Drug Abuse

IX Personality and Addiction: A Dynamic Perspective

Although the opiate addiction of the adolescents we have studied grew out of a long history of maladjustment in which those structural aspects of the personality discussed above were significant, neither maladjustment nor personality structure per se is sufficient to account for their becoming addicted. Two other sets of determinants are involved.

First, from an epidemiological standpoint, the social climate, attitudes, values, stresses, and gratifications current in his community and, of course, the availability of drugs significantly affect the likelihood that any particular youth with the personality characteristics described will experiment with drug use.

Second, from a psychiatric standpoint, the likelihood that he will become an addictive user of opiate drugs is most significantly affected by his experiences with drug use in the context of his current situation as this has been structured by his entire experience. This hypothesis, which we will attempt to illustrate in the following pages, may be formulated more clearly as follows: assuming that other conditions are favorable, the probability of addiction is greater if the person experiences changes in his situation in connection with his use of opiate drugs which may be described as adaptive, functional, or ego-syntonic and which he describes in terms which tell us that he regards the use of opiates as extremely worthwhile despite, or perhaps especially because of, the inconveniences and difficulties of being an addict in our society. We may think of these functional or adaptive changes in terms of forces operating at four levels within the individual: at the level of conscious experience; at the level of certain defenses; at the level of unconscious process; and at the level of psychophysiological reaction.

At the Level of Conscious Experience

Closest to the surface, to the threshold of awareness and to communication, are certain common adaptive aspects of drug use. Though these are, in a sense, known to the users, they are not readily communicated by them because of problems of rapport, shame at confessing personal inadequacies, and their lack of experience in communicating subtle feelings and emotions. As they enter therapeutic relationships, they become more capable of formulating and communicating these phenomena.

One of the most striking of the phenomena is symptom relief. Heroin and morphine are efficient tranquilizing, or ataractic, drugs (at least they unquestionably are so for those individuals who become addicted). Overt symptoms of anxiety, obsessive thinking, and early delusional formations are modified or eliminated. Many individuals feel tense and restless before they begin to use opiates. When they use them they feel comfortable, relaxed, and peaceful. Apart from our own experience, some striking instances of symptom relief have been given by Wilder' and Lindesmith.2

An especially important and common instance of relief from symptoms is that opiate drugs are often helpful in quelling the anxiety and strain which addicts experience in a variety of interpersonal situations. Many feel shy, withdrawn, unacceptable, or socially inhibited. With opiates, they are able to participate more comfortably in the ordinary run of adolescent activities, e.g., dancing, dating, going out with the gang, or even in fighting. This is not to say that these are common activities of addicts, but that, when addicts do participate in them, they do so more effectively and with less malaise with the help of opiates than they would otherwise. This aspect of opiate use is analogous to the social use of alcohol. Paradoxically, this leads many young addicts into situations which they might otherwise avoid, but which, once entered, develop more-or-less inexorably into complex situations with which they cannot cope even with the help of drugs. Opiates can calm anticipatory anxiety, and they may sustain inadequate individuals through the trials of relatively superficial personal association, but the drugs cannot substitute for the basically adequate ego structure these individuals lack.

Many nonaddictive users of heroin may also take the drug for its helpful functions, just as many nonaddictive users of alcohol take an occasional "social drink." We speculate that the individuals who are helped to deal with difficult situations for which they have adequate resources (i.e., the drug is helpful in easing the situation, but is not essential for an adequate performance) do not become addictive users. Those who are helped to enter relatively enduring and demanding situations for which they lack adequate resources respond with increased anxiety as the situations develop and, hence, with a need for further ataraxia. Thus, they are led to the recurrent use of the drug, until they eventually learn to substitute the ataraxia for whatever they can get from coping with difficult situations.

Another important, consciously experienced, phenomenon is the intoxication experience itself, which the addict refers to as "being high." This experience is appreciated and enjoyed by the addict and by regular users, but by only a minority of experimental "normal" subjects. It is not, however, in any true sense, a euphoria—a feeling of stimulation, happiness, excitement.

The point at issue may perhaps be clarified by reference to two contrasting ideals of fulfillment paradise and nirvana. Paradise represents an ideal situation in which all desires are easily satisfied. If one is hungry, one has but to reach out, and the means of satisfying hunger are at hand. Nirvana, by contrast, represents an ideal of fulfillment through absence of desire, and desire is itself viewed as an inherently frustrated state that cannot be compensated for through the pleasure of its gratification.

At least to the normal Western mind,3 however, the prospect of endless fulfillment through an absence of desire is not a particularly attractive one. Normal men, for instance, do not look forward with great eagerness to the attainment of a maturational level in which they will find themselves beyond sexual desire; and, having attained an age characterized by a marked diminution of sexual desire, they do not typically look on this aspect of their attainment as an asset. Nor does the average person look forward to the day when he will be able to satisfy the nutritive needs of his body (and even to anticipate hunger) with a pill. The nirvana-like end state of gratification may be valued and enjoyed, but the pleasure is in the activity that goes into making the end state possible; the end state is itself, at least in part, enjoyable only in the security of the belief that it is not the final end, but that it will give way to remounting desire.

Human beings have devoted great ingenuity and planning to the development of means for intensifying desire and achieving an optimal protraction of the period of activity and of the investment and distribution of effort in achieving the end state.4 Moreover, in the very vision of paradise itself there was implanted an image of the unattainable; it is as if the creators of the myth could not tolerate the vision of the total satisfiabiity of all wants, some degree of frustration being necessary to the very ideal of fulfillment. And it was when they tore away this restriction that Adam and Eve lost their paradise, or perhaps they gained a deeper wisdom—that human beings do not belong in paradise, that their destiny can be achieved only through toil and pain. Adam and Eve could satisfy their wants in the Garden of Eden, but the satisfaction left little to enjoy.

