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Addiction and Opiates

Addiction and Opiates


CHAPTER 5 PROCESSES IN ADDICTION purely fortuitous. The taking of narcotics was a medical necessity, sanctioned by the authority and wisdom of their physician, and had nothing whatever to do with any emotional difficulties. Thus, the patient is self-defined neither as a narcotic addict nor as a psychiatric patient. Rather, her identity is that of a medical patient. . . . To attempt to challenge the patient's identity as a medical patient . . . is invariably to provoke the patient's bitter hostility, something most physicians prefer to avoid .(21) Other marginal or ambiguous patterns of drug use which range from persons who have tried narcotics and pretend to be addicted when they in fact are not, to true or ordinary addiction, have been identified and described.(22) In all or most of such instances the marginality or ambiguity involved arises from the manner in which the patient interprets or perceives his behavior, the drug, and withdrawal distress. In some instances, it is possible that a physiological eccentricity may cause withdrawal distress to be absent or too slight to be of importance. In others, the marginality clearly seems to be related to the fact that the person does not experience the withdrawal symptoms often enough or in a sufficiently severe form. Medical techniques of withdrawing the drug from a physically dependent patient understandably include the attempt to manage the process in such a way as to minimize distress so that it does not intrude itself on the patient's attention. If such an attempt does not succeed the first time it is attempted, the difficulties increase in subsequent attempts and the probabilities of addiction increase. Repeated unsuccessful cures create an unfavorable prognosis because each of them repeats the conditioning experience with withdrawal distress that impresses the craving for the drug on the user. Habituation and Addiction during the Nineteenth Century This point leads to the interesting problem of habituation so prevalent during the nineteenth century and the beginning of the twentieth when opiate-containing patent medicines abounded on the open market. Preparations such as laudanum, McMunn's Elixir of Opium, Godfrey's Cordial, Mother Bailey's Quieting Syrup, Winslow's Soothing Syrup, and Black Drop were widely used. Also, in those days physicians gave opiates liberally, believing that morphine taken hypodermically was not habit forming. (23) As already observed, when heroin was first introduced at the beginning of the twentieth century it was widely hailed as a non-habit-forming substitute for morphine .(24) In 1888, Virgil G. Eaton examined 10,000 prescriptions from Boston drugstores and found that 1,481 of them contained opiates .(25) Of the prescriptions renewed once, 23 per cent contained opiates; of those renewed twice, 61 per cent; and of those renewed three times, 78 per cent contained opiates. Raising the question as to what percentage of patients progressed to addiction through the initial consumption of opiatecontaining medicines, Eaton says: It is bard to learn just what proportion of those who began by taking medicine containing opiates became addicted to the habit. I should say, from what I learned, that the number was fully 25 percent-perhaps more. . . . When a person once becomes an opium slave, the habit usually holds for life.(26) How and why does the change from opiate-containing medicines to morphine, or from innocent habituation to confirmed self-conscious addiction, take place? This transition should have occurred when the user who had become physiologically dependent upon the drug was told, or himself realized, the nature and significance of this dependence; namely, that it was created by withdrawal symptoms induced by consumption of that very same drug. Fortunately, Eaton gives an excellent illustration of how the transition occurs in the story of an old woman who took opiatecontaining "cough balsam" in order to , quiet her nerves." One apothecary told me of an old lady who formerly came to him as often as four times a week and purchased a 50 cent bottle of "cough balsam'' . . . He told her one day that he had sold out of the medicine required, and suggested a substitute which was a preparation containing about the same amount of morphine. On trial, the woman found the new mixture answered every purpose of the old. The druggist then told the woman she had acquired the morphine habit, and from that time on she was a constant morphine user (27) file:///I|/drugtext/local/library/books/adopiates/chapter5.htm[24-8-2010 14:23:36]

