Love and Addiction - 2. What Addiction Is, and What It Has to Do with Drugs
In: Peele, S., with Brodsky, A. (1975), Love and Addiction. New York: Taplinger.
© 1975 Stanton Peele and Archie Brodsky.
Reprinted with permission from Taplinger Publishing Co., Inc.
Breuer preferred what might be called a physiological theory: he thought that the processes which could not find normal outcome were such as had originated during unusual hypnoid mental states. This opened the further question of the origin of these hypnoid states. I, on the other hand was inclined to suspect the existence of an interplay of forces and the operation of intentions and purposes such as are to be observed in normal life.
—SIGMUND FREUD, An Autobiographical Study
When we talk about addictive love relationships, we are not using the term in any metaphorical sense. Vicky's relationship with Bruce was not like an addiction; it was an addiction. If we have trouble grasping this, it is because we have learned to believe that addiction takes place only with drugs. In order to see why this is not the case—to see how "love" can also be an addiction—we have to take a new look at what addiction is, and what it has to do with drugs.
To say that people like Vicky and Bruce are genuinely addicted to each other is to say that addiction to drugs is something other than what most people take it to be. Thus, we must reinterpret the process by which a person becomes dependent on a drug, so that we can trace the inner, psychological experience of drug addiction, or any addiction. That subjective experience is the key to the true meaning of addiction. It is conventionally believed that addiction happens automatically whenever someone takes sufficiently large and frequent doses of certain drugs, particularly the opiates. Recent research that we will cite in this chapter has shown that this assumption is false. People respond to powerful drugs, even regular doses of them, in different ways. At the same time, people respond to a variety of different drugs, as well as experiences that have nothing to do with drugs, with similar patterns of behavior. The response people have to a given drug is determined by their personalities, their cultural backgrounds, and their expectations and feelings about the drug. In other words, the sources of addiction lie within the person, not the drug.
While addiction is only tangentially related to any particular drug, it is still useful to examine people's reactions to the drugs which are commonly believed to produce addiction. Because these drugs are psychoactive—that is, they can alter people's consciousness and feelings—they have a strong appeal for individuals who are desperately looking for escape and reassurance. Drugs are not the only objects which serve this function for people who are predisposed to addiction. By seeing what it is about some drugs, such as heroin, that draws the addict into a repetitive and eventually total involvement with them, we can identify other experiences, such as love relationships, that potentially have the same effect. The dynamics of drug addiction can then be used as a model for understanding these other addictions.
We will see that more than anywhere else in the world, addiction is a major issue in America. It grows out of special features of the culture and history of this country, and to a lesser extent, of Western society generally. In asking why Americans have found it necessary to believe in a false relationship between addiction and the opiates, we discover a major vulnerability in American culture that mirrors the vulnerability of the individual addict. This vulnerability is close to the heart of the very real and very large significance of addiction—drug and otherwise—in our time. Consider our image of the drug addict. The Federal Bureau of Narcotics and fiction like The Man with the Golden Arm have taught us to visualize the "dope fiend" as a criminal psychopath, violently destructive to himself and others, as his habit leads him inexorably toward death. In reality, most addicts are not at all like this. When we look at the addict in human terms, when we try to figure out what is going on inside him, we see more clearly why he acts as he does—with or without drugs. We see something like this portrait of Ric, an on-again off-again addict, from an account given by a friend of his:
I helped Ric, now off his probation period, move out of his parents' house yesterday. I didn't mind the work, since Ric is such a nice guy and has offered to help put new linoleum down in my kitchen. So I set in to do the wall-washing, vacuuming, floor-sweeping, etc., in his room with good spirits. But these were quickly turned into feelings of depression and paralysis by Ric's inability to do anything in a reasonably complete and efficient manner, and by my seeing him, at the age of 32, moving in and out of his parents' house. It was the reductio ad absurdum of all the inadequacies and problems we see around us, and it was goddamned depressing.
I realized that the struggle for life is never done, and that Ric has blown it badly. And he knows it. How could he fail to realize it with his father telling him that he wasn't a man yet and with his mother not wanting to let us take their vacuum cleaner to clean his new apartment? Ric argued, "What do you think I'm going to do—pawn it or something?" which has probably been a real possibility on many occasions, if not this time. Ric was sweating in the morning chill, complaining about that fucking methadone, when it was probably his needing a fix sooner or later and his father noticing and knowing and saying that he couldn't take a little work—that he wasn't a man yet.
I started right in cleaning—Ric said it would be about half an hour's work—because he had been an hour late picking me up and because I wanted to get it over with so as to get away from him and that place. But then he got a phone call and went out, saying he'd be back in a little while. When he returned he went into the john—presumably to fix. I kept on cleaning; he came out, discovered that he didn't have the garbage bags he needed for packing, and went out again. By the time he got back, I had done everything I could, and he finally set into packing and throwing things out to the point where I could help him.
We started to load up Ric's father's truck, but it was bad timing, since his father had just come back. The whole time we carried things down and placed them in the truck, he complained about how he needed it himself. Once, as he and Ric carried down a horrendously heavy bureau, he started in on how it and the rest of the things we were carrying should have stayed where they belonged in the first place, and not been moved in and out. Like Ric stepping out into the world, to love, to work, only to retreat; to be pushed or pulled back inside, to go back in again behind drugs, or jail, or momma or papa—all the things that have safely limited Ric's world for him.
