PART I The Nature of the Opiate Habit

CHAPTER 8 CONCLUSIONS,IMPLICATIONS, PROBLEMS

It has been argued that the power of the opiate habit is derived basically from effects which follow when the drug is removed rather than upon any positive effects which its presence in the body produces. Addiction occurs only when opiates are used to alleviate withdrawal distress, after this distress has been properly understood or interpreted, that is to say, after it has been represented to the individual in terms of the linguistic symbols and cultural patterns which have grown up around the opiate habit. If the individual fails to conceive of his distress as withdrawal distress brought about by the absence of opiates, be does not become addicted, but, if be does, addiction is quickly and permanently established through further use of the drug. Evidence from a wide variety of sources seems uniformly to confirm this conclusion. Data concerning the habit which from other points of view appear paradoxical or contradictory fall into place as logically necessary consequences of the position.

The theory furnishes a relatively simple account of the experience in which the craving for drugs is generated. When this experience is more closely considered, the essential, universal, or common features of addiction can be traced from it in a readily intelligible way. The theory seems to flow from the data and at the same time to make sense of it, even of that part of the data which is constituted by what addicts say. There is, for instance, no need to attribute euphoric effects to the user which the latter denies experiencing, and there is no need for the hackneyed excuse that addicts are unreliable witnesses. In fact, the point of view explicitly developed here can be shown to be implicit in the addict's own special language.

The individual's interpretation of withdrawal distress is a belief or attitude that exists as a cultural and psychological phenomenon. It tends to be imposed upon the addict by his social environment. The crucial fact about it is not is validity, but that the individual, once having accepted it, is subject to influences and social pressures of which he was previously unaware. The attitudes he assumes toward himself are altered. He realizes for the first time that be may be a "dope fiend," and in the privacy of his own thoughts he begins to entertain tentatively that idea of himself and to explore its implications. Further experience with the drug quickly impresses him with the truth of his notion, and be is soon compelled to accept it, though be usually struggles for some time and makes fruitless efforts to free himself. During this time the person is transformed from a non-addict to an addict with all that that implies.

The essential process involved in this transformation and basic to it is a linguistic and conceptual one. It is through the use of the social symbols of language in conversation with himself and with others that the personality changes involved in becoming an addict are initiated and developed. The individual, when be uses the symbols which society provides him, also assumes the attitudes appropriate to those symbols when be applies them to himself. He calls himself a "dope fiend" and gradually hardens himself to the fact that he has become an outcast and a pariah to respectable people. He of necessity seeks the company of other addicts, both because they can help to solve the problems arising out of addiction and because he feels more at home with them. He attempts to quit because be accepts the general public disapproval of addiction and wishes to remove himself from the pariah category. It is this whole process which George Herbert Mead has described as "taking the role of the generalized other" or assuming toward oneself the attitudes of the group or society in which one lives.(1)

The development of addiction presupposes in the individual a complex conception of causality. He must be able to understand and believe that the way he feels at a given moment is due to the presence in his body of a minute quantity of drugs taken many hours earlier. The effects of morphine are subtle and often difficult to detect. A person who is not aware that he is under the influence of the drug often thinks that he is perfectly normal. The association between the effects of the drug and the drug itself is therefore a perception which has to be learned. It involves the association of events which occur separately with a considerable time interval between them. The understanding of withdrawal symptoms is even more complex, since it involves grasping the connection between the interruption of a series of injections and the distress that follows several hours later. It also involves reasoning which is contrary to the ordinary. When a person suddenly becomes ill he usually assumes that a foreign substance has been introduced into his body, not that one has been removed.

