CHAPTER 5 PROCESSES IN ADDICTION

PART I The Nature of the Opiate Habit

CHAPTER 5 PROCESSES IN ADDICTION

The confirmation of a theory, such as that which has been outlined in brief form in the preceding chapter, requires more than mere assertion of a relationship between two kinds of events or processes and the presentation of confirming instances. I assume that the proper meaning of "verifiability" is better expressed by the term "falsifiability." In other words, a genuine theory that proposes to explain a given phenomenon by relating it to another phenomenon must, in the first place, have clear empirical implications which, if not fulfilled, negate the theory. In the absence of such negative evidence a theory may be accepted as valid, but only in a provisional sense, because further evidence accumulated at some future time may require that the theory be rejected or revised. The characteristic of a good scientific theory is that, if it is false, it can readily be shown to be so. It can rarely or never be shown to be absolutely and unconditionally true. The verification of the theory that has been proposed will therefore consist primarily of the description of the search for evidence to negate it.

Another central aspect of scientific explanation that has already been alluded to is that besides identifying the two types of phenomena that are allegedly interrelated, there must be a description of the processes or events that link them. In other words, besides affirming that something causes something else, it . is necessary to indicate how the cause operates to produce the alleged effect. This requires a description of a sequence of interrelated events in which the characteristic attributes of the phenomenon being explained emerge in the later phases as necessary or understandable consequences of earlier phases. To be specific, if it is assumed to be true that the craving for drugs is generated in the experience of using them to alleviate and prevent withdrawal distress which is understood as such by the subject, what are the implications of this and are those implications empirically confirmed?

The Usual Case

While in previous chapters specially selected instances of the addiction process were presented for illustrative purposes, none of the addicts I have interviewed gave any reason for discrediting the theory. Obviously, all drug addicts experience and understand withdrawal symptoms, and, despite occasional claims that addicts sometimes experience no withdrawal distress when their addiction is interrupted, no authenticated case of an addict who never experienced withdrawal has ever been described. It also seems fairly obvious that addicts would not continue using drugs in increasing amounts at great cost and risk if there were no threat of withdrawal and if it were as easy to quit as it is, for example, to quit eating ice cream.

The addicts whom I interviewed can be grouped in two classes with respect to their first experiences with withdrawal symptoms. The first group became acquainted with them gradually, sometimes as a result of repeated experiences with relatively mild symptoms. Others, because they knew in advance what to expect, noticed and recognized the symptoms at once. As users of this type gradually develop an appreciation of these symptoms, they tend to become apprehensive and, without realizing or admitting that they may already be hooked, attempt to stop using the drug to see what will happen. Ordinarily a relatively brief delay of the next injection is sufficient to persuade the user to resume the drug, and as he does so he develops a fuller realization of the insidious nature of the habit. Through repeated brief experiences with the abstinence syndrome users of this type may become thoroughly addicted and fully aware of their dependence on the regular use of the drug without ever passing through the critical type of acute withdrawal.

The second way in which addicts become acquainted with withdrawal symptoms is by having them explained or by realizing their nature suddenly in a flash of insight. Several such instances are cited in the preceding chapter. In this case, the experience often comes to the beginner as a shock and a surprise. The subsequent adaptations evidently proceed relatively rapidly when this point is reached, and addiction is quickly established, although the user may continue for some time to resist the idea that he has become an addict and to nourish the delusion that he will be able to break his habit without too much difficulty when he puts his mind to it.

One addict told me that, in his first experience with narcotics, he was quite confident of his capacity to resist. Later he "began to be afraid of himself" and, in a gradual process of transition, came to a point where he "had to have it." He confided, "Whenever I was full of it, I would wish that I wasn't using it, but when the effects began to wear off, I'd go out for more." In this process, no sudden realization of addiction occurred, and even when encouraged to give a detailed account, be continued to describe his experience as a gradual and continuous transition. This case is at the opposite pole, with all degrees of variation between, from that in which the realization of addiction comes as a sudden fatal flash of insight in connection with severe and prolonged withdrawal.

Addicts of the class to which this case belongs may fail spontaneously to emphasize the role of withdrawal symptoms simply because the whole experience seemed self-evident and was so gradual and unspectacular.

Terry and Pellens observe: "It is self-evident that there can be but one direct cause of addiction, namely, the continued taking of the drug over a sufficiently long period to produce upon withdrawal distress of some kind to the patient.(1) Formal attempts at defining addiction invariably include withdrawal distress. In this connection, Emil Kraepelin's statement is pertinent. He writes:

The severity of the symptoms of withdrawal varies to an extraordinary degree. It depends upon the size of the dose, the duration of the addiction, the general condition of the patient, and the individual tendency. Sometimes the disturbances are limited to a little diarrhea, sweating, excitability and insomnia, while in other patients the condition becomes exceedingly severe, threatening life. My experience, however, does not include an instance of withdrawal wholly without discomfort. When the manifestations are very mild or the health altogether undisturbed, morphine is unquestionably being supplied clandestinely. (2)

As a matter of fact, addicts regard withdrawal symptoms as a perfectly obvious and essential aspect of addiction and cannot conceive of addiction without them. This is why they describe drugs such as cocaine and marihuana as non-habit-forming and differentiate them sharply from the opiates. In order to qualify as addicting, a drug must produce physical dependence and withdrawal symptoms. The addict, admittedly, is not an authority in the field of psychopharmacology, but this particular conclusion of his is solidly grounded in his direct experience of the marked qualitative differences between the drugs that produce physical dependence and those that do not.

