2.  Opiates for pain relief, for tranquilization, and for pleasure

Physicians in the nineteenth century as now prescribed opiates for pain. They were also widely prescribed, however, for cough, diarrhea, dysentery, and a host of other illnesses. Physicians often referred to opium or morphine as "G.O.M."--- "God's own medicine." Dr. H. H. Kane's 1880 textbook, entitled The Hypodermic Injection of Morphia, Its History, Advantages, and Dangers, Based on Experience of 360 Physicians, listed 54 diseases which benefited from morphine injections. They ranged from anemia and angina pectoris through diabetes, insanity, nymphomania, and ovarian neuralgia, to tetanus, vaginismus, and vomiting of pregnancy. To modern readers, this list may appear to be evidence of the incompetence of nineteenth-century physicians. Yet, for the great majority of these conditions, morphine really was of help--- especially in the absence of more specific modern remedies (such as insulin for diabetes). For morphine, as we shall show, can be highly effective in calming--- tranquilizing. The nineteenth-century physician used morphine for a wide range of disorders much as the physician today uses meprobamate (Miltown, Equanil), chlordiazepoxide (Librium), and other tranquilizers and sedatives now in style. The effects are quite different in several respects but the calming or tranquilizing effect is achieved by both groups of drugs.

Yet another nineteenth-century use of opiates was as a substitute for alcohol. As Dr. J. R. Black explained in a paper entitled "Advantages of Substituting the Morphia Habit for the Incurably Alcoholic," published in the Cincinnati Lancet-Clinic in 1889, morphine "is less inimical to healthy life than alcohol." It "calms in place of exciting the baser passions, and hence is less productive of acts of violence and crime; in short . . . the use of morphine in place of alcohol is but a choice of evils, and by far the lesser ." Then he continued:

On the score of economy the morphine habit is by far the better. The regular whiskey drinker can be made content in his craving for stimulation, at least for quite a long time, on two or three grains of morphine a day, divided into appropriate portions, and given at regular intervals. If purchased by the drachm at fifty cents this will last him twenty days. Now it is safe to say that a like amount of spirits for the steady drinker cannot be purchased for two and one half cents a day, * and that the majority of them spend five and ten times that sum a day as a regular thing.

* Comparisons with contemporary doses and prices are difficult, since today's illicit heroin market does not publish statistics. The estimates below are based on a review of the recent literature; they are substantially the same as estimates presented by the Select Committee on Crime of the United States House of Representatives in its January 2, 1971, report:

Although there is wide variation from time to time, from city to city, and even from bag to bag, a typical heroin "bag" today contains 10 milligrams (1/6 grain) of heroin mixed with 90 milligrams of adulterants, and costs five dollars.

Hence, the nineteenth-century morphinist paying 2 1/2 cents a day for 2 or 3 grains of morphine (as in the example above) can be contrasted with today's New York City heroin addict who would have to pay thirty dollars to sixty dollars a day for the equivalent--- one or two grains (60 to 120 milligrams or six to twelve bags) of heroin.

On the score, then, of a lessened liability to fearful diseases and the lessened propagation of pathologically inclined blood, I would urge the substitution of morphine instead of alcohol for all to whom such a craving is an incurable propensity. In this way I have been able to bring peacefulness and quiet to many disturbed and distracted homes. . . . Is it not the duty of a physician when he cannot cure an ill, when there is no reasonable ground for hope that it will ever be done, to do the next best thing-advise a course of treatment that will diminish to an immense extent great evils otherwise irremediable? . . .