A person to whom the drug is given without his knowledge does not feel the buoyant sensations because the opiate's effects in small doses are not unusual enough to produce such a response. But it is evident that the buoyancy can be so interpreted to an ignorant user, and, by virtue of this explanation, he can learn to feel buoyed up with a shot. In order that the explanation may acquire meaning, however, the individual must appreciate the causal sequence that associates his sensations at a given moment with a series of preceding injections. it may be concluded, then, that only those to whom the drug's effects can be explained develop addiction. It has been shown that in many cases the beginning of addiction was marked by an addict's or physician's explanation of the significance of the withdrawal distress. On the other band, patients experiencing withdrawal distress without understanding its connection with opiates, because the connection was not pointed out, escaped addiction. It may, therefore, be concluded that the immunity of the insane, idiots, and young children who may have taken morphine is based upon a feature common to all, namely, that the meaning of withdrawal symptoms cannot be explained to them.

The inexperienced non-addict fails to recognize the long-range effects of the first injection or to associate them with the immediate effect; hence be neglects, at first, to connect the withdrawal distress with prior use of the drug. Each aspect of opiate usage first appears as an isolated occurrence and is responded to in that way. When the withdrawal distress, the injection, and the drug's effects have been united into a single conceptual scheme, the individual no longer reacts to them separately but sees them as an integrated whole, one reaction implying or symbolizing the others. Withdrawal symptoms signify the need of an injection and are identified with the desire for it. The conceptualization of these events not only puts the various parts into relationship with each other but also relates them to the individual's self and to the culture of the group.

It is evident that the drug addict assumes the group's viewpoint with respect to his experience of withdrawal distress by virtue of the fact that, prior to addiction, be has been a non addict and a participating member of society. In view of the very use of language symbols, in terms of which the processes of reevaluation which constitute addiction proceed, the addict necessarily shares the traditional heritage which includes knowledge of, and attitudes toward, the drug habit. Prior to addiction addicts acquire the attitudes of non-addicts, and when they become addicted they must adjust themselves to these attitudes. In other words, as my theory emphasizes, addiction presupposes life in its organized society. Children and animals cannot become addicts because they lack the ability to use and respond to the complex linguistic structures which have grown up in human society.

It is interesting to ask at what point a child can become an addict. Infants of 1 or 9 certainly do not become addicted, but a youth of 15 can. At what age does immunity end and why? Only one case which appears to have some bearing on this question was found in the literature of the subject. This involved an infant to whom opiates bad been given from birth. Withdrawal symptoms had occurred during the first few days of extra uterine life, the mother having been addicted during pregnancy. The drug was withdrawn gradually when the child was 12 years old, and, as far as is known, he did not exhibit the usual tendency to relapse. (2) It is impossible to form an exact conception of the special factors involved in this case because of the meagerness of the data. The work of R. N. Chopra, who demonstrated that the feeding of opium to infants for the first three years of their lives was unrelated to addiction during adulthood, shows that 3-year-olds cannot be regarded as addicts. (3)

The question may be raised whether the cases in which the drug was continually used from birth do not constitute an exception to the assertion that the addict must belong to a social group before becoming addicted. It is evident, since the 3-year-old cannot be called an addict in our sense of the term, that the child who receives the drug continuously from birth would become an addict only with increasing participation in the culture of his group. The developing concepts of self and of causality and the growing appreciation of and the ability to use language are all involved in the normal development of a child; they are also implicated, as already shown, in the process of addiction.

Jean Piaget, describing some aspects of the mental development of children, writes: "Originally the child puts the whole content of consciousness in the world and draws no distinction between the 'I' and the external world. Above all we mean that the constitution of the idea of reality presupposes a progressive splitting up of this protoplasmic consciousness into two complementary universes-the objective universe and the subjective. "(4) Piaget discusses the influence of the progressive differentiation of the subjective and objective upon the child's ideas of physical causality and concludes:

