CHAPTER 3 Who Is a Drug Addict?

THERE IS MORE "EXPERT" CONSENSUS IN THE ANSWER TO the question: "Who is a drug addict?" than to similar questions concerning any other form of social deviation. It is odd therefore, that the answer is more physiological in nature than sociological. With juvenile delinquency, an argument can go on tediously as to which adolescents qualify to be placed in that category. Regional variation in the United States alone is so great that the delinquency of New York City is foreign to the juvenile authorities of Eugene, Oregon. Agreement about the drug addict is far more universal. There may be social consequences when one commits a delinquent act, but there are no systematic changes in the body. Yet, it is precisely the bodily changes that allow us to be so certain of accuracy in the identification of the addict. When deprived of the drug, his body loses physiological equilibrium. Thus, we physiologically detect the social deviant.

As DeRopp points out, the first step to an understanding of addiction is contained in the notion of physical dependence.' Individuals differ markedly in their physiological make-up. Just as a pint of beer may have a powerful effect upon one person and little effect upon another, given quantities of morphine will make some men more dependent than others. However, once any single individual becomes dependent, he needs morphine just like food, water, and salt:

The morphine or heroin addict is physically dependent on a continuous supply of the drug just as a normal man is dependent on a continuous supply of vitamins. If a normal man's vitamins are cut offhe becomes sick. If a heroin addict's drug is cut off he also becomes sick. There is nothing mental or imaginary about this sickness. It is a physiochemical sickness.... After a certain amount of morphine or heroin has circulated in the body for a certain time it actually changes the chemistry of the body in such a way that normal function becomes impossible unless the drug is present. This is the chemical basis of physical dependence.2

More specifically, the opiate addict who can not obtain his necessary supply begins to experience withdrawal from the drug. This typically occurs about twelve to fourteen hours after the last drug injection. Withdrawal begins with a general feeling of queasiness, accompanied by simultaneous shivering and sweating. After a time, a water discharge begins in the eyes and the nose, a discharge which is felt as uncomfortably hot. It is at this point that the addict has the greatest potential of becoming both socially and psychologically dangerous. He knows that unless he can get another supply of drugs, things will get much, much worse. If he decides (or is forced) to undergo complete withdrawal, he will notice excessive yawning during this early period. This can be serious, with muscular and bone abnormalities developing about the jaw. After a few hours of quasi-sleep, he will awaken to find his flesh cold and covered with goose bumps, a condition which has inspired addicts to give to this, and to the whole experience, the name "cold turkey":

to add further to the addict's miseries his bowels begin to act with fantastic violence; great waves of contractions pass over the walls of the stomach, causing explosive vomiting, the vomit being frequently stained with blood. So extreme are the contractions , e the intestines that the surface of the abdomen appears corrugated and knotted. ... Constant symptoms start afresh within eight to twelve hours.'

For some addicts, this may continue for three days, tapering off in intensity after forty hours. For others, it may last for six days with a more gradual subsiding of ailments. A month may pass, however, before debilitating weakness, restlessness, and other problems begin to recede. Because of the conditions and developments discussed in the first chapter, the addict knows that his chances of getting help from a physician are very slim. He also knows that very likely he will be turned away from both private and public hospitals with ill-concealed annoyance and bureaucratic efficiency. All addicts don't make it back from the withdrawal sickness. Some die, and that too, is known. The decision to prostitute or steal is made easier.

However, it is analytically important to separate the notion of physical dependence from psychological craving and desire. Many things fall into the latter category, from cigarettes to pickled-beets ona-warm-night. If one badly wants something of this nature, and the want is not satisfied, there is no evidence of a systematic change in the blood chemistry, no muscular constrictions, no retching, and the like. The whole area of psychosomatic illness is a cloudy one, and psychiatry has generated as much nonempirical speculation on the subject as empirical evidence. Even such problems as duodenal ulcers, long a popular example of the physical consequences of psychological stress, have come under closer critical scrutiny as to the nature of the relationship. There is now considerable and increasing confusion and ambiguity about the cause of ulcers.

Countless pastimes are habit-forming in the psychological sense, but if there is n: physical dependence, it is simply misleading to talk of addiction. There are cases where specific individuals may develop a physical dependency on an item that is not typically addicting, but these cases are rare. The high rate of return to drugs by those who have gone through withdrawal makes this a very important problem for anyone trying to understand drug addiction. Perhaps 8o to 90 per cent of those who leave prisons and rehabilitation centers after several months or even years of being "clean" (free from drug use) return to the drug and become addicted again. This fact has led many to conclude that the psychological dimension is as important to drug addiction as the physical. But the recidivism rate is also high among certain kinds of criminal convicts, and only those using poetic license can talk of "addiction" to crime. If we cancel out the physical dependence element, we are left regarding recidivism to crime or cigarettes as a powerful social or psychological habit-formation.