Linguistic Evidence

Since the experience of addicts are in a sense crystallized and summarized in their special language or argot, it is significant to note some of the features of this language which are relevant to the ideas being considered. Of particular interest is the use of the term "hooked" to designate addiction. The reference to withdrawal symptoms is obvious, and the analogy embodied in the word could scarcely be more appropriate. The addict sometimes speaks of persons who were hooked without knowing it. When he does, he means simply that the individual was physically dependent on the drug without knowing about or recognizing the withdrawal symptoms. Since the addict associates primarily with persons who are booked and know it, there is no particular need or occasion for him to make a sharp analytical distinction between knowing and not knowing that one is hooked. Should a novice fail to recognize the cause of his misery during his first experience of withdrawal, the more experienced addict attaches little significance to enlightening him. This is especially true because of the addict's tendency to identify addiction with physical dependence and withdrawal distress; the person who experiences these already has the habit as far as he is concerned. The fact that some beginners at first do not, recognize withdrawal experiences is regarded as something that is merely odd or interesting.

The possibility of receiving the drug without knowing it, suffering withdrawal symptoms when it is removed without realizing it, and not becoming addicted, is admitted by the addict. Such persons, however, are not regarded as being "really hooked" implying that the process of being "really hooked" involves not only withdrawal symptoms but also realization that they are due to the absence of the opiate. Furthermore, when an addict inquires of someone be meets for the first time, "Have you been hooked?' an affirmative answer not only implies a withdrawal experience, but also a recognition of it. On the other hand, an individual who bad been "hooked without knowing it" would not be likely to comprehend the question, and if it were explained he would answer in the negative.

Anyone who has ever been "hooked" is regarded by other addicts as one of the "in-group." Whether or not he is using opiates at the moment, he is considered "one of the boys," a "junkie," a " user," or as an "ex-junkie" never a "square, " or non-addict. The addict who is temporarily not using drugs is familiar to other addicts and is regarded with tolerance and often encouraged in his effort to stay "off the drug." He is never viewed as an outsider. Since other addicts remember only too well their own helpless efforts to quit, they fully appreciate the position of the former user. Consequently, they wish the abstainer good luck by such remarks as "I hope you make it; I can't." Between the addict who is using drugs and the one who is not there is never the social barrier that separates the addict from the non addict.

In the present study, drug users were asked in their own vernacular whether they had ever known or heard of anyone who had experienced and understood withdrawal and used the drug to avoid these symptoms without becoming addicted. This involved asking the self-contradictory questions, "Have you ever heard of a person who got hooked without becoming an addict?" or "Did you ever hear of an addict who was never hooked?" Both questions were meaningless to addicts, and I was compelled to explain myself. To the drug user, to be "hooked" is to be addicted and to be addicted is to be "hooked."

Another term, "yen," is used popularly as a synonym for "desire"; for example, "I have a yen for a piece of pie." In the addicts' argot, this word signifies the desire for narcotics incidental to abstinence distress. In this sense, the drug user who is full 'of narcotics cannot feel a "yen," nor can he feel it after he has been in prison a few months and the withdrawal symptoms subsequent to the removal of the drug have vanished. The desire for narcotics that persists after abstinence symptoms have vanished is not called a "yen" by addicts. (3) On the other hand, the term is actually applied to the withdrawal symptoms as such, whether they are understood or not by the individual experiencing them. Thus, it will be recalled that in Case 10 (Chapter 4) Mr. 0., who was yawning and feeling bad, was asked if he had a "yen." This question was evidently asked, not because Mr. 0. bad verbally expressed any desire for narcotics, but because be yawned constantly and showed other physical symptoms of opiate withdrawal. The identification of withdrawal symptoms with the desire for narcotics is evident in the warning frequently given to those who experiment with the drug: "You'll put too many shots too close together sometime and wake up some morning with a yen." In other words, the "yen" or "desire," which is basic to addiction, is so inextricably bound up with withdrawal distress that the two are designated by the same term. I once jokingly remarked that I was talking so much about drug addiction, withdrawal, etc., that I was beginning to wonder about the possibilities of developing a yen." The addict's reply was, "It can't be done by proxy."

As further evidence it may be mentioned that when a drug user declares that he "feels his habit," he means that the distress of withdrawal is being felt. On the other hand, the addict who has all the drug he wants does not "feel his habit." Another significant usage distinguishes between the "pleasure user," or "Joy popper," and the addict. A "joy popper" is simply an individual who uses the drug intermittently and who has never been "hooked." It is probably true that most of the so-called pleasure users eventually become addicted, but as long as they space their shots so as to avoid withdrawal symptoms, they are sharply distinguished from those who have been "hooked" and they do not regard themselves as addicts. Those who use drugs irregularly, for example, once a week, are called "pleasure users," or they may be said to have "week-end" or "ice cream" habits. The distinction between the joy popper and the junkie is almost exactly paralleled by that between the "social drinker" and the alcoholic. just as the alcoholic cannot again become a social drinker', the junkie cannot revert to the status of a joy popper. The addict's standard remark, "Once a junkie, always a junkie," possibly refers to this fact. An addict elaborated on this idea by remarking, "Any man who has ever been hooked who says he doesn't want to use morphine again is either a damn fool or a liar."

Immunity to Morphine Effects

The wide range of differences commonly observed with respect to withdrawal effects suggests that certain individuals may use the drug with impunity, or at least without suffering much distress. It is well known that in certain rare cases the drug may have other than the usual pleasant effects during the initial period of use. In such cases, continued injection does not produce tolerance but simply results in progressively aggravated distress. Such persons obviously cannot become addicted. Are there, on the other hand, persons who obtain the usual pleasurable effects from opiates without experiencing the customary withdrawal symptoms? In this connection, I was very interested in the report of an unusually reliable addict concerning a user who was ostensibly immune to the withdrawal symptoms. Since no other pertinent information is available on this case, it is reported with a frank acknowledgment of its hearsay source.