The mayors and police courts would almost languish for lack of business; the criminal dockets, with their attendant legal functionaries, would have much less to do than they now have to the profit and well-being of the community. I might, had I time and space, enlarge by statistics to prove the law-abiding qualities of opium-eating peoples, but of this anyone can perceive somewhat for himself, if he carefully watches and reflects on the quiet, introspective gaze of the morphine habitué and compares it with the riotous devil-may-care leer of the drunkard. *

* An English physician similarly noted in 1873 that while opium users in Britain might be dirty slovenly, lazy, lying, and sanctimonious, "they are not uproarious, and don't swear. There are none of the deeds of brutal violence that are inspired by beer, and none of foul language. "

Many physicians did in fact convert alcoholics to morphine. In Kentucky this practice did not die out among older physicians until the late 1930s or early 1940s. The details are reported in a major contribution to the history of opiate addiction, Narcotics Addicts in Kentucky, by Dr. John A. O'Donnell, published in 1969 by the National Institute of Mental Health, an arm of the United States Department of Health, Education, and Welfare.

Dr. O'Donnell, then chief of the research branch of the NIMH's Clinical Research Center in Lexington, Kentucky, reported on 266 addicts living in Kentucky who were admitted to the Lexington hospital for drug addiction between 1935 and 1959. Of these 266, at least 152 had a record of alcohol excesses prior to becoming addicted to opiates. Among the men in the sample, this relationship was particularly close. "Over one third of the men [75 out of 212] began their addiction through treatment of alcoholism; they were given a narcotic to help in the sobering-up periods, . . , preferred the narcotic to alcohol, and shifted to its use. . . ." In 50 of these 75 cases, it was a physician who gave the alcoholic his first injection of morphine as an alcohol substitute .

One Kentucky physician described a typical case, Dr. O'Donnell reports, in a letter to the Public Health Service Hospital in Lexington at the time of an addict's admission there:

... I decided that these symptoms [acute gastritis, jaundice, liver trouble, and possibly heart disease] were due to overuse of alcoholic drinks, and that an alcoholic cirrhosis was developing. The subject would not drink whiskey when be had morphine, and as he already had a habit for morphine I decided that by prescribing morphine for him he would get along better. This has been true, and the patient has had only a few attacks in the past four years of acute pain in the epigastrium, and these occurred when the subject was short of morphine.

Dr. O'Donnell takes a guarded but on the whole favorable view of this kind of conversion: ". . . the addict whose drugs came from a stable medical source was no great problem to his community. . . . He became a serious problem only if he engaged in illegal activities to obtain narcotics. The alcoholic was more visible, and his arrests more frequent, though each individual offense was a relatively minor one. But the community attitude was generally more accepting of the alcoholic."

In a community where alcohol and the opiates are equally available and equally approved (or disapproved), Dr. O'Donnell adds, "there are reasons, in the physical effects of addiction and alcoholic intoxication, to believe that . . . narcotic addiction would be less disruptive than alcoholism."

The advantages of converting alcoholics to opiates were also pointed out in 1928 by Dr. Lawrence Kolb, Assistant Surgeon General of the United States Public Health Service, a psychiatrist specializing in problems of drug addiction. "More than any other unstable group," Dr. Kolb wrote, "drunkards are likely to be benefited in their social relations by becoming addicts. When they give up alcohol and start using opium [i.e. morphine or other opiates], they are able to secure the effect for which they are striving without becoming drunk or violent."

Among 33 heavy drinkers who converted to morphine, Dr. Kolb added, only one "continued to drink after he became addicted to morphine, and his drinking was then moderate."

An evaluation of the comparative physiological effects of the opiates versus alcohol is also found in A Community Mental Health Approach to Drug Addiction, by Drs. Richard Brotman and Alfred M. Freedman, published in 1968 by the United States Department of Health, Education, and Welfare: " . . . opiates are far less physically damaging that barbiturates or amphetamines-or alcohol. . . . The drug-dependent person who abstains from opiates only to turn to other drugs, specifically alcohol, barbiturates, or amphetamines, cannot be said to be making progress."

