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Addiction and Opiates

Addiction and Opiates


CHAPTER 3 HABITUATION AND ADDICTION with others who have had the experience and a communication barrier between him and those who have not bad it. It is in this sense that addiction may be called incurable. In contrast to the voluntary abstainer, the user whose habit is interrupted by a prison sentence is obviously in a very different category and is usually simply called an addict and regards himself as such. The imprisoned addict commonly connives and schemes to smuggle drugs into the prison and makes his keepers acutely aware that he is different from the other inmates. To a warden of a penitentiary it would seem absurd to argue that an addict ceases to be that whenever he is off drugs. Hence, in this discussion I shall simply use the term "addict" to refer to anyone who has been booked. Relapse Rates There are few reliable general statistics on relapse among American drug addicts, and estimates can be made only by indirect means. A careful study of about 8oo German addicts led to the following findings: 81.6 per cent of the cures were followed by relapse within a year, 93.9 per cent within three years, and 96.7 per cent within five years. It seems probable that the relapse rate among American addicts may be even higher because of the predisposing circumstances in which "cured" American addicts usually find themselves. Moreover, relapse can take place after more than five years of abstention, so that even the remaining 3.3 per cent noted above could scarcely be regarded as cured, in the sense that the impulse to replapse bad been permanently eradicated. On the other hand, it should be observed that some of the addicts who relapsed soon after being withdrawn may well have quit again before the end of the five years. Had the authors determined how many of the 8oo were not using drugs at the end of the five-year interval the percentage would have been substantially higher than 3.3 per cent and the picture would have seemed more hopeful.(5) Because of the addict's propensity to resume his habit it is argued that progress in breaking the habit should be measured in terms of man-hours or days off drugs, rather than simply by whether relapse does or does not occur. The apparently higher rate of abstention among older addicts may mean that older users abstain more often or for longer periods than do the younger ones. In a review of eleven studies of relapse among American addicts O'Donnell notes that the reported relapse rates varied from a low of 8 per cent over a five-year interval to a high of about go per cent over an interval of from one to 4.5 years. He notes that most of the studies focus on whether relapse occurred and do not provide information concerning the actual percentages of the time interval during which the addicts were not using drugs. When the problem is posed in this way, O'Donnell observes that the prospects appear more hopeful and that there appears to be a tendency for older addicts to abstain more on the average than is the case with younger ones. Relapse rates also are related to the addict's status during the period of study. For example, if he is on parole and threatened with reincarceration if he relapses, relapse is likely to be inhibited. The lowest relapse rate of only 8 per cent over a five-year period was secured with physicians who were assured of losing their licenses to practice medicine if they relapsed. Virtually all of the 8 per cent who did relapse under these circumstances committed suicide.(6) Whatever the relapse rates may be for various categories of addicts, it is agreed by all who have studied them in any part of the world that relapse rates are high and that the impulse to relapse is probably permanent and ineradicable. Periodically in the past, special techniques of curing addicts have been announced with claims of an extraordinarily high percentage of cures. In no known instance have such cures turned out to be of any special significance. In some instances they were simply frauds; in others the apparent success hinged upon the brevity of the follow-up period or upon careless methods of determining whether the cured patient was actually off drugs. Clearly the word "cure" may be used in a variety of senses. It is sometimes used merely to indicate that the addict has been taken off drugs. It may also be used to indicate voluntary abstention for periods of time varying from a few weeks or months to five or more years, and it may be used to refer to the elimination of the desire or temptation to relapse. If any addict who abstains voluntarily for a period of several weeks is said to be cured, then one can say of most long term users that they have been cured many times. If, on the other hand, one reserves the term for those in whom the desire for drugs has been permanently eradicated, it is doubtful if there are any cured addicts. The practical problem of controlling addiction, of course, is to promote abstention whenever this is possible. Theoretical interest is more focused on the nature and origin of the craving for drugs than on attempting to understand file:///I|/drugtext/local/library/books/adopiates/chapter3.htm[24-8-2010 14:23:34]

