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Addiction and Opiates

Addiction and Opiates


CHAPTER 3 HABITUATION AND ADDICTION file:///I|/drugtext/local/library/books/adopiates/chapter3.htm[24-8-2010 14:23:34] PART I The Nature of the Opiate Habit CHAPTER 3 HABITUATION AND ADDICTION Not all persons receiving opiates regularly for long periods of time become addicted. Edouard Levinstein, a prominent nineteenth century German authority, designated persons who were not addicted, but who were receiving the drug, as "morphinists," and applied the term "Morphiumsuchtiger" (morphine addict) to those who were addicted. French students made the same distinction. In this country, also, there have been attempts to introduce separate terms for the two conditions.(1) Patients who receive therapeutic doses of opiates for a period of time without becoming addicted do not, however, constitute a homogeneous group requiring separate conceptual consideration. There is no generally accepted term to differentiate the two conditions, and yet they need to be examined separately. One condition involves pharmacological tolerance and withdrawal distress upon removal of the drug, without the usual manifestations of intense desire that occur in addiction, the other concerns, in addition to these two symptoms, intense and persistent desire. That morphine or some other opiate may be given to a patient over a long period of time without creating an independent craving is confirmed by many scientific reports. In a study of morphine use among ex-soldiers, Friedrich Dansauer and Adolf Rieth found many had been using the drug regularly for years, sometimes more than five, but were, nevertheless, not addicted. These users are designated as the "symptomatic type," and are not classified with true addicts, who are called "the idiopathic type." Classifying 240 of their cases in the former category, the authors give representative summaries of about 20. (2) In the more recent literature, the distinction with which we are here concerned has been made by differentiating between drug users and drug addicts. Chein and his associates, for example, remark: It was not until this book was well under way that it dawned on us that even a person with a history of drug use and physiological dependence on the drug might conceivably not be an addict. Such a person might be lacking in what we now regard as an indispensable characteristic of a true addict-craving, that is, a powerful 1 desire for the drug independent of the-degree to which the drug has insinuated itself into the physiological workings of his body.(3) In the discussion that follows, the term "habituation" will be used to refer to the state of the person who is physically dependent on the drug but not addicted to it. The term "addiction" will be reserved for those individuals who have the characteristic craving, whether it be in the form in which it is manifested during regular use or as it exists in the abstaining addict impelling him to resume use. An unconscious patient or one who is given morphine regularly by attendant nurses without his knowing it could thus be described as habituated but obviously not as addicted. Terminological confusion has been increased in the current literature by the introduction of a variety of new terms and redefinitions of old ones. "Habituation" is, for example, sometimes taken to refer to the regular use of a drug like marihuana which does not produce physical dependence as the opiates do. It has been suggested that, because there is ambiguity in the meaning of the terms "addict" and "addiction," the awkward and even more ambiguous terms, "drug abuse" and "drug abuser" be substituted for them. Some writers refer to "opiate-directed behavior" or to "sustained opiate-directed behavior," rather than to "drug use" and "drug addiction." A standardized terminology would be highly desirable, of course, but is not likely to be adopted. Confusion can be avoided only by paying attention to the substantive distinctions rather than to the terminology in which they are expressed. Characteristics of Addiction Behavior In any inquiry the subject matter to be investigated must be defined and described as exactly as possible. This description is usually found at or near the beginning of the study even though the definition itself is to a large extent the result of the research. The distinction between habituation and addiction must be made by describing and enumerating those characteristics of the behavior of addicts which are unique and common and which do not occur

CHAPTER 3 HABITUATION AND ADDICTION among non-addicts. It is particularly necessary that a definition of addiction take into account the similarities and differences between habituation and addiction and sharply differentiate between them. As already indicated, the most obvious characteristic of, the addict's behavior is his intense desire and striving for the drug. This desire is not casual or vague but is a powerful conscious motive driving him to seek satisfaction in the face of almost insuperable obstacles and at the cost of unbelievable sacrifices. A universal aspect of the behavior of addicts is that they permit little or nothing to stand between them and the drug. It would be ridiculous to speak of an addict who wanted drugs but was un aware of the need around which virtually all of his behavior was organized. Another characteristic of the addict, and one that is as universal as the first, is his tendency toward relapse. Once addiction is confirmed, the craving acquires an -independent status; the desire persists even after the original physiological conditions have disappeared. In other words, when the addict's supply is cut off and he has been treated for withdrawal symptoms, he may be restored to apparent health, but he still tends to relapse. Were it not for this, addiction would obviously be no great social problem. It would only be necessary to separate the addict from his source of supply and then release him. Yet, in the vast majority of cases, the cured addict apparently returns to his old habit. There is a belief prevalent among addicts that it is a misnomer to speak of a cure for addiction. They remark, "Once a junkie always a junkie." They admit that now and then an addict may refrain absolutely from using the drug for years, even though it is available, and that others do not use it for long periods of time simply because, either as a result of incarceration or for other reasons, they cannot get it. These cases are not regarded as cures, however, for the habitue knows only too well from bitter personal experience that the so-called cured case is merely one in which the regular use of the drug has been temporarily discontinued. The number of cases accessible for study in which an individual has voluntarily abstained from the narcotic for a period of years is small. Most of the addicts whom I interviewed said that they either knew of no users who bad voluntarily refrained from using drugs for more than five years or that they knew of one, two, or a few who bad. All believed that the impulse to relapse was permanent and ineradicable. Some argued that even those few addicts who manage to abstain for long periods could probably be induced to relapse by skillful propaganda over a day or two. Relapses have been known to occur after more than ten years of abstinence. These expressions of opinion by drug users must be discounted to some extent to allow for the addict's rationalizations. The self help organization known as Synanon is made up of former users, and many of them have abstained from drugs for considerable periods. There is also some indication that with advancing age the user's periods of abstention become longer and that some may quit permanently. In a study of former residents of Kentucky who had been at the Lexington Hospital for addicts it was found that more than half were not using drugs when they were interviewed. This fact was determined by analysis of a urine specimen from each of them. Many of these abstainers succeeded in staying off by moving to small localities where there was no illicit traffic and where they knew of no other users .(4) Such abstainers obviously would not be known to active urban addicts All the evidence suggests that the relapse rates for those addicts who go from institutions to the metropolitan centers where addiction is concentrated are much higher than those reported in the Kentucky study. While there are undoubtedly some drug addicts who voluntarily and permanently renounce their habits, the matter of eradicating the impulse to relapse poses another and different issue. The same one arises with respect to alcoholics, of whom it is said that they cannot become casual or social drinkers no matter how long they abstain. Similarly, once an individual has been booked on opiates his attitudes toward the drug are permanently changed and resumption of the habit after long periods of abstinence is easy. The temporarily abstaining addict is a familiar figure to other addicts, who have themselves usually tried unsuccessfully to break their habits. The users are all too well aware of the boredom of non-use, and they know the rationalizations that the unhappy cured addict uses to seduce himself into a resumption of his habit. Such abstainers are not viewed as "squares" or non addicts, but simply as addicts who happen at the moment to be off drugs. The abstainer himself, like the reformed alcoholic who joins Alcoholics Anonymous, thinks of himself, not as a "non addict" but as an "ex-addict." Having joined the fraternity of those who have been booked, be feels a continuing bond that unites him file:///I|/drugtext/local/library/books/adopiates/chapter3.htm[24-8-2010 14:23:34]

Opioid Addiction