At any rate, the addict's enjoyment of the "high" is not the enjoyment of a stirred-up, zestful state. It is not the enjoyment of intensified sensory input and orgastic excitement, not even on a hallucinatory or fantasied level. De Quincey and others to the contrary notwithstanding, it is not an enjoyment of enhanced creative experience or rich fantasies. It is, in fact, not an enjoyment of anything positive at all, and that it should be thought of as a "high" stands as mute testimony to the utter destitution of the life of the addict with respect to the achievement of positive pleasures and of its repletion with frustration and unresolvable tension. It is, in the main, an enjoyment of a nirvana-like state unpreceded and unenriched by the pleasure of getting there. It is an enjoyment of negatives. Awareness of tension and distress is markedly reduced. Contact with reality diminishes. Ideational and fantasy activity are decreased, often blotting out a disquieting and disturbing fantasy life that is characteristic of the unintoxicated state. Some addicts do manage unelaborated and unimaginative fantasies of wealth and status or masochistic fantasies of self-recrimination and the intention to reform. Addicts feel "out of this world" and content, as if all of their needs have been taken care of. Here, in "the junkie paradise," they experience what Wikler has described as a diminution of their "primary drives," of hunger, thirst, awareness of pain, and sexual tension. Their bodies are satisfied and sated.

There is a remarkable rhapsodic description of thumb-sucking by a grown girl (quoted by Freud in his Three Essays on the Theory of Sexuality [New York: Basic Books, 1962], p. 47), which could just as well illustrate the opiate high.

It is impossible to describe what a lovely feeling goes through your whole body when you suck; you are right away from this world. You are absolutely satisfied, and happy beyond desire. It is a wonderful feeling; you long for nothing but peace—uninterrupted peace. It is just unspeakably lovely: you feel no pain and no sorrow, and ah! you are carried into another world.

The adolescent addict does not usually like to talk about the experience of the high, other than to commend it. First, it is difficult for him to find words to describe the experience. Second, he is ashamed, embarrassed, and secretive about it. In fact, some adolescent addicts attempt to deprecate the experience in the postwithdrawal phase of their addiction; they say that being high on heroin is nothing, marijuana is better, that they would be crazy to go back to an experience which gives them so little and costs them so much. Third, but this is more common among older and more experienced addicts, they often have a superior attitude to the nonaddict based on the idea that they possess a secret, magical, self-administrable source of pleasure which, in their estimation, is better than anything the nonaddict can have. The high is too good; verbalization at best degrades it. "If you want to know what the high is, take heroin and learn for yourself."

At the Level of Certain Defenses

The general function of a psychic defense is to avoid anxiety. This may be accomplished by a subtle reordering of experience or by an alteration in the perception or in the manifestations of inner impulses or outer events (projection, denial, reaction formation, etc.). The phenomena we have alluded to above (symptom relief, social facilitation, and the experience of the high) are to a large measure expressions of the opiate's capacity to inhibit or blunt the perception of inner anxiety and outer strain. In this sense, the drug itself is a diffuse pharmacological defense. However, there is another sense in which opiate addiction is integrated into the psychological defenses of the adolescent addict. The general structure of this integration is a mélange of projection, rationalization, and denial. The fact that he is an addict, despite the personal and social implications of opiate addiction in our society, allays the anxiety he would experience if he were to face, express, or act out certain impulses and wishes. He displaces the responsibility for his behavior onto an auxiliary, executant ego about which, in effect, he can say: "Not I, but the drug in me does these things. I am not responsible; it is the monkey on my back."

That this is not conscious duplicity is attested by the genuine horror and anxiety with which some of these "released" impulses and wishes are recalled in the postwithdrawal phases of addiction. Of course, we do not wish to imply that the opiates per se are "releasers," in some physiological sense, of repressed wishes or impulses of a specifically aggressive or sexual nature. As one of the authors has pointed out in a comparison of alcohol intoxication and opiate addiction,5 the opiate addict to a large measure "acts out" in the process of sustaining his addiction, and usually not in the course of acute intoxication with the drug nor necessarily in the actual physiological distress of the abstinence syndrome. It is sufficient for him to identify himself as being an addict to reap the benefit of this auxiliary ego.

The wishes and impulses expressed through this auxiliary ego are highly individualized. In the course of the addiction, the unspeakable is spoken, and that which should never be done is done. This does not occur in diffuse, patternless, or random misbehavior, but with remarkable precision of aim and aptness to the life situations and relationships with important persons in the lives of the addicts. They do not, of course, recognize the intentions of their behavior, however obvious these intentions may be to us. It requires months of work before a patient can accept the integration of his behavior with ideas or feelings he fears to perceive or communicate. Although there is no limit to the variety of such integrations, there are a few general classes which occur frequently.

In the course of addiction, the addict may begin to express hostility toward parental figures—whom he regards as emasculating or controlling—through theft from the parental home; overt anger (becoming "evil and nasty"); or through the spiteful, wasteful, or destructive use of parental furnishings, money, decorations, or clothing. Even his general delinquency and the use of narcotics itself may contain a strong component vector aimed at his parents. By becoming an addict, he can disappoint or frustrate those parents whose hopes or ambitions for their son are of the highest. Similarly, he may utilize his addiction for the expression of passive-dependent wishes, e.g., by giving up or avoiding employment; begging for money and gifts; soliciting loans without attempt to repay them; and withdrawing from activities, interests, and relationships outside his parental home.

The mother of an addict may want to take a lover or a new husband. This is not infrequent in the lives of the male adolescent addicts we have studied. Even though he regards his mother critically, he is likely to be extremely attached to, dependent on, and overidentified with her. Thus, he experiences his mother's intentions as a threat; he fears that he will lose her love and concern to this rival. His behavior in the course of his addiction then focuses on the rival. It is the rival's suits which are stolen and pawned; it just happens that the addict comes home "high" when his mother is entertaining this friend. In short, he persuades the rival through his behavior in sustaining his addiction that gaining a liaison with his mother is likely to be more trouble than it is worth.

