The last two decades have brought significant social and political changes in the structure of American society and its institutions. We have witnessed a dramatic erosion of traditional values, family life, and particularly of what is called the Protestant ethic's attitudes toward work. The younger generation, brought up in an affluent society, became progressively disenchanted with the meaning of life as conceptualized by their parents and the policies of the government.

 

In the midst of the ambiguity of national purpose of the sixties and seventies, one appealing answer was to avoid all social confrontation and to return to the natural state of things expressed by non-involvement, detachment, and search for reaching a state of happiness—even if artificially induced. Society became progressively more hedonistically oriented and, with it, more drug oriented. In this context, working hard became meaningless to the young generation; stresses of life were supposed to be avoided at any price, and the panacea for going through life was found in drugs.

 

Barbiturates, valium, and quaaludes became the easiest means to cope with any discomfort of living. To understand the staggering amount of the abuse of drugs, in 1978, 280 million prescriptions for psychoactive drugs had been written according to the last report of HEW; 13 million Americans have used stimulants without medical supervision; 9.3 million are using sedatives; and 7.8 million are taking tranquilizers. According to DAWN (Drug Abuse Warning Network), between January and December of 1978, 117,023 drug consultations took place in emergency rooms related to drug abuse. The use of drugs to induce peace of mind became a way of life for an important segment of our population.

 

In addition, drugs were used to add a new dimension to the individual's recreational life. For instance, marijuana became considered the drug of choice for creating a relaxed state of mind which would be beneficial to the individual in stressful social or intimate situations.

 

Between 41 and 47 million Americans have tried marijuana, and between 16 and 20 million use it regularly. It became the prevalent substance used by older adolescents and young adults. Though it is claimed to be a "safe" drug, medical research proved to the contrary. The same applies to PCP (angel dust) which is used by approximately 14 percent of the young adult population between 18 and 25. The medical consequences of this drug are disastrous, leading to violent antisocial behavior, depression, or death.

 

In general, the logic behind the use of these drugs is simple. Since we live in an age of anxiety, the best way to combat it is with a drug that will numb us to unwarranted social pressures. But for some, to relax was not enough. They wanted to control their state of mind according to the need of the moment. They wanted to be stimulated beyond the ordinary pleasurable experiences of life. They were bored with the routine of life. They were seekers of new thresholds of excitement; otherwise, life was too depressing. For some, speed was the drug of choice; it made someone feel good, leaving all problems behind them and requiring no further solution. It is estimated that about four million Americans have received in 1977 prescriptions for amphetamines, and about 1.8 million obtained them illicitly. Some of them were indirectly acquired under the guise of appetite supressants. In addition, they are used under the belief that it changes the personality and makes the person feel more desirable socially, more entertaining, more "in control" of situations.

 

The ill effects of these drugs are too well known to be discussed. Not to mention that after getting high someone addicted in order "to come down" or to go to sleep has to use barbiturates. The ups and downs become another modality to cope with life, giving people the illusion of living life with high intensity while, in reality, they slowly disorganize their lives to the point of removing themselves from the mainstream of social life.

 

If this is part of the scene of the colleges and of the middle class, where people still pretend to be integrated into the fabric of society, for some people from the lower social economic class apparently the situation is somewhat different. They go for the real stuff; they get high with heroin. We have approximately 600,000 hard core addicted to heroin; now, with the latest heroin epidemic, their number might increase as well.

 

There are many social and economic reasons to explain why heroin infiltrated so deeply into the lower social economic class while marijuana and soft tranquilizers appealed to the middle class and cocaine became the drug of choice of the upper class. One of the reasons was the system of distribution of heroin which was done through the lower social economic class. The spread of heroin was in spurts and at times became epidemic according to the availability of the drug and the activity of the pushers (Feldman, 1968). Regardless of the drug of choice of the social class, it could be safely assumed at this point that the spread of drugs could be attributed to the social sickness of our society, where the norms of conduct and expectations from individuals are broken down; where its permissiveness and tolerance to crime produced by drug addiction encouraged further the abuse of drugs.

