Drug Abuse

XIV Some Matters of Perspective (II)

In this chapter, we want to set the record straight on a variety of relevant historical, medical, cultural, psychiatric, and pharmacological matters.

What Is a Drug?

"Drug" is not a scientific term. It has its origin, the dictionary tells us, in a misconception. It is derived from the Low German droge vate, which means literally dry casks or goods stored dry, and the contemporary meaning developed from a linguistic error; the adjective droge, which described the state of the contents, that is, that they were dry, was wrongly taken to be a designation of the contents themselves.

In Goodman and Gilman's textbook of pharmacology,1 the term is defined as "any chemical agent which affects live protoplasm." The authors comment that "few substances would escape inclusion by this definition," but they attempt no further definition. By intent and implication, they use the word for all the substances used by clinical physicians in the treatment of disease or by researchers in the investigation of disease or the physiology of organisms, whether human, mammalian, or whatever.

Despite the fact that physicians prescribe "drugs," which we commonly purchase with toothpaste or household supplies at a "drugstore" from a reputable individual, a graduate pharmacist (Ph.G.) whom we call a "druggist," the predominant associations of the word "drug" emphasize negative, dangerous, or undesirable effects, as "under the influence of drugs" or "he was drugged." Indeed, we have gone along with the popular misuse of the term by using "drug use" and "drug addict" to refer to the subjects of our investigation.

We note the assiduous avoidance of the word "drug" for the great variety of products purchased openly in drug stores, e.g., vitamin pills, analgesics, hormonal preparations, and certain antibiotics, which are sold without prescription and without the name, "drug." In short, what the physician or pharmacologist would term a drug, the layman calls a medicine or remedy, or he evades the issue entirely by identifying his drugs by a common or general pharmaceutical name, e.g., aspirin, vitamin, or hormone.

The only exception that clearly and regularly occurs is in the term "wonder drug," which was used first for the sulfonamides, later for the mold substances (penicillin, Aureomycin, streptomycin, etc.) used in the treatment of bacterial infections, and more recently for the steroid substances (cortisone and other adrenal hormones) used in thé treatment of a variety of diseases of the connective tissues (collagen diseases). It is notable that "drug" is acceptable and common where the use of the substance is novel or "wonderful."

We also note that the term "drug-user" is generally pejorative. When an elderly person with chronic pain (e.g., from an inoperable tumor) uses morphine, Demerol, or codeine, he is not regarded as a drug-user; nor are those who regularly use alcohol, coffee, tea, tobacco, insulin, or vitamin-mineral preparations or the person who makes use of the "wonder drugs." The term "drug-user" is applied only to those using substances which are regarded negatively and critically. Furthermore, these negative and critical evaluations are not apparently based on the nature of the chemical agent or on its effects per se.

With so undisciplined a word, it may be well to recall Owen Meredith's warning:2

Words, however, are things; and the man who accords To his language the license to outrage his soul, Is controll'd by the words he disdains to control.

Social Attitudes toward the Use of Chemical Agents

It is easy to lose perspective when we consider the opiate and cannabis drugs as though they had always been negatively sanctioned or as though they were inherently dangerous, even poisonous, substances. In fact, these drugs have not always been regarded this way; on the other hand, not only alcohol but even coffee and tobacco have been proscribed as harmful and undesirable substances. Indeed, there are some remarkable historical and cultural differences in the acceptability and use of both coffee and tobacco which indicate how sanctions on drug use are related to the putative effects of the drug or to the meanings of the substance for the community (in the sociological sense of this word).

We take our coffee for granted, as though it had always been regarded as a desirable substance, fitting and proper for use by adolescent and adult males and females, at breakfast and coffee break, in coffee houses, and after dinner. Coffee is regarded as a wholesome dietary substance for which a great variety of cooking utensils, serving dishes, and tables are designed and widely advertised. This is so even though persons report dependency on coffee ("I don't feel really right until I have my morning cup of coffee"), psychic craving (there are individuals who regularly drink ten or more cups of coffee daily), and adverse physiological effects ranging from diarrhea to insomnia (for which a large industry assiduously removes the caffeine while retaining the flavor—remember Mr. Coffee Nerves).

The first recorded use of coffee was by the Arabian physician Avicenna about 1000 A.D. Most likely, its use by Near Eastern peoples long precedes this date. There is a legend that the leader of a Mohammedan cloister learned from his herdsmen that goats became frisky and wakeful after eating the beans of a certain plant; he prepared a drink from these beans in order to keep himself and his dervishes awake when they had to conduct prayers throughout the entire night. However, by the sixteenth century, there were religious controversies over coffee in the Moslem world. Some physicians declared it harmful; others vociferously defended it as salutary. Among religious leaders, it was regarded as an intoxicant analogous to alcohol and therefore forbidden any devout Moslem. Indeed, if a man requested his wife to serve him coffee, it was regarded as legal basis for a divorce.

In Europe, by the end of the eighteenth century, coffee was widely accepted, though only after a long history of opposition to its use. In Germany, some of the minor princes not only prohibited coffee-drinking, but offered monetary reward to informers. Severe punishments were applied to people in the illicit coffee business ("pushers," or we might call them dealers). In 1777, the Fiirst-Bischof Wilhelm von Paderborn declared coffee-drinking a privilege of the nobility, the clergy, and high state officials; it was forbidden to mere citizens and peasants. Ludwig Lewin, from whose book, Phantastica,3 these historical nuggets are freely borrowed, commented that coffee was falsely regarded as a cause of infertility and sexual apathy. He quotes a German princess as follows: "Coffee is not necessary for Protestant ministers as it is for Catholic priests, who may not marry and who are required to remain chaste." The princess adds her surprise that anyone likes coffee, since she "finds it to have such a bitter and evil taste which reminds her only of bad breath."

Though we regard these as bizarre historical facts, as mere curiosa, we are still surprised and offended by disregard of our own cultural standards in the use of coffee. Most notable is the fact that it is not regarded proper in the United States for children to drink coffee. A remarkable example of this took place at the Freud lecture (Anna Freud on the fiftieth anniversary of Sigmund Freud's lectures a,t Clark University) at Clark University in 1950. When Anna Freud discussed the eating difficulties of children in Vienna shortly after World War I, she mentioned that the children would go off to school without drinking their coffee. There was an audible sigh and hush of disbelief through the audience, not for the eating difficulties of the children but for the fact that they were expected to drink coffee.4

The contrast between present attitudes toward tobacco use and some of the phenomena which attended its increasing acceptance are extraordinary. In our own generation, we have seen cigarette-smoking change from a daring, mildly disreputable activity of young men and "loose" women to condoned use with quasiapproval for men and women from adolescence (fourteen seems to be the currently acceptable age for children to begin smoking) to senescence—a white-haired grandmother choruses that a certain brand of cigarettes "tastes good like a cigarette should." There is no doubt that American advertising has played an extraordinary role in hastening the acceptance of this substance.

Although cigarette-smoking is probably the most widespread method of using tobacco today, there is a long history of other methods of use. For example, chewing tobacco and snuff is rarely used today except in occasional rural, occupational, and ethnic groups; however, snuff was taken by all classes of society in France and England in the early nineteenth century. It took a papal edict (Urban VIII) to restrain the Spanish priesthood from using snuff or from smoking while conducting Mass. In primitive groups, tobacco is taken not only by men and women, but also by quite young children, often in forms which we would regard as peculiar or revolting. For example, the Jivaros and other tribes in Ecuador smoke tobacco and incorporate its use into the initiation ceremonies of young men. However, they also use tobacco in their daily health rituals in a manner quite foreign to us. They boil the tobacco leaves until they have a watery extract. They then imbibe the extract through the nose and let the fluid run out through the mouth. They believe that this will keep their heads clear and their bodies invigorated and that headaches and colds are prevented by this measure. A number of African tribes chew a mass of tobacco juice and gum, formed in the shape of a loaf of bread, which in certain tribes is flavored with cow manure. In some primitive groups—e.g., the Jivaros, in Bogota—and, as noted by one of the writers, in the rural Philippines, the smoke is inhaled directly without filtering it through a pipe stem or length of unsmoked tobacco, that is, the burning end of the cigar is placed in the mouth.