The addict uses his addiction to express or act out repressed impulses and needs. From the standpoint of the discharge of psychic energy, this is probably pleasurable; in terms of eventual consequences, it can be disastrous. In terms of secondary reactions of guilt, such behavior can provoke tension and distress during abstinence which are alleviated, unfortunately too readily, by further indulgence in opiates.

At the Level of Unconscious Process

It is important to clarify the role of unconscious symbolism in addiction. Dreams, neurotic symptoms, wit, and the psychopathology of everyday life are enriched or burdened by their unconscious meanings. Similarly, many aspects of the addiction experience and process are linked with and emotionally colored by wishes, drives, and bodily experiences pertinent to the addict's early development and relationships. With exceptions, these tend to be communicated or expressed symbolically in the dreams and in the art work of the patients and in their responses to projective test material. For instance, dreams have the manifest content of a needle, fat, long, sticking into my body; being snowed under a mound of heroin; drinking heroin or being attacked by a monster with a huge syringe.

The exceptions, perhaps as important as the regularities, are those patients who tell us quite directly° that the syringe and needle ("the works," as they are called in the argot) are like a breast; when he is high, he feels that he is together with his mother, long ago, warm, comfortable, happy, at peace; when he injects the opiate solution, he mixes the solution with his blood and bounces the blood-opiate mixture back and forth from syringe to vein, and, as he does this, he has fantasies about intercourse.

By and large, those patients who directly associate their addiction experiences with these oral concepts have the most clinically evident ego disturbances; they suffer from anxiety verging on panic or are overtly psychotic. They are least able to repress or otherwise defend themselves against the perception of such ideas and images, and they are thus able to directly verbalize what may only be inferred from the symbolic communications of the others.

It is difficult to ignore the fact that unconscious symbolism of this sort occurs in addiction. The question is, "What role does it play in the genesis of addiction?" Addiction is a complex psychosocial behavior. Obviously, no one takes drugs for the first time with such ideas in mind as that the syringe is a breast or that, through taking opiates, he may regain a state of early infantile unity with his mother. No one becomes an addict simply because he is laden with _unconscious oral fantasies and cravings for breasts, sustenance, or warmth. Rather, as he becomes an addict, the techniques and circumstances of drug use readily lend themselves as vehicles of expression for these facets of his unconscious mental processes. Though these unconscious symbolizations are less weighty in the motivations for becoming an addict than are the forces of conscious experience, especially the high, or the forces of the integration of the addiction in the psychic defenses, they probably do contribute importantly to the appetite for drug use in the same sense that spices, with their volatile oils and esters, may contribute to the appetite for otherwise prosaic foods. However, as the addiction progresses and the addict becomes increasingly involved with
addiction and correspondingly less involved in any attempt to deal with the world and current relationships, ever-larger portions of his psychic life are given over to this primitive level of gratification.

At the Level of Psychophysiological Reaction

The concepts "craving," "dependence," and "tolerance" are usually found in textbooks of pharmacology in the section dealing with the opiate drugs. Our discussion here will emphasize the more psychological aspects of these psychophysiological forces.

CRAVING

"Craving" is, of course, merely a word. In common speech or in jest, we may say that we "crave" sweets or tobacco or love. We have no psychological lien on the term, no proprietary right to restrict its meaning to a particular reference. However, it is a useful rubric, in terms of which we may discuss certain attitudes and orientations. In the sense in which we wish to develop it, craving is a pathological phenomenon which entails recurrent states of liking, wanting, and seeking an entity or object but which differs from normal wanting, liking, and seeking in several important respects.

First, craving implies an abnormal intensity of desire.

Second, craving implies an abnormal intensification of the reaction to the failure to fulfill the desire. When a normal person cannot get what he wants, he may be sad and unhappy; one criterion of normality is that he seeks legitimate means to satisfy the desire, finds appropriate substitute gratifications, or waits until gratification becomes possible. But when a craving is not satisfied, there are intense emotional reactions of anger, rage, sulking, withdrawal, sullen resentment, or action aimed at getting that which is desired without regard to the consequences.

Third, craving implies an abnormal limitation in the modifiability of the desire (e.g., giving it up, lessening its intensity, accepting a substitute) as a result of experiences which emphasize the costs or the consequences of the satisfaction sought.

The development of craving for opiate drugs is an extremely important element in the addiction process. Addicts themselves istinguish varying degrees of craving for opiates. The intensity of craving is only partly related to the history of dependence on opiates. There are addicts who experience craving, in the defined sense, after very little experience with opiates, though in general the intensity of the craving is related to the duration of and the quantity of experience with opiates. We know that craving is not merely a consequence of the ability of the opiate to relieve organic distress. Postoperative and post-traumatic patients rarely become addicted to opiates. Alcoholics, whose general personality structure is remarkably similar to those of opiate addicts,7 readily become addicted to opiates,8 whether they receive opiates in the medical treatment of their alcoholism or illicitly. We know that the use of opiates is a necessary but not a sufficient condition of the development of craving. There are individuals who use heroin for the acute intoxication experience, for the alleviation of organic discomfort, or for the relief of anxiety without the development of craving. We know that craving is not inherent in the reactions to the opiate drugs.

It is extremely difficult to measure craving. We could attempt to measure the sacrifices an addict would accept to pay for a dose of opiates at a particular point in the history of his addiction (or in a particular cycle of addiction). However, such a measure would entail a rational, consistent weighing of price against commodity value (a phenomenon which occurs rarely enough in the purchase of socially approved commodities, e.g., automobiles) ; that is, it would assume the very kinds of ego activity which are foreign to craving. Complicating the issue, craving is not a constant in the individual. We have Often noted sudden fluctuations in the extent of craving, either increasing or decreasing. Craving is not an isolated or automatic psychophysiological process. Nor is it highly correlated with degree of physiological dependence; indeed, it can occur in the truly addicted individual even when he has been completely relieved of physiological dependence on the drug. As the case histories we have cited indicate, the urge for opiate use occurs in complex interpersonal contexts, although they are often difficult to elucidate. Addicts have a considerable defensive stake in maintaining the anonymity and impersonality of their motivations, just as do persons with neurotic character problems who prefer to interpret their behavior as the most reasonable or only possible reactions to their circumstances or, as may be more fashionable today, in terms of psychogenetically formulated rationalizations.

