes et al., 2016; Fraser, Moore, & Keane, 2014; Fraser & valentine, 2008). This body of work illustrates that clinical tools and interventions are not stable or singular but are made (and made multiply) through their interaction with networks of other human and non-human actors in local contexts.
“What constitutes a ‘problem’?” Producing ‘alcohol problems’ through online counselling encounters
2017, International Journal of Drug PolicyEngendering drug problems: Materialising gender in the DUDIT and other screening and diagnostic ‘apparatuses’
2017, International Journal of Drug PolicyCitation Excerpt :As we have argued elsewhere, knowledges produced by these tools are used to justify public policies and programs and direct resource allocations and service delivery. Tools also have considerable potential to shape subjectivities and to influence people’s encounters with social services, the law and other regulatory agencies (Dwyer & Fraser, 2015, 2016). Drawing on science and technology studies (STS), which proposes that expert-knowledge making practices produce realities, rather than merely investigating them (Fraser, Moore, & Keane, 2014; Law & Mol, 2002), we have elsewhere explored how the logics and assumptions embedded in addiction screening and diagnostic tools work to constitute and stabilise particular realities of addiction (Dwyer & Fraser, 2016).
The future of ‘addiction’: Critique and composition
2017, International Journal of Drug PolicyChallenging the addiction/health binary with assemblage thinking: An analysis of consumer accounts
2017, International Journal of Drug PolicyCitation Excerpt :The major international tools currently being used to screen for and diagnose ‘addiction’ (or dependence or disorder) have also been the subject of recent critique. Dwyer and Fraser (2015) deconstruct the validation processes used to establish the legitimacy of addiction screening and diagnostic tools as well as question their claims to independence and objectivity. In a related analysis, the same authors interrogate the logics and assumptions of such tools and argue that they ‘work to establish, standardise and reify addiction as an independent, pre-existing affliction located in individuals’ (Dwyer & Fraser, 2016: 1).