In the course of our studies in child psychology we had expectedto fix upon 7-8 as the age before which no genuinely physical explanation could be given of natural phenomena. Our present inquiry entirely confirms this expectation. After 7-8 the more positive forms of causality gradually supplant the others, and we can say that at the age of about 1 1 12 the evolution is completed. There is therefore, in the domain peculiar to causality, a process of evolution exactly similar to that to which we drew attention in speaking of reality: confusion of the self and the universe, then progressive separation with objectification of the causal sequences.... It is only after having assimilated the activity of external bodies to his own muscular activity that the child turns the new-made instrument upon himself and, thanks to it, becomes conscious of his internal experience.(5)

In view of Piaget's description of a child's developing conceptions of causality, the immunity of children to addiction, the apparently permanent cure of a 12-year-old who bad been given drugs from birth, and the complete absence of addiction in young persons below the age of ten years or thereabouts, are not accidental circumstances but exactly what one would expect.

It is of considerable interest and significance that, during the last fifteen or so years, there has been considerable experimental work with rats and monkeys that has seemed to a number of investigators to confirm the idea that the book in opiates is derived from the experience of relief of withdrawal distress, that is, from negative reinforcement. This convergence of views is notable in that it includes persons of very different professional and ideological commitments, such as sociologists, psychologists, and pharmacologists. The experimental findings with lower animals may be summarized with respect to the theoretical position outlined here by saying that they seem to indicate, insofar as animals are capable of responding to opiates as human subjects do, that the similarity is produced by the same basic mechanisms but in a simpler form. In other words, in so far as rats and monkeys can be hooked on drugs, the processes of their becoming so follow the same patterns as in human subjects.

A point of controversy is the question of how far lower animals can go in duplicating human responses. This question is part of the broader question of man's special place in the animal kingdom, his extraordinary intellectual capacities, and his possession of language. Complex human responses, it is argued, are mediated by language symbols, by ideas or concepts. The significance of a stimulus or situation is not inherent and fixed, but is determined by the way in which it is perceived or conceived. Applied to addiction, these ideas suggest that the effects of drugs on behavior would be expected to depend on how they were understood and interpreted.

Man's possession of language and conceptual thought also enables him to organize and integrate his responses on a more complex level than is the case with lower animals.

Human addiction, unlike the reactions of lower animals, is a cultural or societal phenomenon. It becomes that when the person understands or grasps conceptually what is happening to him and identifies himself as an addict. When the raw biological and pharmacological events are conceptually elaborated they enter into relationships with other conceptual processes, such as conceptions of self and those connected with laws, rules, morality, punishment, and guilt. The complexities of addiction behavior which arise from the 'Cultural nature of man and the fact that he is the only language-manipulating animal are naturally not found in rats and monkeys.

Addicting and Non-addicting Drugs

The drugs designated as addicting, such as barbiturates, opiates, and alcohol, share the characteristic feature that all produce physical dependence and withdrawal distress. Non-addicting drugs, such as LSD, marihuana, cocaine, and others, do not involve these features. Confusion arises from the fact that there are persons who use non-addicting drugs regularly just as there are persons who use addicting drugs irregularly.

What is implied by the preceding analysis is that the attachments to these two types of substances are qualitatively different and are established in two very different ways. In the case of addicting drugs, we have argued that it is the push of withdrawal distress that fixes the habit; in the case of the non-addicting subtances it is the pull of positive pleasure that motivates use. While the opiate addict says be takes the drug to feel normal, the users of LSD and marihuana obviously take these substances to feel other than normal. While opiate addicts under certain circumstances can be deceived about whether they are under the drug's influence, it is inconceivable that an experienced LSD user could take a trip without knowing it or be sent on a trip with a placebo. In the language of reinforcement theory, one may suggest, therefore, that the powerful habits connected with addicting drugs are established by the mechanisms of negative reinforcement, while the weaker habits connected with non-addicting drugs are based on those of positive reinforcement.