Further complicating the issue is the distinction we have already drawn, especially in Chapter II, between craving and involvement. That is, some people find rewards in the use of narcotics, for the sake of which they suffer serious penalties, but which have nothing to do with the psychophysiological effects of the drug. Involvement with the drug and the drug-using subculture gives them a sense of a personal identity, a place in society, a commitment, personal associations based on a seemingly common purpose, a feeling of belonging to an in-group, a vocation and an avocation, and a means of filling the void in an otherwise empty life. Such people, too, may feel that they crave the drug; but this is not craving in the sense in which we are using the term. Craving is not a response to emptiness, but a characteristic mode of coping with even minor stresses of anxiety, frustration, and pain by an intense desire to revert to an intrauterine-like state of apparent selfsufficiency—a state that the drug can induce. In a sense, it is the direct opposite of involvement, although both craving and involvement may be found in the same individual. Involvement with narcotics is an expression of a need for a sense of being alive; craving is an expression of a need to withdraw from any semblance of active life.

Why do addicts develop a craving for opiate drugs? We have no final answer to this question. First, craving is conditional on valued personal experiences with the drugs. No one craves an experience that is wholly distasteful. The positive evaluation of the intoxication experience depends on the psychophysiological reactions to the drug; the situation in which the drug is used, which influences the evaluation of the intoxication experience; and the extent of experience with the drug as a source of satisfaction and as a means for the resolution of tension and distress.

Second, craving is an expression of the preferred modes of gratification adopted by the individual and, as such, is dependent on the individual's attitudes toward objects or sources of satisfaction independently of and preceding experience with opiate drugs. Whether an individual can or is likely to develop craving depends on the degree to which craving fits into his preferred modes of gratification and on the readiness with which (and the circumstances under which) he relapses into preference for modes of gratification into which craving fits. These are matters which are best viewed in the context of the psychosexual development of the individual.

We regard the strength of an individual's craving for opiates as a resultant of two groups of forces—those which have to do with personal experiences in relation to opiate drugs and those which have to do with the shaping of the individual's preferred modes of gratification. Consequently, we would expect to, and do, observe marked individual differences in the strength of craving. We would not expect these differences to be simple, nor would we expect simple relationships between intensity of craving and any one factor—the duration of opiate use, for instance. We would expect to observe individuals who sustain themselves for prolonged periods of their lives with small doses of opiates and others whose entire lives rapidly become dedicated to the intake of large quantities of these drugs.

THE PSYCHOPHYSIOLOGICAL REACTION TO OPIATE DRUGS

Opiate intoxication is not an inherently delightful state;9 neither, for that matter, is any kind or degree of intoxication. The pleasures of alcoholic beverages must be learned; they are learned in a context of beliefs and usages which support, modify, and interpret the individual's psychopharmacological reactions. Becker's study of marijuana use" documents the role of other users in support, modification, and interpretation of the effects of marijuana as a force in marijuana use in our culture. But it does not follow that the psychopharmacological effects of the opiates or their enjoyment are merely conditional on beliefs and usages. Indeed, it has been found that a minority of naïve subjects who are given opiates experimentally regard the effects as pleasant or desirable and that, by and large, this minority consists or the psychologically most disturbed of the subjects. Similarly, we believe that the prospective adolescent addict is to be found among the seriously disturbed adolescent population in those areas where drug use is endemic and among the even more seriously disturbed in those areas where it is not endemic, and we have found that, unlike naïve experimental subjects, the majority of prospective addicts enjoyed the effect of opiates from the beginning. This supports the hypothesis that psychological deviancy is a conditioning phenomenon for the liking of opiates. However, this need not be necessarily or entirely so.

There are a few apparently normal persons we have known who did enjoy their first experiences with experimental doses of opiates without apparent serious psychiatric illness. These, however, have not been naïve subjects; they knew that they were going to receive morphine, and they expected that the morphine would in some way influence their mood or ideational state. One colleague compared the experience with a day in a Turkish bath; he liked it, but had no inclination to repeat the experience. In short, it is possible that a "normal" subject would regard his first opiate intoxication as pleasant, but it is unlikely that he would begin to crave on the basis of this experience. It should also be remembered (from chapters VI and VIII) that a substantial minority of regular users initially found the effects unpleasant. On the assumption that some of these were truly addicted, it follows that unpleasant effects on first experience are not incompatible with later addictive use.

What is enticing about the effects of opiates for those disturbed persons who do become addicts? Or, to put it differently, what are the relevant effects of the opiates on the emotional lives of these persons?
A major effect of opiates is that they reduce the awareness of sources of distress and increase the sense of detachment from or otherwise diminish the unpleasantness of the experience that would be associated with distress in less clouded states of consciousness. The pain threshold (i.e., the intensity of stimulation needed to produce pain), for example, is raised and the anxiety associated with pain is diminished so that normally painful stimulation becomes tolerable. Drive—hunger and sexual tension, for instance—is also reduced, so that there is relief from the discomforts of drive states which are blocked from normal channels of relief and from anxiety that may be associated with the unreduced drives. Opiates thus, in one way or another, give relief from distress. It is almost axiomatic that this relief-giving psychopharmacological property of opiates is a major factor in the development of craving. Conversely, a chronic need for such relief—whether because of an abnormally frequent recurrence of distress or because of an inability to tolerate relatively minor distress or to cope with sources of distress in more adaptive ways—is a necessary condition of the development of craving. Parenthetically, this is also a factor in the behavior of addicts who postpone their dose of opiates until they begin to have withdrawal symptoms; they do this to maximize the experience of relief.