It is not likely that Ric will die of his habit, or kill for it. It is not likely that his body will rot and that he will be reduced to a disease-ridden degenerate. We can see, however, that he is severely debilitated, though not primarily, or initially, by drugs. What makes a heroin addict? The answer lies in those aspects of a person's history and social setting which leave him in need of outside help in order to cope with the world. Ric's addiction stems from his weakness and incompetence, his lack of personal wholeness. Heroin reflects and reinforces all his other dependencies, even as he uses it to forget them. Ric is an addict, and he would be one whether he were dependent on drugs or love or any of the other objects that people turn to repeatedly under the stress of an incomplete existence. The choice of one drug over another—or of drugs at all—has to do primarily with ethnic and social background and circles of acquaintance. The addict, heroin or otherwise, is addicted not to a chemical, but to a sensation, a prop, an experience which structures his life. What causes that experience to become an addiction is that it makes it more and more difficult for the person to deal with his real needs, thereby making his sense of well-being depend increasingly on a single, external source of support.
Addiction and Drugs
No one has ever been able to show how and why "physical dependence" occurs when people take narcotics (i.e., the opiates: opium, heroin, and morphine) regularly. Lately it has become clear that there is no way to measure physical dependence. In fact, nothing like it occurs with a surprising number of narcotic users. We know now that there is no universal or exclusive connection between addiction and the opiates (universal, in the sense that addiction is an inevitable consequence of opiate use; exclusive, in the sense that addiction occurs only with the opiates as opposed to other drugs). Supporting this conclusion is a wide range of evidence which we will review briefly here. An Appendix has been provided for those who want to explore further the scientific basis of the findings about drugs which are reported in this chapter. The reader may also want to consult some excellent recent books such as Erich Goode's Drugs in American Society, Norman Zinberg and John Robertson's Drugs and the Public, and Henry Lennard's Mystification and Drug Misuse. These books reflect the consensus among well-informed observers that the effects of drugs are relative to the people who take them and the settings in which they are taken. As Norman Zinberg and David Lewis concluded a decade ago after an in-depth study of 200 narcotic users, "most of the problems of narcotic use do not fall into the classic definition of addiction . . . [i.e., craving, tolerance, and withdrawal]. Indeed, the range of cases that do not fit the stereotype of the narcotic addict is very wide...."
In the first place, exactly what are the withdrawal symptoms we hear so much about? The most commonly observed symptoms of severe withdrawal distress call to mind a case of the flu—rapid respiration, loss of appetite, fever, sweating, chills, rhinitis, nausea, vomiting, diarrhea, abdominal cramps, and restlessness together with lethargy. That is to say, withdrawal isn't a unique, definite syndrome that can be precisely distinguished from many other cases of bodily discomfort or disorientation. Whenever the body's internal balance is upset, whether through withdrawal from a drug or an attack of illness, it can manifest these signs of physical and psychological distress. Indeed, the most intensely felt symptom of withdrawal, one that we know about only from the statements of addicts themselves, is not chemical at all. It is an agonizing sense of the absence of well-being, a sense of some terrible deficiency inside oneself. This is the major, personal upheaval that results from the loss of a comfortable buffer against reality, which is where the real wallop of narcotic addiction comes from.
Tolerance, the other major identifying mark of addiction, is the tendency for a person to adapt to a drug, so that a larger dose is required to produce the same effect that resulted initially from a smaller dose. There are limits to this process, however; both monkeys in the laboratory and human addicts soon reach a ceiling point where their usage level is stabilized. Like withdrawal, tolerance is something we know about from observing people's behavior and listening to what they tell us. People show tolerance for all drugs, and individuals vary greatly in the tolerance they show for a given drug. Just how much variation there can be in withdrawal and tolerance effects stemming from the use of opiates and other drugs is revealed by the following studies and observations of different groups of users:
1. Vietnam veterans, hospital patients. After it became known that perhaps one-fourth of all American soldiers in Vietnam were using heroin, there was widespread concern that returning veterans would trigger an epidemic of addiction in the United States. Nothing of the sort happened. Jerome Jaffe, the physician who headed the Government's rehabilitation program for drug-dependent veterans, explained why in an article in Psychology Today entitled "As Far as Heroin Is Concerned, the Worst Is Over." Dr. Jaffe found that most of the G.I.s used heroin in response to the unbearable conditions they faced in Vietnam. As they prepared to return to America, where they would be able to resume their normal lives, they withdrew from the drug with little difficulty and apparently showed no further interest in it. Dr. Richard S. Wilbur, then Assistant Secretary of Defense for Health and Environment, said that this conclusion to the heroin experience in Vietnam amazed him, and caused him to revise the notions about addiction that he had learned in medical school, where he "was taught that anyone who ever tried heroin was instantly, totally, and perpetually hooked."
Similarly, hospital patients often receive morphine for relief of pain without becoming addicted. Norman Zinberg interviewed 100 patients who had received an opiate regularly (at higher than street-level doses) for ten days or longer. Only one recalled having felt any desire for more injections once the pain had ceased.
2. Controlled users. Hospital patients and Vietnam veterans are accidental or temporary opiate users. There are also people who take regular doses of powerful drugs as part of their normal life routine. They do not experience tolerance, or physical or mental deterioration. These individuals are called "controlled users." Controlled use is a more widely recognized phenomenon with alcohol, but there are also controlled users of opiates. Many of them are prominent, successful people who have the wherewithal to maintain their habit and keep it secret. One example is provided by Clifford Allbutt and W. E. Dixon, eminent British authorities on drugs around the turn of the century:
A patient of one of us took a grain of opium in a pill every morning and every evening of the last fifteen years of a long, laborious and distinguished career. A man of great force of character, concerned in affairs of weight and of national importance, and of stainless character, he persisted in this habit, as being one . . . which toned and strengthened him for his deliberations and engagements.