Dr. Black's 1889 view that an opiate "calms in place of exciting the baser passions" was very widely agreed upon, and was the basis for the widespread use of opiates as tranquilizers. The first recorded use of the word "tranquilizer" in the English language, according to the Oxford English Dictionary, was by Thomas De Quincey, in his Confessions of an English Opium-Eater in 1822. Dr. Horatio Day described the tranquilizing role of the opiates in The Opium Habit (1868), three years after the close of the Civil War: "Maimed and shattered survivors from a hundred battlefields, diseased and disabled soldiers released from hostile prisons, anguished and hopeless wives and mothers, made so by the slaughter of those who were dearest to them, have found, many of them, temporary relief from their sufferings in opium."

The same tranquilization theme echoed down through the decades. In 1886, Dr. William Pepper, in his System of Practical Medicine, pointed out that the range of opium's effects extended from assuaging the oppression of the working class to allaying the ennui of upper-class women. The American Textbook of Applied Therapeutics (1896) spoke of patients using narcotics "to soothe their shattered nervous systems." T. C. Allbutt's System of Medicine ( 1905) spoke of morphine as bringing "tranquility and well-being." L. L. Stanley, writing in the Journal of the American Institute of Criminal Law and Criminology in 1915, spoke of society women who "indulge in opium to calm their shattered nerves."

During the last half century, the function of the opiates as tranquilizers has been lost from sight. Old truths, however, tend to be rediscovered. An official 1963 publication setting forth the United States Public Health Service's views made the point clearly: "Last century the pain that led to addiction was often physical; today it is mainly psychic. Most of today's addicted persons have discovered, in other words, that opiates relieve their anxieties, tensions, feelings of inadequacy, and other emotional conditions they cannot bring themselves to cope with in a normal way." *

* The Public Health Service report did not, however, define the "normal way" for untrained and unemployed black or Puerto Rican adolescents living in urban slums to cope with "their anxieties, tensions, feelings of inadequacy and other emotional conditions."

The tranquilizing effects of narcotics were also clearly revealed during a remarkable 1956 study of many hundreds of addicts in Vancouver, British Columbia. This research was reported in a 658-page document (plus a hundred pages of appendices), "Drug Addiction in British Columbia-A Research Survey," one of the broadest and most insightful ever written on heroin addiction; unfortunately it has never been published. Prepared under the direction of a psychiatrist, Dr. George H. Stevenson, in collaboration with a psychologist, Lewis R. A. Lingley, a social worker, George E. Trasov, and an internist, Dr. Hugh Stansfield, it exists only as a typed manuscript in the Library of the University of British Columbia. A few photocopies have been made, but even large medical libraries lack copies. To make the findings available to a wider audience, as well as for their intrinsic worth, quotations from this report will be frequently used in the chapters that follow.

Among the many inquiries undertaken in the British Columbia study, one sought to determine what mood effects addicts reported experiencing while on heroin. One group of addicts was given a list of seventeen terms descriptive of moods; some of the terms indicated a tranquilizing effect, others a mood-elevating effect. The addicts were asked to check which of the terms described the way they felt.

The 71 addicts made a total of 449 check marks. Only 8 addicts considered the heroin experience "thrilling" and only 11 considered it "joyful" or "jolly"--- as contrasted with 65 who said it "relaxed" them and 53 who thought it "relieved worry."

Twentieth-century research, moreover, suggests that even the beneficial effect of the opiates on physical pain is in considerable part a tranquilizing effect. One standard method of testing a drug's effects on pain is to apply warmth to a spot on the skin of a laboratory subject, and then gradually raise the temperature until the subject signals that it has become painful. A subject who has received the usual pain-relieving dose of morphine readily recognizes the sensation of pain when so tested-and it takes only a slightly hotter stimulus to produce the sensation. Another common test is to ask a subject to compare two levels of pain, and to place them on a scale ranging from one "dol" (barely painful) to nine "dols" (intolerable). Subjects rate a given stimulus only slightly lower on the dol scale while they are on morphine. If this direct effect on pain sensations were the only effect of the opiates, they would be relatively poor pain relievers. Their enormous usefulness in medicine results from the fact that they also alleviate a patient's fear of pain, his anxiety about the pain, and both his physical and his emotional reactions to the pain. In a word, they tranquilize him. (In some other respects, of course, the effects of the opiates are very different from the effects of modern tranquilizers.)

