Appendix

The Nature and Significance of Addiction

Addiction is the word which is popularly in use to describe compulsive drug taking. In scientific writing the word (and the underlying concept) has to an extent been supplanted by the phrase drug dependence. Here though the complexities of scientific nomenclature need not be gone into, and it seems better to retain the older and slightly less cumbersome term.
The opiates are drugs of addiction. There are variations in individual susceptibility, but anyone who takes an opiate for a long enough period and in sufficient dose will become addicted. What is the nature of this condition which trails with it so many fears and stereotypes, and which seems often to be thought of almost as possession rather than as intelligible happening? This question is very relevant to an understanding of the problems which society encountered over that long period when opium was so readily available that it could provide the conditions where addiction must have been common and endemic.
Opiates are drugs to which the individual's central nervous system will, on repeated exposure, develop a high degree of tolerance - a much bigger dose of the drug is then required to produce the same and desired effect in the tolerant than in the naive subject. There is therefore in the drug's intrinsic properties a ready and in-built invitation to escalate the dose. If the drug was taken for, say, a chronic neuralgia, its effectiveness would at first be very evident and much valued, but if it was to go on being of use to the person purchasing his laudanum from the corner grocer's shop, he would soon find that to produce the original effects he was having to take the laudanum in larger quantities. But every addict sooner or later finds his plateau dose, and there is considerable variation in levels and patterns of use. Many reach a fairly moderate dose level which suits them, and stick to it. This is what nineteenth-century writers on addiction were referring to when they cited cases of `moderate addicts' who showed no tendency to continuing escalation.
Tolerance is then intimately linked to the onset of withdrawal symptom experience and physical dependence. The tolerant individual begins to find that some hours after his last dose he feels restless, that he develops goose pimples and begins to yawn, that his eyes are watering and his nose running, and that he is generally uncomfortable. With increasing dependence more severe withdrawal symptoms will be experienced, and if this person is then deprived of his drug for twelve or more hours he risks an agonizing withdrawal experience characterized particularly by great restlessness and anxiety, severe abdominal cramps and profuse diarrhoea. Appalling though the experience may then be, the condition is not life-threatening unless there is some severe intercurrent illness or infection. The patient recovers. Lesser degrees of addiction carry risks only of lesser withdrawal symptoms, and like the drug effect itself the withdrawal experience is much influenced by set and expectation.
Addiction to opiates may best be pictured as both a psychological- and biological condition, characterized by a desire to continue taking the drug in high dosage, a salience of this drug-seeking drive over other life considerations and a tendency to relapse. It seems likely that repeated experience of the powerful euphoriant effect of the drug contributes to the initiation of addiction : in simple terms a habit is built up because it is intensely pleasurable. But what also very importantly contributes to the enhancement of this `learnt drive' is the repeated experience of withdrawal and the concomitant experience of repeated and wonderfully reassuring relief which is afforded by the next drug dose. The addict is conditioned to crave that next dose. Such a view of addiction can, however, be criticized for placing too great an emphasis on the drug itself and its user's experience in isolation from environmental determinants which initiate and sustain drug use, and which give the drug its symbolic meaning and the user his social role. The pharmacological qualities cited here and the psychological experience of the users are important, but it is difficult to see how, on their own, they can provide a coherent idea of a condition called addiction or dependence. Here can be seen very plainly what is meant by the need to integrate different levels of explanation.
So much for the nature of addiction. What about its significance, and in particular its significance for nineteenth-century society? The threat which is posed by addiction to oral preparations of opiates is much less than the dangers of addiction to the drug in injected form, and it was of course the latter type of addiction which characterized the British `heroin epidemic' of the 1960s, and characterizes the large-scale contemporary drug problem in the U.S.A. The special dangers of injected drug use include the ease of accidental overdose and the risks of accidental infection caused by a dirty needle. Today's picture of injected heroin use must therefore not be allowed too easily to colour any assumptions as to what would have been the familiar picture, in the nineteenth century, of addiction to opium or opium preparations taken by mouth. There would have been risks of overdose, sometimes as a result of the unreliable strength of many of the available commercial preparations, but the risks would be nothing like so great as those encountered by the twentieth-century heroin addict who injects the drug directly into his veins. What proportion of overdose cases in the nineteenth century were occurring among addicts and what proportion among casual users is unknown, but certainly the contemporary concern with self-poisoning did not simply equate overdosing with addiction. The problem of accidental infection is then irrelevant to oral use. Another possible medical implication of addiction which received nineteenth-century attention was the general question of whether habitual opium use shortened life, but here too the problem was conceived in terms of the fact of high usage rather than the underlying fact of the addiction. On the longevity issue the present judgement would probably be that opiates themselves produce no directly damaging or life-shortening effect on the body and that addiction itself is not a physically damaging condition.
The problems which the nineteenth century encountered with addiction were therefore presumably more in the social than the medical sphere. Opium may have been cheap, but a heavily tolerant individual might well build up to such a dose as to involve a weekly cash outlay to embarrass the family's finances in a working-class household where every penny counted. The drive towards continued drug use would mean that the family's welfare easily became neglected. There might also be other social complications -neglect in child care, for instance, or impairment of working capacity. Such possible social complications do not seem much to have caught the nineteenth-century eye, although there were occasional references to matters of this sort. Indeed, the fact that addiction itself was not sharply conceptualized for the larger part of the century, in many of the relevant debates and social movements, meant that the addict did not suffer the sort of secondary social damage which comes from labelling and stigma, and which has been so much part of the present-day reaction of the Western world to drug-taking and the drug-taker.
Addiction to drugs other than opiates has features specific to each drug group. Cocaine can produce an intensely compulsive drive towards continued drug use, despite the absence of withdrawal symptoms. Depressant substances such as chloral can also induce addiction, with a well-marked withdrawal picture. Psychomimetic substances in general do not give rise to addiction, and if cannabis has any addictive potential this was certainly not an issue with the sort of doses and preparations which the nineteenth century encountered.
Far from the physical attributes of the drugs in question being a side-issue or something quite separate from the main business, an understanding of the extraordinary subtlety and potency of the actions of these substances on the human mind and body helps not only to make intelligible the social processes which were the game evolved around them, but re-inforces one's sense also of the astonishing subtlety and potency of accidental and informal, or formal and purposive social processes, which allow society at different phases in history to live on terms with these strange mindacting chemicals.

Reference
A very useful general source book on pharmacology is L. S. Goodman and A. Gilman, Pharmacological Basis of Therapeutics, 5th edn (New York, Macmillan, 1975).