Tobacco use in Europe was not readily or casually accepted. At some times in the seventeenth century, smoking was a crime punishable by death in Turkey, Persia, Russia, and some parts of Germany. In Hungary in 1689, there was a fine for smoking; individuals caught growing tobacco were subject to confiscation of their property. In Switzerland, particularly in Berne, in 1660, smoking was considered a major crime. This continued in somewhat modified form in Switzerland; as late as 1849 there was a law in the canton of Wallis that minors arrested for smoking were subject to a fine, and recidivists were placed in jail. But by 1900, because of the widespread use of tobacco, the law was repealed as unenforceable. In Turkey, tobacco was zealously opposed by the religious. Users of tobacco could be punished in the following manner: a hole was bored in the nose, and a pipe stem placed in this hole; then the miscreant was ridden about on an ass to be publicly mocked. In Russia, Peter the Great abolished the death penalty for smoking (which had been supplemented by the appropriation, by the state, of the property of persons in the tobacco business). At the same time, he sold to the English for 15,000 pounds sterling the privilege of exporting tobacco to Russia.

King James I of England attributed many of the evils of mankind to tobacco. However, like the enlightened Peter, he learned that his disapproval of tobacco could have its most effective public expression by taxing it. This was an excellent source of revenue. A similar moral can be drawn from our own history; since we repealed the Eighteenth Amendment, we have taxed liquor heavily.5

Turning from history to sociology, we note that the attitudes toward the use of any drug—or, in fact, of any dietary entity—range from prescription to proscription; that these attitudes are related to differences in the social structure, e.g., to age group, sex, and social role; and that the attitudes are integrated with certain social functions, e.g., rituals, medical or therapeutic settings, and certain informal group interactions.

Many groups in contemporary America insist that all members, including children, have at least a sip of wine or brandy on festive or religious occasions. Jews drink in this fashion at Passover, on Sabbath eve, and the high holidays. Catholics and some Protestant sects sip wine at Communion. Most ethnic groups in this country encourage alcohol-drinking among all participating adults at weddings, religious confirmations, and similar family feasts. Many groups virtually prescribe alcohol-drinking at some social gatherings, e.g., the cocktail party and the wake. The use of table wine or beer is proscribed in this country for most children at least up to adolescence, though in France (where there probably is a serious alcoholism problem)6 and in Italy (where there probably is not) children take table wine from early childhood.7

In the United States and many European countries, drunkenness is regarded as a vice or weakness. The ideal is to drink as much or more than the next person without becoming visibly intoxicated; the goal is to "hold" your liquor. This is in remarkable contrast to the majority of primitive peoples, who take alcoholic beverages to become as drunk as they can as quickly as possible.8

Sanctions and Science

Our survey indicated that there have been extreme sanctions against the use of certain substances which are now in common usage. These sanctions are hardly justified by the inherent or unconditional harmfulness of the substance. Demonstrable harmfulness is, at best, a supplementary basis for legal sanctions; if invoked at all, it is as secondary argument. There is no need to invoke moral sanctions against the public sale of arsenic and strychnine. They are identified as toxic substances, and measures are taken to prevent their misuse and to make publicly available means for coping with and preventing their accidental, malicious, or careless use. On the other hand, some demonstrably harmful drugs are used freely.

Alcohol is a dangerous substance. Used excessively—no rarity in our civilization—it is a pathogenic factor in the etiology of cirrhosis of the liver, industrial absenteeism and accidents, traffic fatalities, and diseases of the central and peripheral nervous systems. There is a growing body of evidence that tobacco, and particularly cigarette-smoking, is pathogenic in or a contributor to the etiology of certain cardiovascular and neoplastic diseases and good evidence that it is a harmful substance for personswith peripheral vascular disease. However, it is unlikely that either alcohol (again) or tobacco (ever) will be prohibited or federally controlled in this country. Many patent medicines, vitamins, hormones (in so-called beauty preparations), cathartics, analgesics, stimulants, sedatives, and the like are not difficult to obtain without prescription by a physician. Since most of the bodily troubles of mankind, the aches and pains, insomnia, indigestion, skin discomforts, menstrual pains, constipation, and so on are not usually based on demonstrable organic disease, not much harm is done by the substances per se. However, harmful temporizing with malignant tumors, endocrine disturbances, chronic infections, and serious emotional disturbances through legally permissive self-diagnosis and self-medication has had dangerous consequences.

The permissive use of certain drugs known to have harmful effects, like the sanctions against the use of other drugs, is not based on objective scientific grounds, other than that the substance is not very harmful in itself as it is "intended" to be or is customarily used. Conversely, we are quite aware of the fact that positive steps benefiting the health and welfare of the public are hindered by antiscientific considerations, e.g., the current social issues of fluoridation of public water supplies, establishment of medically sound commitment procedures to state hospitals, reasonable divorce laws, and the like.

In review, the basis for sanctions is predominantly attitudinal-moral; when culture and custom support the use of a substance, considerations of this substance's harmfulness are remarkably ineffective. When culture and custom proscribe the use of a substance, arguments based on scientific evidence are far from effective.

Drugs Have Many Functions and Effects

The textbooks of pharmacology make elaborate distinctions between classes of drugs in accordance with their major uses or pharmacological characteristics. A vast number of drugs intended for other purposes may nevertheless be used in one way or another for psychic satisfaCtion, for the relief of tension or distress, or for other more limited medical function. For example, carbon tetrachloride is used in the treatment of certain types of intestinal worm; it is also a dangerous source of intoxication, dangerous because of its effects on the kidneys and liver. Although penicillin has no direct effect on the central nervous system, the anxiety associated with pneumonia is alleviated as the bacterial infection is controlled. Some cathartics act primarily by irritant stimulation of the colon; fecal evacuation per se is a form of pleasure which is not (yet) widely advertised in uneuphemistic terms, but we know that for some individuals the function of the bowels is related to both pleasure and conflict. The widespread use of cathartic medicines for children is largely based on the psychic needs of parents and only to a trifling extent on the child's "defective" bowel function. In one way or another, a drug may attain psychological meanings and effects entirely unrelated to its explicit or intended use. Patients may, for instance, demand antibiotics for minor virus infections for which they are not indicated.

On the other hand, there are drugs which are used for their effects on mood, ideation, affect, feeling, anxiety, pain, or tension. These drugs may be used in distressing organic diseases which affect the psychic organization; e.g., in acute coronary thrombosis, morphine is used to combat the pain and anxiety (not infrequently bordering on panic) associated with the illness. In other circumstances, these drugs are used outside the context of distressing organic disease for the effects of the drug on the psychic organization itself. Since the pharmacology of these drugs is so varied, it is difficult to categorize them with any of the conventional pharmaceutical names. We suggest that this growing class of drugs (alcohol, the xanthines, cannabis, mescaline, cocaine, amphetamine, the barbiturates, Thorazine, Serpasil, lysergic acid, and so forth) be called "psychic modifiers."

They are of particular pharmacological and psychiatric interest because their effects as psychic modifiers are neither consistent nor universal, whereas their effects in the laboratory on limited tissues or organs may be quite specific and consistent. Morphine has quite consistent effects on smooth muscle in the gastrointestinal tract, on pupillary contraction, and on respiration. Nicotine is an autonomic blocking agent and also blocks the neuromuscular junction of skeletal muscle, having a curare-like action which may lead to respiratory failure. Alcohol is an irritant to the gastric mucosa and a depressant of the central nervous system, probably impeding the transmission of impulses across the synapses of the brain cells, particularly of the cortex.° However, when we observe the response of the whole person to such commonly used psychic modifiers as cannabis, alcohol, and the opiates, we note that there are remarkable individual and cultural differences in the responses to these substances. The next two sections report some of the cultural and experimental psychopharmacological data relevant to this point.

Cultural Setting and Drug Effects

Two of the most common and widely used psychic modifiers are cannabis and alcohol. The cannabis drugs are prepared from the flowering tops, leaves, seeds, and stems of the hemp plant, cannabis sativa. This may be made into cigarettes (sometimes mixed with tobacco), eaten as a confection prepared with honey, or drunk as a watery or alcoholic solution. Names for various preparations from this plant are legion. It is best known in the United States as marijuana or by a number of slang terms. Descriptions of the effects of the cannabis drugs are quite varied, owing in part to the concentration of the active principle in different specimens of the plant and different degrees of extraction of the active principle in accordance with the method of preparation and in part to the effects of the drugs with which it may be taken, e.g., alcohol. The varied means for fermentation and distillation of sugar, starch, grains, or fruits are the basic means of preparation of ethyl alcohol, are well known, and need not be discussed here.