CHAPTER 3 HABITUATION AND ADDICTION and explain the peculiar persistence of this craving when the drug has been removed. Similar problems exist with respect to smoking, alcohol addiction, and other habits which are periodically renounced and easily resumed. Habituation and Addiction Compared Mere drug use without addiction, which we designate here as habituation, does not involve the tendency to relapse which is so Characteristic of the addict. Patients who use or take morphine to the point of physical dependence do not, as has been indicated, necessarily become addicted. When they do not, the discontinuance of the drug does not predispose them to resume its use unless, of course, the pain or disease for which it was being used recurs. The contrast may best be brought out by the consideration of a number of cases of habituation, keeping in mind the behavior of the addict in similar circumstances. Dansauer and Rieth report the case, for example, of a patient who was given an opiate regularly from 1922 to 1927; when the drug was withdrawn the patient was weak and unable to work for seven months, after which he resumed his activities. These investigators do not classify this man as a genuine addict. Similar cases are reported elsewhere in the same treatise .(7) In all instances, the drug had been used daily for several years, yet the conclusion was that since these patients showed none of the craving typical of addicts they could not be considered addicts. The outstanding characteristics of these cases are that the use of the drug was related to painful and chronic disease and that upon withdrawal the patient had no desire for the drug, nor did he resort to it except when the disease recurred. Then, too, drug craving as expressed verbally and as manifested in the devices and chicanery employed by addicts to obtain narcotics was absent. These cases are no more distinctive or unusual than hospital patients to whom other types of medicine have been given with good results.(8) The work of Dansauer and Rieth has been emphasized here because of the long period of time during which opiates were administered to their subjects (in some instances for more than ten years) without inducing a state of addiction. Although the time factor involved in similar cases known to me was less crucial, the situation on the whole was essentially the same. For example, a patient who bad received the drug for two months suffered considerable distress when it was withdrawn, without knowing the reason until the nurse later explained it. When he heard that I was studying drug addiction, be expressed amazement that one could become addicted to morphine. He bad felt absolutely Do desire for it when the morphine treatment was suspended. All the cases of habituation interviewed in the present study conform to this pattern. In summary, then, there are two principal aspects of addiction which distinguish it from non-addiction and from habituation. First, the addict desires the drug continuously, intensely, and consciously. Second, this craving, once established, becomes independent of the physiological conditions of tolerance and physical dependence, and predisposes the individual to return to the drug even after a lapse of years. The chronic user in prison, for example, often looks forward eagerly to his release and upon his discharge usually loses little time in securing an injection. He learns in advance exactly where to go to get his shot in the briefest possible time. The desire for the drug in such cases has become an independent psychological complex. (9) There is still another difference between the addict and the individual who for a time is merely the passive recipient of the drug. The former, while under the influence of the drug, is constantly aware of his dependence on it, and attributes his state of mind to its effects.(10) The latter, on the other hand, receiving the drug unknowingly in connection with illness, cannot analyze its precise effects, even though he is under its influence and dependent upon it physiologically. In describing a cancer patient habituated to morphine, Bernhard Legewie reports that the drug obviously stimulated the sufferer and made him feel better. However, the patient failed to associate the beneficial effects with the injection, so that instead of desiring the drug he came to dislike it. According to Legewie, "the lack of desire for the drug in our patient was striking.(11) This attitude may be contrasted with that of the typical addict, whose point of view was well expressed by J. C. Layard, himself an addict. After a period of abstinence, be resumed taking the drug, and reported: "I now liked to work, the harder and the more of it, the better. The morphine has such a bracing and tonic effect! I felt when I walked as though I bad a man on each side of me, supporting me. (12) Dependence upon morphine or other opiates in the case of addicts is particularly emphasized when the drug is file:///I|/drugtext/local/library/books/adopiates/chapter3.htm[24-8-2010 14:23:34]

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