(quoted by Aubrey Lewis in Hannah Steinberg, ed., Scientific Basis of Drug Dependence)
Doctors are the best-known single group of controlled drug users. Historically, we can cite Sir Arthur Conan Doyle's cocaine habit and the distinguished surgeon William Halsted's daily use of morphine. Today, estimates of the number of physicians taking opiates run to about one in every hundred. The very circumstance that prompts many doctors to use narcotics—their ready access to such drugs as morphine or the synthetic narcotic Demerol—makes such users difficult to uncover, especially when they remain in control of their habit and of themselves. Charles Winick, a New York physician and public health official who has investigated many aspects of opiate use, studied physician users who had been publicly exposed, but who were not obviously incapacitated, either in their own eyes or in the eyes of others. Only two out of the ninety-eight doctors Winick questioned turned themselves in because they found they needed increasing dosages of the narcotic. On the whole, the doctors Winick studied were more successful than average. "Most were useful and effective members of their community," Winick notes, and continued to be while they were involved with drugs.
It is not only middle-class and professional people who can use narcotics without meeting the fate which supposedly awaits addicts. Both Donald Louria (in Newark) and Irving Lukoff and his colleagues (in Brooklyn) have found evidence of controlled heroin use in the lower class. Their studies show that heroin users in these ghetto communities are more numerous, better off financially, and better educated than was previously supposed. In many cases, in fact, heroin users are doing better economically than the average ghetto resident.
3. Ritualistic drug use. In The Road to H. Isidor Chein and his coworkers investigated the variety of heroin usage patterns in the ghettos of New York. Along with regular, controlled users, they found some adolescents who were taking the drug irregularly and without withdrawal, and others who were drug-dependent even when they were getting the drug in doses too weak to have any physical effect. Addicts in the latter circumstances have even been observed to go through withdrawal. Chein believes that people like these are dependent not on the drug itself, but on the ritual of obtaining and administering it. Thus a large majority of the addicts interviewed by John Ball and his colleagues rejected the idea of legalized heroin, because that would eliminate the secretive and illicit rituals of their drug use.
4. Maturing out of addiction. By going over the Federal Bureau of Narcotics' lists of addicts, and comparing the names which appeared on the lists at five-year intervals, Charles Winick discovered that street addicts commonly grow out of their dependency on heroin. In his study, entitled "Maturing Out of Narcotic Addiction," Winick demonstrated that one-fourth of all known addicts become inactive by the age of 26, and three-fourths by 36. He concluded from these findings that heroin addiction is largely an adolescent habit, one which most people get over at some point in their adulthood.
5. Reactions to a morphine placebo. A placebo is a neutral substance (like sugared water) which is given to a patient in the guise of an active medication. Since people can show moderate or practically nonexistent reactions to morphine, it is not surprising that they also may experience the effects of morphine when they simply imagine that they are receiving the drug. In a classic study of the placebo effect, Louis Lasagna and his co-workers found that 30 to 40 percent of a group of postoperative patients couldn't tell the difference between morphine and a placebo that they were told was morphine. For them, the placebo relieved pain as well as the morphine did. The morphine itself worked only 60 to 80 percent of the time, so that although it was somewhat more effective than the placebo as a painkiller, it too was not infallible (see Appendix A).
6. Addictions transferred from one drug to another. If the action of a powerful drug can be simulated by an injection of sugared water, then we should certainly expect people to be able to substitute one drug for another when the effects of the drugs are similar. For example, pharmacologists consider barbiturates and alcohol to be cross-dependent. That is, a person who is addicted to either of them can suppress the withdrawal symptoms that result from not getting the one drug by taking the other. Both of these drugs also serve as substitutes for the opiates. The historical evidence, presented by Lawrence Kolb and Harris Isbell in the anthology Narcotic Drug Addiction Problems, shows that the fact that all three substances are depressants makes them roughly interchangeable for the purposes of addiction (see Appendix B). When there is a shortage of available heroin, addicts typically resort to barbiturates, as they did in World War II when the normal channels for importation of heroin were cut off. And many of the Americans who became opiate users in the nineteenth century had been heavy drinkers before the arrival of opium in this country. Among heroin addicts whom John O'Donnell surveyed in Kentucky, those who were no longer able to obtain the drug tended heavily to become alcoholics. This shift to alcoholism by narcotic users has been commonly observed in many other settings
7. Addiction to everyday drugs. Addiction occurs not only with strong depressant drugs like heroin, alcohol, and barbiturates, but with mild sedatives and pain-relievers like tranquilizers and aspirin. It also appears with commonly used stimulants like cigarettes (nicotine) and coffee, tea, and cola (caffeine). Imagine someone who begins smoking a few cigarettes a day and works up to a stable daily habit of one or two or three packs; or a habitual coffee drinker who eventually needs five cups in the morning to get started and several more during the day to feel normal. Think how uncomfortable such a person gets when there are no cigarettes or coffee in the house, and to what lengths he or she will go to obtain some. If an inveterate smoker can't get a cigarette, or tries to give up smoking, he may show the full symptoms of withdrawal—shaking nervously, becoming uncomfortable, agitated, uncontrollably restless, and so on.
In the Consumers Union report, Licit and Illicit Drugs, Edward Brecher states that no essential difference exists between the heroin and nicotine habits. He cites cigarette-deprived, post-World War II Germany, where proper citizens begged, stole, prostituted themselves, and traded off precious commodities—all in order to obtain tobacco. Closer to home, Joseph Alsop devoted a series of newspaper columns to the problem many ex-smokers have in concentrating on their work after giving up their habit—a difficulty heroin treatment programs traditionally have had to deal with in addicts. Alsop wrote that the first of these articles "brought in scores of readers' letters saying in effect, 'Thank God you wrote about not being able to work. We've told the doctors again and again, and they won't believe it.' "
Social and Cultural Variations in Drug Effects
If many drugs can addict, and if not everyone gets addicted to any particular drug, then there can be no single physiological mechanism which explains addiction. Something else has to account for the variety of reactions people have when different chemicals are introduced into their bodies. The signs which are taken as indicators of addiction, withdrawal and tolerance, are affected by a host of situational and personal variables. The way people respond to a drug depends on how they view the drug—that is, what they expect from it—which is called their "set," and on the influences they feel from their surroundings, which comprise the setting. Set and setting are in turn shaped by the underlying dimensions of culture and social structure.