In India, an infusion of the stems and the leaves of the hemp plant (bhang) is used by Brahmans, who, according to Carstairs," find a "modicum of bhang to be helpful. . . in their practice of devoting some minutes or hours every day to sitting in a state of abstraction and prayer." Among the Brahman priesthood, large quantities of bhang may be taken to facilitate entering devotional trances. Although they appear drunk—their coordination and gait are grossly impaired, and their orientation in time and place is disturbed—they regard themselves, when under the influence of bhang, as empty of all worldly distractions, concerned only with God. The god Shiva is cited by them as a bhang drinker and as a paragon of the contemplative life. The use of bang is consecrated to achievement of their contemplative and ascetic ideal, to the practice of severe and prolonged austerity, to the withdrawal of their attention from the distractions of the sensible world. The holy man attempts to go beyond the minutes or hours of abstraction and prayer of the lay Brahman to the point where he exists for hours in an oblivious, inward state.

The Tunisian cannabis-users smoke a preparation called takrouri; they smoke it in a quiet room, scented and decorated with flowers and with erotic prints calculated to stimulate vivid ideas and images appropriate to their anticipation of paradise. Though the themes of intoxication differ from those of the Brahmans, like the Brahman, the Tunisian Muslim uses cannabis in the context of his religious beliefs.

Carstairs cites a number of sources and his own experiences to suggest that cannabis leads to feelings of detachment, extreme introspection, loss of volition, and a dreamlike impression of heightened reality. As he describes the cannabis drugs, they are a means to attain renunciation of the active life. He contrasts this to the effects of and the motives for using alcohol, which he describes as a means of releasing sexual and aggressive impulses, of proving or asserting in an exaggerated manner the individual's competence to deal with the problems, fears, and anxieties of life in the tangible outer world. We learn from him that the Brahmans revile daru, a potent distilled alcoholic beverage. The Brahman regards the use of alcoholic beverages as "foul, polluting, carnal and destructive to the spark of Godhead which every man carries within him." Carstairs quotes one informant: "The result of eating meat and drinking liquor is that you get filled with passion, rage—and then what happens? The spirit of God flies out from you."

Most North African users of cannabis also use alcohol. In short, there is no pharmacological basis for not mixing these drugs. In the United States, the cannabis user, like his Indian counterpart, typically does not use alcohol, although he does not "revile" alcoholic beverages. That is to say, he uses alcohol if he cannot get cannabis (marijuana). However, when we contrast his cannabis use (in the form of marijuana cigarettes) to the Indian use of bhang, we note that the goals of use, the behavioral effects, the themes of meaning and interpretation, the social behavior, and the setting are all remarkably different. First, marijuana is most often used in a social setting, in a group of users who mutually enjoy the effects of the drug. Second, the intent is to heighten enjoyment of outer experiences, e.g., conversation, listening to or performing music, dancing, joking. Unlike the Brahman priest, whose vocabulary during his intoxication is limited to repeating one of the names of his God, the marijuana devotee laughs, giggles, eats without restraint, tells jokes, participates in sexual relationships, and takes pleasure in the company of both men and women, especially if they are also using marijuana. Third, the effects are interpreted by a marijuana-user as analogous to those of alcohol. He prefers marijuana because the effects are more rapid and "neater"; there is no hangover and no debilitating physical consequences of chronic use.11

Thus, the use of cannabis in our society is to attain an experience which, far from renouncing the active life in favor of a contemplative, ascetic ideal, affirms the pleasures of sex, music, food, laughter, and human companionship. Among contemporary American students of drugs and their effects in our society, cannabis is likened to the effects of alcoho1,12 in contrast to the European and Oriental sources cited by Carstairs, which suggest or state that the effects of cannabis and alcohol are almost antithetical.

Wilder has pointed out how carefully one must define the experimental conditions in which the "pharmacologic effects" of a drug are observed." We must add to his remarks the caveat: the cultural setting in which a drug is used is a significant determinant of the effects of the drug as a psychic modifier.

Similar data indicating gross cultural differences in the goals of use, behavioral effects, and themes of meaning and interpretation of alcohol have been reported by Bunzel" and Horton." Bunzel described two Central American cultures, both of which used alcoholic beverages in feast-day rituals and to varying degrees in their personal lives. Among the Chichicastanango, feast-day drinking leads to fighting, quarreling, and sexual license—violation of the central norms of their domestic life in which the repressed anger associated with their rigidly patriarchal, patrilineal, and repressive social order gains some outlet, only to be followed by guilt and depression in their subsequent sobriety. Among the Chamula, drinking is part of the everyday life of almost the entire community. From the youngest child to the oldest woman, drinkhig of aguardiente—a potent distilled beverage—is the rule. Drinking is an essential part of their daily social interactions, and drinking to intoxication is the norm. Unlike the Chichicastanango, it is usual for the Chamula to wake up the morning after one of the stupendous drinking bouts a little weak and shaky, but otherwise well and cheerful, ready to laugh at the absurdities of the previous day. There are no complaints of headache or dizziness, no guilt, and no noticeable repression.

Horton has pointed out a remarkable uniformity in the drinking behavior of primitive peoples. In general, they drink to get drunk as quickly as possible, with no emphasis on the taste of the beverage or on the subtle appreciation of mild changes in mood or thinking, e.g., philosophical reflections on man, on his nature, or on the relaxed conviviality which enters so strongly into our own rationalizations for drink. This is remarkably in contrast with the rich variety of group responses to alcoholic beverages among our civilized contemporaries.

We are familiar with social types and groups whose use of alcohol is for social facilitation or ritual; consider the wine-taster or the connoisseur of brandy, Scotch whisky, or beer. We are also familiar with such groups as Horton's primitives which drink to excess for the loss of restraints and the acting out of sexual or aggressive impulses with the support of their coparticipants. We are also familiar with the problem drinker whose drinking may be consciously motivated by a wish for social facilitation or group-supported "unrestraint," but who recurrently leaves these motives far behind as he progresses to a degree of intoxication which permits neither social facilitation nor group-structured activities, restrained or unrestrained.

In short, the use of alcohol, however consistently it may act as a depressant (inhibitor) of synaptic transmission, elicits behavior and leads to the expression of motives which are inherent in the user and/or in the social setting of use, and not in the alcohol itself. Even in a single social setting, the cosmopolitan cocktail party, there are remarkably individual reactions to alcoholic beverages, which are not only observed, but actively discussed by the participants. There is the person who becomes sleepy after a few drinks; the melancholy Slavic soul whose grandparents immigrated to this country from Russia sixty years before but who still must become moody or depressed to advertise his heritage; there is the cocktail party lecher, politician, and Indian wrestler; there are those who stop drinking at a point where they anticipate they might misbehave and those who continue to drink to the point where others may be obliged to intervene to stop them from misbehaving. What is remarkable—or commonplace, depending on one's perspective—is the fact that there are also extraordinary differences in response to the opiate drugs.

Individual Responses to Drugs

Though we have no formal anthropological study of the opiate drugs in various cultures, we have another and even more relevant source of data. In the past few years, a number of systematic laboratory studies comparing the effects of some psychic modifiers have been made which indicate that there are remarkable individual differences in reactions to the psychic modifiers in the laboratory and that these differences are related to the personality structure, level of anxiety, type and adequacy of ego controls, and to the presence and type of psychiatric pathology.18

The majority of normal subjects, young men ranging in age from twenty-one to twenty-seven, in controlled studies of response to drugs, reported displeasure or experienced no effects on their moods from initial injection of heroin or morphine. Pleasure was experienced by only the minority of nonaddicts; the typical response was indifference or actual dislike. Those subjects who received second injections of morphine or heroin had essentially the same reactions as they did to their first. There is no evidence that repeating the experience enhances the acceptability or liking of these drugs. Lowering the dosage to levels well below those of clinical practice (i.e., for the relief of pain) increased the proportion of subjects who experienced no effect on their moods. There is no evidence that the use of these drugs in such subclinical dosages enhances the acceptability or liking of the drugs.