Case 12. Mr. Y. was a rather heavy drinker who sometimes used morphine in association with friends of his who were drug addicts. According to the informant, who was a professional thief, Mr. Y. used morphine regularly for at least two weeks and probably longer. At the end of this time he stopped it abruptly, gave away whatever morphine he had left, and went about his affairs. The addicts with whom he had associated were dumfounded at his casual attitude toward the drug and his ability to withstand addiction. He himself was astonished and discussed the situation with his friends. With the exception of a pain in his back lasting only a few hours, he noted nothing unusual after be stopped and bad neither an inclination to use the drug steadily nor a craving for it. In fact, he considered the behavior of addicts with as great surprise as they did his. Their constant conniving and sacrifices to keep themselves supplied with the drug were absolutely unintelligible to him, and be told them so. In his entire association with these men he never succeeded in acquiring an understanding of them nor did he become addicted. One occasion particularly impressed the informant. Setting out to attend the funeral of a mutual friend who bad died from an overdose of morphine, the group stopped their automobile in front of the public library to administer shots of morphine in the library washrooms. Mr. Y. was amazed and remarked upon the utter absurdity of a group of apparently sane individuals attending the funeral of a user who died from the effects of morphine and finding it necessary to consume the same poison before going to the funeral!

Since there was no way for me to communicate with Mr. Y. I questioned the informant closely. No motive for exaggeration or distortion of the facts was found.

The First Shot

At first glance it may seem that those cases of addiction in which the results of the first injection were tremendously impressive and led at once to continuous use are apparent exceptions to the theory in that addiction may have preceded the experience of withdrawal symptoms. A very intelligent addict, asked to explain the drug habit, cited his own case to support his contention that the very first injection was decisive.(4)

Case 13. Mr. F. was wounded in World War I and, during his convalescence in an English hospital, was employed by the hospital authorities. He bad hoped the work would be easy, because of his condition, but found instead that he had to spend fifteen to sixteen hours a day at it. Consequently, he became exhausted and, in an effort to overcome his chronic fatigue, drank whiskey in small quantities in company with other members of the staff. As he said, "For months I wasn't either entirely sober or entirely drunk." The drug supplies of the hospital were under his care, and one day he determined to try a little heroin to see if it would help overcome his chronic fatigue. He sniffed a little and found the effects marvelous. It not only enabled him to work long hours, but gave him energy for recreation and entertainment. He used the drug a little each day for two months.

At this point in his story be stopped, feeling that be bad sufficiently explained the crucial importance of his first experience. Encouraged to go on, he continued his story.

After two months of using the drug regularly, he went on a short vacation without taking a supply, for it did not occur to him that there was any need for it. Gradually he became more and more affected by withdrawal distress. At first be was unable to diagnose his trouble, but eventually be realized what it was. The symptoms became so severe that he was forced to take the train back to the city where he worked in order to replenish his supply. It was then be realized, though in an incomplete way, that he was "hooked." After about six months be returned to Canada, using the voyage as an opportunity to quit his habit. He threw his supplies overboard. Persons on board attributed his withdrawal symptoms to seasickness. After surviving the abstinence distress, he was certain that he could stay off the drug, but he relapsed after about six months, stating that he was then convinced that this thing was stronger than I was."

In spite of Mr. F's own theory, it should be noted that in his case, as in others, the drug was continued for reasons intimately associated with the very use of the drug itself and not because of the original drive. The fact that Mr. F. abandoned his source of supply without providing for-future needs demonstrates that his attitude toward the drug did not at that time qualify him as an addict. What really impressed addiction upon him was his experience with the acute withdrawal distress during the sea voyage. Evidently during the first four months of use the withdrawal symptoms were an unconscious and unrecognized factor which favored the continuance of the drug, although Mr. F. himself thought that he used it solely to avoid fatigue and to increase efficiency. After his experience with withdrawal, however, these symptoms became conscious factors in his conduct.

Mr. F.'s account is representative of those instances in which the initial effects of the drug are so pleasurable and impressive to the beginner, that, provided he has no strong inhibitions against it, regular use is likely to be continued. In such instances one may say that there is a desire for the drug and even a habit of using it prior to addiction. This habit and desire, however, were obviously very different qualitatively from the subsequent addiction and the craving that it entailed. The fact that Mr. F. went on a vacation in England without thinking of taking a supply with him is sufficient evidence of this. Clearly also, while Mr. F. thought that he used heroin for the first two months because of its positive effects in reducing fatigue and stimulating him, it was not for such reasons that be resumed its use after he had tried to quit. It should also be remembered that, however marvelous the initial effects of morphine or heroin may seem during the beginning or honeymoon period of use, they are considerably less than marvelous when addiction is fully established. The determined effort made by Mr. F. to break his habit on his return to Canada suggests that he bad discovered this.

In a discussion of cases of this sort in which the authors speak of a primary or pre-existing desire for euphoric drugs in what might be called addiction-prone personalities, Ernest Joel and Fritz Frankel remark:

The unusual and complicating aspect of this second phenomenon is that the continued use of morphine with the gradual development of tolerance and the appearance of withdrawal distress upon the removal of the drug, leads to a morphine-hunger which has not the slightest connection with the original desire for euphoric drugs. ... It is possible to make a drug addict out of anyone, regardless of his constitutional make-up. (5)

In the same connection, Kolb comments: "The original impulse [toward narcotics] may have subsided long ago, but this new craving grows stronger and is more difficult to throw off the longer the drug is used. Normal people, who never had an intoxication or narcotic impulse, are as much subject to it as the inebriate.(6) In another article, the same author asserts: "It thus happens that the drug taken in the beginning because of its power to raise an inferior individual above his normal level, must be taken in the end to keep him from sinking slowly below it and to relieve conditions that the drug itself has produced.(7)

Self-Experimentation

A consideration of cases of self -experimentation by technical workers with advance theoretical knowledge of the habit presents interesting problems. If one assumes, for example, that a thorough-going acquaintance with the phenomenon of addiction confers upon the investigator the ability to control his reaction, it follows that opiates could be systematically used for relatively long periods without inducing addiction. Louis Faucher, as noted above, may be placed in such a category. He used the drug only once a day for six days and affirmed that knowing what to expect enabled him to take precautions to discontinue its use after that time. What would have happened had he extended the experiment for six weeks? Faucher declares that further use of the drug even a short time would have made him an addict. How may one account for the difference between this case and that of the patient mentioned by Dansauer and Rieth who received opiates steadily for six years without showing any desire for the drug? (8)

The implications of the theory advanced here with respect to such cases is quite clear. The deliberate self-experimenter, who knows what to expect, will note and understand the withdrawal distress sooner and more certainly than an ignorant layman, and he is, therefore, more susceptible to addiction under these conditions. Morphine addiction seems to be a case in which foreknowledge is a dangerous thing, in the sense, that, if the drug is administered regularly, this very knowledge aggravates susceptibility to addiction rather than providing immunity. In the light of this interpretation, it should, therefore, be expected that cases of habituation which did not lead to addiction would be relatively more numerous among non-medically trained individuals than among members of the medical profession.