Lasagna's placebo experiment demonstrated that people's reactions to a drug are determined as much by what they think the drug is as by what it actually is. An important study that showed people's expectations working in combination with pressures from the social environment was conducted by Stanley Schachter and Jerome Singer. In it, individuals who were given a shot of adrenalin responded to the drug in entirely different ways, depending on whether they knew ahead of time to anticipate the effects of the stimulant, and on what mood they observed being acted out by someone else in the same situation. When they weren't sure what they were getting in the injection, they looked to see how the other person was acting in order to know how they should feel (see Appendix C). On a larger scale, this is how drugs are defined as being addictive or nonaddictive. People model their response to a given drug on the way they see other people responding, either in their social group or in the society as a whole.
A striking example of this social learning is provided by Howard Becker's study (in his book Outsiders) of the initiation of novice marijuana smokers into groups of experienced smokers. The novice has to be taught first that feeling certain sensations means that he is high, and then that these sensations are pleasurable. Similarly, groups of people who took LSD together in the 1960s were often known as tribes. These groups had widely differing experiences with the drug, and people who joined a tribe quickly learned to experience whatever it was that the rest of the group encountered in a trip. In the case of heroin, Norman Zinberg reports in his December, 1971, New York Times Magazine article, "G.I.'s and O.J.'s in Vietnam," that army units each developed their own specific withdrawal symptoms. The symptoms tended to be uniform within a unit, but varied greatly among units. In Drugs and the Public, Zinberg and John Robertson also note that withdrawal was consistently milder at the Daytop Village addiction treatment center than it was, for the same addicts, in jail. The difference was that the social atmosphere at Daytop did not allow severe withdrawal symptoms to appear because they could not be used as an excuse for not doing one's work.
Whole societies, too, teach specific lessons about drugs in line with their attitudes toward them. Historically, the drugs which other cultures have considered dangerous often have not been the same ones that we, in our culture, think of in such a light. In The Soul of the Ape, for example, Eugene Marais describes the devastating effects of our ordinary smoking tobacco on the Bushmen and Hottentots of nineteenth-century South Africa, who were familiar and moderate users of dagga (marijuana). Opium, which has been taken as a pain-killer since antiquity, was not regarded as a special drug menace before the late nineteenth century, and it was only then, according to Glenn Sonnedecker, that the term "addiction" began to be applied to this drug alone with its present meaning. Previously, the negative side effects of opium were lumped together with those of coffee, tobacco and alcohol, which, according to the data compiled by Richard Blum in Society and Drugs, were often objects of greater concern. China banned tobacco-smoking a century before it prohibited opium in 1729. Persia, Russia, parts of Germany, and Turkey all at some time made the production or use of tobacco a capital offense. Coffee was outlawed in the Arab world around 1300 and in Germany in the 1500s.
Consider the following description of drug dependence: "The sufferer is tremulous and loses his self-command; he is subject to fits of agitation and depression. He has a haggard appearance.... As with other such agents, a renewed dose of the poison gives temporary relief, but at the cost of future misery." The drug in question is coffee (caffeine), as seen by the turn-of-the-century British pharmacologists Allbutt and Dixon. Here is their view of tea: "An hour or two after breakfast at which tea has been taken . . . a grievous sinking . . . may seize upon a sufferer, so that to speak is an effort. ... The speech may become weak and vague.... By miseries such as these, the best years of life may be spoilt."
What seems dangerous and uncontrollable at one time or in one place becomes natural and comfortable to deal with in another setting. Although tobacco has been proved to be injurious to health in any number of ways, and recent investigations suggest that coffee may be equally harmful, Americans do not, by and large, strongly mistrust either substance (see Appendix D). The ease we feel in handling the two drugs has led us to underestimate or disregard their chemical potency. Our sense of being psychologically secure with tobacco and coffee stems, in turn, from the fact that energizing, stimulant drugs closely fit the ethos of American and other Western cultures.
A culture's reaction to a drug is conditioned by its image of that drug. If the drug is seen as mysterious and uncontrollable, or if it stands for escape and oblivion, then it will be widely misused. This usually happens when a drug is newly introduced to a culture on a large scale. Where people can readily accept a drug, then dramatic personal deterioration and social disruption will not result from its use. This is usually the case when a drug is well-integrated into life in a culture. For instance, studies by Giorgio Lolli and Richard Jessor have shown that Italians, who have a long and settled experience with liquor, do not think of alcohol as possessing the same potent ability to console that Americans ascribe to it. As a result, Italians manifest less alcoholism, and the personality traits which are associated with alcoholism among Americans are not related to drinking patterns among Italians.
Based on Richard Blum's analysis of alcohol, we can develop a set of criteria for whether a drug will be used addictively or nonaddictively by a particular culture. If the drug is consumed in connection with prescribed patterns of behavior and traditional social customs and regulations, it is not likely to cause major problems. If, on the other hand, either the use or control of the drug is introduced without respect to existing institutions and cultural practices, and is associated either with political repression or with rebellion, excessive or asocial usage patterns will be present. Blum contrasts the American Indians, in whom chronic alcoholism developed in the wake of the white man's disruption of their cultures, with three rural Greek villages where drinking is so fully integrated into a traditional way of life that alcoholism as a social problem is not even conceived of.
The same relationships hold true for the opiates. In India, where opium has long been grown and is used in folk medicine, there has never been an opium problem. In China, however, where the drug was imported by Arab and British traders and was associated with colonial exploitation, its use got out of hand. But not even in China has opium been as disruptive a force as in America. Brought to America by Chinese laborers in the 1850s, opium caught on quickly here, first in the form of morphine injections for wounded soldiers in the Civil War, and later in patent medicines. Nonetheless, according to accounts by Isbell and Sonnedecker, doctors and pharmacists did not regard opiate addiction as a problem different from other drug dependencies until the two decades between 1890 and 1909, when opium importation increased dramatically. It was during this period that the most concentrated opiate, heroin, was first produced from morphine. Since then, narcotic addiction in America has grown to unprecedented proportions, despite—or perhaps in part due to—our determined attempts to ban the opiates.