Hospitalized men and women, ranging in age from forty-five to eighty-seven, chronically ill with malignant disease or neurological disorder, described their responses to the injections of drugs. Only one-third felt happy (or "happier") after injections of heroin or morphine. Since the same proportion felt happy (or "happier") after the injection of a placebo, there is no evidence that the opiates are inherently euphoriant even for individuals suffering from pain or the distress of chronic illness. Indeed, the use of morphine for relief of pain is rarely followed by euphoria; only three of 150 postoperative patients studied in Beecher's laboratory had genuine euphoria following morphine, although a larger minority felt "pleased" for relief of their pain.

Only about half the sample of hospitalized postaddicts (a term used in the Lexington laboratory to describe subjects in the research wards at Lexington who had been addicted to opiate drugs) reported a pleasurable response to heroin, whereas almost all of such subjects reported pleasant reactions to morphine. Thus, even for postaddicts, morphine is preferred to heroin; heroin's reputation as a superior "euphoriant" is hardly supported by these data. Only those "normal subjects" whose reactions to psychic modifiers differ from those of the majority of their peers (atypical reactors) are likely to regard the sedative effects of morphine or heroin as valuable, desirable, or attractive.

These data indicate that opiates are not inherently attractive, euphoric, or stimulant substances. The danger of addiction to opiates resides in the person, not in the drug.

Despite these findings, the opiate drugs are commonly regarded as seductive substances which should be kept away from the unsuspecting and the innocent, who otherwise, it is feared, would become addicted.

An elaborate system of social controls and sanctions has been constructed for their protection; to what extent these controls and sanctions are effective or useful, to what extent they introduce corollary social problems of equal or greater moment than addiction to opiates, are complex and important questions.

Sanctions and the "Dangerous" Drugs

The League of Nations, the United Nations, and state and federal bodies governing the distribution and use of certain drugs have never found or utilized an adequate, encompassing definition or designation of the drugs they seek to control. Although perfection of definition is hardly a necessary basis for sanctions, whatever definitions have been written have not been applied. The term "addicting" is used largely out of tradition; drugs which are clearly not addicting in the sense of inducing physical dependency—e.g., cannabis and cocaine—are included in their lists. Drugs which are demonstrably dependency-inducing and/or dangerous, with serious withdrawal syndromes—e.g., barbiturates and alcohol—are not. The various regulating bodies have generally fallen back on the term "dangerous" and have specified each drug they regard as such, rather than depending on any general formula, theory, or pharmacological reasoning. But, however accurately the
sanctions against the use of certain drugs reflect their inherent "dangerousness," it is clear that these sanctions, once they are imposed, contribute to the danger of any use of the drug outside prescribed settings.

Since the opiates are legally regarded as dangerous drugs, their use is proscribed outside medical settings for the treatment of illness or of the withdrawal syndrome of addicts. In this country, opiates may not be prescribed for the maintenance of addiction, according to the Bureau of Narcotics of the Treasury Department and according to most, though not all, interpretations of the pertinent laws by the Supreme Court» This has far-reaching consequences for the illicit user of opiates.

Since opiates cannot be purchased legally, the addict is forced to purchase an uncontrolled product of dangerously variable concentration and often containing poisonous adulterants. He does not receive instruction in the hygiene of self-administration and, even if he knows better, is typically compelled to take the drug under circumstances that do not favor sensible precautions. He literally stakes his life every time he takes a dose; death, both of the quick and relatively slow varieties, is tragically common.

If he has previously had access to a private physician, the physician is, more often than not, too terrorized to treat him, even for ailments other than his addiction—a terror of police persecution, not of any direct menace in the behavior of the addict—and shunts him off to the relatively impersonal, understaffed, overcrowded, and underequipped public clinic. Abuses by some physicians have created a condition in which every physician who treats an addict is, in the eyes of the narcotics agents, guilty until proven innocent, and he has some reason to expect continuous harassment once he comes under their scrutiny. In the light of the right of every physician to select his own patients so long as other sources of treatment are available, the Hippocratic oath readily funcfions, when it comes to addicts, on a sharply sliding scale.

Because the possession of narcotics is illegal, the addict is necessarily in violation of the law. The effect of the illegality is, however, far more extensive. The unconscionably high black market prices place the drug far beyond his capacity for legitimate income. Normal employment becomes meaningless to him. Inevitably, he is driven to the unlawful activities that promise him the income he needs to maintain his habit. If he has had any law-abiding associates, these must be sacrificed to the all-absorbing preoccupation with maintaining his contacts and his standing with his illegal sources of supply. Willy filly, he becomes a cog in an international criminal business. Sooner or later, he falls into the toils of the law and becomes a marked man. He has stepped onto the merry-go-round which carries him in and out of hospitals, in and out of jails, from degradation to degradation, increasingly enmeshed in the company of the scum of the earth, with nothing to look forward to but the ever-more-blessed relief of narcotized oblivion.

Let us not exaggerate. We are not suggesting that the typical addict would lead a sane, respectable, productive, and responsible life if the drug were legitimately accessible or, for that matter, if he had never had access to the drug in the first place. Our point is that whatever chance he may have had to make something of his life, whatever modicum of human dignity it may have been possible for him to extract from it, virtually disappear once he has become an addict. This is not because of any intrinsic effect of enslavement to the drug, but because he is enslaved to a drug the possession of which and traffic in which is subject to vigorous persecution. By far the worse consequences of addiction are associated with its illegality.

At the same time, the illegality contributes to the reputation of opiates as esoteric, euphoriant substances and lends them the aura of forbidden fruit. The use of opiates in this unsanctioned setting makes it disruptive to the user and to the community. However, the sanctions on opiates were not established with these consequences in mind. They were intended to control the use of the drugs. Why? This is difficult to understand without appreciating the historical context in which this prohibition or limitation of the use of opiate drugs took place.

The Historical Context and Sanctions on Opiates

There are three historic phenomena of particular relevance. First, the temperance movement itself, with its particular but not exclusive emphasis on alcoholic beverages; second, the international conferences intended to cope with the problem of the use of opiates in the Orient; third, the need to protect the public against the patent medicines whose active ingredients were predominantly unlabeled, unidentified opiate drugs.

The prohibition or temperance movement regarded all intoxicants as harinful on moral as well as on medical-social grounds. Though it did not succeed in maintaining prohibition of alcoholic beverages for more than two decades, there evidently was enough popular support for the ideals and opinions of the movement to pass an amendment to the Constitution. The logic and assumptions of this movement have been summarized by Warner in a panel discussion on the temperance movement.18 From his remarks, we have abstracted three major assumptions of the temperance movement.

First, any substance which is liable to rob a man of his senses and render him foolish, irascible, uncontrollable, or dangerous is unsafe. Second, alcohol offers neither a natural nor a healthy way to achieve happiness or reduce unhappiness; the natural means for achievement are through work, play, socialization, and so forth. Third, the gratifications afforded the moderate user of alcohol are outweighed by the dangers to society of immoderate use and the fact that, with alcohol available, there will always be incontinent users.

The legality of prohibition of alcoholic beverages (for other than medical, sacramental, mechanical, or scientific purposes) was supported by the Supreme Court, which accepted the "demoralizing effect of drunkenness upon society." The justices agreed that:

The state has the right to subject those members of society who indulge in the use of such liquors without injury to themselves to deprivation of access to liquor, in order to remove temptation from those whom its use would demoralize. . . . When liquors are taken in excess the injuries are [not] confined to the party offending. . . . The injuries it is true first fall upon him in his health, which the habit undermines, in his morals, which it weakens, and in the self-abasement which it creates. But, as it leads to neglect of business and waste of property and general demoralization, it affects those who are immediately connected with and dependent upon him.19

In 1914, the House of Representatives passed the Hobson Afnendment, which "proposed to prohibit merely [sic] the sale, manufacture for sale, and transportation for sale of intoxicating liquors." However, it did not receive the required two-thirds vote for passage to the Senate for ratification prior to being voted on in the states in order to become an amendment to the Constitution.