From considerations of this kind it is reasonable to suppose that other addictions, such as those involving barbiturates and alcohol, follow the same pattern and involve essentially the same mechanisms as opiate addiction. This point has been made explicitly by Bales with respect to alcoholism.(6) Hebb has argued that there is addiction. to -food and that the mechanisms that establish this necessary form of addiction may be the same as those of opiate addiction. Withdrawal distress in this case is called hunger. As with opiates, the child is taught to recognize the symptoms and what to do about them. As the individual increases in sophistication, hunger ceases to be the almost purely biological matter that it is at birth and becomes a conceptually and socially controlled process that is linked in intricate ways with other higher cortical functions. As in the case of opium, deprivation or prolonged suffering from hunger and undernourishment intensify the craving and lead to overindulgence when the opportunity offers itself. just as the symptoms of opiate withdrawal and the desire for opiates are identified with each other by the drug user, so also is the word "hunger" used to refer both to a bodily condition and to a desire for food, which is sometimes linked with the bodily condition and sometimes not.(7)

There are substances like' The vitamins, which produce withdrawal symptoms when they are withdrawn, but which do not generate a craving and do not produce an immediately identifiable impact or kick when they are injected. One may speculate that, if the symptoms of severe vitamin deficiency were relieved immediately and dramatically by taking the vitamin, a psychological dependence or craving for such substances might be developed. Conversely, if the symptoms of opiate withdrawal vanished only very gradually over a considerable time period after a shot, it may be supposed that no craving would be produced. Speculations of this kind raise questions as to what the timing must be in the relief of distress of this sort for the subject to experience it as euphoria.

Psychoses and Addiction

The contention that addiction requires a relatively normal cognitive ability sufficient to understand withdrawal symptoms or to grasp a proffered explanation of them implies that full-fledged psychotics with seriously disturbed cognitive processes should be immune to addiction. Pertinent observations by physicians concerning this point may be cited. Sceleth and Kuh, for example, remarked:

Several hundred patients suffering from the depressed stage of manic depressive insanity were given large doses of opium orally in many instances for periods of from six months to one year. Not one of these patients ever knew what drug he was taking or ever showed any untoward results when it was withdrawn, or in any other way gave evidence of a desire to continue its use. Nor do we recall a single instance recorded in the medical literature of the period during which this form of treatment was administered quite commonly, in which either withdrawal symptoms or a craving for narcotics was reported. This is significant in view of the idea that manic depressive insanity is based on an inherited unstable nervous system.(8)

Dr. Paul Wolff, formerly of Germany, reported the answers to the following question, which was asked of many leading German medical men: "When is the prescription of opium justified?" Three of those who replied referred incidentally to the absence of addiction among psychotics. Dr. Wolff concluded:

Opium is indispensable in dealing with the fear states of the melancholic individual. But here we make the surprising discovery that the continued administration of opium, in the form of opium tincture, during the melancholic mental disturbances, even when continued over a long period of time does not produce drug addiction. That is, it does not, provided the dosage is adapted to the diseased mental state of the patient and provided that the doctor is careful to withdraw the drug at the correct time, as soon as he notes a decrease in the fear tension or excitement of the psychotic patient. In the last three and one-half decades I have seen a number of cases of morphine addiction develop as a consequence of the over-hasty application of morphine in physical distress or disease, but do not recall one single instance in which the administration of scopolaminemorphine during a psychosis led to a craving which lasted beyond the period of the illness."(9)

Dr. Emil Bratz, director of the Berlin Sanitarium, replying to Dr. Wolff's questionnaire, made the following observation on this question, recommending morphine for use in case of depression and for endogenous psychoses:

... but also only in endogenous, that is in simple or periodic melancholia arising from a constitutional basis, and even then it should be administered only by an experienced neurologist. Warning must be issued against the administratiorr of opiate preparations in cases of reactive depression in psychopaths-that is, depression in response to the vicissitudes of life. In these cases, it leads with especial ease to the development of addiction.(10)

Professor Karl Bonhoeffer stated:

Opium is indispensable in many cases of endogenous depressions. . The prescription of opiates for states of depression is unobjectionable also because we know from experience that the depressed persons feel no need for narcotics when the depression has passed away, and practically never become addicts."(11)

These medical opinions clearly suggest that - the individual who is isolated from society by certain kinds of mental disease is immune to addiction. It is especially significant that some of the authorities insisted upon the distinction between "endogenous" depressions and those brought about, as Bratz said, by "the vicissitudes of life." The latter, it is indicated, are associated with susceptibility to addiction, the former with immunity.