This is precisely the situation found among German medical men; here addiction, defined by Pohliscb as the use of more than 1-5 grains of Morphine or its equivalent per day for at least six months, was over 100 times more prevalent in the medical profession than in the general population.(9) The percentage of drug using doctors estimated to be not addicted was only 6.6 per cent, in comparison with 48.9 per cent of the non-doctors.(10) Pohlisch's distinction between addiction and habituation, based solely on the size of the dosage, is, of course, arbitrary and subject to error, as has already been indicated.

The literature on the subject records numerous instances of personal excursions into addiction by curious individuals who have been lured into smoking opium once or twice or trying a few injections of morphine. During part of the nineteenth century and earlier, when the drug habit was little understood and its dangers inadequately realized, such experiments were more common than they are today. Nevertheless, so far as I have been able to ascertain, not a single instance has come to light of a self experiment, carried out beyond the several weeks' trial admittedly necessary to establish full-fledged withdrawal symptoms, which did Dot end in the addiction of the experimenter.

This is all the more significant in view of the frequent accounts of supposedly "cured" addicts, and the interest in "cures." One would suppose that a user, demonstrating his immunity to the habit-forming tendencies of the drug would be widely advertised and pointed out as proof that persons with "strong will power" or a certain type of character might escape addiction despite steady and prolonged use. Apparently, such experiments have always ended in grief, for while it is easy to find accounts of addicts who began out of "curiosity" or a desire to experiment, accounts of individuals who have knowingly experimented with severe withdrawal symptoms and escaped addiction are entirely absent.

William Willcox describes a patient who believed that regular use of heroin or morphine would not be dangerous:

This patient, who is a man of very strong will and brilliant attainments took morphine some years ago in order to relieve the pain of sciatic neuralgia. He said, I have a strong will, and there is no risk in my taking morphine, though others should Dot do so." He has been an addict for fifteen years.(11)

In another article, Willcox declares:

It has been said with truth, I think, that the administration of morphine or heroin hypodermically daily for a month is likely to give rise to addiction in a person of normal temperament. We know people who say: "I am a man, and one having a strong will. Morphine or heroin will not affect me; I can take it as long as I like without becoming an addict." I have known people-sometimes medical men-who have made that boast, and without exception they have come to grief.(12)

Dr. J. B. Mattison records instances resulting from too frequent selfexperimentation; commenting on the causes of the frequent addiction among medical men, he states: "Still another genetic 'factor, and in my opinion the one which outranks all others relative to the frequency of this disease in medical men, is their ignorance or unbelief as to the subtle, seductive, snaref ul power of morphia. (13) He adds that physicians do not usually use the drug for pleasure:

"Rather, they are impelled thereto by force of physical conditions that, with the largely prevailing failure to realize the risk incident to incautious morphia using, are practically beyond control.... The subtly ensnaring power of morphia is simply incredible to one who has not had personal observation or experience.... I make bold to say that the man does not live who, under certain conditions, can bear up against it.... Let him not be blinded by an underestimate of the poppy's power to ensnare. Let him not be deluded by an over-confidence in his own strength to resist, for along this line history has repeated itself with sorrowful frequency and, as my experience will well attest, on these two treacherous rocks hundreds of promising lives have gone awreck.(14)

Thus, though the theory advanced in this study makes the reaction to withdrawal symptoms the decisive factor in the establishment of addiction, and although this theory could be destroyed by the selfexperimentation of a single person, if he demonstrated his immunity, no such negative evidence has appeared in the literature of the last century. Those who have been bold or foolhardy enough knowingly to risk the prolonged experimental use of morphine on themselves apparently either have stopped before it was too late, as did Faucher, or have fallen into the ranks of the addicted. New recruits are being enlisted in this manner today. I have often been told by non-addicts with perfect assurance that they would never become addicts, even though they might take morphine or heroin regularly for a long time. Most addicts believed this before they became addicted.

Alexander Lambert, an outstanding authority on addiction, makes the following' assertion:

Morphine given daily for three weeks or longer, in small doses, almost invariably produces that peculiar narcotic necessity which we designate as the narcotic habit. Some patients may resist longer than others; but the average power of resistance is slight.(15)

Charles E. Sceleth, another well-known student of the subject, states that three weeks of regular use of opiates can form the habit in anyone, no matter bow strong his will, and that three months will make it impossible to break the habit unaided.(16), C. C. Wholey likewise affirms:

Unlike the poet, the morphinist may be made, not born such; there need be neither special neuropathologic constitution, nor hereditary taint. . . . The average individual can take alcohol in ordinary doses for long periods and still retain his independence; no individual can do this with morphine. It is not a rare occurrence for some alcoholic of some length of habit to take a brace and the pledge, and remain sober ever after. But after a corresponding period with morphine-a period much less in point of duration-it is almost unheard of that an habitue is able voluntarily to break away from his habit.(17)

Similar statements, common in the literature, would seem to conflict with another well-established finding, namely, that many persons who receive narcotics regularly for long periods of time do not become addicts. These statements apparently imply that addiction is simply the invariable and necessary consequence of the development of tolerance, but the assumption is obviously implicit in them that tolerance and physiological dependence are accompanied by awareness. Otherwise they would be contradicted by an immense body of evidence which proves beyond question that the development of tolerance for morphine in medical practice is, in fact, rarely followed by addiction.(18) If it may be said that statements such as those quoted assume that the prolonged and regular use of morphine inevitably leads to addiction, when accompanied by the addict's full recognition and understanding of his dependence upon the drug, then they clearly accord with the theory that has been advanced.