Addiction, the Opiates, and Other Drugs in America
The belief in addiction encourages a susceptibility to addiction. In Addiction and Opiates, Alfred Lindesmith states that addiction is more regularly a consequence of heroin use now than in the nineteenth century, because, he argues, people now "know" what to expect from the drug. In that case, this new knowledge we have is a dangerous thing. The very concept that one can be addicted to a drug, especially heroin, has been put into people's minds by society's belaboring of that idea. By convincing people that such a thing as physiological addiction exists, that there are drugs which can take control of one's mind and body, society makes it easier for people to relinquish themselves to a drug's power. In other words, the American conception of drug addiction is not just a mistaken interpretation of the facts, it is itself part of the problem—part of what addiction is about. Its effects go beyond drug dependencies per se to the whole issue of personal competence and the ability to control one's destiny in a confusing, technologically and organizationally complex world. So it is important that we ask why Americans have believed in addiction so strongly, feared it so much, and linked it so erroneously with one class of drugs. What characteristics of American culture account for such outsized misunderstanding and irrationality?
In his essay entitled "On the Presence of Demons," Blum attempts to explain the American hypersensitivity to drugs, which he describes this way:
Mind-altering drugs have been invested by the public with qualities which are not directly linked to their visible or most probable effects. They have been elevated to the status of a power deemed capable of tempting, possessing, corrupting, and destroying persons without regard to the prior conduct or condition of those persons—a power which has all-or-none effects.
Blum's thesis is that Americans are especially threatened by the psychoactive properties of drugs because of a unique Puritan heritage of insecurity and fear, including the special fear of possession by spirits that was apparent in the Salem witch trials. This interpretation is a good start toward understanding the problem, but ultimately it breaks down. For one thing, the belief in witchcraft also existed throughout Europe. For another, it cannot be said that Americans, compared to people in other countries, have an inordinately strong sense of their own powerlessness before outside forces. On the contrary, America has traditionally placed more stock in internal strength and personal autonomy than have most cultures, both because of its Protestant roots and the open opportunities it offered for exploration and initiative. We must start, in fact, with America's ideal of individualism if we are to understand why drugs have become such a sensitive issue in this country.
America has been faced with a perplexing conflict over its inability to live out the Puritan principle of inner vision and the pioneer spirit which are part of its ethos. (This conflict has been analyzed from different angles in works like Edmund Morgan's Visible Saints, David Riesman's The Lonely Crowd, and David McClelland's The Achieving Society.) That is, because they idealized the individual's integrity and self-direction, Americans were especially hard hit by evolving conditions of modern life that assaulted those ideals. Such developments included the institutionalization of work within large industries and bureaucracies in the place of farming, craftsmanship, and small enterprises; the regimentation of education through the public school system; and the disappearance of free land to which the individual could migrate. All three of these processes came to a head in the latter half of the nineteenth century, just when opium was being introduced to America. For example, Frederick Jackson Turner dated the closing of the frontier—and the profound social changes he attached to that event—at 1890, the beginning of the period of most rapid growth in opium importation.
This radical transformation of American society, with its undermining of the potential for individual effort and enterprise, left Americans unable to control their destinies as much as, in keeping with their beliefs, they felt they should. The opiates appealed to Americans because these drugs act to assuage the consciousness of personal deficiencies and impotence. But at the same time, because they contribute to this impotence by making it more difficult for a person to cope effectively, the opiates came to symbolize the feelings of loss of control that also appeared in this era. It is at this point in American history that the concept of addiction emerged with its contemporary meaning; earlier, the word merely stood for the idea of a bad habit, a vice of some kind. Now narcotics began to evoke a magical awe in people's minds, and to assume a farther-reaching power than they had ever had.
Thus, through their introduction into the United States at this time, heroin and the other opiates became a part of a larger conflict within the society. As one more form of control that lay outside the individual, they aroused the fear and defensiveness of people already troubled by these issues. They also drew the ire of the bureaucratic institutions which were growing up alongside of opiates in America—institutions which exercised a similar type of power psychologically to that of the narcotics, and with which, therefore, the drugs were essentially competing. This atmosphere spawned the fervent organized and official efforts that were made to combat opiate use. Because opiates had become the focus for America's anxieties, they provided a means to direct attention away from the deeper reality of addiction. Addiction is a complex and wide-ranging reaction in society to the constriction and subjugation of the individual psyche. The technological and social change that created it has been a worldwide phenomenon. By a combination of factors, including historical accident and other variables which no one analysis can take into account, this psychological process has been linked especially strongly to one class of drugs in America. And the arbitrary association persists to this day.
Because of their misconceptions and their desire to establish themselves as final arbiters over what drugs were proper for regular consumption by Americans, two organizations—the Federal Bureau of Narcotics and the American Medical Association—launched a propaganda campaign against the opiates and their users, exaggerating both the extent and the severity of the problem at that time. Both of these institutions were intent on consolidating their own power over drugs and related matters in the society, the Narcotics Bureau branching out from collecting drug taxes within the Treasury Department, and the AMA striving to reinforce its position as the certifying body for physicians and approved medical practices. Together, they had a powerful influence on American policy and attitudes toward narcotics in the early twentieth century.