 

In this context we can say that the motives for taking drugs and starting a career as a drug abuser, as have already been described in literature, are related to thrill seeking, curiosity, relaxation, sense of well being, instant gratification and peer acceptance, yet they do not explain why the drug user becomes addicted. Why does one become dependent on the drug instead of taking it only occasionally, for instance, in socially entertaining situations? Though most of potential drug users are introduced to it by a trusted friend who wants to share with him the experience of getting high, it does not tell us why some will continue on drugs and others will not. The argument that the addict becomes addicted because of his friends does not hold under closer scrutiny. Not everyone will stay a junkie in order to maintain the friendship and get the approval of his friends who are taking it.

 

Although, admittedly, drug novice is initiated in the drug activity sometimes ignorant of the long term effect of the drug but, persuaded by his friends,of its favorable effects, it does not explain why he continues after seeing the ill effects of it.

 

One scientific explanation for addiction is based on the assumption that the individual is unable to give up the drug because of the unpleasant effects of withdrawal. In fact, the classical theory of drug addiction was based on the concept of Lindesmith that the chronic drug abuser does not get high any more on the drug, but is forced to use it in order to feel "normal", free of withdrawal's signs (McAuliffe, 1974). Though this might be partially true, it does not explain why drug addicts, after successfully withdrawing from a drug, later go back to it repeatedly. It is well known that approximately 70 percent of drug addicts return to drugs within two years after their abstinence (Fracchia, 1976). It means that the element of pleasure which he experienced by taking the drug is still the main motivating factor in resuming the habit.

 

This is supported by the conclusion of McAuliffe and others who found that the drug dependent person continues to use the drug not only because of fear of withdrawal but because he wants to get high in at least 40 percent of the cases (Serban, 1978). In these terms, the drug abuser does not take drugs to ward off the unpleasantness of withdrawal but because he created his own world of living in which the reality of his life, perceived as unpleasant, is replaced with a continuous state of pleasure induced by the use of drugs.

 

These two theoretical hypotheses have serious social and psychological implications. If the basic assumption of Lindesmith's theory that the drug dependent abuses the drug in the need to avoid the suffering of withdrawal, then obviously the successful withdrawal from the drug should cure the disease. But, on the other hand, if the drug addict is a pleasure seeker with a low motivation for integration into society, even after he is successfully freed from the drug he still poses serious problems in terms of the ability to successfully cure him.

 

These theoretical models and these different conceptualizations of the etiology of drug addiction are reflected in the diversity of therapeutic approaches. The whole concept of heroin substitutes like methadone, LAAM, etc, is based on the assumption that the established addiction is hard to change and as such should be maintained by more controlled means of the same drug, or at best to reduce its use by a slow process leading, whenever possible, to the discontinuation of the drug. In this context, other approaches like that of easing of withdrawal signs by the use of clonidine or lofexidine will work out in the long term provided that the individual is not attempting to reexperience the initial "rush," the feeling of high. Otherwise, the withdrawal is useless since this need will bring him back to taking the drug whenever past psycho-social difficulties created by the drug will be forgotten. Even the use of a "perfect" drug such as naltrexone, which suppresses the euphoric effect of heroin, is of no value if the addict refuses to take it because he voluntarily wants to feel high.

 

In reality, it is a fact that most hard-core drug addicts enroll in the program when they have serious brushes with the law and are unable to support their habit anymore. This is why the social rehabilitation process starts only when the addict has reached his lowest physical, emotional and social point in order to make him feel that any available social alternative of support is salutory. These specific factors add new dimensions to the problem of drug addiction, making it more elusive to cure regardless of the implementation of various medical treatments or social rehabilitation programs.