Marginal Cases

There are, of course, many instances reported of persons who have become mildly physically dependent upon opiates and who have experienced and understood the milder manifestations of withdrawal, as Faucher did, without continuing the use of the drug or perhaps continuing for only a brief period. Since the theory proposes that the constellation of behavior patterns and attitudes that constitute addiction are learned over a period of time from a substantial number of repetitions of the experience that generates these changes, it follows that one or a very small number of repetitions would not be expected to be sufficient to complete the process of establishing addiction. It appears, however, that a very few repetitions or even a single such experience does start the process. Persons who have had brief encounters

with morphine withdrawal in medical practice, for example, develop attitudes toward the drug and toward addiction which are characteristically different from those of persons who have not had such experiences. Common effects of limited exposure to the addicting experience are that the individual loses some of his self-confidence about his capacity to resist the drug, that he becomes apprehensive about possibly becoming addicted, that he reports some degree of understanding of what it is like to be addicted, and that he exercises caution with respect to the regular consumption of a drug.

The above points have been clearly documented by a study,(19) made in Los Angeles by Robert Schasre, of young persons who used heroin for a time but stopped before the full pattern of addiction was established. In nine of the forty instances examined use of heroin had been discontinued, according to the individuals' own statements in interviews, because of fears and apprehensions associated with the fact that they bad used heroin long enough to become physically dependent and bad become somewhat aware of this. The author remarks:

All nine of these cases hastened to point out the fact that they bad only had "little habits they were not "strung out." They emphasized strongly the fact that they had only felt a "little sick." These people had used for at least six months, three of them had used for nine months to a year; all related that they had experienced fear as well as surprise at the realization they were "hooked."

In each of these cases the decision was made to "quit using before it got out of control." In none of these nine cases, apparently, was there immediately recourse to narcotics of any kind to ward off the relatively mild withdrawal distress which ensued. Six of the cases reported getting advice from personally known users or addicts to "quit now." Three of these admonitions had involved the same addicts who were present at the interviews. [All of these persons were interviewed with an addict present.] Interestingly, in three of the other interviews where the ex-users cited physical addiction as the reason for quitting heroin usage, rather heated exchanges were touched off between the non-user and the addict being interviewed.

The addict interviewees in these three cases found it difficult to conceive of. In their opinion, "Once you get a habit-even a little one you've had it! (20)

In medical practice the patient's comprehension of withdrawal distress is frequently blurred by the tendency to confuse it with the symptoms of the disease for which the drug is administered or prescribed. The patient may complain vigorously to his physician about pains which are in part those of withdrawal but neither he nor his doctor may be able to distinguish those connected with the disease from those connected with the drug. In this situation of cognitive confusion the patient often only dimly realizes or suspects that he may be physically dependent on the drug and he may deny it utterly. There has been deplorably little systematic research on such marginal cases, but it appears that many or most of them probably do not end in full fledged addictiona result which is again implied by the theory.

A representative of a drug company told me of a technique used by his company to assist doctors in withdrawing drugs from such marginal patients. It consisted of selling the doctor bottles apparently containing capsules of a drug, with a certain variable percentage of the capsules being placebos, that is, containing none of the drug. Since the placebos could not be externally identified, neither the doctor nor his patient could be sure whether a given administration was of a drug or of a placebo. The doctors, without telling the patient, might, for example, begin the withdrawal process by administering injections from a container in which 10 per cent of the capsules were placebos and progress to others in which the placebos constituted 50 per cent or more. At some point in this process the patient would have matters explained to him and would discover to his surprise that he bad been getting along quite well and would usually be convinced that be did not need the drug and could get along without it. My informant stated that his company bad received many grateful letters from physicians concerning this device.

As has been noted, the realization of addiction is traumatic for most persons, and it can readily be understood that it will be avoided or resisted when this is possible. In most of the previously cited instances of the origin of the habit, the situation of the user was relatively unambiguous and the correct cognitive conclusions concerning it could hardly be escaped. However, when opiates are used in medical practice to relieve pain, the patient sometimes faces an ambiguous situation in which it is possible for him, even though physically dependent on the drug, to cling to his former identity as a nonaddict and to reject identification or self-definition as an addict. This may be accomplished by insisting that the drug is required for medical reasons to relieve pain associated with organic disease, in short, by selfidentification as a medical patient rather than as a junkie.

F. B. Glaser, in a study at Lexington, compared 25 cases of this type with 30 ordinary addicts as controls. The findings indicated concerning those claiming the "medical patient" identity: (1) they had first used narcotics to relieve pain, obtained their supplies primarily from physicians, and had never obtained them from an illicit dealer; (2) none had ever used heroin or marihuana, none preferred the hypodermic method of injection, and it had Dot occurred to most of them; (3) all supported themselves by legal means, and none had ever been arrested for a narcotics offense or ever sold narcotics; and (4) they did not identify themselves with the addict subculture.

Despite the fact that these persons had come to or been sent to the Lexington hospital to have the drug withdrawn, Glaser observes:

Our patients do not, by their acts, identify themselves as addicts.... The patient's frequent remark that 'I'm not like the other patients here' is borne out by the study. But clinical experience indicates that the pain-prone patients do not see themselves as persons with psychological problems either. In their view, their presence in a psychiatric hospital is purely fortuitous. The taking of narcotics was a medical necessity, sanctioned by the authority and wisdom of their physician, and had nothing whatever to do with any emotional difficulties.

Thus, the patient is self-defined neither as a narcotic addict nor as a psychiatric patient. Rather, her identity is that of a medical patient. . . .