CHAPTER 5 PROCESSES IN ADDICTION In 1-881, D. W. Nolan observed: The careless manner in which physicians prescribe opiates, and the prevailing custom among druggists of duplicating prescriptions, are prolific sources of the evil. The physician prescribes morphia for a patient suffering from some painful disease, and relief is obtained. Moreover, the sensations experienced under the influence of the medicine are peculiarly pleasurable. He goes back to the drug store and has the medicine renewed without the physician's advice or direction. He finally learns that it Is morphia he has been taking, purchases a quantity, and finds that by its use be can relieve his pain or waft himself into Elysium at pleasure. Finally, he ascertains that his health is being injured, or is otherwise warned of the danger, and attempts to give up its use. Suddenly his eyes are opened to his folly and he realizes the startling fact that he is in the toils of a serpent as merciless as the boa-constrictor and as relentless as fate. With a firm determination to free himself he discontinues its use. Now his sufferings begin and steadily increase until they become unbearable. The tortures of Dives are his; but unlike the miser, he has only to stretch forth his hand to find oceans with which to satisfy his thirst. That human nature is not often equal to so extraordinary a self-denial affords little cause for astonishment. At length he surrenders, but with bad grace, determined to renew the contest at no distant day under more favorable circumstances; returns to the drug and is again happy-happier than ever in contrast with the misery lately endured-but far from satisfied. He realizes that he is being enslaved and suddenly resolves that it shall not be. Little he reckons that he is enslaved already, or that his late submission has shortened his chain a link. He waits for the favorable opportunity, meantime increasing the quantity imperceptibly but steadily, and, when the effort is repeated, finds himself more firmly bound than before. Again and again be essays release from a bondage so humiliating, but meets with failure only, and -at last submits to his fate-a confirmed opium-eater. The effort made and the misery endured before finally submitting can never be realized by the self -righteous man who arrogantly inquires: Why doesnt he stop it? Is it strange that opium eating is styled by the people of the East the "Sorcery of Majoon" or that superstition attributed the power of the poppy to the influence of an evil spirit? (28) Old accounts such as this indicate that, although the methods of consumption were oral rather than hypodermic and the manner of exposure was different than at present, the same essential steps were involved. The startled surprise of the beginner at his first experience of withdrawal distress and his realization of its significance are the same; so also is the struggle against the withdrawal symptoms which fixes the habit. The theory that addiction begins with perception of the significance of withdrawal symptoms, and the subsequent use of the drug to relieve or to forestall suffering, explains why some users of opiatecontaining patent medicines became addicts and others did not. It also permits an acceptable explanation of the consequences of the Harrison Act. After passage of this and other restrictive laws, opiate users were eliminated from the legitimate market. Many who were habituated to laudanum and opiate-containing patent medicines undoubtedly discontinued their use, experienced varying degrees of discomfort, and were none the wiser. On the other hand, it is equally certain that some who had the misfortune to know the nature of their ailment continued to use the drug illegally. (29) Addiction in India As would be expected, the basic features of drug addiction in India are the same as they are in the United States and in other countries of the world. Sociologists sometimes argue that generalizations about human behavior are necessarily culture-bound, that is, that they can be valid only in a given culture because of the enormous cultural differences that exist in the world. Admittedly and obviously, addiction in India differs in many respects from the contemporary American pattern just as the latter differs from that of nineteenth-century America. If a theory of addiction that applies to twentieth-century America cannot apply to India or to nineteenth century America, then it seems evident that DO genuinely general theory of addiction is possible. The assumption that is made here is the contrary one; namely, that while addiction, like malaria, manifests itself in a variety of superficially different forms in various parts of the world and at different times in the same part of the world, the basic processes that produce it are always the same the world over, as they are in the case of malaria. Even a superficial reading of the available literature on addiction in other countries creates an overwhelming impression that this is the case. Everywhere the addict shows the same characteristic craving for his drug, and everywhere he does what he must to obtain a supply of it. The power of the habit and the difficulties in breaking it are apparently much the same everywhere. The extensive publications of Chopra and his associates in India demonstrate that this is certainly true in that country. Chopra and Gremal tell of a "curious" case in which an individual regularly drank opiate-containing tea with a friend. When the friend left, this person became miserable even though be file:///I|/drugtext/local/library/books/adopiates/chapter5.htm[24-8-2010 14:23:36]

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