 

For all these reasons, another closer look might be necessary to be taken to approach this multidimensional problem. It appears that a constellation of factors are significant in the orientation of the initial drug taker toward a career of a lifetime of abuse. In the forefront of the constellation is his orientation toward immediate gratification combined with an inability to cope with the problems of his life and a magical organization of thinking, they appear to be necessary for the beginning of the drug abuse career. This particular cognitive—emotional approach to events of life and to frustration with the social environment leads the individual to experience lack of success in reaching his goals. It results later on in an underlying depression and a sense of futility due to his inability to meet his expectations. However, the magical elements of his thinking, where he believes he is able to withdraw from the drug as he pleases because he is in control of himself, contribute to the experimentation with drugs. This attitude, superimposed on the need to look for immediate, painless solutions to his life problem, reinforces his addiction. In general, the problems of the addict could be reduced to a particular mode of viewing life in which a permissive and conducive social environment acts as a reinforcer.

 

The assumption made by some clinicians about the existence of an addictive personality is in reality a post hoc, after effect description of the state of addiction. Many characteristics have been attributed to the addict personality. Obviously, the first one is that of obsessive compulsive behavior about the use of drugs. But this is a circular explanation. Other researchers found out that addicts have a tendency to equate needs for success and independence with nonconformity and experimentation. They have difficulty in interpersonal relationships, inability to have friends and intrapsychic conflicts revolving around dependency (Lawrence, 1973). All might be true, but still this cannot explain the addiction as based on a simple need for acceptance and socialization where in long term the contrary is true. He becomes more alienated from community and friends.

 

The second controversial issue is the contribution of a depressive personality or a depressive condition to the use of drugs. In our own research, confirmed by others, we have found a strong depressive component favoring the habituation to drugs. In fact, in a pilot study done at NYU in which we have treated 117 ex-methadone and soft drug addicts with only antidepressants and anxiolytics, we found that 54 percent of soft drug abusers became abstinent for a period of nine months followup. In this group, particularly for some ex-methadone, depression appeared to be the main factor for continuation of drug abuse, but not for beginning its use. However, for the soft drug addict, the need for psychoactive or stimulant drugs was due mainly to inability to cope with stresses of life which led to frustration and experimentation with drugs (1981).

 

The need to get high, to feel relaxed, might be related in some drug addicts to the underlying depression possibly intensified by the disturbance in the pleasure centers induced by heroin (Hunt, 1971). The role of endorphin in the development and maintenance of addiction is not yet fully elucidated.

 

Though it is common knowledge for the drug abusers to switch easily from one category of drug abuse to another, sometimes combining both, the fact remains that the hard core drug addict finds it extremely difficult to give up his heroin need or to switch to a soft drug even after the physiological dependence has been eliminated.

 

Yet all these personality aspects cannot explain the etiology of drug addiction since some hard core addicts are able to remain abstinent while others are not. It means that other psychological and social factors are contributing to the maintenance of addiction which appear to be related to the style and concept of life of the addicted, as previously mentioned. Due to these factors, the taking of the drug, after the initial curiosity or need for thrill seeking, becomes a necessity and a habit. For him, it represents not only a solution to a gamut of unsolved conflicts with which he's unable to cope, but it reaches a state of emotional comfort unable to give up. The initial feelings of getting high and the desire for "the rush" stay with him and he craves to relive it again and again as a compensation for his underlying perceived meaninglessness of life.

 

This is true too to some extent for the soft drug abuser. It is self-evident that the marijuana or stimulant user is psychologically addicted to maintaining a state of pleasure against the adversities of life. In the same context, we may find an explanation for the recent fad of cocaine use. Successful people from the world of art, movies and television are using it to enhance their sense of well being beyond the point of the natural experience of pleasure to a state of euphoria.

 

The need for a pleasurable state of mind sought by cocaine users could be translated in the illegal import of approximately 66 thousand pounds, totalling an expenditure of around 20 billion dollars a year (1981). Basically, there is not too much difference between the Harlem addicted and the Hollywood-New York entertainers who, in the final analysis, are taking drugs, be it heroin or cocaine, to transcend whatever they perceive as painful or unpleasant in their lives, or to attempt to reach the final state of ataraxia-peace of mind. Both groups may start for similar reasons; either sheer curiosity or peer acceptance, of sharing the experience of getting high, be it in a dark alley between the dilapidated buildings of Harlem or in a sumptuous living room of a Beverly Hills-Park Ave. mansion. Both groups want to push the threshold of the reality, defined as unpleasant for the Harlem people and boring unstimulating for Hollywood-New York, into the realm of euphoria.

