CHAPTER 5 PROCESSES IN ADDICTION file:///I|/drugtext/local/library/books/adopiates/chapter5.htm[24-8-2010 14:23:36] 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.
CHAPTER 5 PROCESSES IN ADDICTION 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 nonhabit-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. file:///I|/drugtext/local/library/books/adopiates/chapter5.htm[24-8-2010 14:23:36]