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manage a full-time job at a petrol station where smoking would be impossible during the working day. The impossibility of satisfying the nicotine craving in such a situation will reduce the abstinence and make it more endurable, in rather the same way as a seaman can more easily repress his sexual craving amid the storms at sea than amid the brothels in port.
When nicotinists are in a situation where the satisfaction of the nicotine craving does not give rise to any inconvenience, they consume the required dose. lf confirmed nicotinists are unable to administer a couple of milligrams of nicotine every 20th to 30th minute during their waking hours, they feel that something essential is missing. ln my opinion, the process described here represents the general dynamics of how a drug dependence arises.
lf for any reason the nicotinist in this situation wants to stop smoking, it is, as we know, always an uncertain venture; and this is the case even if the individual is aware of the serious consequences of smoking on health.
THE lMPORTANCE OF THE BASlC PERSONALlTY
The basic personality is not without significance for the development of nicotinism or for whether the individual will eventually overcome the dependence. lt is not, however, of any decisive importance in what sort of brain nicotinism lies. Let us take as a hypothetical experiment that nicotinism afflicts an individual without any physical, mental, erotic, social, economic, or other problem. lf the individual's sole problem is nicotinism, this will not make it essentially easier for him or her to stop smoking than it would for anyone else.
When the nicotinists, both those who are free from problems and those overwhelmed by them, discontinue their administration of nicotine, they enter into the same kind of abstinence state, characterized by strong and frequent waves of intense nicotine hunger. We know from experience that most of them quickly relapse into their smoking habit. One year after an ambitious treatment program for smokers, about 75 percent of them have relapsed, even in the case of well-motivated groups.
lf we have a singularly determined and strong-willed person, who, in addition, has definitely determined to stop smoking, we know that the waves of strong nicotine hunger will in time decline in strength and frequency. After a few months, they will have almost disappeared, but even years latei—when the ocean, so to speak, is as smooth as a mirror—there may still arise isolated, strong swells of nicotine suction, particularly in situations where previously the individual always began smoking, for instance, while playing bridge or after a good meal. lt shows that smoking is often supported by several reinforcing conditioning factors. Even these late swells fade away in time, but l have heard of several ex-smokers who have experienced them several years after a free interval, and after more than ten years of total abstinence.
DEPENDENCE MECHANlSM AND THE
lf a previously heavy smoker undergoes such a prolonged period of abstinence that even the late abstinence effects have ceased many years previously, the individual has still not recovered, but is only an abstinent nicotinist with a latent nicotinism for the rest of his or her life. lf the abstinent nicotinist, after 10, 15, or 20 years, smokes a few cigarettes through a desire "to see how it feels now," this will almost without exception lead to continued smoking—after a certain threshold consumption is exceeded. After a short period, the individual usually reverts to the same advanced pattern of consumption, and the length of the intermediary abstinence period seems to be of secondary importance (E-F, figure 1).
ln reality, nicotinism seems to be an "incurable" condition in the sense that a very long period of total abstinence does not cure nicotine dependence. There can be no return to the youthful, innocent relation to tobacco or to the previous learning period, the voluntary phase, when experimentation with tobacco and sporadic or regular smoking was under full voluntary control.
DEPENDENCE: A CONDlTlON lN lTSELF
There is nothing remarkable about the mechanisms surrounding nicotinism; they follow the well-known laws of learning theories. ln my opinion, this shows very clearly that nicotinism represents a drug dependence and also that dependence is not a symptom, but a condition of its own.
Smoking the first cigarette is a result (symptom) of youthful curiosity. A couple of decades later, smoking perhaps a pack of cigarettes a day is not a late symptom or expression of the curiosity of those early years or a need to imitate older friends; it is a condition of its own—a nicotine dependence. A dialectical change has taken place, a change in quality from the voluntary phase to the phase of dependence.