 

The nagging question to be asked is why this need for drug addicts to maintain a constant state of happiness when life presupposes an amount of unpleasant, effortful processes? Is it because they are mentally ill? Apparently, here starts the confusion between the medical model and the social model utilized to understand addicts.

 

The medical model supports the hypothesis that drug addiction is a metabolic illness comparable to that of diabetes, an analogy liked by the exponents of this hypothesis. It is assumed that the metabolic disturbance produced by the long term use of heroin is due to the interference with normal release of various types of endorphin into the central nervous system. As a result, the addict has a psychophysiological imbalance, translated into a disturbance in equilibrium of the pleasure centers resulting in a craving for heroin. Though there is some evidence to partially favor this hypothesis, still it does not explain why some drug addicts are able to become abstinent while others are not. Based on this concept, the attempt to cure drug addiction is futile, and the only solution will be long-term maintenance on heroin, methadone, LAAM.

 

The opponents of this concept believe drug addiction is a pure social problem, a modality of coping with the environment, an attitude toward life that is a search for pleasure. In this context, after the initial period of withdrawal, the individual has a choice to stay sober, abstinent or not.

 

While it's true that the medical model did not come up with the final answer to the etiology of drug addiction and might have confounded some pathogenic conditions produced by it with its etiology, in other words, the effect with the cause, yet there is enough evidence that psychophysiological factors are heavily involved in the maintenance of addiction.

 

By the same token, the social factors reinforcing and maintaining the addiction cannot be overlooked. Their totality is responsible for making the addict a career pleasure seeker. In this context, drug addiction appears to be a bio-psychosocial disease in which both sets of factors are reinforcing each other negatively in maintaining the condition. It means that the detoxification must be a medical problem but not necessarily the only problem of addiction. The value of the medical model necessarily stops here unless the patient is placed on a maintenance program such as methadone or LAAM. The overlooking of the psychosocial aspects of the problems of addiction and the specific personality responses explains the limited success with drug abusers either in treating or preventing their relapses.

 

The disregard for the social mode might explain why most of the drug addicts are unwilling to follow any course of treatment. Not to mention that the use of one treatment for one category of patients is totally unsuccessful for another group. This heterogeneity of causes producing addiction appears to be responsible for the wide spectrum of treatment, claiming success with such diverse and contradictory approaches.

 

Finally, the common denominator which should be sought by all this treatment, after the individual is detoxified by medication or without it in a "cold turkey" fashion, is to change his state of mind, for acceptance of the unpleasant reality of life with the accompanying daily problems which he has to face and solve. On the other hand, it is nothing new about this need of the individual to transcend reality. Since time immemorial, man has attempted to transcend the unpleasant reality by escaping in reverie, meditation or artificial use of herbs and seeds with sedative or hallucinogenic effects. Now, a new dimension has been added to it.

 

Our society is strongly committed to the utopian goal of elimination of pain, suffering and discomfort. The drug addict appears to be "the avant-garde" of these new aims; they are the forerunners in the pursuit of happiness. Let us not forget that happiness is a human invention, as St. Just remarked during the French Revolution; its pursuit does indeed require artificial means of reaching and experiencing.

 

Finally, what role does stress play in the extensive use of drugs? It is a fact that the more complicated society becomes, the more stresses it induces in its citizens and the less people are able to cope with it, which means that they might experience more anxiety and/or depression. In a recent study at NYU investigating the amount of stress experienced by the population between 18 and 60 in the United States, we have found that approximately 70 percent of the population is under moderate to heavy stress. The stress is produced by the rapid social changes affecting the interaction and the role of the sexes, marital relationships, the job and other economic hardships. People who cannot cope with these stresses were found to rely on religion, sometimes magic and others on drugs. It should also be mentioned that 51.9 percent of the men and 60.1 percent of the women experience high to moderate anxiety, while 34.2 percent of the men and 41.3 percent of the women experience depressive episodes (Serban, 1981). The staggering use of valium and alcohol in our society is said to be related to stress.