The assumptions of the temperance movement vis-à-vis alcohol and the legal opinions of the Supreme Court are equally applicable as arguments against the use of opiate drugs. Indeed, the same Congress which passed the Hobson Amendment passed the Harrison Act. It is an interesting historical anomaly that the Hobson Amendment could not pass into law without an amendment to the Constitution, whereas the Harrison Act was effectual as a prohibition of opiates solely on the basis of a tax measure and interpretations of rulings of the Treasury Department. In retrospect, it is quite unlikely that there would have been much difficulty in passing an amendment to prohibit or limit the use of opiate drugs, and it is equally unlikely that such an amendement would have been counteramended, as the Eighteenth Amendment was by the Twenty-first.

The widespread use of opium by the Chinese, to the economic advantage of the British, and to a lesser degree the American, shipping industries, was regarded not only as immoral, but also as a basis or a strong supporting factor of the lack of material progress and political growth of the Chinese people. Although there are no data of number or percentage of Chinese who used opiates in an addictive manner (in the sense of daily use with development of dependence and tolerance), probably very many did use opium. To what extent this was a consequence of the lack of opportunity for material welfare and personal development and to what extent a cause of these conditions is difficult to say. But, however little the cost of the opiates per dose, any money not utilized for capital development, the development of industry, the improvement of agriculture, and the improvement of the public health drains money from the public welfare of an impoverished population. For a poor country, the widespread use of opiates is an ill-afforded luxury which may not only quell the pains of hunger and soothe the anxiety and sadness of a marginal existence, but may also inhibit or depress the inclination to do something about these conditions. Karl Marx characterized religion as "the opiate of the masses," but in fact opium itself has been and, in certain undeveloped Eastern countries, still is the opiate of the masses.

On the basis of such reasoning, the British House of Commons adopted "a resolution to the effect that 'this house reaffirms its conviction that the Indo-China opium trade is undefensible, and requests the government to bring it to a close.' 2° American missionaries in the Orient appealed to Pres. Theodore Roosevelt "that the United States take the initiative in obtaining an international agreement to control the use of opium by those governments in whose far eastern territories opium smoking was a problem."21 In 1908, an international commission of these governments met in Shanghai to discuss the problem and recommend possible solutions. In 1911, an international conference took place in The Hague which culminated in an international legal instrument, the Hague International Opium Convention of 1912, pledging the contracting powers to "enact pharmacy laws or regulations to limit [the opiates] exclusively to medical and legitimate purposes. This became the basis of our Harrison Act.

In the nineteenth century, prior to the development of medicine as a science, self-medication and self-diagnosis were commonplace. Patent medicines were advertised for the cure or amelioration of almost any condition without specification of their ingredients. Most of these nostrums were used for the endemic coughs, dysenteries, and upper respiratory infections which were the consequence of poor or primitive sanitation and hygiene,23 as well as for the more serious cardiovascular and pulmonary diseases, especially tuberculosis. Sufferers from dysmenorrhea and unspecified "female complaints," from the pains of chronic infection, poorly performed amputations, and traumatic neuritides (these last the legacy of the Civil War) were a splendid market for remedies whose effective agents were alcohol and opium, morphine, or heroin.

The user of the patent medicines was in a difficult situation. The unidentified opiates did relieve his pain or cough, but since the source of his distress was often a chronic or subacute disease process, he made daily or more frequent use of these nostrums for relief. However, when he sought to stop taking the nostrum when the symptoms abated, he developed malaise, aches and pains, and gastrointestinal and other symptoms which could be perceived as a relapse and occasion for continued medication, but which in fact were indications of early dependence on the opiates. Though there are no contemporary data on how many persons became medically addicted through the use of such patent medicines, the impression from the sources cited by Terry and Pellens is that great numbers of persons became addicted in this fashion.24 But it is to be noted that "addiction" is here used in the sense of "dependence" and that there is no basis whatever for determining the proportion of addicts who also developed craving.

Another reason for the great number of persons who were medically addicted—not through self-medication but through the prescription of physicians—was that the opiates, and morphine in particular, were among the few widely effective drugs available to the practicing physician. There was no rational pharmacopoeia based on systematic clinical and experimental observation, and disease processes were only beginning to be understood. Symptomatic relief—and the opiates could grant this blessing for a variety of symptoms—was often the aim of medical care.

The situation today is quite different. Our knowledge of disease is vastly superior to that of the nineteenth-century physician. Today, the aim of most medical treatment is to affect the underlying disease or physiological process, not merely to yield relief of distressing symptoms. Furthermore, with improvements in public sanitation and water supply, improved surgical technique and asepsis, with the freer use of that true miracle drug—aspirin—and other more dramatic pharmacological developments, the medical need for opiates has diminished. Even by the early 1900's, however, the use of opiates for prolonged treatment of illness or bodily distress was not so much a consequence of the limitations of medical science as it was of the patent medicine industry, which was, from a physician's standpoint, very much in need of control.

The Attitudinal Context

By the middle of the twentieth century, along with the development of sanctions on opiate drugs, certain attitudes about the effects of opiates on personality and social behavior developed which continue to be prevalent in this country. These may be generalized simply: the use of opiates is harmful to health, morality, and public welfare.

Since social attitudes are rarely based on medical or other scientific evidence, the common notion that opiates are harmful to health is perforce vague, expressed in terms of "degeneration" or "deterioration" rather than by reference to disorders of particular organs, systems, or tissues. There is a stereotype of the opiate addict: his complexion is sallow, posture stooped, musculature weak and flaccid; he is emaciated and dirty or at least unkempt. This stereotype is justified at least in part by experience. The "down-and-out" addict who has spent his last nickel and pawned his clothing to purchase drugs—which are dreadfully expensive on the illicit market—is concerned with his appearance, nutrition, and sleep only after his need for drugs has been satisfied. But the stereotype reflects the problems of obtaining drugs rather than the effects of the drugs themselves. Those who are able to obtain drugs without the difficulties imposed by our laws appear no different when chronically addicted than when in a prolonged period of abstinence. Anecdotal reports of persons who were not recognized as drug addicts until they were in a setting where drugs could not be obtained lend credence to this statement. Most relevant, however, is the appearance of post-addicts who are readdicted in the research wards at Lexington. They appear healthy, well-nourished, clean, and respectable.

Turning from the nonspecific stereotype to the systematic study of the effects of opiates on health, we note that there are no known diseases of any tissue or organ associated with chronic addiction to opiates, as there appears to be with chronic use of alcohol, tobacco, or with chronically excessive caloric intake (the diseases associated with or intensified by obesity). This is not to say that opiates have no effects on the functions of the body. Examples of the effects are pupillary constriction, paradoxical constipation, orgastic impotence in the male, and amenorrhea and/or infertility in the female. However, none of these conditions interfere greatly with day-to-day living, nor are they permanent or total.

However, the health of drug addicts in the present social and legal context may be impaired by prolonged neglect of diet and by participation in deviant (mostly lower-class) social environments where venereal and other diseases are widespread. There are, furthermore, the special risks of being an addict in our society. For example, as we pointed out before, they may receive poisonous adulterants in their heroin. When they steal, they run the occupational risks of the criminal, for example, being shot by the police. Death by suicide or by accidental overdose of heroin is also a serious hazard. Although the suicide may come at a point in the cycle of addiction when the addict is no longer able to obtain sufficient drugs to experience the psychic effects he craves, in our experience with adolescent addicts, suicide occurred early in a cycle of readdiction after discharge from a hospital, at a point when the addict was remorseful and depressed by his failure to remain abstinent and by his intensified awareness of the difficulties of being an addict in our society.

The putative effects of opiates on morality are based largely on the characteristics of those social groups who notoriously used opium (or other intoxicant drugs). In part, this is a legacy of the opening of the Far West and particularly of California, where many of the men without families who gambled, sought gold mines, or swindled their fellows adopted the smoking of opium from the Chinese.25 As a group, these men separated themselves from the conventional morality and standards of the Eastern United States. They valued neither their own nor their neighbors' lives highly; they sought whatever excitement and novel experience they regarded as worthwhile or interesting. Since they used opiates, it was simple to identify their values—which included the use of opiates and especially smoking opium—with the effects of the drug itself.

On the other hand, there is the divergent tradition that opiate use leads to submission to an unrewarding life. This is based primarily on observation of the materially depressed Chinese laborers (in China and the United States) who did, in fact, utilize opium in their need to adjust to a way of life in which personal upward mobility or even marriage and a family was often impossible.

