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Addiction and Opiates

Addiction and Opiates

CHAPTER 3 HABITUATION

CHAPTER 3 HABITUATION AND ADDICTION withdrawn. Craving for the drug and dependence upon it drive the user almost irresistibly to any lengths to obtain a supply. A writer, himself an addict, states that he knew of two suicides resulting from failure to secure drugs: "The awful mystery of death, which they rashly solved, had no terrors for them equal to a life without opium, and the morning found them hanging in their cells glad to get 'anywhere, anywhere out of the world."' The same writer describes a Chinese addict whom be saw "tear his hair, dig his nails into his flesh, and with a ghastly look of despair, and face from which all hope had fled and which looked like a bit of shriveled yellow parchment, implore for it [opium] as if for more than life."(13) The addict, of necessity, organizes his entire life around his need for the drug. This preoccupation with the narcotic and slavish dependence upon it are incomprehensible both to the patient who is only habituated and to the neophyte. As Calkins observed, "Opium, an equivocal luxury in the beginning, daintily approached, becomes ere long under the demands of perverted appetite a dire alternative, a magisterially controlling power."(14) The hospital patient who every four hours is given an injection, the nature of which he does not know and concerning which he does not trouble himself, clearly cannot be compared with the addict who is eager to sacrifice anything to obtain the same substance. The addict, if awake, is usually keenly aware of the fact that a shot buoys him up, and he knows precisely when he must have another. He proceeds to regulate his activities almost exclusively in terms of this drive. He takes a shot when be goes to bed. Upon awakening, his first thought is of the drug, and his first act, sometimes even before be gets out of bed, is to take his morning dose. Should be awaken during the night, the thought of a shot tempts him, and if he lies awake for any length of time he is likely to yield to the desire. In other words, the addict is dependent upon the drug during every conscious moment. The thought of the drug constantly sustains him. By contrast, the patient who is only habituated reveals a different mode of behavior. A physician told the writer of the following incident: A woman went to a quack doctor with a stomach complaint. He gave her medicine which helped her, but in the course of time she noticed that whenever she stopped taking the medicine for a time her stomach trouble came back. Wishing to be really cured of her disease, she decided to consult another doctor. She realized that the prescription was helping her, but was troubled by the fact that (as it seemed to her) the medicine had only repressed her ailment without eliminating it. The new doctor found that the medicine contained opiates and that there was nothing whatever wrong with her except that she had become habituated to the drug. This case is a prototype of habituation associated with physical disease, the drug being used because of actual pain associated with the disease. The important factor is obviously the patient's belief. It will be shown later that as long as a patient believes he is using the drug solely to relieve pain, and regards it as a "medicine," be does not become an addict. When the pain or disease vanishes the drug may be removed without danger of relapse. The patient's sense of dependence on drugs in the above case was clearly different from that of the addict; her preoccupation was with a disease rather than with the effects of opiates, which she recognized only vaguely. When she swallowed her medicine, the disease seemed to be abated. In the same way, a person who has a headache and takes an aspirin knows only that his headache is gone and that a hindrance to normality has been eliminated. He does not believe that normality is dependent upon the drug. This type of opiate use has frequently been termed "innocent" addiction, and-in contrast with the exceedingly pessimistic prognosis for genuine addiction-it is usually permanently cured following withdrawal of the drug, provided the disease does not recur. T. D. Crothers, a prominent American authority, distinguishes these two types in the following manner: Where morphine has been used ignorantly, or from a physician's prescription for the relief of some temporary pain, the permanent cure of the case may generally be expected to follow its withdrawal. ... In cases where the patient has bad a long preliminary occasional use of the drug, and then a period of protracted use until immunity to very large doses has been established, the withdrawal is always difficult, and the permanence of any cure is somewhat doubtful.(15) Discussing the possibility of a cure for addiction, Lawrence Kolb expresses the belief that there are thousands of cured addicts in the country (though the word "cure" evidently refers here to addicts who are merely off the drug). He says: "If we class as former addicts all those persons who after several weeks of opiate medication suffered for a few days with mild withdrawal such as restlessness, insomnia, and overactivity of certain glandular functions-the number of file:///I|/drugtext/local/library/books/adopiates/chapter3.htm[24-8-2010 14:23:34]

CHAPTER 3 HABITUATION AND ADDICTION cured addicts must exceed those who remain uncured."(16) Another important respect in which habituation usually differs from genuine addiction is in the size of the dose and in its progressive increase. Physiological reasons for increasing the dosage are well established. For example, when morphine is administered over a period of months to a patient with incurable cancer, the dose is necessarily increased, but rarely, if ever, in the proportions that the addict finds necessary. The latter is so powerfully impelled to increase the dosage that be often regards an excess as essential and finds it virtually impossible to reduce it voluntarily. In therapeutic treatment, even in cases of protracted illness and pain, a daily dose of 3 or 4 grains is regarded as an extraordinary amount. The addict who has a large supply available to him regards 3 or 4 grains of morphine a day, taken in "skin shots" or orally, as a small allotment. The difference between the addict's dosage and that of the patient in the condition of habituation is effectively demonstrated by data collected by Kurt Pohlisch in an attempt to determine the approximate number of drug addicts in Germany. (17) These data were taken largely from druggists' prescription blanks, and Pohlisch was therefore compelled to define addiction purely in terms of the size of the doses and the length of time during which they were taken. He was familiar with the distinctions made by Levinstein, Erlenmeyer, and others between "habituation" and "addiction," and be recognized the validity of this distinction; nevertheless, he was forced by the nature of his data to take these things into account only as they could be translated into amounts used per day. Therefore, he established the minimum dosage as 1.5 grains per day but admitted that his figure classified too many as addicts.(18) If one were to use the concept of addiction (Morphinismus) generally employed in German clinics, the limit might have been placed, he said, at 4.5 grains per day. By using a very low limit be corrected unavoidable errors in the other direction. When his cases are distributed according to dosage, they fall into a frequency pattern which does not at all correspond to expectations concerning addicts.(19) It will be noted that the number of patients using less than 3 grains per day is very large, about 65 per cent of the total, and that the number in each classification becomes progressively larger as one approaches the smaller doses. This, of course, contradicts general experience with addicts. Kolb found in a study of 119 cases of addiction that the average dose was 7.66 grains per day.(20) His subjects were medical cases, that is, persons who bad become addicted in medical practice, and were not of the underworld. Since the majority obtained their supplies from legitimate sources, the average dosage reported by Kolb is therefore more reliable than figures derived from the testimony of underworld file:///I|/drugtext/local/library/books/adopiates/chapter3.htm[24-8-2010 14:23:34]

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