The only way to settle an argument as to whether the psychic or physical dependence is the more critical element would be to find some drug which produced the approximate perceived effect of an opiate and yet was not physically addicting. If such a drug could be found, then psychological dependency could clearly be established independent of the physical dependency. For the heuristic purpose of clarifying the issues in the argument, we can come close enough with marijuana. It often has the overall effect of a depressant, but in the earlier stages is something of a stimulant. There is no physical dependence with marijuana. According to the definition to be used, marijuana is therefore not addicting. However, this would merely avoid by definition the critical theoretical question, if marijuana users have the same pattern and frequency of usage as heroin users. It is the case, empirically, that there is no similarity of usage. After the first experiences, frequency of intake with marijuana is far less than with heroin, even though the individual may continue taking marijuana over as long a time span as the opiate user.

This is an argument against the tendency to give equal weight to psychological proclivity and physical dependence. To be sure, a better case could be made if heroin and morphine could be produced in such a form that there were no physically addicting qualities, but until then, this is the best empirical approximation there is. If we concern ourselves only with psychological dependency, there is very strong evidence that cigarettes are more habit-forming than marijuana. The pattern of tobacco usage is much more frequent and conclusive. Admittedly, marijuana is much more expensive than ordinary cigarettes; but then heroin is very much more expensive than marijuana, and people get addicted to heroin and not to marijuana.

While the psychic and the physical are intertwined in drug use, analytically it is the best tactic to separate the two kinds of dependency, calling the former "habit-forming" and the latter "addicting." One has the cigarette habit, but the opium addiction. That is not to say that an individual can not also be psychologically dependent upon heroin. That is clearly possible. The first defining quality of an addict, then, is the definite physical dependence signaled by radical body changes in equilibrium once denied the drug.

Using this kind of conceptualization of the quality of being addicted, I therefore find myself in at least a terminological disagreement with another way of viewing addiction. I have reference to Alfred Linde-smith's earliest work on the subject, Opiate Addiction.4 Lindesmith's book, which deservedly remains one of the most important statements on the study of the problem, incorporates the psychological dimension of cognition into the notion of addiction. Unless the subject knows that the withdrawal is caused by the drug, says Lindesmith, he is not addicted. It is clear that at the root of this definition is the attempt to explain subsequent behavior of the opiate user. If the user recognizes the connection, then he behaves in such a way as to alleviate withdrawal, and hence, according to Lindesmith, he is addicted. If he does not recognize the connection, then he can hardly be motivated to take more morphine since he has no reason to suspect that he will achieve comfort from it.

The primary difficulty with Lindesmith's definition is ironically a deficiency in the ability to categorize and explain behavioral alternatives which are called addiction. In what category does one place the actor who recognizes the tie-up between his withdrawal and opium ingestion, and yet refuses to take more opium?5 For Lindesmith, such a person would not be addicted because, while recognition is said to be a necessary condition, sufficiency is satisfied only with subsequent patterned intake. But suppose we turn the clock back to 1899. The individual maintains himself on a large quantity of morphine over a long period of time because he thinks that the morphine is the cure for his "other" ailments of diarrhea, muscular constriction, and so on.' Is he addicted? By Lindesmith's definition of necessary and sufficient conditions, the answer is no. Yet Lindesmith acknowledges that large numbers of such people were indeed "addicted" in the late nineteenth century in just such circumstances. By using the definition of addiction totally in the sense of physical dependency we can circumvent the confusion in Lindesmith's necessary-sufficient psychological-behavioral dimension. The transformations in physiological equilibrium constitute both necessary and sufficient conditions for addiction. How the actor then responds behaviorally is an empirical question, rot a logical or definitional one.

If the addicted person declines to take drugs, either selecting cold-turkey or symptomatic treatment, he may be said to have broken the addiction. (The physical dependence is broken, and therefore, the addiction is broken.) His possible subsequent return to narcotics use is then primarily a cognitive psychological and sociological issue of great complexity; but it is simply confusing to include in the definition of addiction the psychological dimensions of cognition and predisposition. That dimension is problematic and empiric J, as is evidenced by the simple fact that some addicts do not return to narcotics use.

In sum, one is addicted when there is physical dependence to the degree that, due to the lack of the drug, the physiology of the body is thrown into the disequilibrium already described.