Though the exuberant search for new experience and submission to fate are antithetical, popular attitudes about the effects of opiates on behavior have synthesized these disparate notions into the concept that opiate use is harmful to morality. The fact is that the cart was simply placed before the horse. It is true that persons who dissociate themselves from the norms and values of their fellows may, in a search for new experience, use opiates. It is true that the opiates have been used by materially depressed populations. The point is that the use of opiates is one way to fulfill these needs; it does not initiate them.

There are three aspects to the notion that opiate use is harmful to the public welfare. The first is that opiate use releases or stimulates violent and antisocial impulses. Opiate intoxication is not clearly differentiated attitudinally, as it is in fact, from intoxication with alcoholic beverages. Consequently, the opiate addict is thought to become aggressive and sexually stimulated when he is under the influence of opiates. There is, for instance, a passage in Briffault's novel, Europa, in which a sexual orgy is aggressively initiated by a protagonist after he gives himself an injection of heroin. A generation or more of American readers and movie-goers acquired their image of the addict from Sax Rohmer's, The
Mysterious Dr. Fu Manchu.

In fact, however, the effect of the opiates is remarkably unlike this. Though the addict does not necessarily object to company or to participating in sexual play or intercourse, he usually prefers to be by himself, quietly withdrawn from any social interaction. If disturbed, he may become irritable and short-tempered. "Don't bother me," rather than, "I'll bother you," is the motif of his behavior. The behavior of the opiate addict after an injection of morphine or heroin is remarkably unlike that of the usual social drinkers (or problem drinkers) in our society, who so often become boisterous, aggressive, or troublesome after a few drinks. With regard to effects on sexuality, the effect of the opiates is to diminish, if not do away with, sexual appetite. The addict "loses his nature." He may participate in sexual play, but with retarded ejaculation or orgastic impotence. The woman addict is almost always frigid or uninterested in sex after receiving opiates.

The second aspect of this image is that use of opiates seriously undermines the person's interest or ability to work. But, in fact, the relationship between opiate addiction and work is quite complex. The number of professionally successful persons who were or are addicted to opiates is an indication that there is no necessary relationship between opiate use and an unproductive life. There are also a number of addicts who, indeed, never worked, if they could help it, before they used drugs and who continue not to work, if they can possibly avoid it, after they become addicted. There are a number of such marginal deviants as racetrack characters, gamblers, hustlers, and confidence men of various persuasions who become addicts and continue to support their addiction through these vocations.

There are many addicts we studied who continued at their jobs, with sufficient industry and deportment to satisfy their employers. If; however, they were unable to satisfy their self-induced need for drugs before going to work, they might be too restless and irritable (early symptoms of the withdrawal syndrome) to work or be late or absent from work because of many hours spent "making a connection." If addicts lose their jobs, it is because they could not regularly obtain drugs, not because the opiates made their work unsatisfactory to their employers. In our experience, there are also a number of addicts who are able to work better when receiving drugs than when abstinent. Such a person is often preoccupied with obsessive doubts which inhibit him in the simplest tasks; when he uses opiates, he gets "drive," his obsessive doubts are suppressed, and he is able to make decisions and act."

The work habits of the few carefully observed patients who were re-addicted in the research wards at the United States Public Health Service Hospital in Lexington, were not sufficiently different from those of the other, abstinent patients to provoke comment. These patients may have worked at a slower pace than some of their peers, but their efficiency and attentiveness were not otherwise impaired.

In brief, there is no simple or single effect of opiates on work and productivity. Instead, a variety of behaviors vis-à-vis work may occur when a person is regularly using opiates. Whatever behavior we observe in a particular addict resulted not merely from the opiates, but rather as a consequence of interactions between his needs and motives for addiction, his personality structure, and the neurophysiological effects of the drugs.

The third aspect of this image is that the use of opiates leads to crime. We have already dealt with this issue at some length. There is no evidence that opiate use produces such temporary abeyance of judgment as would lead to violence or destructiveness. We have been told that at one time such claims were made by attorneys who pleaded temporary insanity caused by intoxication with opiates in defense of their clients. In fact, the opiates sedate rather than stimulate, pacify anger and resentment rather than encourage these sentiments. In periods of addiction, when the person needs to make connections to purchase drugs or steals money for this purpose, he has no heart for gratuitous aggression; he is seriously devoted to the most efficient and least conspicuous means of achieving these goals. Though he will disregard the property rights of other persons, he has no interest in hurting them.

In summary, the attitude that opiate use per se is harmful to health, morality, and the public welfare finds no support in any evidence known to us. There is evidence that persons already participating in a life whose values and goals are regarded as harmful to morality and to the public welfare will probably continue in such a life after they become addicts. However, there is considerable evidence that there are unanticipated consequences of the attempt to proscribe opiate use which are, in fact, harmful both to the addict and to the common good.

Opiate Use outside the Historical and Attitudinal Context

AN EXERCISE IN "WHAT IF?"

What predictions and general observations are to be made about opiates if they are regarded neutrally, solely in terms of their pharmacological and behavioral effects and in terms of the social interactions and behavior of users?

First, we would have to note that opiate use is hazardous. Overdose leads to respiratory inhibition, coma, or death. Since the quantity of opiates sufficient to produce such respiratory failure is considerably greater than dosages used for the treatment of pain or for other psychic effects, it would be appropriate to recommend that they always be carefully labeled and compounded in such a fashion—e.g., in varisized and -colored capsules—as to avoid accidental misuse. This is particularly important for heroin, which is readily mixed with milk sugar and other vehicles. Furthermore, people should be informed of proper techniques for the sterilization and use of their injection apparatus to avoid abscesses and other infections of the skin and veins and to avoid contagion with malaria, hepatitis, or other diseases.

Second, we would note that there are a number of disturbances of bodily function associated with the opiates; for example, pupillary constriction may interfere with vision under conditions of poor illumination. Constipation, amenorrhea, and sexual apathy may also occur.

Third, we would note that the regular use of opiates leads to physiological dependence and tolerance. This dependence and tolerance develops according to the frequency of dosage, the quantity of opiates used, and the characteristics of particular drugs, e.g., the dependence on Demerol or codeine is less marked than on morphine or heroin. In order to satisfy the dependence and also to obtain psychic effects, the dosage will probably be gradually raised to a point far beyond initial levels of use. Theoretically, a level of physiological dependenc-e and tolerance may be reached for which no quantity of opiates would suffice except to forestall symptoms of withdrawal. Practically, the addict usually continues for long periods at a particular dosage. In order to achieve a lower level of dependence and tolerance, a brief period of abstinence is necessary. Since there is an unpleasant withdrawal syndrome during this period of acute abstinence, he may seek medical assistance. This pattern is likely to persist for many years. There are no systematic data indicating how often the pattern is spontaneously given up. It may, however, be recalled from our discussion in Chapter II of the Federal Narcotics Bureau file of drug-users that more than 9 per cent of drug-users whose names were first listed during 1955 and who were not known to have used drugs in the following five years were individuals who had a history of drug use extending from ten to fifty-one years prior to 1955.27 On the other hand, there are many cases of lifelong habituation.

We must also note that the addict does not find the dependence or habituation so burdensome as one might anticipate. Indeed, because of the gratification it affords him, he finds it far less burdensome than does the diabetic, who may also have a lifelong dependence on a drug. Nonetheless, it should be made explicit that the regular use of opiates may place the person in a prolonged dependence on drugs and on the apparatus for injecting the drugs which may limit his travels or occupation, since unavailability of opiates would subject him to quite disagreeable and, in rare circumstances, dangerous symptoms.

Fourth, we would note that some people find the occasional use of opiates a welcome form of intoxication. The major overt effect on their behavior and mood is relaxation and somnolence. Most people, however, do not value this experience highly. Though they may feel relaxed, they do not experience those subtle effects on their mood and ideation which the few characterize as a special sense of well-being. Others may find that this occasional intoxication facilitates their social behavior, just as many welcome occasional intoxication with alcoholic beverages, especially when their social behavior has been severely inhibited by anxiety, feelings of inadequacy, or of "not belonging." However, acute intoxication with opiates is quite unlike acute intoxication with alcohol.