Since the intensity of distress is a determinant of the quantity of relief (as impact is determined by the height from which an object falls), we would expect the degree of positive evaluation of opiate intoxication to be highly correlated with the initial level of distress. This is supported by the previously cited work of Lasagna et al. However, detailed research is still to be done. Moreover, although it is certain that opiates can influence anxiety and other distressing states, there may be important constitutional differences in responsiveness to these drugs and in the potential for relief from distress which they might afford.

There are psychopharmacological phenomena associated with intoxication with opiates apart from the "relief experience." To what extent these enter into the positive evaluation of the drug and the development of craving, it is difficult to say. For example, there is a feeling of "impact" in the stomach following intravenous injection of morphine or heroin which is characterized in addicts' terminology as "a bang." The addict may also enjoy sensations of bodily warmth, of tingling like "pins and needles," and pleasant eroticized scratching and itching. Some addicts talk of these visceral experiences as an aesthete or a gourmet talks of the objects of his special interest. However, since these visceral experiences occur at the threshold of the opiate intoxication experience and since they are most intense and evident in one particular means of opiate intoxication, particularly with the intravenous use of opiate drugs, we believe that they are of secondary importance in the development of craving.

Though it is partly feasible to discuss the psychopharmacological reaction to opiates apart from the situation in which they are used, in the reality of the addiction process this never occurs. In fact, at least in our society and in the social context in which we have studied aOdiction among adolescents, the life situation plays an important role in the positive evaluation of the intoxication experience.

SITUATION AND THE POSITIVE EVALUATION OF OPIATE INTOXICATION

Many adolescent addicts we have studied were able to tell us quite explicitly that they began their opiate use in a life situation rife with anxiety, tension, or disappointment and asserted that they experienced relief from these states in their initial intoxication. We know that the condition we have described for the development of craving—a high level of distress—is a common, probably a regular, phenomenon in the early addiction history of adolescent addicts. Since there are marked difficulties of communication with adolescent addicts, we do not learn easily about the level of emotional distress as a factor in the early establishment of a positive evaluation of the intoxication experience.

The situation is seemingly complicated by the fact that the relief experience may not occur in their initial opiate intoxication. The dosage may be inappropriate, e.g., too small to effect relief or so far above the individual's tolerance level that the appreciation of the distress-relief phenomenon may be blunted by the quick onset of coma or extreme somnolence. Moreover, these emotional states may not be consciously perceived or recognized. The adolescent addict may only recall or recognize, in the course of a therapeutic investigation, that he was highly perturbed by aspects of his life situation at the time when he began to use opiates. Then, too, the situation at the initial use of opiates need not be exceptionally anxious, tense, or depressive, even though, in fact, the prevalent level of malfunction of the novice is higher than of his peers who do not use opiates. Indeed, as has already been indicated, there may be long periods of opiate use without the development of craving. Many cases can be cited of individuals who liked the effect of opiates from the beginning, but did not develop craving until a psychosexual crisis occurred. With the need for relief from anxiety verging on panic, their craving began.

Rado has hypothesized that a "tense depression" was the unique or special emotional state which was relieved by opiate intoxication.11 In our experience, this has not been so; i.e., it is not the unique or particular emotional state in the prelude to addiction. Acute anxiety, bewilderment, incipient panic, increasing despair, and unhappiness born of a ,sequence of failures and disappointments are other common emotional states preceding addiction in the adolescent addicts we studied. There is another type of emotional state in the Anlage of addiction which is important, not so much for its frequency as for its bearing on the life situation; this is a state of longing, a distressing condition of unfuiflilment pervasive of all the experience which is alleviated by opiate intoxication and may be conducive to craving.

There are some indications in the literature that something like craving may develop passively in experimental animals.12 However, this obscures rather than clarifies the issue. Craving as clinically observed, unquestionably develops in persons who liked and wanted opiates prior to any indications of pharmacological dependence on these drugs; craving much more typically leads to the pattern of use which establishes dependence than vice versa.

There are two other phenomena in the total situation of the person who becomes an addict which influence the positive evaluation of opiate intoxication. One is the fact that the current disturbed emotional state we have discussed above is an outstanding feature in a total situation which is grossly unsatisfactory. The "preaddict," if we may use this term, has been notoriously unsuccessful in his educational, occupational, sexual, or familial life. For those few exceptions who were able to manage without conspicuous failures in one or several of these areas, there are quite evident anxieties or psychiatric symptoms which contaminated, blunted, or negated whatever else was satisfactory in their lives. Since, by and large, they have not found satisfaction or achievement elsewhere in their lives, the opiate intoxication experience stands out with particular clarity and vividness; with opiate intoxication, they felt good as they had not felt good before and as they had not felt good with other sources of intoxication, e.g., marijuana or alcohol.

For a person who is not accustomed to the wine of success, any good feeling he creates for himself not only makes him feel good about the experience itself, but also makes him feel better about himself; in short, he has an experience of increased self-esteem or can prevent a decline in self-esteem. This is, of course, not due to the opiate itself; enhanced self-esteem is not observed in medical or surgical practice after the relief of pain by morphine. In part, it results from the achievement of a status and the provision of an alibi for failure. In addicts with strong craving, however, it is in large measure a psychic consequence of achieving a state of relaxation and relief from tension or distress through one's own activities, not through a physician's recommendation or prescription, but through an esoteric, illegal, and dangerous nostrum. We can observe an analogous phenomenon in people who win the Irish Sweepstakes; win on dice, cards, horses, or numbers; or even in persons who park in no-parking zones without getting a traffic ticket. They feel that their luck is running good; they feel important, worthwhile, and interesting; they feel a sense of pride and accomplishment. Such an illusory achievement is an important psychic phenomenon, particularly important when it stands out by contrast with the remainder of a person's life.

There is a telling Yiddish anecdote about two cockroaches who were swept out of a garbage heap in a barn. One fell onto a pile of horse manure; the other fell onto the bare ground. The one who fell in the horse manure became fat and glossy. The one who fell on the bare ground became thin and bedraggled. One day they met in the barnyard. The thin one was astonished by the appearance of his old companion and asked him, "Yankel, what is this? You are so fat and wealthy, and I am so skinny and poor." "My good fellow," Yankel replied, "my fortune is the inevitable consequence of superior industriousness, intelligently applied." The moral is that good fortune can be experienced as (belated) recognition of one's intrinsic worth. When self-esteem is meager, any satisfying experience may be a source of enhanced self-esteem, as well as of pleasure, and the means through which this experience is attained is cherished.