CHEMICALLY INDUCED ADDICTIONS
As we know, a large number of chemical substances may give rise to drug dependence of varying strength. Common to them all is the fact that they give pleasant effects in one way or another. Often it may be the subtle and, for the experimenter, perhaps completely unconscious effects which are decisive for the development of dependence. Drugs that give more unpleasant than pleasant sensations are obviously unsuitable as intoxicants or as a source of enjoyment. Even though certain drugs, specifically alcohol, tobacco, and cannabis, may on first contact seem repellent or uninteresting, the individual may nonetheless persist because of cultural pressure and learn to appreciate the euphoric qualities which were not initially discernible. Other drugs seem to give pleasant effects from the first dose (if the dose is of adequate size). These are caffeine, amphetamine, cocaine, and morphine.
From the aspects of biology and learning theory, it seems that there is no difference, in principle, between caffeinism, nicotinism, alcoholism, and what is usually called drug addiction. On the other hand, drugs vary greatly in the intensity of the euphoria they provide, the toxic effects, and the subsequent ability of the user to function socially. Some may be enjoyed daily throughout life without noticeable injurious effects (caffeine), others give rise to marked complications only after prolonged consumption, while a third group may result in rapid dependence and entail severe complications (heroin and cocaine).
The social acceptance of different types of drug use varies greatly in different cultures and circles within cultures. Risk groups and initiation mechanisms vary greatly also for different drugs and different conditions. We will return to this later.
PHYSICAL DEPENDENCE: ONLY A COMPLICATION
Until the 1970s, pharmacologists had stubbornly held that it is the direct pharmacological effects of certain drugs upon the nervous system, and the vegetative reactions when these drugs are withdrawn (abstinence syndrome) which constitute addiction. "Physical dependence" was conceived as an essential component in the concept of addiction. During recent years, however, even pharmacologists and neurophysiologists are inclined to agree that addiction has a more general import than pharmacological effects and vegetative reactions to them (Olds and Milner 1954). The development of tolerance and the irrelevance of vegetative phenomena for dependence may be illustrated by a couple of examples.
The newborn infant of an opiate-dependent mother may be on the verge of death from the severe vegetative abstinence reactions (vomiting, diarrhea, etc.), but such a child is not, and has never been, an addict, since it has not learned to appreciate the euphoric effects of opiates, but has only been exposed to the development of tolerance.
lf, in an intramural milieu, we were to give a group of people methadone (a morphine substitute with prolonged effects) mixed in their food, they would, after a month, be completely saturated with (tolerant of) opiates, and this without their becoming aware of it themselves. They would, of course, notice the constipation and the lack of sexual appetite, but would not suspect the secret administration of drugs. An intravenous injection of heroin in this situation would be without effect, either in regard to euphoria or pharmacologic toxicity (overdose). lf in this situation the methadone administration were suddenly stopped, the individuals would soon become very ill and might think that they had food poisoning. lf, instead, the doses were reduced gradually, they could recover from tolerance in a month without knowing that they had had maximal doses of opiates in their bodies and a fully developed tolerance. (The methadone blockade treatment of heroinists is based on these principles.)
ln the same way, the risk for the development of dependence is small when patients suffering from pain are given morphine in adequate doses. The euphoric effects are "neutralized" by the pain and anxiety, and the patient is relieved of a great deal of suffering. lf morphine is given in an inadequate way, the patient may experience a pleasurable morphine reaction. lf, in addition, he or she is then told what had produced the pleasant effects, the basis would be laid for dependence as a complication of the medical treatment.
PLEASURE AS A BIOLOGICAL PREFERENCE SYSTEM
lt is well known that animal behavior is steered by a number of internal and external factors—genetic and acquired, persistent and incidental. Hunger, thirst, sexual craving, aggression, fear, self-preservation, and the ability of the individual and the race to adjust and survive are well-known steering factors.
Unconsciously it seems that all observable internal and external conditions and previous memories and acquired knowledge are weighed, together with constitutional resources and current physiological conditions, in deciding behavior at each moment. Thus a thirsty animal seeks a source of water, but if it suspects danger, the animal will endure its thirst or find a safer place in which to satisfy it.
All stimuli, schematically speaking, must be experienced either as pleasant, unpleasant, or indifferent. ln this way, everything can be reduced to pleasure or pain, and the balance between these experiences seems to steer behavior.