The Animal as an Addict

Men no longer impute to nonhumans such things as morality or an introspectively achieved personality. Therefore, the addiction of rats and monkeys should provide some interesting material for study, especially as it relates to parallel behavior patterns usually associated with personality and morality in humans. The rat addicted to morphine does not display personality in the sense of psychic integration, nor does he reflect an awareness of the concept of self. Nonetheless, he does have cognition. That is, there is every indication that he "connects" his addicted condition and alleviation to a specific substance (morphine syringe and not food) and "knows" that substance will bring him comfort from his withdrawal stress.

There have been many studies on addiction in animals. A few have tried to set up a situation for the animal which is as close as possible to the human physical situation. As early as 194o, experimentation with chimpanzees demonstrated pronounced morphine-seeking behavior on the part of the addicted animals.' Hungry and about to experience withdrawal, the addicted chimpanzees were presented with two boxes. One had food, the other had a hypodermic syringe which the chimpanzee associated with injection. The animals chose the latter box. However, when the chimpanzees were addicted but in equilibrium, they chose the food box.

An improved research model would have the animal taking his own drugs, as humans often do. Experiments in the last decade have included this. In one such design, rats were addicted to morphine water over ordinary water despite the extremely bitter taste of the former.8 James Weeks reports an experiment that is even a better approximation to the physical setting in which humans take drugs.' Weeks used the technique of "operant conditioning" developed by B. F. Skinner and his associates. The rats are trained to expect a response, say food, from pressing on a pedal. Weeks used morphine injection as the response from pressing the pedal.

The apparatus directed an injection tube into the vein of the rat, and the equipment remained saddled upon him during the duration of the experiment. In the first stages, the rat was injected at periodic intervals by the experimenter until such time as physical dependence was established. Then the experimenter stopped initiating the injections, and the rat controlled the process by pressing or not pressing the morphine pedal. Weeks reports that after dependence was established:

the rat began to press the lever at regular intervals—about once every two hours, more or less, depending on the individual. Some of the rats went into a sort of trance immediately on receiving the injection, sometimes resting on the pedal for a minute. But as soon as they were prodded, they would move about normally without any evidence of the depressive effects of morphine.10

It is extremely relevant to this discussion to notice Weeks' caution:

One might be tempted to assume at this point that the rat "liked" the morphine, but it is important not to read human reactions and emotions into animals' behavior. Moreover, although human morphine addicts say they "like" the drug, even in humans it is not clear to what extent the drug is a positive pleasure and to what extent it simply brings relief from the rigors of abstinence. The fact is that the rat may not "like" the morphine at all but has learned that pressing the pedal stops punishment of early abstinence.) 1

In this experiment, the dosage was then gradually decreased, and then stopped completely, so that the rat got no morphine when he pressed the pedal.

When the dose was cut from io to 3.2 milligrams per kilogram, the rats responded more frequently in an effort to satisfy their habit. Then I disconnected the syringe completely.... There was an abrupt increase in the frequency of responses, which then diminished gradually as the rats developed a severe abstinence syndrome. They became nervous and agitated (but never vicious), breathed rapidly, tried to escape their cages and were sensitive to handling, as if being touched were painful. Gastrointestinal activity increased, the feces became soft and by the next morning the rats had suffered as much as 20 per cent loss in weight. They were very sick rats, but a single injection put an end to all their symptoms.l2

In a second experiment, Weeks constructed the injection apparatus so that the rat had to press 10 times to achieve one morphine injection. Then, gradually, he increased the number of times the rat had to press the pedal to 20, and then to 32 times in order to get one injection. Finally, the ratio was increased to so, then 75, 120, 180, 270, and 40o to 1 injection. As would be expected, the rats pressed the pedal more and more often, until finally they received an injection.

In 1964, preliminary reports from researchers indicated that addicted monkeys had kept themselves addicted by self-injection for a period of almost two years.13 The conditions were the closest physical approximations yet to the human situation. If the simulation were precise enough, we would probably see nonaddicted affluent monkeys robbed by addicted monkeys so that they could get enough simulated money to trade to a simulated monkey peddler. Anthropomorphism is increasingly rare, and though experiments with animals may simulate behavior patterns of humans, it is impossible to impute to monkeys moral reflections upon the goodness or evil of prostituting the self, or self-censure for theft. What we can do with the animal research is to clearly separate the moral-personality issues from the physiologicalimpulse-cognitive issues. We can do this when we refuse to impute morality, personality integration, and self-reflection to animals.

