The Epidemiology of Opiate Addiction in the United States

Compiled and Edited by
JOHN C. BALL, Ph.D. CARL D. CHAMBERS, Ph.D.
Professor, Department o f Psychiatry Research Director
Temple University Health State of New York Narcotic
Sciences Center Addiction Control Commission
Philadelphia, Pennsylvania New York, New York

With a Preface by
Griffith Edwards, D.M.
Addiction Research UnitInstitute of Psychiatry
London, England

This volume is dedicated to two outstanding physicians,
Michael J. Pescor and Harris Isbell

Preface

THE notion of extending the use of the word epidemiology to other than infectious diseases is largely one of recent decades. In 1963 Shepherd and Cooper reviewed the history of the application of epidemiological methods to the study of mental illness in general and suggested that not until the Milbank Conference of 1949 did the phrase epidemiology of mental illness come into wide use. They also noted, as did Lewis in 1962, that an earlier
generation of psychiatrists were familiar with the relationship between mental illness and factors such as migration, isolation, occupation, and socioeconomic change. Durkheim's ecological study of suicide first published in1897 had certainly been a harbinger of things to come. Still, the leaders of psychiatric thinking in the latter part of the nineteenth and first part of the twentieth century had been men who taught a focus on the individual case rather than a concern with the general population. The boom in epidemiological studies of mental illness waited on the postwar development of a psychiatry which focussed on the community.

The detailed history of the application of epidemiological thinking to the study of society's consumption of psychoactive substances has yet to be written, but it would seem likely that chemical abuse should in fact be listed among the first mental health problems to have forced on the medical profession an awareness of the need to take an epidemiological viewpoint. Thus, a British Home Office Report of 1834 took a more epidemiological than clinical view of drunkenness and proposed social rather than clinical remedies. Several early American papers reprinted in the volume edited by O'Donnell and Ball (1966) show that in the United States the epidemiological study of opiate abuse was not simply an event of recent years-in 1878 Marshall reported results of "an enquiry into the opium habit" based on a postal questionnaire sent to two hundred Michigan physicians. The Indian Hemp Drugs Commission Report of 1894 also looked at drug use in a social setting. By 1928 Terry and Pellens had completed a comprehensive review of the problem of drug use in American society. A reprint from their classic work, The Opium Problem, is included in the present volume.

With chemicals as with mental illness it is, however, in the postwar period that epidemiological methods have burgeoned. Alcoholism studies have probably led the way in terms of sophistication with Riley, Marden, and Lifshitz being the first (1948) to take a detailed look not only at the pattern of drug use but at the correlated motivations for use. In 1964 the epidemiological approach to the study of chemical abuse scored a dramatic success when Doll and Hill proved the statistical relationship between cigarette smoking and lung cancer. Now, scarcely a week passes without the publication of yet one more paper on the epidemiology of the misuse of some chemical-either old established substances such as the opiates, alcohol, and tobacco or such late newcomers as the sedatives, amphetamines, and hallucinogens.

It is against this historical perspective that the present volume must be seen. The editors have put together a book which is very much a witness to and a product of the thought and feeling of our own particular period. It is a period in which faith in treatment as an exclusive answer to many health problems of multiple etiology is at a low ebb. And addiction is typical of those problems in that it is not a condition for which "a singular answer" will be found but rather "its explanation almost certainly resides in the same conglomerate of factors which promotes and sustains other manifestations of social and personal maladjustment and inadequacy" (Hawks, 1970) . It is an age too in which rather shattering calculations are likely to be made which tot up-on the one hand, a nation's resources in terms of treatment personnel and health funding and on the other hand, the potential case load; there is no doubt as to which hand is the heavier. The casualties cannot and should not be refused humane help, but so far as drug, alcohol, and tobacco abuse are concerned, effective prevention offers the only hope of an answer commensurate with the scope of the problem. That hope is not close.

Epidemiology is that branch of study which is perhaps most likely to provide those insights on which an intelligent prevention program can ultimately be based, as well as offering rationality to the planning of community treatment. To quote the conclusion of Chapter 1 of this book, "policy . . . should follow rather than precede an analysis of the problem." Would that every parliament house had that thought engraved above the door.

This book is also a product of its time in that its contributors have largely concerned themselves with the collection of data which is valid and reliable while eschewing theory. Skinner, in 1950, writing on the place of theory in another behavioral science, wrote thus: "Perhaps to do without theories altogether is a tour de force that is too much to expect as a general practice. Theories are fun. But it is possible that the most rapid progress toward an understanding of learning may be made by research that is not designed to test theories."

The contributors to this volume do not throw theory to the winds and have certainly not attempted to achieve Skinner's wistfully hoped-for tour de force. Nonetheless, the emphasis of the Lexington style of research has been on first establishing the basic facts. Anyone who comes, then, to this field with the desire to test more refined social or psychological hypotheses is going to find a starting point in the data contained in this book.

Sometimes a society's response to its drug problem shows remarkable similarities to the more classical manifestations of individual psychopathology. There is the societal ego-defense of paranoid projection. Thailand showed this mechanism in psychotic proportions when the government shot a handful of heroin pedlars, but borderline psychosis is endemic much nearer home. Sublimation can defend against guilt by the funding of expensive treatment programs while the ghetto down the road is left to breed its casualties. Schizophrenic splitting leads society to collect tobacco revenue which may contribute to the financing of thoracic surgery. Some manically identify with the hippie and would have us believe that society must abandon all restraint and enjoy an orgy of regression.

What does the present boot: offer to our pathologies? It seems to force a harsh and accurate confrontation with reality, and that, after all, is sometimes the start of the patient's recovery. For research workers, for planners of health services, for those who have responsibility to legislate-legislation makes epidemiology experimental-this book presents cogent new material of great relevance. There can be little doubt that when a later generation looks back on the historical development of the application of epidemiology to the drug problem, this book will be recognized and valued as a stark, unadorned, but enormously important landmark in the best undecorated style of its age. It is an honor to be asked to write the Preface.

Griffith Edwards
Addiction Research Unit
Institute o f Psychiatry
London, England

Contributors

Acknowledgments

THE National Institute of Mental Health generously supported most of the research reported in this volume. While within this organization, we had the intellectual freedom to study problems of drug use in American society as we saw fit as well as the nesessary resources to carry forward our plans.

Many of the authors were not only contributors to this work but friends and colleagues as well. We wish to thank them for their encouragement to continue our epidemiological studies.

We are indebted to Drs. Ernst Jokl, James F. Maddux, Daniel Glaser, Gerald Klee, and Harriet Aronson as well as judge Irving Lang for helpful comments concerning various portions of the manuscript. Dr. Vincent P. Dole was kind enough to provide us with comparative data pertaining to New York City addicts which were incorporated in Chapter 1.

The figures in Chapters 1, 7 and 19 were drawn by Robert T. Clough. Stanton W. Saltzman provided advice concerning these and other illustrations.

Bonnie Edington and Joan Bakove labored diligently and cheerfully in the preparation of the final manuscript.

The entire book would not have been possible without the steadfast encouragement of R. Bruce Sloan.

JOHN C. BALL
CARL. D. CHAMBERS

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