The relation of the opiates to pleasure as distinct from tranquility is complex and controversial. There is frequent reference in the medical literature (and in the mass media) to the "kick," "bang," or "rush" that the addict is said to feel immediately after mainlining morphine or heroin.

This rush has even been likened to "an abdominal orgasm"; and the view has been expressed that addicts shoot morphine or heroin for the purpose of experiencing this ecstatically pleasurable rush.

There can be no doubt that the injection directly into a vein of a substantial dose of morphine or heroin produces a readily identifiable sensation. Nonaddicts often describe it as a sudden flush of warmth, and some localize it as warmth in the pit of the stomach. Few nonaddicts perceive the rush as particularly pleasurable, however.

Addicts who take opiates by mouth, or who smoke them, or sniff them, or inject them under the skin or into a muscle, do not experience a rush yet they may become as firmly "hooked" as addicts who mainline their drug. Hence, a desire for the rush is not the basis for addiction.

In general, the rush appears to be subject to tolerance; that is, the addict who injects the same dose several times a day, day after day, no longer experiences a rush. Doubt surrounds this point, however. Most American black-market heroin is adulterated with quinine and quinine also produces a rush when mainlined. Moreover, street addicts are not often able to take uniform doses at regular intervals day after day. If an addict waits an hour or two too long for his next "fix," or if his previous fix was of less than the usual potency, he may suffer incipient withdrawal discomfort-and the next fix may produce an inextricably interwoven mixture of relief from withdrawal distress and the rush sensation. (A fuller discussion of physical dependence, the withdrawal syndrome, tolerance, and other aspects of addiction follows in Chapter 10.)

During the nineteenth century, many highly reputable addicts-whose addiction arose during the medicinal use of opiates-insisted that they had never in their lives experienced a moment's pleasure from opiates; they took their drug solely to forestall withdrawal distress and the unpleasant "post-addiction syndrome," to be described below. Today's addicts almost all concede that they get a highly enjoyable bang or rush from their heroin injections. They may, however, be mistaken. For them as for nonaddicts, the rush may be merely an abdominal sensation of warmth. For the addicts, however, the sensation may have a highly charged meaning-since it will generally signal imminent relief from withdrawal distress. It is exceedingly difficult to distinguish a positive feeling of pleasure from the pleasantness that follows the relief of distress or pain. Perhaps there is no difference. Some theorists have even suggested that addicts shoot heroin in order to achieve withdrawal distress--- a distress that can then be pleasurably relieved by the next fix.

Most addicts who mainline heroin, when asked what happens when they "kick the habit," describe the classic withdrawal syndrome--- nausea, vomiting, aches and pains, yawning, sneezing, and so on. When asked what happens after withdrawal, they describe an equally specific "post-addiction syndrome"-a wavering, unstable composite of anxiety, depression, and craving for the drug. The craving is not continuous but seems to come and go in waves of varying intensity, for months, even years, after withdrawal. It is particularly likely to return in moments of emotional stress. Following an intense wave of craving, drug-seeking behavior is likely to set in, and the ex-addict relapses. When asked how he feels following a return to heroin, he is likely to reply, "It makes me feel normal again"--- that is, it relieves the ex-addict's chronic triad of anxiety, depression, and craving.

It is this view--- that an addict takes heroin in order to "feel normal" * --- that is hardest for a nonaddict to understand and to believe. Yet it is consonant with everything else that is known about narcotics addiction--- and there is not a scrap of scientific evidence to impugn the addict's own view. The ex-addict who returns to heroin, if this view is accepted, is not a pleasure-craving hedonist but an anxious, depressed patient who desperately craves a return to a normal mood and state of mind.