 

It is assumed that nine million people are alcohol abusers and 200,000 deaths yearly that are related to alcohol seem due to the stress of life. It is said that the more stressful the human interaction becomes, the more increase we will see in the use of alcohol or drugs; up to a point this is true. According to some statistics, in the past 15 years alcohol consumption increased about 30 percent. In addition, 90 million prescriptions for only minor tranquilizers were filled, according to the statistics of 1977. Yet, these data convey, at best, a meaningful connection between stress and drug abuse; we cannot say that the large proportion of alcohol abusers attempt to control stress in their overindulgence in alcohol. Basically, more of them regardless of stress are closer to the group of pleasure seekers—the drug users.

 

If stress plays a minor role in the alcoholic addiction—it plays even less of one in the abuse of drugs by teenagers.

 

The four million adolescents between 12 and 17 who are using marijuana and the 1.5 million who use PCP are using it for pleasure and not because of the stress in their lives. And the same applies to 8.5 million marijuana and 4.2 million PCP users between 17 and 25. It is estimated that about 37 percent of the high school students use marijuana periodically, and 11 percent of them are using it daily as recreational.

 

It is a mistake to assume that most of the soft drug users are relying on drugs to alleviate the stresses of their lives. Though some of them might start to take a sedative or mild tranquilizers in response to the stresses of life, most of them are continuing to take the drug to induce an artificial state of pleasure. This distinction is important to make because these two groups are responding differently to treatment. While the drug user who takes drugs to relieve the pressure of life could be easily treated the other one is not. The same applies to the use of drugs in the adult population. In general, the reason for the abuse of drugs by teenagers is basically that of thrill, while for adults this is not necessarily so.

 

It could be a combination of social and psychological reasons. In the first case the problem of relapse will not be solved unless the addicted person is ready to change his style of life, his concept of sought happiness, while in the second situation it requires also a social rehabilitation to reduce the stresses of life.

 

Due to the complexity of the problems involved in drug abuse, encompassing psychological, sociological, not to mention the biological aspect of it, the prevention is not necessarily successful, as proven by research, by the simple presentation to the public of the unfavorable consequences of drug use. This approach is not a deterrant for the use of drugs in a hedonistically oriented society. It requires, as well, a change in the attitude of people, a reorientation of life toward work, and toward facing and coping with the inherent adversities of life. Only in this context will the rehabilitation program be able to help the individual to develop psychological and social coping mechanisms to assess and respond realistically to life's events.

 

REFERENCES

 

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Cocaine: The lethal status symbol. MD Magazine 25, 27:56-65, 1981

Feldman WH: Ideological supports to becoming and remaining a heroin addict. Journal of Health and Social Behavior 9:131-139, 1968

Fracchia J and Sheppard C: Needs of society and heroin addicts: Some general and

specific implications for treatment. Psychiatry Digest 14-22:July, 1976

HEW: Drug Abuse, Prevention, Treatment and Rehabilitation. Second Annual Report, 1979

Hunt W, Barnet CW and Branch LC: Relapse rate in addiction programs. Journal of Consulting Clinical Psychology 4:445, 1971

Lawrence S: Cingulate Self Stimulation in the Rat; Influence of Repeated Morphine Administration. Proceedings, 80th Annual Convention, APA, pp 835-836, 1973

McAuliffe W and Gordon AR: A test of Lindesmith's theory of addiction: The frequency of euphoria among long term addicts. Am J Sociol 79(4):795-840, 1974

Serban G: New approach to the rehabilitation of the hard core drug addict (heroin methadone addicts); A pilot study. Journal of Clinical Psychiatry 111-116:Feb., 1978

Serban G: Present social values as possible stressors—A survey of the U.S. population. Journal of Preventive Psychiatry (in press)