There is a general sequence of events which commonly occurs when a sober person begins to drink alcoholic beverages. These events are expressions of the degree to which the person has lost control over his speech, emotional expression, and motor behavior. The rate at which this effect takes place is related to the quantity of alcohol ingested, to the rapidity of absorption, and to the body weight of the drinker. With the first few "social" drinks, the individual's judgment and inhibitions are affected. He talks and otherwise participates more freely in social interaction. In the early stages of intoxication, his cultural expectations of the effects of alcoholic beverages on behavior or mood may lead to •the expression of such effects long before sufficient alcohol is ingested and absorbed to "account" for these effects neurophysiologically. As intake continues and the blood-alcohol level rises, motor coordination becomes poorer. The drinker's insight into his level of coordination may also become poorer, so that he may endanger himself and others by driving a car, attempting feats of strength or skill, and so forth. As drinking continues, motor incoordination is accentuated, and social behavior deviates even more from the individual's usual roles and norms. Finally, with continued drinking, stumbling, slovenliness, loss of bladder control, anesthesia, stupor, and even coma ensue.

Acute intoxication with opiates is very different. In part, but not entirely, the effects differ for the novice and for the habituated user. The common sequence of events after administration of a dose of opiates is as follows: (1) There is a transitory nausea which may, particularly in the novice, be followed by effortless and emotionally nondistressing vomiting. (2) There is a period of maximal appreciation of the subtle effects of the drug. Some of these are: body sensations, for example, a feeling of impact in the stomach, bodily warmth, "pins and needles," and itching sensations of a rather pleasant and eroticized nature; a feeling of lethargy, somnolence, relaxation, and relief from tension or anxiety; and the experience of the "high." This experience, as reconstructed from the reports of addicts and some normal subjects, is one of comfortable detachment from and lack of involvement in current experiences. The person feels "out of this world," all his demands have been fulfilled, everything is taken care of. Perhaps the most instructive of a variety of phrases used by addicts to describe this experience is "being in the junkie's paradise" (3) Following the period of maximal appreciation of the effects of the drug, there is a gradual return to a "normal" state. The user returns to his normal activities but continues to maintain, although to a lessened degree, the comfort, detachment, and loss of tension which he had experienced most intensely in the first hour or two after taking the drug. Depending for its rate of onset on the degree of physiological dependence, in the next few hours there develop feelings of discomfort comparable at first to normal hunger, but mounting in infensity until relieved by a new dose or until the appearance of the full-scale withdrawal reaction.

Chronic intoxication with opiates is quite unlike chronic intoxication with barbiturates or alcohol; the latter drugs progressively interfere with the person's coordination, intellectual functioning, and judgment. With chronic opiate intoxication, disturbances in coordination, intellectual functioning, and judgment are strikingly associated with withdrawal from opiates rather than with the intoxication per se. The alcoholic may be said to suffer in his intoxication; the opiate addict suffers in his abstinence. The alcoholic pays the piper through the disabilities of his intoxication; the opiate addict pays through the disabilities of abstinence.

Fifth, what about the effect on social behavior? It is likely that addicts would be treated with disdain or lowered respect whether or not their behavior were conspicuous or deviant. According to various religious elements in our culture, comfort and pleasure are regarded as the just rewards of effort and achievement; it is not quite moral to be happy or at ease without earning it through struggle and work. On the other hand, among the rebellious, individualistic, and antiauthoritarian elements in our culture, it is not fitting to be quietly and inconspicuously intoxicated. The drinking boasts of the pioneer and the frontiersman are not merely expressions of alcoholic exuberance; they express significant and normative cultural themes. Speaking generally, we esteem both moral discipline and immoral rebellion; speaking equally generally, opiate intoxication quietly thumbs its nose at both of these, quietly sidesteps the virtues and excesses of both.

However, discipline and rebellion do not exhaust the variety of possible patterns of living in our multifaceted culture. There is still some room for the person who holds his peace and lives inconspicuously with minimal striving for personal possessions or even personal expression. Such a person is often regarded as weak, ill, or deviant; however, he may also be regarded as harmless. Partly in reaction to their rejection by the majority for being culturally out-of-step, it is likely that many addicts would dissociate themselves from the mainstream of American life. It is probable that they would continue to participate in work and in certain limited social interactions without full involvement or without lending much credence or support to the dominant ethos.

Sixth, we cannot assume that people with criminal or other deviant associations and behavior will not use opiate drugs; however, their behavior in the course of acute or chronic intoxication with opiates should not be excused or explained by the drugs themselves.

This exercise in "what if" may be summarized briefly. It seems possible to have a society in which opiate addiction is not prohibited by law without disastrous effects on the social structure. We are not, at this point, recommending such a change in our social arrangements, but merely pointing out that prima facie it does not seem intrinsically evil or unmanageable. All novel social arrangements probably have undesirable and unintended consequences, and we are at this point intensely aware of the unintended consequences of the Harrison Act. Whether other social arrangements for the addicted person and the use of opiates could be made more wisely and effectively is a moot question to which we shall return.

Why Is Opiate Addiction a Social Problem?

Having reviewed some of the historical, sociological, cultural, pharmacological, and personal phenomena of opiate addiction, we can now turn to the central problem of this chapter, namely, why should we be concerned with opiate addiction, as social scientists, physicians, or as citizens? There seem to be two groups of reasons for concern. The first is because opiate addiction and use is occurring in a historical and attitudinal context which makes its use a social problem.

Whether or not we regard the assumptions, traditions, and historical currents as a sufficient and logical basis for our current proscriptive legislation, these proscriptive laws and supporting sanctions do nonetheless exist. Whether we approve of these laws or not, they have consequences which make opiate addiction a major hazard to the person who becomes an addict and a burden to the community in which opiate addiction or use is endemic. Thus, a person who obtains drugs outside authorized medical settings is perforce participating in a criminal transaction. Through such transactions, he helps support local and international criminal organizations; he lends support to what we surmise to be the interlocking directorates of extralegal big business. Indirectly, he supports a variety of antisocial organizations and activities. He incurs the possibility of arrest and a jail sentence. Through regular use, he incurs the possibility of addiction and the need for the daily use of a cheap substance at an exorbitant price. Since the drugs he buys illegally are neither carefully compounded nor honestly sold, he runs the risk of not even getting his money's worth or of purchasing inert or poisonous adulterants. If the person who uses opiates illegally wants to obtain a period free from drugs, he is not likely to find sympathetic and objective medical care without stigma unless he happens to be extremely wealthy. His stature in the community is threatened.

For the community, extralegal use of opiates calls for the utilization of public money and social energy for special police, courts, and hospitals.

The second group of reasons has to do with the individual apart from the legal context and its consequences. We now know that the person who becomes addicted to drugs or who uses drugs regularly and persistently for the alleviation of tension, anxiety, or for more subtle reasons of which he may not be aware is seeking help which he has not been able to find elsewhere in his life. He is not easily motivated to use drugs. Like schizophrenia, drug use is "a way of life."

We have reason to believe that, even if there were no sanctions against opiate use, we would regard or would learn to regard the people who become addicts as seriously disturbed in their relationships with themselves, with their families, and in the complexities of their relationships with what is loosely called "reality." Conversely, had there never been a possibility for adolescent opiate addicts to obtain drugs, we have reason to believe that, by virtue of their functioning prior to and apart from their first use of opiates, their lives would have entered other maladaptive paths, ranging from serious behavior disturbances to neurotic character disorders to psychoses. We would have to be concerned under either of these conditions (i.e., whether opiates were freely available or absolutely unobtainable) with the person for whom opiate addiction represents a valid potential. In short, we have reason to be concerned with opiate addiction because of its human significance as an indicator of trouble within the individual and, because of the endemic nature of opiate addiction, as an indicator of trouble within many individuals in our society.

There is a related basis for regarding opiate use as harmful to the individual. This reason is based on some of the ethical assumptions of psychoanalytic theory and of much medical practice, to say nothing of the ethical imperatives of a democratic society. We assume that a major therapeutic goal is to help every person achieve the fullest development of his capacities to love, to work, to play, and to conduct himself as a reasonably responsible member of society. We regard anxiety as a significant value in human development and growth, as a stimulus calling for adaptive responses. These responses are not merely means for coping with present sources of anxiety, but rather the nucleus around which a further development and enrichment of the person may occur.