Predisposition and the Separate Ingredients

The sociological issue is complicated, however, by this primarily physical designation of the "addict." Whether one is a respectable physician in a middle-sized midwestern town or whether one is a rhesus monkey in a pharmacologist's laboratory, one can be addicted to morphine and heroin. The notion of physical dependence guarantees that identification. This is not true of a concept like delinquency. As Cicourel has pointed out, the police may treat the exact same act perpetrated by one youth as delinquency, but regard it as idle and insignificant behavior when engaged in by another.14 The criteria for classification are social.

When it is clear that physical dependence is the defining property of addiction, what sense can be made of the addiction problem with a social analysis? Just because the pattern of physical dependence is the same, does it make any sociological sense to lump together in a single category called "addicts" a nurse, a boxer, a succumbing aged person, an exploring working-class adolescent, a physician, a jazz musician, and a professional thief? Clearly, the social differences that exist among the myriad of persons who are addicted are so great that any sociological observer would have an impossible time speaking with confidence about the patterned social properties of addicts, which is one of his major tasks.

The first problem is therefore to clarify what it is that allows one group of addicted individuals to be singled out for differential treatment. It is a problem that the student of delinquency never need face. The characteristics associated with placing boys in this category are basically social in nature, and more easily lend themselves to sociological analysis.

Of the total population of persons who are addicted, only a certain type are known. Because some are unable to maintain themselves on the drug unless they supplement their income by illegal means, this part of the addict population becomes delinquent, and the delinquency is known. Most social and psychological theories of addiction (as well as the response to and treatment of the addict) are limited to this particular part of the known population, and the remainder of those addicted escape analysis. This study is different only in the self-conscious realization that its boundaries do not extend to the total addict population. Every statement about "addicts" should contain the explicit qualification: "socially known."

Who a drug addict is, then, is determined by the physical syndrome described ; but only a select proportion of addicts (and that proportion is unknown) are commonly thought about when laymen and behavioral scientists conceive of and theorize about addicts. These are the relatively youthful lower- and working-class delinquents and criminals known to the police for their theft, prostitution, and drug sales. Extreme caution should be exercised in theorizing about the personality of the addict as it is affected by drug use. One should be very wary of assertions that connect "people who are addicted" to generic delinquent behavior, or to statements like "addicts are delinquent types," and therefore take drugs.

Despite all of this, there is now rather common acceptance in lay and professional circles that addicts are addicted primarily because of some psychological problem. The issues here are far more serious than that of a provincial interdisciplinary squabble between psychology, physiology, and sociology as to which discipline is more correct in explaining the drug problem. The way in which men choose to explain a moral issue is a prelude to directives for action or inaction. I am concerned here with the commonly held conception of the nature of addiction. This conception is primarily a psychological one, and this in turn becomes the basis of the way in which addicts are regarded and treated.

Using physical dependence as the sole criterion of addiction, it would be possible to exclude marijuana users, cocaine users, LSD users, peyote experimenters, and morning-glory seed eaters from further discussion of who is addicted. Correspondingly, included in the discussion would be barbiturate and amphetamine addicts, along with heroin and morphine addicts. As indicated, this presents considerable difficulty for an attempted clarification of some of the basic social and psychological issues in narcotics use. For example, barbiturate and morphine users are likely to have somewhat similar social characteristics, while heroin and ghetto marijuana users are likely to be more similar to each other than are heroin and suburban amphetamine users.

Whether a drug is addicting or not clearly has nothing to do with the social context of its use, nor does this information allow one to distinguish differing patterns of individual motivation in its use. Further, whether a drug is addicting tells nothing about the treatment afforded to the user. A barbiturate addict can usually get treatment at a public hospital, whereas a heroin addict usually can not. Amphetamines (addicting) are legally available on the market; LSD (nonaddicting) is not. Illegal use of addicting heroin and nonaddicting marijuana are both felonies, whereas illegal use of addicting amphetamines and nonaddicting peyote is usually only a misdemeanor. Sustained use and addiction to barbiturates is far more debilitating than sustained use and addiction to heroin, yet heroin is illegal in both medical and nonmedical circles. Even more ironic, the undesirable physiological side effects from legal barbiturates are far more numerous than the side effects from illegal heroin. The list could go on, but the point should be made that the addicting properties of a drug have little to do with the social response to its use.