Marginal Patterns

Reference has already been made to patterns of drug dependence among patients in medical practice in which the individual does not identify himself as an addict even though he is not altogether ignorant of his actual situation. Between the patient who has no idea what drug he is receiving and knows nothing of withdrawal and physical dependence and one who becomes addicted in the ordinary and usual sense, there is evidently a range of.
variation which has been inadequately investigated. In the case of the drug-dependent person who defines himself as a medical patient and considers morphine as a "medicine" which be must have to control or alleviate disease symptoms or pain, it appears that there must be something in the objective situation to validate and support this self-conception. Such objective elements may be the actual presence of organic pathology and the very fact that the drug is prescribed by the physician and administered in a medical setting. When such a patient takes the step of administering drugs to himself it seems probable that this tends to undermine and soon destroy his conception of himself as a medical patient. Since the person ordinarily has strong motivations for preferring to be a patient rather than a dope addict, it would be expected that self-deceiving rationalizations would be employed to maintain the former identity whenever possible. By the same token, the person who, in his own mind, has, made the switch and
knows he is simply an addict would be expected to conceal this fact and prevent others from realizing it.

The settings in which drugs are taken or in which withdrawal distress occurs are, known to have profound effects upon the human subject's evaluation of these experiences. Thus, initialeuphoric effects are often not noticed when the drug is first takenin a medical setting for medical reasons. An experienced addict,invited to give himself an injection in the police station with several narcotic agents as an audience, is not likely to enjoy theexperience. Withdrawal distress appears markedly more severewhen the addict kicks his habit in a cell in a jail than when hekicks it in Synanon attended and surrounded by friends who arealso addicts. Related phenomena which contribute to the samepoint are that some of the unpleasant effects associated with thefirst few trials of the drug, such as dizziness and nausea, come tobe highly prized and desired by the addict and that some of thewithdrawal symptoms may be evoked in the abstaining addict bysuggestions communicated to him. Considerations of this kindindicate that pleasure and pain are elusive, subjective phenomenaand that the perception of pain and pleasure may sometimes beconsiderably modified, neutralized, or even reversed by influences of a conceptual nature derived from the social environment.

It should thus not be surprising that persons who become addicted in medical practice sometimes report that they have never experienced euphoria from the drug. Drug-dependent patients and others who receive opiates for shorter periods no doubt exhibit a wide range of cognitive responses to their situations. A more systematic exploration of this area, with close attention given to the patient's ideas, would be of the greatest interest and importance to the social psychologist concerned with the study of drug effects. The same may be said of experiments with opiates in which placebos are employed. A fuller exploitation of data from these sources would undoubtedly contribute greatly to a more discriminating analysis of addiction than is presently possible.

Extremely interesting and challenging theoretical notions are implicit in the Dole-Nyswander project in New York City in which heroin addicts taken from street of the city are provided with maintenance doses of methadone, a synthetic equivalent of heroin. The methadone is provided the addict gratis once or twice a day in orange juice in sufficient quantity to maintain body equilibrium and prevent withdrawal distress from appearing. Dole and Nyswander describe what they do in medical terms: they provide "patients" with a "medicine" which "blocks the craving for heroin." The manifestations of heroin addiction are controlled, they argue, much as those of diabetes are controlled by insulin. The program is entirely voluntary and contains no punishment and no threats. The subjects are encouraged to get jobs or to go on to school, and most do.