The other factor which conditions the positive evaluation of the opiate intoxication experience is of a social-psychological nature; it may be characterized as "looking for kicks." This phenomenon is related to widespread attitudes among contemporary adolescents, and particularly among those belonging to deprived urban groups. It is also related to the readiness for craving which we will discuss later in this chapter.

The search for kicks is a polar extreme of a valuable human and particularly adolescent phenomenon, that is, the search for new experience. Normally, the search for new experience leads to the broadening of one's intellectual and sensory horizons and to the pleasures of working at challenging and difficult situations and tasks which, despite anxiety and strain, are capped with some degree of mastery or even with nondisgraceful failure. In what strike us as the happiest lives, this is a never-ending process. In other instances, the outcome is not so fortunate. At one extreme, there is a total blunting of this complex drive; these are persons who live a life of stultifying routine. Indeed, some clever adolescents regard adult life as dull and unperceptive because they recognize that the tempo and intensity of this drive is lowered by increasing responsibilities. The search for kicks is, on the surface, at the other pole. It expresses a conscious search for new experience of a special kind; what is sought is fun, excitement, novelty, and new sensations, as though the experience of novelty per se were substituted for the confrontation and mastery of ever-new and challenging situations. The never-ending search for the essentially passive experience of novelty masquerades as a zest for living.

Any novel experience, legal or not, is regarded as worth trying, as an expression of joy, pride, and pleasure in living, provided that the venture is not fraught with the peril of evoking contempt or disgrace in the peer subculture. Though the opiate intoxication experience may be compared to other intoxications or to other experiences of release and relaxation, it is sui generis. The peculiar sequence of bodily sensations, of vascular and glandular responses, is undoubtedly a new experience, as is the partial disturbance of consciousness which accompanies this experience. In the argot of addicts: "Man, it's good, it's cool, it's gone." It is commendable as a kick in terms of the preaddict's values. Though we do not believe that the value of novelty per se is responsible for an inclination toward addictive use or toward craving, this is another force in the initial positive evaluation of the opiate's intoxication experience which encourages initial use and facilitates return to an experience which offered kicks.

There is a painful contrast between the theory of kicks and its manifestations in the lives of those adolescents who become addicts. In fact, looking for kicks is not a happy state of affairs or any kind of expression of joy in living. The kicks they seek are inseparably linked with trouble from the onset. Their kicks are usually highly mannered, group-oriented, and stereotyped. By and large, the new experiences they seek are limited to new ways of being intoxicated and new ways of affirming individuality through mannerisms of dress, hair style, speech, and gesture. Some have got their earlier kicks through gang membership and fighting; others, through the use of alcohol. Kicks, in effect, is a pleasure orientation by youngsters with an extraordinary lack of the capacity to feel happy; what they probably mean by the search for kiCks is that they wish they could be happy and that they will try anything to achieve it. With opiates, they probably do not get what the word kicks seems to connote, but they do get relief, both from this complex drive and from other more simple drives, e.g., pain, sex, and hunger.

DEPENDENCE

"Dependence" means simply and literally that the addict comes to require, need, or lean on opiates for the maintenance of his normal or comfortable physiological functioning. We say that the addict becomes dependent on opiates in consequence of the regular use of these substances. The rate at which such dependence develops varies with the type of drugs and the quantity taken. For instance, he can become dependent on morphine through using the same small quantity once daily for a week. In order to become dependent on heroin in the dosages that are typically ingested, it must be taken at intervals closer to twelve hours than to twenty-four. One would, however, expect individual variability in this respect.

Dependence is not a conscious process, though its corollary, the acute abstinence syndrome, may be consciously experienced. When opiate drugs are taken with sufficient regularity, they insinuate themselves into the physiological processes (enzyme systems) of the central nervous system so that they become essential elements of its milieu When this regular intake of opiate drugs is abruptly discontinued, a characteristic disturbance occurs; the intensity of this disturbance is a function of the duration of the regular use and the amount of drugs which are regularly ingested. Dependence is not related to psychological needs or motives; decerebrate dogs and newborn infants of addicted mothers can have an acute abstinence syndrome. Dependence is a biological process which entails the maintenance of a certain level of opiate drugs to maintain apparently normal bodily function, and, in this sense, the biological dependence on the opiates can be a force in the addiction process; without the opiate, the person indeed becomes physically ill.

The abstinence syndrome, however, unlike the fact of dependence, is much influenced and modified by psychosocial factors. It is true, in the novice addict, that the intensity of this self-limiting illness (nausea, goose flesh, restlessness, etc.) is far from unbearable. The intensity of these symptoms hardly justifies the illicit use of opiates to quell the symptoms, particularly since each evasion of the acute abstinence syndrome intensifies the ultimate experience of the abstinence syndrome. To the addict and the individual in the process of becoming an addict, however, even this relatively minor distress is intolerable; his inability to act in terms of long-range goals precludes consideration of the inevitable consequences of permitting the degree of dependence to build up.

In the case of the experienced addict, dependent on four or more injections of heroin a day to prevent the abstinence syndrome, abrupt withdrawal is an unquestionably severe physiological disturbance; he develops chills and fever, lacrimation, perspiration, vomiting, smooth and striated muscle cramps, diarrhea, tachycardia, insomnia, or restlessness. Despite this fact, even in an addict with signs of severe physiological disturbance at the withdrawal of opiates, the amount of distress is conditional on the setting in which the distress is experienced. Alone, it can be an almost unbearable experience. In a hospital ward, remarkably little medication often stills the distress associated with quite severe physiological disturbance, e.g., painful cramps and diarrhea. Conversely, patients with minor overt symptoms may be very demanding of medication. In this regard, Pfeffer has described the beneficial influence of group therapeutic interaction on a withdrawal ward." Though dependence can be interpreted as a biological phenomenon, the patient's attitude toward the manifestations of dependence can only be understood psychosocially.