To attempt to challenge the patient's identity as a medical patient . . . is invariably to provoke the patient's bitter hostility, something most physicians prefer to avoid .(21)

Other marginal or ambiguous patterns of drug use which range from persons who have tried narcotics and pretend to be addicted when they in fact are not, to true or ordinary addiction, have been identified and described.(22) In all or most of such instances the marginality or ambiguity involved arises from the manner in which the patient interprets or perceives his behavior, the drug, and withdrawal distress. In some instances, it is possible that a physiological eccentricity may cause withdrawal distress to be absent or too slight to be of importance. In others, the marginality clearly seems to be related to the fact that the person does not experience the withdrawal symptoms often enough or in a sufficiently severe form. Medical techniques of withdrawing the drug from a physically dependent patient understandably include the attempt to manage the process in such a way as to minimize distress so that it does not intrude itself on the patient's attention. If such an attempt does not succeed the first time it is attempted, the difficulties increase in subsequent attempts and the probabilities of addiction increase. Repeated unsuccessful cures create an unfavorable prognosis because each of them repeats the conditioning experience with withdrawal distress that impresses the craving for the drug on the user.

Habituation and Addiction during the Nineteenth Century

This point leads to the interesting problem of habituation so prevalent during the nineteenth century and the beginning of the twentieth when opiate-containing patent medicines abounded on the open market. Preparations such as laudanum, McMunn's Elixir of Opium, Godfrey's Cordial, Mother Bailey's Quieting Syrup, Winslow's Soothing Syrup, and Black Drop were widely used. Also, in those days physicians gave opiates liberally, believing that morphine taken hypodermically was not habit forming. (23) As already observed, when heroin was first introduced at the beginning of the twentieth century it was widely hailed as a non-habit-forming substitute for morphine .(24)

In 1888, Virgil G. Eaton examined 10,000 prescriptions from Boston drugstores and found that 1,481 of them contained opiates .(25) Of the prescriptions renewed once, 23 per cent contained opiates; of those renewed twice, 61 per cent; and of those renewed three times, 78 per cent contained opiates. Raising the question as to what percentage of patients progressed to addiction through the initial consumption of opiatecontaining medicines, Eaton says:

It is bard to learn just what proportion of those who began by taking medicine containing opiates became addicted to the habit. I should say, from what I learned, that the number was fully 25 percent-perhaps more. . . . When a person once becomes an opium slave, the habit usually holds for life.(26)

How and why does the change from opiate-containing medicines to morphine, or from innocent habituation to confirmed self-conscious addiction, take place? This transition should have occurred when the user who had become physiologically dependent upon the drug was told, or himself realized, the nature and significance of this dependence; namely, that it was created by withdrawal symptoms induced by consumption of that very same drug.

Fortunately, Eaton gives an excellent illustration of how the transition occurs in the story of an old woman who took opiatecontaining "cough balsam" in order to , quiet her nerves."

One apothecary told me of an old lady who formerly came to him as often as four times a week and purchased a 50 cent bottle of "cough balsam'' . . . He told her one day that he had sold out of the medicine required, and suggested a substitute which was a preparation containing about the same amount of morphine. On trial, the woman found the new mixture answered every purpose of the old. The druggist then told the woman she had acquired the morphine habit, and from that time on she was a constant morphine user (27)

In 1-881, D. W. Nolan observed:

The careless manner in which physicians prescribe opiates, and the prevailing custom among druggists of duplicating prescriptions, are prolific sources of the evil. The physician prescribes morphia for a patient suffering from some painful disease, and relief is obtained. Moreover, the sensations experienced under the influence of the medicine are peculiarly pleasurable. He goes back to the drug store and has the medicine renewed without the physician's advice or direction. He finally learns that it Is morphia he has been taking, purchases a quantity, and finds that by its use be can relieve his pain or waft himself into Elysium at pleasure. Finally, he ascertains that his health is being injured, or is otherwise warned of the danger, and attempts to give up its use. Suddenly his eyes are opened to his folly and he realizes the startling fact that he is in the toils of a serpent as merciless as the boa-constrictor and as relentless as fate. With a firm determination to free himself he discontinues its use. Now his sufferings begin and steadily increase until they become unbearable. The tortures of Dives are his; but unlike the miser, he has only to stretch forth his hand to find oceans with which to satisfy his thirst. That human nature is not often equal to so extraordinary a self-denial affords little cause for astonishment. At length he surrenders, but with bad grace, determined to renew the contest at no distant day under more favorable circumstances; returns to the drug and is again happy-happier than ever in contrast with the misery lately endured-but far from satisfied. He realizes that he is being enslaved and suddenly resolves that it shall not be. Little he reckons that he is enslaved already, or that his late submission has shortened his chain a link. He waits for the favorable opportunity, meantime increasing the quantity imperceptibly but steadily, and, when the effort is repeated, finds himself more firmly bound than before. Again and again be essays release from a bondage so humiliating, but meets with failure only, and -at last submits to his fate-a confirmed opium-eater. The effort made and the misery endured before finally submitting can never be realized by the self -righteous man who arrogantly inquires: Why doesnt he stop it? Is it strange that opium eating is styled by the people of the East the "Sorcery of Majoon" or that superstition attributed the power of the poppy to the influence of an evil spirit? (28)

Old accounts such as this indicate that, although the methods of consumption were oral rather than hypodermic and the manner of exposure was different than at present, the same essential steps were involved. The startled surprise of the beginner at his first experience of withdrawal distress and his realization of its significance are the same; so also is the struggle against the withdrawal symptoms which fixes the habit. The theory that addiction begins with perception of the significance of withdrawal symptoms, and the subsequent use of the drug to relieve or to forestall suffering, explains why some users of opiatecontaining patent medicines became addicts and others did not. It also permits an acceptable explanation of the consequences of the Harrison Act. After passage of this and other restrictive laws, opiate users were eliminated from the legitimate market. Many who were habituated to laudanum and opiate-containing patent medicines undoubtedly discontinued their use, experienced varying degrees of discomfort, and were none the wiser. On the other hand, it is equally certain that some who had the misfortune to know the nature of their ailment continued to use the drug illegally. (29)

Addiction in India

As would be expected, the basic features of drug addiction in India are the same as they are in the United States and in other countries of the world. Sociologists sometimes argue that generalizations about human behavior are necessarily culture-bound, that is, that they can be valid only in a given culture because of the enormous cultural differences that exist in the world. Admittedly and obviously, addiction in India differs in many respects from the contemporary American pattern just as the latter differs from that of nineteenth-century America. If a theory of addiction that applies to twentieth-century America cannot apply to India or to nineteenth century America, then it seems evident that DO genuinely general theory of addiction is possible. The assumption that is made here is the contrary one; namely, that while addiction, like malaria, manifests itself in a variety of superficially different forms in various parts of the world and at different times in the same part of the world, the basic processes that produce it are always the same the world over, as they are in the case of malaria.