Under this program the behavior of the subjects changes in a remarkable manner. For example, they begin to speak of their addiction in the past tense, they spontaneously stop talking much about dope and report that they think about it very much less. It appears, in short, that their identity conceptions are changed; they are no longer junkies, but medical patients, and there are corresponding behavioral changes implied by the redefinition. It has been reported repeatedly that there has been no problem in stabilizing the daily dosage of the subjects and that the addict's usual impulse to increase it is either greatly diminished or absent. The subjects seem to act and think like medical patients. Some of the reported effects are no doubt connected with the reduction in anxiety that is associated with having an assured supply of pure drugs made available without any of the usual risks and with much less stigma .(12)

Cures of Addiction

If the craving for opiates which characterizes addiction is indeed dependent upon withdrawal distress in the manner that has been suggested, the longstanding idea that the problem of narcotics addiction might be solved by the discovery of a non-habit forming substitute for morphine or heroin is illusory. In a sense, addicts desire the drug because it is habit forming, that is, because it produces physical dependence and withdrawal distress.
A drug which did not have such effects could not conceivably be the psychological equivalent of morphine; such an equivalent

drug would necessarily have to be another habit-forming drug. One may argue that there are many non-habit-forming substitutes for opiates available at present, if one means by this drugs which produce pleasant sensations but no physical dependence or withdrawal reaction. Marihuana is such a drug, and cocaine is another and a much more powerful one. Neither functions as a substitute for heroin or morphine. The idea of a non-habit forming substitute for habit-forming drugs, conceived as a solution of the narcotics problem, is comparable to the idea of a non nutritious substitute for food or a non-liquid substitute for water.

When cures of addiction are discussed, the reference is usually to the process of separating the addict from his drug or to voluntary abstention from use. Little attention is given to the relapse impulse itself, which apparently persists for very long periods of time and probably permanently, in the abstinent addict. This feature of drug addiction is not peculiar to it but is also apparent in other habits. As has been suggested, the cognitive changes that addiction produces as the individual learns from direct experience about the drug and its effects on him may well constitute the most ineradicable feature of the relapse impulse. It is inappropriate to speak of a cure for knowledge. Curing a person of addiction might, in this sense, be compared with curing a person of a college education.

1. George H. Mead, "A Behavioristic Account of the Significant Symbol," Journal of Philosophy (1922), 19 16o.

2. CharlesE. Terry and Mildred Pellens,The Opium Problem (New York: Committee on Drug Addiction and Bureau of Social Hygiene,1928), pp. 426-27.

3. R. N. Chopra andG. S. Chopra, "The Administration of Opium to Infants in India,"Indian Medical Gazette (1934), 69: 489--94.

4. Jean Piaget,The Child's Conception of Physical Causality (New York: Harcourt, Brace,1930), P. 242.

5. Ibid., p. 286.

6. R. F. Bales,The "Fixation Factor" in Alcohol Addiction (unpublished doctoral dissertation, Harvard University, 1944).

7. D. 0. Hebb,The Organization of Behavior (New York: JohnWiley, 1949), P. 199.

8. CharlesE. Sceleth and Sidney Kuh, "Drug Addiction,"Journal of the American Medical Association (1924), 82: 68o.

9. Paul Wolff, "Wann ist die Verschreibung von Opiaten artzlich Begrundet?"Deutsche Medizinische Wochenschrift (1931), 57: 266. Wolff reported the results of the inquiry in a series of five articles beginning on pages133, 178, 223, 266, and318 of the volume cited.

10. Ibid., p. 181.

11. Ibid., P. 223.

12. Vincent P. Dole and Marie E. Nyswander, "A Medical Treatment for Diacetylmorphine (Heroin) Addiction, A Clinical Trial with Methadone Hydrochloride,"Journal of the American Medical Association (August 23, 1965), 193 (8): 8o-84, and by the same authors, "Rehabilitation of Heroin Addicts after Blockade with Methadone,"New York State Journal of Medicine (August 1, 1966), 66 (15): 2011-17. This description is based in part on my conversations with Dole and Nyswander.