Lawrence Kolb, in Livingston's Narcotic Drug Addiction Problems, and John Clausen, in Merton and Nisbet's Contemporary Social Problems, have recounted the destructive consequences of this policy, consequences which are still with us today. The Supreme Court gave a controversial, prohibitionist interpretation to the Harrison Act of 1914, which originally had provided only for the taxation and registration of persons handling drugs. This decision was part of a decisive shift in popular opinion by which the regulation of narcotics use was taken out of the hands of the individual addict and his physician and given over to the government. The major impact of this move, in fact, was to make the criminal underworld the agency largely responsible for the propagation of drugs and drug habits in the United States. In England, where the medical community has retained control over opiate distribution and the maintenance of addicts, addiction has been a mild phenomenon, with the number of addicts remaining constant at a few thousand. Addiction there has also been largely unconnected with crime, and most of the addicts lead stable, middle-class lives.
One important effect of the official war against narcotics carried out in America was to banish the opiates from respectable society and consign them to the lower class. The image that was created of the heroin addict as an uncontrolled, criminal degenerate made it difficult for middle-class people to become involved with the drug. As the heroin user was made into a social outcast, public disgust influenced his own conception of himself and his habit. Before 1914, opiate takers had been mainstream Americans; now addicts are concentrated in various minority groups, especially blacks. Meanwhile, society has provided the middle class with different addictions—some representing social and institutional attachments, others merely consisting of dependencies on different drugs. For example, the "bored housewife" syndrome created many opiate users in the nineteenth century out of women who no longer had an energetic role to play at home or in independent family enterprises. Today these women drink or take tranquilizers. Nothing is more indicative of the unresolved problem of addiction than the wistful search for a nonaddicting anodyne. Since the advent of morphine, we have welcomed hypodermic injections, heroin, the barbiturates, Demerol, methadone, and various sedatives as offering the chance to escape pain without causing us to become addicted. But the more effective at its purpose each drug has been, the more clearly its addictiveness has been established.
The persistence of our addictive susceptibilities is also evident in our conflicting and irrational attitudes toward other popular drugs. Alcohol, like opium a depressant drug with soothing effects, has been regarded with ambivalence in this country, even though a longer familiarity has prevented reactions quite as extreme as the sort opium aroused. Throughout the period from 1850 to 1933, attempts at prohibition of alcohol were repeatedly made at the local, state, and national levels. Today, alcoholism is considered our largest-scale drug problem. Explaining the reasons for alcohol misuse, David McClelland and his colleagues discovered in The Drinking Man that heavy, uncontrolled drinking occurs in cultures which explicitly value personal assertiveness while at the same time suppressing its expression. This conflict, which alcohol eases by offering its users the illusion of power, is precisely the conflict which gripped America during the period when opiate use grew and was outlawed, and when our society had such a hard time deciding what to do about alcohol.
Another instructive example is marijuana. As long as this drug was novel and threatening and was associated with deviant minorities, it was defined as "addictive" and classed as a narcotic. That definition was accepted not only by the authorities, but by those who used the drug, as in the Harlem of the 1940s evoked in Malcolm X's autobiography. In recent years, however, middle-class whites have discovered that marijuana is a relatively safe experience. Although we still get sporadic, alarmist reports on one or another harmful aspect of marijuana, respected organs of society are now calling for the decriminalization of the drug. We are near the end of a process of cultural acceptance of marijuana. Students and young professionals, many of whom lead very staid lives, have become comfortable with it, while still feeling sure that people who take heroin become addicted. They do not realize they are engaging in the cultural stereotyping which currently is removing marijuana from the locked "dope" cabinet and placing it on an open shelf alongside alcohol, tranquilizers, nicotine, and caffeine.
A more potent hallucinogen than marijuana, LSD has aroused the intense aversion reserved for strong drugs like heroin, even though it has never been regarded as addictive. Before it became both popular and controversial in the 1960s, LSD was used in medical research as an experimental means of inducing temporary psychosis. In 1960, while the drug was still known only to a few doctors and psychologists, Sidney Cohen surveyed these researchers on the incidence of serious complications from LSD use among experimental volunteers and psychiatric patients. The rate of such complications (suicide attempts and prolonged psychotic reactions) was minuscule. It seems that without prior public knowledge, long-term LSD effects were about as minor as those resulting from the use of any other psychoactive drug.
Since then, however, anti-LSD propaganda and rumors spread by people in and around the drug-using subculture have made it impossible for observers and potential users to assess the drug's properties objectively. Even users can no longer give us an unbiased picture of what their trips have been like, since their experiences with LSD are governed by their own group's preconceptions, as well as by a larger cultural set defining the drug as dangerous and unpredictable. Now that people have been taught to fear the worst, they are ready to panic when a trip takes a bad turn. An entirely new dimension has been added to the LSD trip by the evolution of cultural perspectives on that drug.
As the psychological consequences of LSD use began to look more threatening, the majority of people—even among those who considered themselves in the cultural vanguard—became reluctant to expose themselves to the self-revelations that an LSD trip entailed. This is understandable, but the way they opted out was by sanctifying an entirely fallacious report of the effects of LSD use. The study, published by Maimon Cohen and others in Science in 1967, stated that LSD caused an increased breakage rate in human chromosomes, and thus raised the specter of genetic mutations and birth defects. The newspapers seized upon these findings, and the chromosome scare had a great impact within the drug scene. In fact, though, the study began to be refuted almost as soon as it was published, and it was eventually discredited. A review of LSD research by Norman Dishotsky and others which was published in Science four years later showed that Cohen's findings were an artifact of laboratory conditions, and concluded that there was no reason to fear LSD on the grounds originally put forward—or at least no more reason to fear LSD than aspirin and caffeine, which caused chromosome breakage at approximately the same rate under the same conditions (see Appendix E).