It is essential to make clear that there are varying social interpretations of particular kinds of addiction. To be hooked on barbiturates means something quite different to the general population than to be hooked on heroin. Users of both drugs may be addicted, but they are accorded systematically differential treatment by the society. The psychological question is why certain personalities choose one addiction and not the other. The sociological question is why there is such a different social-legal response to the two physically addicting drugs. If the answers lie in the differing uses and effects of the drugs, there is little pressure to push further. That is not the case here. Since the most common interpretation of addiction is in terms of the choice of individual personalities, this problem will be explored before turning to the second question. As has been stated, addicts are commonly said to be psychologically inadequate and morally weak. If one has observed that addicts are psychologically inadequate, the question can be asked, under what conditions might the observer be forced to conclude that this observation was wrong? In other words, what would the observer have to see in order to conclude that addicts are not psychologically inadequate?

Once this question is posed realistically to those who hold this position, it is likely that the one piece of evidence they require is that they see the addict give up narcotics usage. To see a man remain on drugs while he simultaneously holds a middle-class occupation, refrains from theft or any illegal activity, is considerate, noble, kind, and just is all irrelevant for the purposes of characterizing the user as psychologically inadequate. The simple fact that he is "using" is regarded as sufficient evidence of inadequacy. This reasoning is circular, tautological, or simply "true" by assertion and definition. Sustained drug usage or addiction is therein defined as the manifestation of psychological inadequacy. "If a human uses drugs, he is psychologically inadequate !" Once such a definition is made, it can never be proven wrong. It follows that all we need to know is whether the person is addicted, and if he is, we know that his personality is deficient. However, if the question is left open to empirical investigation, assumptions we so often take for granted become problematic. For example, if the question is raised as to what it means to be psychologically inadequate (without tying it to drug addiction) the issue usually rests empirically with such problems as "an individual who has a hard time coping `normally' with the world."" However, it is known that if the addict is getting his supply of heroin, he can cope with the world in such a way that the observer regards him as normal.1ó There are addicts with sufficient income to supply their habit without engaging in other illegal activity. This means that if one is economically or financially adequate, one can maintain the appearances of psychological adequacy in coping with the world, and the observer can not detect the difference, which is not true for the alcoholic. If, despite this, one insists that drug usage itself demonstrates psychological inadequacy, it is simply a matter of returning to a definition which equates the two.

The question has significance for the idea of the "decision" to become an addict. Clearly, if one has an inadequate personality, this may explain the drive or the compulsion to narcotics. Conversely, if one has an adequate personality, by the definition of those who take this position, he will not use drugs.

The sociological analysis of the question, "Who is a drug addict" revolves around the social identity of the addicted individual. Only when he becomes socially visible is he a problem, since it is only then that he can obtain differential treatment. In the public sphere, most men are treated according to that segmentalized aspect of the person that is most relevant. For example, at a cocktail party the guests are more concerned with sexual attractiveness and sociability than with the demonstration of athletic skill. At other times, the same persons may be more concerned with formal education or income or religion.

Men single out some element of the individual for the purpose of addressing that element more fully. There is a common awareness of this, and usually an acknowledgment that there are many other elements that might also be acknowledged and emphasized. However, there are some categories that have an unusually strong ability to influence the judgment of a total person. These categories are so strong that men often can not see any other part of the individual as independent of it. Such is the case with moral categories, and drug addiction has come to be just such a category in the twentieth century. A moral category provides more than a partial identity for the person so characterized.° It is more than simply a way of emphasizing and addressing an individual in particular circumstances and situations. The moral category infuses every situation; it permeates the whole character of the individual and becomes his total identity."

Prostitution is one example of a moral category. It carries with it the power of coloring every other way in which a woman might be regarded. As soon as it is known that a female is a prostitute, she is prevented from being partially identified in some other way. The movie Never on Sunday was resented and banned in many parts of the United States not just because it portrayed a prostitute, but because the prostitute possessed warmth and compassion, and her morality in every other sphere was quite acceptable if not admirable to Americans. The strongest argument brought against the movie was that it portrayed prostitution in a favorable way. There was no specific scene of a sexual nature that needed to be censored, so the major issue concerned the appropriate way of portraying the prostitute. The quality of the total person was thereby infused with being a prostitute, so that one should not be able to conceive of "such a woman" in any way other than that tied to sexual morality, or immorality, and thus to an immoral person.

The drug addict is presently in the same situation: his being a drug addict is the important category that permeates his total identity. Just as with the prostitute, when the discovery is made that an individual is a drug addict, the typical response is that, "I now know what there is to be known about that person." The essential property of the total identity is that it allows the observer to explain the behavior of the person in terms of that identity. The drug addict is treated as morally capable of theft because he is a drug addict. That he also might be capable of a stable middle-class family life is jarring to the notion of a total identity, and so that is rejected out of hand.