Lindesmith has placed considerable emphasis on this as the basic phenomenon in opiate addiction» He has presented case material in support of the thesis that accepting the fact that one is "hooked" and that one must continue to rely on opiates in order to ensure freedom from withdrawal symptoms is central to identifying oneself as an addict. In part, he is correct; among adolescent addicts, the self-identification as addicts—i.e., as persons who require opiates for comfortable functioning—is an important phenomenon in their developing addiction, even though they may, in fact, at that time not yet be demonstrably dependent on opiates. The idea, "I need to have opiates," is certainly influenced by the phenomenon of dependence, but, indeed, is poorly correlated with the intensity of this biological phenomenon. An addict may experience some of the phenomena of withdrawal after a year of enforced abstinence as he enters a situation in which opiates may be obtained. By the same token, the diagnosis of withdrawal symptoms as evidence of true dependence is not a simple matter.

There is another aspect to the withdrawal syndrome; it is not merely the bane of addiction to opiates, but also its badge. Many addicts discuss their own and others' withdrawal experiences with heavy humor and boastful exaggeration, not unlike children who compete in describing the rigors of their measles or draftees who boast about the meanness of their noncommissioned officers in basic training. We are not suggesting that they regard the withdrawal experience as pleasurable, but rather that its occurrence and severity become integrated in their self-images as a valid, interesting, and necessary aspect of themselves. Though the nonaddict may regard the withdrawal experience as a terrible deterrent to addiction, the addict develops the same attitude toward dependence on opiates as the organization man does toward the "rat race" of business life in large corporations.

There is a minority of addicts who choose to endure withdrawal symptoms without medical help. They appear silent and sullen in the face of the severest symptoms. With persistence and interest, we can learn that they rationalize it as the most effective method of "kicking the habit" and, more fundamentally, that' they are enacting a drama of sin and penance; they deserve to suffer for the misdeeds of their addiction, and through suffering they achieve catharsis. Generally speaking, these are the oldest and most experienced addicts, who are among the quickest to relapse after leaving a hospital, since they feel that suffering has undone their misbehavior and that they are free to sin again.

TOLERANCE

Tolerance is a concomitant of dependence. It occurs at a much slower rate than dependence; the body becomes dependent on a certain level of drug taken at a certain frequency much more readily than it acquires tolerance to that level. "Tolerance" refers to the fact that the body adapts—to varying degrees and at differing rates by the several organ systems of the body—to certain of the effects of the drug. The addict can, for instance, take quantities of opiates which would produce coma or death from respiratory inhibition in the nonaddict. Most germane to our discussion, tolerance is developed to the subtle emotional effects of the opiate which the addict craves. Though the addict can satisfy his need for normal bodily function without increasing his dosage, he must gradually raise his intake if he wishes to satisfy his craving. In the vernacular, he "can keep normal but can't get high." He no longer experiences a change of state. He is "tranquilized" so long as he can avoid withdrawal symptoms, but he gets no kicks, and he cannot "go on the nod," that is, he can no longer experience intensified relaxation and inwardness.

Interestingly, keeping normal even without getting high can for a short period be a valued experience for the addict who experiences craving. This depends on what is essentially a form or aspect of gratification through involvement. The addict holds off taking opiates as long as possible, so that he can experience the beginning of the abstinence syndrome; at this point, when he takes his usual or available dose, he experiences relief from a self-imposed physical distress. The rhythm of distress and relief, distress and relief again, becomes valued in itself. However, if his life situation is particularly difficult at this point in his addiction, he will not be satisfied with keeping normal; he will strive to get high again by increasing his dosage either in frequency or in quantity. Indeed, in general, when an addict reaches a point in a cycle of addiction where he cannot do more than keep normal either for economic reasons (the high cost and the poor quality of illicit drugs) or because he has become negatively adapted to the subtle emotional effects of the drugs, he usually "seeks a free period"15— withdrawal from the drug, acute abstinence, and at least a few weeks of detoxification—to be able to recapture the most valued experience of being high at a far lower level of dosage. Such patterns (postponement of drug-taking to enhance the effects, seeking a "free period," and discontent with dosage levels sufficient to merely ward off the abstinence syndrome), incidentally, may well provide diagnostic criteria of craving.

To review, the psychophysiological framework of opiate addiction may be generalized as follows: Insofar as psychophysiological factors play a role in addiction, the primary force in initiating and intensifying a cycle of addiction is craving. Dependence is a sustaining force, both physiologically and psychologically—relevant, but clearly secondary. Tolerance is a psychophysiological phenomenon which forces either increasing dosage or a free period, i.e., a period of abstinence to recapture certain of the satisfactions of opiate intoxication. Dependence is, of course, also relevant in the noncraving types of addiction, but is again secondary in importance to the underlying motivations in the development of the addiction. It may, however, play a major role, in affecting the likelihood of getting into trouble. The development of tolerance is relatively unimportant in the involvement-without-craving type of addiction; in the noncraving, noninvolvement type, it plays a role in those searching for "kicks."

 

1 Abraham Wikler, Opiate Addiction, "Psychological and Neurophysiological Aspects in Relation to Clinical Problems" (Springfield, Ill.: Charles C Thomas, 1953).