Even a superficial reading of the available literature on addiction in other countries creates an overwhelming impression that this is the case. Everywhere the addict shows the same characteristic craving for his drug, and everywhere he does what he must to obtain a supply of it. The power of the habit and the difficulties in breaking it are apparently much the same everywhere. The extensive publications of Chopra and his associates in India demonstrate that this is certainly true in that country. Chopra and Gremal tell of a "curious" case in which an individual regularly drank opiate-containing tea with a friend. When the friend left, this person became miserable even though be continued to drink tea .(30) Chopra and Gremal do not say how be discovered that the tea contained opiates, but this was evidently the case, for be became addicted. This report and others indicate that the role of withdrawal symptoms in causing addiction among Indian users is the same as in the United States. (31)

Modern Medical Precautions

While there can be little question that physicians and druggists were to a great extent responsible for opiate addiction during the nineteenth century, it is agreed that medical practice is responsible for only a few addicts developed today. What are the reasons for this change?

A report of the British Ministry of Health in 1926 furnishes a clue to the answer. It points out that, although psychoneurotics may experience greater initial pleasure from opiates than most normal persons, they can be saved from addiction if the proper precautions are taken in opiate administration.(32) The report emphasizes that when these precautions are not taken, anyone may become an addict. Therefore, two of its chief recommendations are: that the patient be kept in absolute ignorance of the drug being used and that the utilization of the hypodermic needle be avoided. Both precautions have been stressed for a long time, for it was soon appreciated that a patient who was ignorant of the dose, or who bad been deceived about its true contents, could not become an addict. Pertinent is the statement of a physician in 1896:

The danger of physicians creating morphine fiends, it needs hardly be said, is greatly overestimated. Intelligently used, there is little danger of such results. With our highly neurotic temperaments we must, however, exercise more than usual tact, so as not to be deceived into its unnecessary use. It is the general and erroneous impression of the laity that all hypodermic injections are necessarily composed of morphia-it is the only drug that they can associate with them. When one has a patient wherein the protracted and regular hypodermic use of morphia may be required for a length of time, it would be well if an occasional hypodermic of strychnia were given, with particular care that some of the family, or the patient, should pick up that vial and read the label . . . It is a mistake to tell the patient that you are using morphia ... Diminish the dose, or substitute something else with the dosage as you gradually diminish the morphia. Do not make a consultant of your patient in these matters. (33)

Dr. Paul Wolff, an eminent German student of addiction, comments appropriately:

In my opinion a further great advance would be made if morphine, etc., were replaced as far as possible by the use of suppositories. Not only do these produce the same qualitative and quantitative effects, but also the patient is not immediately aware that he has received morphine. In many cases where medical treatment is the origin of addiction, numerous mental associations would be avoided in the absence of the symbol of the syringe. (34)

It can be seen that the "mental associations" referred to are connected with the patient's previous knowledge of stereotypes concerning drug addiction. When these associations are made he becomes attentive to certain effects and expects them. The same effects under different conditions might have elicited no response, but when understood they place him in the dangerous position of understanding the reasons for whatever distress be may experience when the drug is removed.

These two devices-avoiding the syringe and keeping the patient in ignorance-as well as other precautions such as mixing the opiate with less pleasant drugs, changing methods of administration, using sterile hypodermics, disguising the opiate in medicine, misinforming the patient, and gradually reducing the dosage when it is desirable to eliminate further use, all serve the same end. By preventing the patient from gaining a clear conception of the significance of his sensations and keeping him from associating what be knows or thinks be knows about drug addiction with his post-injection feelings, addiction is avoided. When a patient has been completely and successfully deceived and is completely in the dark concerning his withdrawal distress and the drug that produces it, he cannot, in the nature of the case, consciously desire opiates as a means of relief. What be ordinarily does instead of this is to attribute his discomfort to the disease from which he is suffering, or in some instances, to the aftereffects of surgery.

Experimental- Type Evidence

The methodological assumptions of the present study are those that form the logical foundations of the experimental method, and the theory proposed clearly suggests experimental operations, which, if they could be performed with human subjects, would directly verify or falsify it. This fact has been observed by experimental psychologists who have reformulated the theory in terms of positive and negative reinforcement and subjected it to experimental test with lower animals. I shall describe this experimentation in the following section and shall be concerned here with occurrences which, although they happen spontaneously without experimental intervention, are of precisely the same type and seem to carry the same weight as if they were actual experiments.

When the fundamental theoretical propositions of this study had been developed to an appropriate point, it occurred to me that it should be possible to find instances in which persons who had become physically dependent on opiates and escaped addiction had, in a later and separate episode again become physically dependent and also addicted. It was inferred in advance of the examination of any such instances that, after the second episode in which addiction was established, the person would retrospectively report that he had not recognized withdrawal distress during the first episode. Such instances seemed to provide the possibility of something very like a crucial test of the proposed theory. Since the same individual would be involved in both episodes, it would be logically unsound to attribute the addiction following the second to defects of personality structure which are often cited as explanations of addiction. It was also anticipated that any single instance of this type which clearly contradicted the deductive implications of the theory would carry sufficient weight to invalidate or cast serious doubt on the whole theory. However, this contingency did not arise, because all of the instances of this type which I was later able to find were in striking conformity with the deductive predictions implicit in the theory.