It is unlikely that a chromosome scare would induce many users of aspirin, coffee, or Coca-Cola to give up those drugs. But the users and potential users of LSD turned away from it almost in relief. To this day, many people who refuse to have anything to do with LSD justify their position by citing that now-invalidated piece of research. This could happen, even among drug-sophisticated young people, because LSD doesn't fit into a comfort-seeking approach to drugs. People who didn't want to admit that this was why they were avoiding the drug were handed a convenient rationalization by the selective reports that newspapers printed, reports which didn't reflect the body of scientific knowledge about LSD. Turning down experimental psychic journeys (which it was their privilege to do), these people found it necessary to defend their reluctance with spurious testimony.
Such recent instances of fear and irrationality with regard to psychoactive drugs show that addiction is still very much with us as a society: addiction, in the sense of an unsureness of our own strength and power, coupled with a need to find scapegoats for our uncertainties. And while we are distracted with questions of what drugs can do to us, our misunderstanding of the nature and causes of addiction makes it possible for addictions to slip in where we least expect to find them—in safe, respectable places like our love relationships.
A New Concept of Addiction
At present, the general confusion about drugs and their effects is a reflection of a similar confusion felt by scientists. Experts throw up their hands when confronted with the wide range of reactions people can have to the same drugs, and the wide range of substances which can produce addiction in some people. This confusion is expressed in Scientific Basis of Drug Dependence, a report on a British colloquium of the world's leading authorities on drugs. Predictably, the participants gave up trying to talk about addiction altogether, and addressed themselves instead to the broader phenomenon of "drug dependence." After the discussions the chairman, Professor W. D. M. Paton of the Department of Pharmacology at Oxford, summarized the major conclusions which had been reached. First, drug dependence is no longer equated with the "classical withdrawal syndrome." In its place, "the central issue of drug dependence has shifted elsewhere and seems to lie in the nature of the primary 'reward' which the drug provides." That is, the scientists have begun to think of drug dependence in terms of the benefits which habitual users get from a drug—its making them feel good, or helping them forget their problems and pain. Along with this change in emphasis has come a less exclusive concentration on the opiates as addicting drugs, and also a greater recognition of the importance of cultural factors in drug dependence.
These are all constructive steps toward a more flexible, people-centered definition of addiction. But they also reveal that in abandoning the old idea of narcotic addiction, the scientists have been left with a mass of unorganized facts about different drugs and different ways of using drugs. In a misguided effort to catalogue these facts in something resembling the old familiar way, pharmacologists have simply replaced the term "physical dependence" with "psychic dependence" in their classifications of drugs. With the discovery or popularization of many new drugs in recent years, a new concept was needed to explain this diversity. The notion of psychic dependence could be applied to more drugs than could addiction, since it was even less precisely defined than addiction. If we go by a table of drugs prepared by Dale Cameron under the aegis of the World Health Organization, there is not one commonly used psychoactive drug that does not produce psychic dependence.
Such an assertion is the reductio ad absurdum of drug classification. For a scientific concept to have any value, it has to distinguish between some things and others. With the shift to the category of psychic dependence, pharmacologists have lost whatever meaning the earlier concept of physical dependence might have had, since, looked at on their own, drugs could only bring about a dependence of chemical origin. And if dependence does not stem from any specific properties of the drugs themselves, then why single out drugs as dependency-producing objects at all? As Erich Goode puts it, to say that a drug like marijuana creates psychic dependence is to say merely that some people have reason regularly to do something of which you disapprove. Where the experts have gone wrong, of course, is in conceiving of the creation of dependence as an attribute of drugs, whereas in reality it is an attribute of people. There is such a thing as addiction; we just haven't known where to look for it.
We need a new concept of addiction to make understandable the observed facts that have been left in a theoretical limbo by the breakdown of the old concept. In their recognition that drug use has many causes and takes many forms, drug experts have reached that critical point in the history of a science where an old idea has been discredited, but where there is not yet a new idea to take its place. Unlike these experts, however—unlike even Goode and Zinberg, the most informed investigators in the field—I believe we do not have to stop short by acknowledging that drug effects can vary almost without limit. Rather, we can understand that some types of drug use are dependencies, and that there are equivalent dependencies of many other sorts. To do this, we need a concept of addiction that emphasizes the way people interpret and organize their experience. As Paton says, we have to start with people's needs, and then ask how drugs fit into those needs. What psychological benefits does a habitual user seek from a drug? (See Appendix F.) What does the fact that he needs this type of gratification say about him, and what are the consequences for him of obtaining it? Finally, what does this tell us about the possibilities for addiction to things other than drugs?
First, drugs do have real effects. Although these effects can be mimicked or masked by placebos, drug-using rituals, and other means of manipulating people's expectations, ultimately there are specific actions which drugs have and which differ from one drug to another. There will be times when nothing but the effects of a particular drug will do. For example, in demonstrating that cigarette-smoking is a genuine drug addiction (rather than an addiction to the activity of smoking), Edward Brecher cites studies where people were observed to puff harder on cigarettes which contained a lower concentration of nicotine. Similarly, given that the mere name of heroin is enough to trigger strong reactions in individuals who are exposed only to a placebo or the injection ritual, there must be something about heroin that inspires the addictive reactions of varying severity that large numbers of people have to it. Clearly, the real effects of heroin—or nicotine—produce a state of being that a person desires. At the same time, the drug also symbolizes this state of being even when, as Chein found among New York addicts, there is little or no direct effect from the drug. In this state of being, whatever it is, lies the key to understanding addiction.
Narcotics, barbiturates, and alcohol suppress the user's consciousness of things he wants to forget. In terms of their chemical action, all three drugs are depressants. For example, they inhibit reflexes and sensitivity to outside stimulation. Heroin in particular detaches a person from feelings of pain, lessening the awareness of physical and emotional discomfort. The heroin user experiences what is called "total drive satiation"; his appetite and sex drive are suppressed, and his motivation to achieve—or his guilt at not achieving—likewise disappear. Thus, opiates remove memories and worries about unresolved issues and reduce life to a single striving. The heroin or morphine high is not one which in itself produces ecstasy for most people. Rather, opiates are desired because they bring welcome relief from other sensations and feelings which the addict finds unpleasant.