As was pointed out in Chapter I, simply to be known as an addict is tantamount to being considered a criminal. In order to be a criminal in Western society, the individual must have the intent to commit the criminal act. If there is a pathological state of the mind which calls into question the responsibility of the offender, there can be no crime. The fact that addiction is now conceived primarily in moral terms, with moral consensus directed toward criminal punishment, means that Americans find themselves in a logical bind on this issue. On the one hand, they are forced to impute to the addict criminal intent with its accompanying conscious, rational, willful motivation to commit the act. On the other hand, there seems to be no way for us to understand the willful intent to take drugs (and subsequent addiction) without imputing pathology of personality, or perhaps even mental illness to the individual.

One way to get out of this bind and escape the central issue is to reject the notion of knowledgeability, and to impute naivete to the unsuspecting preaddict. Such interpretations rest explanations on the malicious peddler who lures the young with free marijuana and heroin, only to later ensnare them. Federal law allows the death penalty for an adult peddler who sells to a person below the age of eighteen. Another path of explanation is to assume that addicts are morally depraved. But being morally depraved and being stupid are quite different, and even the morally depraved (who are knowledgeable, willful, and responsible for their actions) should have sense enough not to become addicted to narcotics. The list of possible descriptions could go on, ranging from being culturally deprived to evil, but the central confusion remains.

On the "Decision" to Become a Drug Addict

In the minds of those who have never tried narcotics, there is a great puzzle over the question of how one becomes addicted in the first place. How is it possible, it is asked over and over again, that a man who is individually responsible for his actions could become addicted? Men make decisions on such matters if they are responsible. It is difficult to imagine that at some turning point in his life, the nonaddict made the willful decision to become an addict. That is incomprehensible, and we are left fumbling around for some explanation of the psychic state that produces the desire for drugs. Accordingly, the reigning interpretation of addiction is a psychological one. The language of this interpretation refers to the inadequacy of the personality; the choice is made either from a self-conscious realization and a decision to flee reality, or from a deeply subconscious unrealized motivation.

This point of view acknowledges that social and cultural factors are important at some level, but is willing to place the burden of interpretation upon how the individual is able to cope with these factors. "If one copes successfully, he decides to become a nonaddicted law-abiding citizen. If he is unable to cope, he decides to become addicted."

The evidence that this point of view marshals seems incontrovertible, namely, the existence of addicts. The trouble with this argument is the same as that with any argument that documents its case by pointing to the existence of men in various categories as evidence for the theory of how they got there. For example, those who are convinced that the poor are poor because they lack motivation or because they are psychologically inadequate can always find "sufficient evidence" for this position simply by citing the existence of poor people.

What exists can always be explained on the grounds that it exists, and then any explanation will do. It can be said just as authoritatively that addicts or the poor are possessed by devils.

We should instead raise the question as to whether men do have the conscious intent to become addicts. For those incarcerated at the California Rehabilitation Center, the answer seems to be negative, as we shall see in later chapters. There is a pattern to the responses which the inmates gave concerning their first contact with narcotics. Almost all of them knew before they ever took heroin that it was addicting. The distribution of knowledge on this critical point is presumably wide-. spread. Almost everyone knows about the addicting potential of heroin, and so it is impossible to argue that men are unsuspecting and ignorant about the effects of the drug and are lured into it by nefarious dope peddlers who speak of it as harmless candy and a one-time shot.

Second, addicts seem to know that heroin in overdose is lethal. This is a more important piece of knowledge than appears at first glance. The strength of any particular purchase of heroin is unknown to the purchaser. It may be weakened many times over before it finally reaches the consumer. The white, powdery substance that he takes may be a certain strength, or it may be four times that strength. Only a chemist with the appropriate measuring instrument could determine the nature of the heroin. Thus it happens that when a particular shipment is not weakened as much as usual one may inject a lethal dose of heroin. This is commonly known even before the first encounter.

Further, the overwhelming majority know before their first experiences with narcotics what the legal consequences of being caught would be. Ignorance cannot possibly be used to explain the first plunge into drug use. The fact that the important and relevant information about the problem is so universally distributed simply reinforces the notion of a responsible man making a decision to become an addict.

The individual user never believes he himself will become addicted. Perhaps we see here the same mechanism that allows a soldier on a battlefield to surge forward and continue fighting while he sees soldiers around him dying from wounds. One can be firmly set in the belief that the self is inviolable, unique, and not subject to suffering, accident, or death. It is unlikely that traditional ground wars could be fought unless men believed that they personally would not die on the battlefield.

A less appropriate but more commonly appreciable analogue is the automobile driver who takes chances on the highway that the observing passenger regards as foolish. But the observing passenger may take the same kind of chances himself when he drives because he believes that the self is indestructible.