2 A. R. Lindesmith, Opiate Addiction (Bloomington, Ind.: Principia Press, 1947).

3 That the issue may well transcend cultural differentiation is indicated by various experiments on rats described by Leon Festinger. In one experiment, for instance, it was established that hungry rats develop a preference for a box in which they are delayed on their way to food. "The Psychological Effects of Insufficient Rewards," American Psychologist, 16 (1961), 1-11.
It may also be noted that the same culture which produced the concept of nirvana also produced the most elaborate techniques for the continuance of sexual intercourse with the postponement of orgasm. If the absence of desire is the desideratum, then, short of eliminating desire altogether, the optimum condition should be to get rid of it with the utmost dispatch. The issue here is, however, complicated by one of the mastery of desire through its disciplined expression; the completely disciplined control of the expression of desire may be viewed as a more effective step in the direction of the conquest of desire than the attempt to suppress it. Closely related is the notion that pleasure itself is a snare and a delusion, not because it is sinful, but because its experience makes more difficult the passage to a state beyond desire. Hence, a major aspect of the disciplined expression of desire is the systematic cultivation of a sense of affective detachment from one's participation, an attitude remarkably akin to the high value placed by those of our youth who are attracted to narcotics on the capacity to remain "cool." In the latter terms, the most admirable performance, whether in sex, music, dancing, or whatever, is that of the virtuoso who displays no feeling whatsoever in the course of the performance. We may only be displaying our own culturocentrism when we express the suspicion that such a philosophy is attractive only to people who have been impelled by desire and tantalized by the vision of gratification, only to meet with frustration and disappointment.

4 A great deal of confusion is generated by the failure to distinguish the pleasure of the activity leading to the end state from the pleasantness (to coin a verbal distinction, "pleasure" here signifying a turbulent, stirred-up, zestful enjoyment; "pleasantness," a serene, calm, passive enjoyment) of the end state. Even Freud, who was well aware of the significance of foreplay in sexual activity in building up the tension of desire and presumably also of the uneven crescendo of activity leading to the climax, failed to take account of this in his theoretical formulations and landed in serious theoretical difficulties as a result. Thus, in his characterization of an instinctual drive, Freud distinguished a source (a bodily state which leads to a continuous input of excitation), an object (with which it is necessary to interact in order to achieve the aim), and an aim (the elimination of the excitation). He identified the achievement of the aim with pleasure and so formulated the pleasure principle, a formulation that would in strict logic imply that aim-inhibited activity cannot be pleasurable—a conclusion inconsistent with other aspects of the theoretical system. At any rate, he recognized that he was in trouble when he realized that he had formulated the pleasure and nirvana (a basic striving to eliminate excitation) principles in identical terms. Since he must have known that the two principles referred to basically different aspects of behavior, he did not take the logical step of concluding that there was only one principle at work, but instead accepted the weak conclusion that there must be some qualitative difference in the fate of the energies involved in the two principles. Cf. Freud, "The Economic Problem in Masochism," Collected Papers (New York: Basic Books, 1959), II, 255-268.
It will be noted that Freud's basic characterization of an instinctual drive took no note whatever of the nature of the interaction with the object and, hence, of the potentially pleasurable (and sought) aspects of this interaction. In other contexts, however, he distinguished two kinds of pleasure in sexual activity. Thus, in his Three Essays on the Theory of Sexuality (New York: Basic Books, 1962) he wrote that the erogenous zones "are all used to provide a certain amount of pleasure by being stimulated in the way appropriate to them. This pleasure then leads to an increase in tension which in its turn is responsible for producing the necessary motor energy for the conclusion of the sexual act. The penultimate stage of that act is once again the appropriate stimulation of an erotogenic zone . . . by the appropriate object . . . ; and from the pleasure yielded by this excitation the motor energy is obtained . . . , which brings about the discharge of the sexual substances. This last pleasure is the highest in intensity. . . . It is wholly a pleasure of satisfaction and with it the tension of the libido is for the time being extinguished. . . . This distinction between the one kind of pleasure due to the excitation of erotogenic zones and the other kind due to the discharge of the sexual substances deserves . . . a difference in nomenclature. The former may be suitably described as 'fore-pleasure' in contrast to the 'end-pleasure . . " (pp. 76 ff.; italics added). It is likely that Freud somehow failed to distinguish in the "end-pleasure" the pleasure of the orgasm per se ( a highly stirred-up state) and the pleasantness of the aftermath (the state of reduced tension), else it is difficult to see how he identified the pleasure principle with the reduction of tension. In any case, he did not think that the "end-pleasure" was available prior to puberty, which would imply that the prepubescent individual could not be governed by the pleasure principle, an obvious internal contradiction. Similarly, his notion that perversions arise from an excess of fore-pleasure with a resultant rejection of the "normal sexual aim"—i.e., the "end-pleasure"—would imply that sexual perverts are not governed by the pleasure principle.
In other major (and typically more rigorously formulated) psychological systems, one also finds difficulties that may be traced to the failure to make the distinction. Cf. Isidor Chein, "The Image of Man," Journal of Social Issues, XVIII (1962), 1-35, to be published in expanded form by Basic Books.

5 Donald L. Gerard, "Intoxication and Addiction," Quarterly Journal of Studies on Alcohol, 16 (1955), 681-699.

6 Obviously, in a strict sense of the term "unconscious," such directly communicated meanings are not unconscious. The term is, however, also used in an extended sense to include that which is typically unconscious in the normal person under normal circumstances. We have elected to go along with such usage which is likely to have a familiar ring to most readers rather than enter into a discussion of such concepts as "primary" and "secondary" process and their relation to the concepts conscious—preconscious—unconscious, on the one hand, and to idego—superego, on the other.

7 Donald L. Gerard, "Intoxication and Addiction," op. cit.

8 Michael J. Pescor, "A Statistical Analysis of the Clinical Records of Hospitalized Drug Addicts," U. S. Public Health Report Supplement No. 143 (1943).

9L. Lasagna, J. M. von Felsinger, and H. K. Beecher. "Drug-induced Mood Changes in Man," Journal of the American Medical Association, 157, (1955), 1006, 1113.

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

11 S. Rado, "Psychoanalysis of Pharmacothymia," Psychoanalytic Quarterly, 21 (1933), 1-23.

12 S. D. S. Spragg, "Morphine Addiction in Chimpanzees," Comparative Psychology Monograph, 15 (1940).

13 A. Z. Pfeffer, personal communication.

14 A. R. Lindesmith, op. cit.

15 S. Rado, op. cit.

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