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in before lighting up the opium joint seemed to be followed all over the country, even though the units in the north or in the highlands had no direct contact with those in the Delta (Zinberg 1971). To what extent this ritual aided control is, of course, impossible to determine. Having observed it many times, however, l can say that it was almost always done in a group and thus formed part of the social experience of heroin use. While one person was performing the ritual, the others sat quietly and watched in anticipation. lt would be my guess that the degree of socialization achieved through this ritual could have had important Implications for control.

Still, the development of social sanctions and rituals probably occurs more slowly in the secretive world of illicit drug use than with the use of a licit drug like alcohol, and it is hard to imagine that any coherent social development occurred in the incredible pressure cooker of Vietnam. Now the whole experience has receded so far into history that it is impossible to nail down what specific social learning might have taken place to be passed on. But certainly Vietnam illustrates the power of the social setting to influence large numbers of apparently ordinary people to engage in drug activity that was viewed as extremely deviant and to limit that activity to that setting. Vietnam also showed that heroin, too, despite its tremendous pharmaceutically addictive potential, is not universally or inevitably addictive.

Further study of various patterns of heroin use, including controlled use, in the United States confirms the lessons taught by the history of alcohol use in America, the use of psychedelics in the 1960s, and the use of heroin during the Vietnam War. The social setting, with its formal and informal controls, its capacity to develop new informal social sanctions and rituals, and its transmission of information in numerous informal ways, is a crucial factor in the controlled use of any intoxicant. This does not mean, however, that the pharmaceutical properties of the drug or the attitudes and personality of the user count for little or nothing. As l stated at the beginning of this essay, all three variables—drug, set, and setting—must be included in any valid theory of drug use. ln every case of use it is necessary to understand how the specific characteristics of the drug and the personality of the user interact and are modified by the social setting and its controls.

THEORIES ON

One's Relationship to Nature Addiction to Pleasure

A Biological and Social-Psychological
Theory of Addiction

Nils Bejerot, M.D.

INTRODUCTION

ln my experience, the debate on the nature of addiction has been too narrowly limited to lead to a general theory that can explain the varied and complicated phenomena which these conditions present.

The earliest explanations were that the soul of the individual was possessed by the devil or by satanic forces. ln medical circles in the first half of the nineteenth century it was believed that dependence was associated with the digestive system (opium eaters and their severe opium hunger). From the viewpoint of cultural history, we can trace the development of this alimentary theory in the psychoanalytical concept of oral fixation.

When the subcutaneous injection needle was introduced in 1856, physicians thought that the addiction problem could be eliminated as a medical complication. During the American Civil War, however, it was found that subcutaneous injections led to dependence more rapidly than oral administration, and thousands of wounded soldiers were afflicted by an addiction which remained even after the physical injury and pain had completely disappeared. Because of this, morphinism was for a time called the "soldiers' disease" or the "army disease" in the United States (O'Donnell and Ball 1966).

During the twentieth century, the development of tolerance and physical dependence has played an important part and has obscured the mechanism of addiction (Fishman 1978). Before describing these interpretations and theories, l will give a simple example of what l mean by the development of a dependence.

NICOTINISM AS A MODEL DEPENDENCE

The malignant addictions are so emotionally charged and subject to so many contradictory explanatory models that it is difficult to discuss them without a continual risk of misunderstanding. We need to examine an addiction which is not emotionally enflamed, is not surrounded by social sanctions, which is well known and of common occurrence in different societies and groups, and, in addition, presents all the relevant phenomena of dependence. l consider that nicotinism is a simple and good example of the development of dependence.

The dotted line A-B in figure 1 shows a young person who has not yet come in contact with tobacco. ln time, tobacco makes its entry (B).

We can immediately state that the young debutant has neither an innate need for nicotine nor a nicotine craving. No psychological or sociological analyses are required to show that the totally decisive reason why a child smokes a cigarette for the first time is purely and simply curiosity.

Nicotine is a fairly strong stimulant. An ordinary cigarette contains only about 1.5 mg nicotine, but this is a large dose for someone who is not used to smoking or snuffing tobacco and who has perhaps half the weight of an adult.

The debutant in our example feels giddy, suffers from nausea and headache, and may even vomit. ln spite of the discomfort, the common pattern is that the beginner obstinately coughs through one pack of cigarettes after the other (B-C). This may in itself seem strange, since the beginner at this stage has still not developed a craving for nicotine or a dependence upon it. The reason for continuation of the initial smoking is usually that the individual wishes to imitate older friends and adults, and in this way to appear more grown up and self-confident than he or she really is.

VOLUNTARY PHASE

Our young smoker still has complete voluntary control over nicotine consumption. lt is no problem at all to refrain from smoking a cigarette when this fits his or her (usually unconscious) goal. At this stage, the smoker has aims other than to satisfy a craving for nicotine, as this has not yet been established. Some smokers remain their whole lives in this stage, which may suitably be described as the voluntary phase (B-C in figure 1). These persons may sometimes take a cigarette instead of a biscuit with coffee, since this reduces their intake of calories. Or they may smoke a cigarette in order to have something to do with their hands in company where they do not really feel at home, or perhaps just to make an impression and appear to be sunk in thought when they really want to hide their shyness, etc. Typical of the voluntary phase is that there is some motive for smoking other than to satisfy a still nonexistent craving for nicotine.

Voluntary smokers are not to be regarded as nicotinists in this definitional system. l would describe them as incidental smokers. The characteristic factor in the voluntary phase is that the will and commonsense are in control of the drug effects and emotions. lt is the individual's "independent will" which steers behavior.

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A-B The period betore the tobacco debut

B-C Controlled smoking or voluntary phase

C~D Compulsive smoking or phase of active dependence

D~E Phase ot achieved or accidental abstinence or latent
dependence

E~F Relapse or active dependence

F-G Renewed abstinence period

G~H Relapse and chronic nicotinism

THE DEPENDENCE PHASE

lf one is unwise enough to continue for a time to inspire nicotine, certain elements in the nervous system are stimulated, and the individual begins to learn how to appreciate the pleasant stimulant effect of nicotine. Through learning, a direct conditioning, the individual glides imperceptibly into a nicotine dependence. A craving for nicotine—or rather for the effects of nicotine—begins to develop.

As far as l know, there are no investigations into whether it requires 10, 50, or 100 packs of cigarettes before an individual glides into a manifest nicotine dependence. The phenomenon appears to be an ordinary pharmacological dose-response relation, with variables such as the size of the dose (the nicotine content of the cigarettes), the intensity of the dose (how often one smokes), the duration of smoking, and the individual variations which always occur in a biological material.

lt is characteristic for the phase of dependence that the craving for nicotine resembles the character and force of a natural drive. Another way of expressing this is that the acquired craving for satisfaction which has developed from the effects of nicotine is in control of the "will," which adjusts to the craving in a similar way as to innate biological drives. ln psychoanalytic terminology one would say that the forces in the "id" have taken control over the forces of the "ego" and "superego."

lf smoking is forbidden during lectures and meetings, the nicotinist, without great distress, can delay smoking until there is a pause, in the same way as he or she can delay the satisfaction of sexual needs. The nicotinist would also, with a certain amount of effort, be able to

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