This, I think, is the first ingredient that makes addiction possible for those knowledgeable about the legal, moral, and addicting aspects of narcotic usage. It is important to keep in mind that this quality is a common one. Most possess the firm belief that "Nothing like that could happen to me."

Even at this point in the discussion, the "decision" to become an addict is very questionable. One no more decides to become an addict than one decides to die on the battlefield, or for that matter, decides to have a serious accident on the highway. However, there are more particular and detailed problems in the physiology of addiction which illuminate the question of a conscious decision.

As with alcohol, the amount of drugs that it takes to affect the mind varies with the individual. At first contact, some men are affected by one glass of wine and some are unaffected by four. Some are in euphoria on a quarter of a grain of heroin, and some are only mildly affected by twice the amount. Nonetheless, it is possible to assert that most men feel the effects of their first experience with an opium derivative. Those who know the feeling produced by morphine and heroin say that they can no more describe the sensation to the uninitiated than they can describe sound to those born deaf. "To someone who has never tasted a pear, try and describe the taste of a pear." With these drugs, most describe this first experience as rather pleasant, at the least. The body's systems function in a state of balance and equilibrium. When heroin or morphine is injected, the equilibrium is disturbed in such a way that the autonomic nerve centers compensate for its effect with depressant mechanisms. It is this depressant effect which is so pleasurable, in that the subject is no longer troubled by physical pain or even his worldly problems. Physically, the immediate response after injection is usually a tingling sensation in the abdomen, a flushing of the face, and then the pleasant detachment, if not euphoria.

The effects last for about four hours, during which time the user may drift into somnolence, wake momentarily, and drift back again, having constant daydreams. The observer, however, would have a difficult time saying definitely whether one was under the influence or not. A man under the influence may move a bit slower than usual, but not so much as to be noticeable to the unsuspecting observer.

After the first experience wears off, there may be a very slight headache, or slight nausea, but it soon goes away. For the user, it is a small price to pay for the sensation derived from the drug. Still, one may take it or leave it. Many never take it a second time. Many try it again after some days, or perhaps weeks. The "reasons" for the second time are often as normal and social as the first. The physiological response of the organism is the same. Once the drug ceases to be effective, the slight nausea and slight headache may reappear, but this is small discomfort. It is hardly more than the ordinary, mild annoyances that men experience in everyday life. At this point in his career as a user, the individual usually makes a connection between discomfort and the use of the drug. He knows that the nausea results from the drug. In a sense, this knowledge leads him to a conclusion that sends him further along the road to addiction. He reasons to himself that his own body is such that it responds in this way to narcotics. In a word, he makes the erroneous conclusion that the slight nausea and slight headache are his own version of withdrawal.

The user may continue for several months in this part of the syndrome, until finally he understands that he must increase the strength of the dosage to get the same kick that he got originally with a smaller dosage. This is somewhat alarming, but once again, he "knows" what his physiological response to narcotics will be. The stronger dose produces the desired effect, and the penalty is merely a headache and nausea. Because there has been a history of this response, it is treated lightly. The old cliché about the hot tub of water getting hotter with the bather oblivious to the degree of increased heat is appropriate.

After a few more months, the nausea may have progressed to throwing up, and the headache may be intensified and accompanied by fever. There are now hot flashes and cold chills. Diarrhea is common. When the user realizes that he can get quick relief from these discomforts by taking more narcotics, and does so, he is psychologically habituated. This means that he can no longer "take it or leave it," and the willful character of action is suspended. Not a single person, addict or nonaddict, desires a state of affairs where he is at the mercy of an exorbitant market to maintain his body at equilibrium. No one intends or desires this kind of addiction.

Let us turn now to the social situation of the individual when he uses narcotics for the first time. It is rarely, if ever, that a peddler introduces the user to drugs. According to data to be reported later, about two thirds of the time it is a friend who is the first source of contact. The first venture is usually an unplanned affair, where one happens to be in the right place at the right time. A relatively small proportion of addicts made a conscious plan to go out and shoot heroin or smoke marijuana on a given night in the future, or even "later tonight." This description of the spontaneous and communal character of the first contact with narcotics is at odds with the most popular interpretations of the road to addiction. We usually hear that one takes drugs in a psychologically despondent state, fleeing from anxiety and reality, and compensating for an inability to cope with the world.

Addicts report no depressed state when they decide to try dope. To the contrary, they typically report how normal the situation was. A friend, or group of friends, or sometimes a sexual partner knows about the availability, and on the spur of the moment (with long-range planning or despondency almost unheard of), they go off with them and find the first experience pleasant.