* Dr. J. Yerbury Dent, editor of the British Journal of Addiction, stated (1952): "An addict is one who cannot be normal without a drug."

The term "craving," used here and later in this Report, is not in good repute among many psychologists today. For craving is a subjective feeling; and like other subjective feelings, subjects may, or may not report accurately on its presence or absence. It cannot be objectively measured. In the case of the craving for narcotics, however, we need not rely solely on addicts' subjective reports. We may reliably infer that an ex-addict still staffers from a heroin craving if he goes wandering the streets in search of heroin. If he engages in drug-seeking behavior despite the fact that his whole future, including his future freedom from imprisonment, depends on his remaining abstinent, we may infer that the craving is quite strong-or nagging and persistent, difficult to resist. If he engages in such behavior especially in times of emotional stress, we may infer that the craving recurs or is intensified when stress is experienced. If he again engages in such behavior after years of abstinence from narcotics, we may infer that the craving is long-lived. As we shall see below, both the craving and tendency to drug-seeking behavior are indeed difficult to resist, stress associated, and long-lasting.

This discussion of the pleasure factor and craving factor in addiction is certainly not definitive. It takes no account, for example, of individual differences--- and they are very great. But regardless of details, three central points seem reasonably well established: the addict does not mainline heroin solely or primarily for pleasure; the addicting nature of narcotics is quite distinct from whatever pleasure the drugs may on occasion provide some addicts; relapse results, not from a striving for pleasure, but from the need for release from the postaddiction syndrome--- anxiety, depression, and craving. Thus, the postaddiction syndrome might also be called the "pre-relapse syndrome."

It is commonly stated that anyone who takes heroin daily for a few weeks or longer is in imminent danger of addiction. This is probably true, but it is almost beside the point. The important question is: if someone takes heroin occasionally, what is the likelihood that he will graduate to using it daily for a few weeks or longer--- and thus very probably become addicted?

Unfortunately, there are no statistics on which to base an answer to that question. We can only indicate a spectrum of possible outcomes.

At one extreme are the few addicts who report that they "fell in love" with heroin on their first fix. Thereafter they continued uninterruptedly on the drug. They are a small minority--- perhaps 2 or 3 percent. At the other extreme are the unaddicted opiate users who maintain that they have used heroin or morphine occasionally--- on Saturday nights, for instance--- for prolonged periods, perhaps even for years, without becoming addicted. These long-term "weekend users," or "chippers," are also believed to be rare--- how rare, nobody knows.

The great majority of addicts fall between these extremes. They report, no doubt truthfully, that they started off as occasional users. They did not intend to become addicted; indeed, they were confident that they would escape addiction by using the drug only on occasion. Then the kinds of occasions on which they used heroin became more numerous, and the intervals shorter. After weeks or months of increasing use, daily use began--- and soon thereafter the casual user became an addict.

The likelihood of addiction is said to be affected by the drug used; heroin, for example, is believed to be more likely to lead to addiction than codeine. It is commonly stated that route of use affects the outcome; thus, heroin sniffed or smoked is alleged to be less addicting than heroin injected. Whether this is literally true, or simply due to the fact that a given dose has it greater effect when injected, remains in doubt. The most that can be said is this: there is a great likelihood that anyone who uses a narcotic once will use it again, and then occasionally, and then daily--- and will become addicted. No one can tell in advance whether he will be one of the few who reportedly are able to go on using occasionally.

Some young people today, rightly contemptuous of the myth that a single shot of heroin produces addiction, may point out that they have friends who have been weekend users for months, perhaps many months. This may well be true--- but there is unfortunately no assurance that their friends, even after months as "chippers," will not soon become daily, users--- and thereafter addicts.