From this standpoint, every neurotic symptom is a hindrance to the fruition of the person. Similarly, every substance (such as the tranquilizer drugs) which, through its pharmacological nature, can alleviate anxiety may impede the development of the person's own resources. We do not mean to be uncompromising, moralistic, or rigid. Such substances or such symptoms may be valuable and necessary alternatives to states of anxiety beyond the defensive and constructive powers of a person's ego. But there is the possibility that escape by pharmacological means may not be the best available route; the possibility exists not only that the person might find socially less incommoding means, but also that the search might in itself strengthen his self-esteem and his capacity to bear what may have been perceived as an unbearable anxiety.

For a person whose contact with the world is painful in consequence of, for example, a weakened capacity to mediate between his impulses and the situational possibilities for gratifying them, the potential of the opiates to relieve anxiety may be extremely seductive. In this sense, by camouflaging anxiety beneath the haze of an altered state of consciousness, opiates may harm the person in his development. By offering immediate relief from tension or anxiety, the opiates make him less willing to participate in the difficult processes of growth.

We must, however, take note of the fact that society's concern for the problem of opiate addiction is not based on this kind of concern for the welfare or development of the addict. Indeed, were it not for the legal situation, the addict would probably be regarded as far less of a nuisance than a person with a drinking problem or one who is chronically unemployable or dependent. As an individual human being, the addict deserves no more or less of the benevolent concern of the community than the person who has other, e.g., neurotic, difficulties in living. The authors have come to regard addiction, viewed outside the legal context, as another complex expression of human suffering and human attempts to cope with it and as another manifestation of widespread need for therapeutic and preventive efforts. We must also note, however, that taking away this inferior mode of adaptation on the high-sounding excuse that it is good for the person while doing nothing to help him find and remove the obstacles to a superior form of adaptation is the sheerest hypocrisy and a refined form of cruelty.

THE PROBLEM OF ADOLESCENT ADDICTION

To this point in this chapter, we have not attempted to demarcate adolescent from adult opiate addiction. When we began our research, it was in a context of beliefs which sought to differentiate the "innocent" adolescent user from the "vicious" adult addict. A tentative early report by competent psychiatrists28—erroneously, we believe—fostered this belief by stating that the adolescent did not have an addiction problem. This was based on two special facts. First, the investigators had at that time limited clinical experience with adolescent drug-users (and probably even less with adult drug-users). Second, the hospital population they studied was limited to boys who had not reached their sixteenth birthday. Thus, they reported on a limited segment of what we would regard as the adolescent period (from puberty to legal majority) and, as we were later to learn, on that range of the adolescent years which largely precede those in which opiates are first used by adolescents who later become addicts.

There were, however, more enduring sources for these beliefs. It was shocking to the public understanding and attitudes about opiate addiction to think that any adolescent, any child, would endanger his life by the use of such nefarious substances as heroin without having been somehow seduced or deceived by a vicious adult into using them. In this "age of the child," it is painful to accept the fact that many adolescents are already active bearers of the traits and attitudes which would be regarded in their adult counterparts with intense disapproval. Redl and Wineman have pointed out that the programs of support for youths who are delinquent (who act against or outside social norms) sow the seeds of their future disappointment and discouragement by unrealistic and exaggerated sympathy for the delinquent as a victim.29 Victim he often is, but in the sense that a monstrous neonate is the victim of an unfavorable prenatal environment; he has been transformed in the course of his victimization and cannot be restored to normalcy by procedures that ignore what he has become.

In this regard, it is quite unlikely that any significant support for special hospitals or for research into the problems of adolescent opiate addiction would have been available if the adolescent opiate-user had not been seen as vastly different from the adult opiate-user. Yet this is a helief which seems impossible to substantiate by our research or experience. The adolescent addict is not typically seduced by vicious adults; he does have an addiction problem; he is an active bearer of the traits and attitudes of the adult addict. In fact, statistical studies in the 1920's and 1930's had already pointed out that the majority of adult addicts began their addiction in their adolescence or in early adulthood.8° Thus, we cannot regard the problem of adolescent opiate addiction as inherently separate from the addiction problem in general.

Our justification for studying adolescent opiate addiction per se is —at least a posteriori—not that we regarded adolescent addiction as different from the adult addiction problem, but rather that the public concern and action on behalf of the adolescent addict permitted us to identify and study adolescent addicts more readily than adult addicts. Second, because of his age, the adolescent addict is still more closely connected to the community and familial setting in which his addiction began. In this sense, we can study adolescent opiate addiction, if not in statu nascendi, at least in closer physical and temporal relationship to the onset and early development of addiction. Though our study has focused on the adolescent addict, we believe that our findings are relevant for the majority of the addict population.

1 L. Goodman and A. Gilman, The Pharmacological Basis of Therapeutics (New York: Macmillan, 1941).

2 Owen Meredith, Lucile, Part I, Canto II, Stanza 10.

3 L. Lewin, Phantastica, die betaubenden und erre gunden Genussmittel (Berlin: Georg Stilke, 1924), pp. 262-264, 272.

4 In fact, the coffee served the Austrian children was quite weak, diluted with hot milk; we would call it "coffee milk." The point is the reaction of the audience, not the actual beverage.

5 The preceding historical and ethnological details are also from Lewin, op. cit., pp. 305-335.

6 G. Mouchot, "Letter from France," in R. G. McCarthy, ed., Drinking and Intoxication (Glencoe, Ill.: The Free Press, 1959).

7 G. Lolli, Social Drinking (Cleveland and New York: World Publishing Co., 1960).

8 Donald Horton, "The Functions of Alcohol in Primitive Societies," in Alcohol, Science, and Society (New Haven: Quarterly Journal of Studies on Alcohol, 1957).

9 Actually, the neuropharmacology of alcohol is far more complex, but the details are not relevant here.

10 G. M. Carstairs, "Daru and Bhang: Cultural Factors in the Choice of Intoxicates," Quarterly Journal of Studies on Alcohol, 15 (1954), 220-237.

11 H. S. Becker, "Becoming a Marijuana User," American Journal of Sociology, 59 (1953), 235-242.

12 Loc. cit.

13 A. Wikler, Opiate Addiction (Springfield, Ill.: Thomas, 1953).

14 R. Bunzel, "The Role of Alcoholism in Two Central American Cultures," Psychiatry, 3 (1940), 361-387.

15 Horton, op. cit.

16L. Lasagna, J. M. von Felsinger, and H. K. Beecher, "Drug-induced Mood Changes in Man," Journal of the American Medical Association, 157 (1955), 1113.

17 William L. Prosser, ed., "The Narcotic Problem," UCLA Law Review, 4 (1954). Rufus King, "Narcotic Drug Laws and Enforcement Problems," Law and Contemporary Problems, 22 (1957), 113-131.

18 H. S. Warner, "Philosophy of the Temperance Movement," in Alcohol, Science, and Society (New Haven: Quarterly Journal of Studies on Alcohol, 1957).

19 Quoted in E. B. Dunford, "Moral Aspects of Prohibition," in Alcohol, Science, and Society (New Haven: Quarterly Journal of Studies on Alcohol, 1957).

20 Prosser, op. cit., p. 458.

21 Ibid., p. 459.

22 Ibid., p. 459.

23 The paper cup, screening against flies, pasteurization of milk, safe public water supplies, inspection of public markets and restaurants—commonplaces of our day—were rarities, opposed or not thought of.

24 Charles E. Terry and Mildred Pellens, The Opium Problem (New York: The Committee on Drug Addiction in Collaboration with the Bureau of Social Hygiene, Inc., 1928).

25 Alva Johnston, The Legendary Mizners (New York: Farrar, Straus, 1953).

26 We are not suggesting that opiates generally improve motor performance. These addicts were individuals unable to function because of anxiety, tension, ambivalence, or other disturbances.

27 Charles Winick, "Maturing out of Narcotic Addiction," Bulletin on Narcotics, 14 (1962), 1-7.

28 P. Zimmering et al., "Heroin Addiction in Adolescent Boys," Journal of Nervous and Mental Diseases, 114 (1951), 19-34.

29 Fritz Redl and David Wineman, Children Who Hate (Glencoe, Ill.: The Free Press, 1951).

30 Alan S. Meyer, Social and Psychological Factors in Opiate Addiction: A Review of Findings together with an Annotated Bibliography (New York: Bureau of Applied Social Research, Columbia University, 1952), pp. 60-64.

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