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Addiction and Opiates

Addiction and Opiates

CHAPTER 5 PROCESSES IN

CHAPTER 5 PROCESSES IN ADDICTION continued to drink tea .(30) Chopra and Gremal do not say how be discovered that the tea contained opiates, but this was evidently the case, for be became addicted. This report and others indicate that the role of withdrawal symptoms in causing addiction among Indian users is the same as in the United States. (31) Modern Medical Precautions While there can be little question that physicians and druggists were to a great extent responsible for opiate addiction during the nineteenth century, it is agreed that medical practice is responsible for only a few addicts developed today. What are the reasons for this change? A report of the British Ministry of Health in 1926 furnishes a clue to the answer. It points out that, although psychoneurotics may experience greater initial pleasure from opiates than most normal persons, they can be saved from addiction if the proper precautions are taken in opiate administration.(32) The report emphasizes that when these precautions are not taken, anyone may become an addict. Therefore, two of its chief recommendations are: that the patient be kept in absolute ignorance of the drug being used and that the utilization of the hypodermic needle be avoided. Both precautions have been stressed for a long time, for it was soon appreciated that a patient who was ignorant of the dose, or who bad been deceived about its true contents, could not become an addict. Pertinent is the statement of a physician in 1896: The danger of physicians creating morphine fiends, it needs hardly be said, is greatly overestimated. Intelligently used, there is little danger of such results. With our highly neurotic temperaments we must, however, exercise more than usual tact, so as not to be deceived into its unnecessary use. It is the general and erroneous impression of the laity that all hypodermic injections are necessarily composed of morphia-it is the only drug that they can associate with them. When one has a patient wherein the protracted and regular hypodermic use of morphia may be required for a length of time, it would be well if an occasional hypodermic of strychnia were given, with particular care that some of the family, or the patient, should pick up that vial and read the label . . . It is a mistake to tell the patient that you are using morphia ... Diminish the dose, or substitute something else with the dosage as you gradually diminish the morphia. Do not make a consultant of your patient in these matters. (33) Dr. Paul Wolff, an eminent German student of addiction, comments appropriately: In my opinion a further great advance would be made if morphine, etc., were replaced as far as possible by the use of suppositories. Not only do these produce the same qualitative and quantitative effects, but also the patient is not immediately aware that he has received morphine. In many cases where medical treatment is the origin of addiction, numerous mental associations would be avoided in the absence of the symbol of the syringe. (34) It can be seen that the "mental associations" referred to are connected with the patient's previous knowledge of stereotypes concerning drug addiction. When these associations are made he becomes attentive to certain effects and expects them. The same effects under different conditions might have elicited no response, but when understood they place him in the dangerous position of understanding the reasons for whatever distress be may experience when the drug is removed. These two devices-avoiding the syringe and keeping the patient in ignorance-as well as other precautions such as mixing the opiate with less pleasant drugs, changing methods of administration, using sterile hypodermics, disguising the opiate in medicine, misinforming the patient, and gradually reducing the dosage when it is desirable to eliminate further use, all serve the same end. By preventing the patient from gaining a clear conception of the significance of his sensations and keeping him from associating what be knows or thinks be knows about drug addiction with his postinjection feelings, addiction is avoided. When a patient has been completely and successfully deceived and is completely in the dark concerning his withdrawal distress and the drug that produces it, he cannot, in the nature of the case, consciously desire opiates as a means of relief. What be ordinarily does instead of this is to attribute his discomfort to the disease from which he is suffering, or in some instances, to the aftereffects of surgery. file:///I|/drugtext/local/library/books/adopiates/chapter5.htm[24-8-2010 14:23:36]

CHAPTER 5 PROCESSES IN ADDICTION Experimental- Type Evidence The methodological assumptions of the present study are those that form the logical foundations of the experimental method, and the theory proposed clearly suggests experimental operations, which, if they could be performed with human subjects, would directly verify or falsify it. This fact has been observed by experimental psychologists who have reformulated the theory in terms of positive and negative reinforcement and subjected it to experimental test with lower animals. I shall describe this experimentation in the following section and shall be concerned here with occurrences which, although they happen spontaneously without experimental intervention, are of precisely the same type and seem to carry the same weight as if they were actual experiments. When the fundamental theoretical propositions of this study had been developed to an appropriate point, it occurred to me that it should be possible to find instances in which persons who had become physically dependent on opiates and escaped addiction had, in a later and separate episode again become physically dependent and also addicted. It was inferred in advance of the examination of any such instances that, after the second episode in which addiction was established, the person would retrospectively report that he had not recognized withdrawal distress during the first episode. Such instances seemed to provide the possibility of something very like a crucial test of the proposed theory. Since the same individual would be involved in both episodes, it would be logically unsound to attribute the addiction following the second to defects of personality structure which are often cited as explanations of addiction. It was also anticipated that any single instance of this type which clearly contradicted the deductive implications of the theory would carry sufficient weight to invalidate or cast serious doubt on the whole theory. However, this contingency did not arise, because all of the instances of this type which I was later able to find were in striking conformity with the deductive predictions implicit in the theory. One instance of this type, Case 3 in Chapter 4, has already been described. It involved a physician who became physically dependent upon morphine during a serious illness that involved repeated surgery and a fairly long period of hospitalization. The drug was successfully withdrawn, and the doctor resumed his normal life for a period of several years. A subsequent attack of gallstones again led to the regular use of morphine, and this time resulted in addiction. During this second episode, this physician reported that he realized in retrospect that he had also suffered withdrawal symptoms during the first episode but without recognizing them. He had been hooked, he said, without knowing it. Four other instances of same kind were uncovered, three of them in the literature. The fourth was an addict whom I interviewed and whose story followed the pattern of the case of the doctor cited above. Erwin Straus tells of a German woman who was given a morphine injection twice daily for Six Months (February-July, 1907) because of gallstones. (35) In July she was operated upon, and during her ensuing convalescence the drug was successfully removed. Nine years later, at the age of 49, she lost her only son in World War I and was prostrated by grief After weeks of anguish and thoughts of suicide, she happened to recall that she had once benefited from morphine. She then purchased some in a drugstore and began to use it. In a short time she became addicted. When asked by the physician if she had experienced withdrawal symptoms in 1907, when the drug had been withdrawn, she replied that she did not recall any. I had not anticipated this particular response but I should have. It corroborates the theoretical position even more strikingly than the others by indicating that the memory of withdrawal distress, and of events in general, is strongly affected by the manner in which they are perceived and by the significance attached to them. The addict, for example, generally has a clear, even vivid recollection of his first experiences with the abstinence syndrome, which he realizes marks a dramatic turning point in his life. Another instance of the same general type is briefly summarized by Dansauer and Rieth, (36) and another was found in documents collected by Dr. Bingham Dai which I was permitted to examine. While instances of this kind are understandably rare, the fact that all that could be found conformed closely to theoretical expectations gives considerable additional weight to the theory. There is, moreover, no other current theory that is applicable to such instances. Recent Experiments with Lower Animals When I first published a fully developed account of my theoretical position on opiate addiction in 1947, very little file:///I|/drugtext/local/library/books/adopiates/chapter5.htm[24-8-2010 14:23:36]

PRESCRIPTION ADDICTION
Opioid Addiction