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Addiction and Opiates

Addiction and Opiates


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

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

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