The dulling of sensibility, the soothing feeling that all is well, is a powerful experience for some people, and it may be that few of us are entirely immune to its appeal. Those who depend totally on such an experience do so because it gives their lives a structure and secures them, at least subjectively, against the press of what is novel and demanding. This is what they are addicted to. In addition, since heroin diminishes mental and physical performance, it reduces the habituated user's ability to cope with his world. In other words, while he is involved with the drug and feeling relief from his problems, he is even less able to deal with these problems, and thereby becomes less prepared to confront them than he was before. So naturally, when he is deprived of the sensations which the drug provides, he feels inwardly threatened and disoriented, which exacerbates his reactions to the physical symptoms that removal from a course of drugs invariably produces. This is the extremity of withdrawal that is sometimes noted among heroin addicts.
The hallucinogens, such as peyote and LSD, are not generally addictive. It is possible, however, for an individual's self-image to become based upon notions of special perception and intensified experience that the regular use of hallucinogens encourages. In this occasional case, the person will be dependent on a hallucinogen for his feelings that he has a secure place in the world, will seek the drug out regularly, and will be correspondingly traumatized when he is deprived of it.
Marijuana, as both a mild hallucinogen and sedative, can be used addictively, although such use is less common now that the drug is generally accepted. But with the stimulants—nicotine, caffeine, amphetamines, cocaine—we do find widespread addiction in our society, and the parallel with the depressants is striking. Paradoxically, the excitation of the nervous system by a stimulant drug serves to shield the habituated user from the emotional impact of external events. Thus the stimulant taker cloaks the tension that dealing with his environment causes him, and imposes an overriding constancy of sensation in its place. In a study of "Chronic Smoking and Emotionality," Paul Nesbitt found that while cigarette smokers are more anxious than nonsmokers, they feel more calm when they are smoking. With the constant elevation of their heart rate, blood pressure, cardiac output, and blood sugar level, they are inured to variations in outside stimulation. Here, as with the depressants (but not hallucinogens), an artificial sameness is the keynote of the addictive experience.
The primary action of a stimulant is to give a person the illusion of being energized through the freeing of stored energy for immediate use. Since that energy is not being replaced, the chronic stimulant taker is living on borrowed energy. Like the heroin user, he is doing nothing to build up his basic resources. His true physical or emotional state is hidden from him by the artificial boosts he gets from the drug. If he is withdrawn from the drug, he experiences all at once his actual, now very depleted condition, and he feels wrecked. Again, as with heroin, addiction is not an unrelated side effect, but stems from the intrinsic action of the drug.
People imagine that heroin soothes, and it also addicts; that nicotine or caffeine energizes, and it also keeps you coming back for more. That misconception, which separates what in reality are two sides of the same thing, lies behind the futile search for a nonaddictive pain-killer. Addiction is not a mysterious chemical process; it is the logical outgrowth of the way a drug makes a person feel. When we understand this, we can see how natural (though unhealthy) a process it is (see Appendix G). A person repeatedly seeks artificial infusions of a sensation, whether it be one of somnolence or vitality, that is not supplied by the organic balance of his life as a whole. Such infusions insulate him from the fact that the world he perceives psychologically is becoming farther and farther removed from the real state of his body or his life. When the dosages are stopped, the addict is made painfully aware of the discrepancy, which he must now negotiate unprotected. This is addiction, whether it be a socially approved addiction or an addiction whose consequences are aggravated by social disapproval.
The insight that both stimulants and depressants have aftereffects which destroy the immediate sensations they offer is the starting point for a comprehensive theory of motivation proposed by the psychologists Richard Solomon and John Corbit. Their approach explains drug addiction as just one of a set of basic human reactions. According to Solomon and Corbit, most sensations are followed by an opposite aftereffect. If the original sensation is unpleasant, the aftereffect is pleasant, as in the relief one feels when pain lets up. With repeated exposures the aftereffect grows in intensity, until it is dominant almost from the outset, neutralizing even the immediate effect of the stimulus. For example, the novice parachute jumper begins his first jump in terror. When it is over, he is too stunned to feel much positive relief. As he becomes practiced at jumping, however, he makes his preparations with a tense alertness which he no longer experiences as agony. After jumping, he is overwhelmed with exhilaration. This is how a positive aftereffect overcomes initially negative stimulation.
Using this model, Solomon and Corbit demonstrate a fundamental similarity between opiate addiction and love. In both cases, a person repeatedly seeks out a kind of stimulation which is intensely pleasurable. But as time goes on, he finds that he needs it more even as he enjoys it less. The heroin addict gets less and less of a positive kick from the drug, yet he must return to it to counteract the insistent pain caused by its absence. The lover is no longer so excited by his or her partner, but is more and more dependent on the comfort of the partner's continued presence, and is less able to handle a separation. Here the negative aftereffect overcomes initially positive stimulation.
Solomon and Corbit's "opponent-process" theory is a creative demonstration that addiction is not a special reaction to a drug, but a primary and universal form of motivation. The theory, however, does not really explain the psychology of addiction. In its abstractness it doesn't explore the cultural and personality factors—the when, where, and why—in addiction. What accounts for the differences in human consciousness that enable some people to act on the basis of a larger and more varied set of motivations, while others have their entire lives determined by the mechanistic effects of the opponent process? After all, not everyone becomes mired down in a once positive experience which has gone sour. Thus, this model doesn't deal with what sets some drug users apart from other drug users, some lovers from other lovers—i.e., the addict from the person who is not addicted. It doesn't leave room, for example, for a kind of love relationship that counteracts encroaching boredom by constantly introducing challenge and growth into the relationship. These latter factors make the difference between experiences which are not addictions and those which are. To identify these essential differences in human involvements, we must consider the nature of the addict's personality and outlook.
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