One instance of this type, Case 3 in Chapter 4, has already been described. It involved a physician who became physically dependent upon morphine during a serious illness that involved repeated surgery and a fairly long period of hospitalization. The drug was successfully withdrawn, and the doctor resumed his normal life for a period of several years. A subsequent attack of gallstones again led to the regular use of morphine, and this time resulted in addiction. During this second episode, this physician reported that he realized in retrospect that he had also suffered withdrawal symptoms during the first episode but without recognizing them. He had been hooked, he said, without knowing it. Four other instances of same kind were uncovered, three of them in the literature. The fourth was an addict whom I interviewed and whose story followed the pattern of the case of the doctor cited above.

Erwin Straus tells of a German woman who was given a morphine injection twice daily for Six Months (February-July, 1907) because of gallstones. (35) In July she was operated upon, and during her ensuing convalescence the drug was successfully removed. Nine years later, at the age of 49, she lost her only son in World War I and was prostrated by grief After weeks of anguish and thoughts of suicide, she happened to recall that she had once benefited from morphine. She then purchased some in a drugstore and began to use it. In a short time she became addicted. When asked by the physician if she had experienced withdrawal symptoms in 1907, when the drug had been withdrawn, she replied that she did not recall any. I had not anticipated this particular response but I should have. It corroborates the theoretical position even more strikingly than the others by indicating that the memory of withdrawal distress, and of events in general, is strongly affected by the manner in which they are perceived and by the significance attached to them. The addict, for example, generally has a clear, even vivid recollection of his first experiences with the abstinence syndrome, which he realizes marks a dramatic turning point in his life.

Another instance of the same general type is briefly summarized by Dansauer and Rieth, (36) and another was found in documents collected by Dr. Bingham Dai which I was permitted to examine. While instances of this kind are understandably rare, the fact that all that could be found conformed closely to theoretical expectations gives considerable additional weight to the theory. There is, moreover, no other current theory that is applicable to such instances.

Recent Experiments with Lower Animals

When I first published a fully developed account of my theoretical position on opiate addiction in 1947, very little experimental work of any direct relevance to the analysis and interpretation of human responses to opiates as manifested by the addict had been done with lower animals. 1 noted at that time in the process of defining the basic characteristics of addiction behavior that this behavior was not found in the lower animals and could not be induced in them because it presupposes the higher cortical functions associated with language behavior and found only in man. While this conclusion still seems generally valid, some qualification of it is now necessary in order to take account of subsequent experimental work with animal subjects.

The work of J. R. Nichols is of special relevance in this connection. He began his work by taking my theory as his point of departure and reformulating it in the terms of reinforcement theory and concepts as developed in B. F. Skinner's theories of operant conditioning. He then developed ingenious experimental techniques designed to test the idea that the book in morphine, for animals as well as men, comes from using the drug to alleviate withdrawal distress rather than from positive euphoric effects.

In one of Nichols' experiments rats were first given morphine injections over a considerable period of time so as to establish physical dependence. Using some of these rats as his experimental group and the others as controls, Nichols then subjected the experimental group to "training sessions" which involved depriving them of morphine and all fluids for 24 hours. For the next 24 hours they were given nothing to drink but a bitter morphine solution which rats ordinarily dislike and reject. Since the rats during the second day of the training period were suffering both from thirst and from drug withdrawal, drinking the bitter morphine solution simultaneously relieved both the thirst and the withdrawal. After a number of repetitions of such training periods the morphine was withdrawn and, after 14 and 49 days when the withdrawal symptoms were largely gone, the rats were offered the alternatives of drinking either plain water or the morphine solution in any quantity. Nichols found that the rats that had learned to drink the morphine solution in connection with withdrawal now spontaneously drank much more of the bitter morphine solution and that some of them drank enough to reestablish physical dependence. The control animals, on the other hand, in this and other similar experiments, showed no similar interest in the drug, even though they had in some instances received much more of it than had the experimental animals .(37) The controls were not subjected to the two-day training periods but received the drug continuously.

While the control devices used by Nichols and others who have made similar experiments cannot be adequately described here, it is relevant to note that Nichols' conclusion that the attachment to morphine which he succeeded in inducing in rats (which he called "sustained opiate directed behavior") depended upon negative reinforcement involved in the relief of withdrawal distress and not upon the positive effects of the drug has been accepted and corroborated by a number of other investigators who have performed similar experiments on the same issue. Among the latter are Abraham Wikler, J. R. Weeks, and H. D. Beach.(38) Other aspects of Nichols' conclusions, such as those connected with his attempt to interpret his findings and the phenomena of addiction generally in terms of operant conditioning, are more dubious and debatable and will be considered in a subsequent chapter. While my statement of 1947 that relapse behavior had never been induced in lower animals and probably could not be, has been shown to be incorrect, and while the gap between animal and human responses to opiates has been narrowed by experimental work of the type described, it still appears unwarranted to argue that the behavior of rats and Monkeys in response to opiates in these experimental situations is essentially identical with the behavior of human addicts or that it is justifiable to call these animals addicts. A conclusion of this sort appears untenable both because it is inconsistent with existing knowledge of the differences between men and animals and also because the necessary point-by-point empirical comparison between the behavior of human addicts and their animal counterparts has not yet been made.

Summary

In this chapter, the theory outlined in earlier chapters has been further elaborated and evidence that tests its consistency, validity, and applicability to the data of addiction behavior has been presented. It was noted that the theory is indirectly confirmed in the addict's argot and directly supported by evidence which indicates that persons who knowingly experiment with severe withdrawal distress invariably become addicts while those who experience it without understanding it do not. Persons who have Only very brief encounters with this distress of withdrawal or whose understanding of it is incomplete or blurred, although they may not become addicted, manifest some of the initial changes in behavior and attitude which characterize the beginning of the fixation of the habit The practice of preventing addiction in patients, even when they appear to be addiction-prone, by keeping them in ignorance of the drug and its effects, fits neatly into the proposed analytical scheme. Finally, the theory is directly and strikingly confirmed by the instances in which persons become physically dependent on the drug on one occasion without becoming addicted and subsequently become addicted. It is also confirmed somewhat indirectly by a considerable number of experiments with lower animals which suggest that whatever book opiates have for animals is derived from the alleviation of withdrawal distress and not from the positive effects of the drug.