There is an important difference between males and females in drug usage in general, and on first contact in particular. (As in almost every arena of reported criminal activity, males outnumber females by a ratio of at least 8 to 1).19 When a man first tries dope, he is likely to try it in a group. Later on in his career, he may be one of the minority users who shifts over and becomes a loner. That is, he may move into a class of addicts that take the drug in complete solitude. Unlike the more typical communal addict who shoots dope with his buddies in a social club atmosphere, the solitary addict shoots a whole load of heroin all at one time, and leaves this world. Although he is atypical, he is the stereotype. He is the more serious addict in several ways. His withdrawal will be more severe, and his need will be more desperate for a single, strong shot of relief. Accordingly, he will be more adventuresome and dangerous in trying to get that relief. The social addict takes dope in smaller quantities at several points, trying to savor both the physiological transformations and the community in which it occurs. Whereas the loner may shoot a half a grain of heroin all at once, the social addict will divide that same half grain into six separate shots within the space of four hours.

This is the male pattern, and it differs significantly from the conditions and manners of female usage. Whereas a friend usually initiates the male, it is usually the lover who initiates the female into narcotics. It can be the husband, the boyfriend, or sometimes the homosexual partner, but it is usually someone with whom the female has an intense emotional relationship. Many women use not because they independently desire the drug, but so that they can please the other person.

The male user is often wary about the possibility that his female acquaintance who does not use will turn him in, or leave him because he uses. Also, he may wish genuinely to share the experience with someone who is close to him. In either case, the motivation is strong to draw the female into the relationship more tightly by getting her to use.

Although women are the small minority of addicts they are among the few who can come even close to the designation of decision-makers on the question of addiction. They are confronted with a choice of action that is usually very explicit. The alternatives are weighed beforehand. Does one risk the loss of the other by refusing to use, or does one solidify the relationship further by engaging in the communal act? Many decide against narcotics when the problem is put in these terms. A few decide to take the drug in a planned, rational frame of mind. However, it is stretching the interpretation to conclude that these women therefore decided upon addiction. Just as with the battlefield soldier and the male preaddict, she concludes that she is an exception, and that she will be able to use and escape addiction. Probably the most common conception of the decision to live a life on drugs is that, after the first experience, the preaddict so likes the feeling that he decides that this is what he wants. This is a reasonable conjecture of what most Americans believe, since they treat marijuana with almost the same horror as they treat opiates, despite the fact that many know that marijuana is not addicting. The great fear is that one will try harmless marijuana and like it so much that the mind and desire will graduate to the more serious heroin.

High-school students are continually warned about marijuana as the first step on the road to addiction. A federal law passed within this decade makes possession of marijuana a crime equal to the illegal sale and distribution of an opiate derivative. Law enforcement officials claim that they never enforce this law on users, but only on sellers of marijuana. Arrests for marijuana usage are not as common as they might be, but the law is on the books, and it specifies equal treatment. This being the case, it would seem that the "decision" to take marijuana is as much of a decision as that concerning heroin. It is clear, however, that marijuana usage far exceeds heroin usage in this country. Some of the supply lines for marijuana feed into the middle-class college communities. Almost every heroin addict has had some experience with marijuana, but the reverse is far from true.

Summary
Not all persons physically dependent upon drugs are known, either to the law enforcement agents or to the small circle of friends around them. Those who are known are likely to be a certain social type, and theories of addiction are thus limited to this specific type. The layman's and the behavioral scientist's view is limited to the kind of addict who has insufficient funds to maintain himself on a supply of drugs without engaging in flagrant public violations of the law. The addict who is criminally delinquent in ways other than simply using drugs is the only addict focused upon in theory and speculation. Because of his association with criminal deviance, there has been a general tendency to regard this addict as "the addict," with his problem as an aberration of personality and morality. As was demonstrated in Chapter i, this is historical shortsightedness of some magnitude. The contemporary known addict is infused with the total identity of an immoral person with an inadequate personality. The interpretation of reasons for immoral behavior is also a directive as to what should be done to the deviant. Americans have now concluded that the way to treat the addict is as an individual with a personality problem curable by techniques that get at the individual psyche. Americans have reified the idea of who an addict is, to the point where they can not entertain other alternatives as to who the addict might be. We have ignored the fact that the stereotyped addict comes from a specific and delimited stereotyped social context. But therein may lie an alternative conceptualization of the addict and of the deviant, and thus, as well, an alternative directive for a solution to the current problems, both theoretical and practical.