As for the possibility of addiction stemming from medically administered narcotics, the medical literature generally cautions physicians to exercise great prudence in prescribing narcotics for the treatment of pain or physical illness, to minimize the likelihood of a patient's developing "dependence." The results of this policy would seem to be something of a mystery. In the nineteenth century, medical treatment was the commonest source of addiction. But today, Dr. Jerome H. Jaffe writes in the 1970 edition of The Pharmacological Basis of Therapeutics, edited by Drs. Louis S. Goodman and Alfred Gilman, "Considering the frequency with which opiate analgesics are used in clinical medicine, addiction as a complication of medical treatment is quite uncommon ."

No recent study has been reported of just what does happen to patients who receive narcotics medicinally for several days or weeks. Many of them, of course, are terminal patients whose medical treatment ends in death. Some patients, particularly some who have undergone surgery, complain that physicians are too prudent--- that they do not prescribe enough narcotics, or enough narcotics often enough, to relieve pain; are such complaints valid?

When nonaddicted patients receive medicinal narcotics regularly for an extended period, do they suffer a kind of postaddiction depression, anxiety, and craving when they stop taking the drug? Do they turn for relief to other drugs--- for example, to increased consumption of alcohol? (Studies to be reviewed below indicate that a substantial proportion of morphine and heroin addicts who "kick the habit" become skid-row alcoholics.)

The answers to these and related questions are not known. For now, as in the case of other prescription drugs to be discussed in this Report, it is unclear whether physicians are prescribing narcotics prudently, excessively--- or overcautiously.

Footnotes
Chapter 2

8. Ibid., p. 138.

9. Ibid., p. 140.

10. Ibid.

11. Lawrence Kolb, Drug Addiction, A Medical Problem (Springfield, Ill.: Charles C Thomas, 1962), pp. 55-59.

12. Richard Brotman and Alfred M. Freedman, A Community Mental Health Approach to Drug Addiction, U.S. Department of Health, Education, and Welfare, Social and Rehabilitation Service, Office of juvenile Delinquency and Youth Development (Washington, D.C.: U.S. Government Printing Office, 1968), P. 36,

13. Horatio Day, The Opium Habit (1868), cited in Terry and Pellens, p. 5.

14. William Pepper, System of Practical Medicine (1886), cited in Terry and Pellens, p. 100.

15. J. C. Wilson and A. A. Eshner, American Textbook of Applied Therapeutics (1896), cited in Terry and Pellens, p. 104.

16. Thomas C. Allbutt, A System of Medicine (1905), cited in Terry and Pellens, p. 186.

17. L. L. Stanley, "Morphinism," Journal of the American Institute of Criminal Law and Criminology, 6 (November 4, 1915): 586.

18. U.S. Department of Health, Education, and Welfare, Public Health Service, Narcotic Drug Addiction, U. S. Public Health Service Mental Health Monograph No. 2, Publication No. 1021 (Washington, D.C.: U. S. Government Printing Office, 1963), p. 8.

19. George H. Stevenson et al., "Drug Addiction in British Columbia: A Research (University of British Columbia, 1956); unpublished. Hereinafter cited as British Columbia Study.

20. Ibid., p. 391.

21. James D. Hardy, Harold G. Wolff, and Helen Goodell, Pain Sensations and Reactions (Baltimore: Williams & Wilkins, 1952), p. 264.

22. Louis Lasagna, John M. von Felsinger, and Henry K. Beecher, "Drug-Induced Mood Changes in Man," in JAMA, 157 (March 19, 1955): 1006-1020; Henry K. Beecher, "Analgesics and the Reaction Component of Pain," in Drugs and the Brain, ed. Perry Black (Baltimore: Johns Hopkins Press, 1969), p. 169.

23. J. Yerbury Dent, in British Journal of Addiction, 49 (1952): 17.

24. Jerome H. Jaffe, in Louis S. Goodman and Alfred Gilman, eds., The Pharmacological Basis of Therapeutics (New York: Macmillan), 4th ed. (1970), pp, 285-286. Hereinafter cited as Goodman and Gilman preceded by contributors name and followed by edition number and year (3rd ed., 1965, or 4th ed., 1970).