Neurophysiologists have analyzed the mechanisms of pleasure in the mid-brain and limbic system. Olds and Milner (1954) applied electric stimulation to the pleasure center of the hypothalamus of rats which were able to tramp on a pedal and receive an electric current. This was obviously quite pleasurable and resulted in strong repetitive behavior. The males stimulated themselves up to 5,000 times a day until they fell down, unconscious, from exhaustion. They did not even give themselves time to drink, eat, or take an interest in females in heat. This phenomenon may be seen as the biological archetype for addiction. Not only the social and pharmacological factors, but the psychological factors had been eliminated here, and addiction appears as a fixation in a monotonous stimulation of the pleasure centers with a repetitive behavior of enormous persistence as a result. The behavior experienced is so pleasurable that, if interrupted, it is desired again with the force and character of a natural drive. This direct stimulation of the pleasure mechanisms and fixation to a repetitive behavior may be seen as the simplest model for addiction.
ADDICTION WITHOUT DRUGS
Freud, on one occasion, described masturbation as "the primary addiction" and compared it with drug dependence. This seems to be very sharp sighted and relevant. Sexuality may be seen as a biological, endogenic, and very potent pleasure system which normally dominates the efforts and pleasure seeking of animals and humans during long periods of their lives.
Numerous exogenic stimuli may, in various ways, lead to strong feelings of pleasure and through learning give rise to a conditioning which directs the future pleasure-seeking behavior of the individual in a way similar to natural drives, and is strongly reminiscent of sexuality. When this is brought about by means of drugs we call it drug addiction, but the phenomenon may also be initiated in many other ways. As an example of an addiction without drugs we may take gambling, which is characterized by all the elements that occur in a drug addiction except that the stimulation is derived from a game. Other conditions that
seem to have a similar basic mechanism are pyromania, kleptomania, anorexia nervosa, and overeating. ln a more general model it seems that even nail biting, neurodermatitis, phobia, compulsive neuroses, perhaps paranoia querulans, and many other disturbances fit into this pattern. They have in common that a great discomfort is reduced or eliminated for a time through certain thought patterns or behavior, and in this way they provide a pleasurable gain. Thoughts may in such conditions fill the same function as action.
DRUG ADDICTION: A CHEMICAL LOVE
The pleasure mechanism may be stimulated in a number of ways and give rise to a strong fixation on repetitive behavior. Stimulation with drugs is only one of many ways, but one of the simplest, strongest, and often also the most destructive.
When strongly euphoric drugs are given to experimental animals, it seems that all of them continue to seek the drugs, providing that they have learned to appreciate them and that they are not in a state of exhaustion caused by the drug (as, for instance, on prolonged overstimulation with central nervous system stimulants and associated dehydration, etc.). From the biological viewpoint, it therefore seems to be normal to continue with chemical pleasure stimulation once it has commenced and the behavior has been learned. ln humans, on the other hand, it is regarded as abnormal, "deviant," or morbid to continue with intoxicating behavior, while the biologically atypical behavior—to refrain from pleasure or to use the drug "with restraint"—is socially recommended, accepted, or tolerated.
lf the pleasure stimulation becomes so strong that it captivates an individual with the compulsion and force characteristic of natural drives, then there exists what l would describe as an addiction. This addiction usually—but not inevitably—is expressed in addictive behavior, that is, a specific, repetitive pleasure stimulation with lack of motivation to change this behavior, even if the individual realizes that it is extremely injurious. Addiction may easily become even stronger than the instinct for self-preservation.
A pseudomotivation for treatment is a very common phenomenon in addiction. The individual seeks help and treatment of troublesome somatic, psychic, social, and many other kinds of complications to addiction without really being prepared to give up the special source of pleasure that causes the addiction. ln the more advanced and socially unaccepted addictions (alcoholism, heroinism, anorexia nervosa, etc.), addicts usually act as full-time defense lawyers for their addiction, and usually succeed in hiding their deepest aims from relatives, physicians, psychologists, social workers, attorneys, and judges, in a cunning defensive game around the protection of their addiction.
The simplest way of regarding a drug addiction is to see it as falling in love with specific, pleasurable sensations (or the means to prevent pain). The lack of "treatment motivation" and honesty in regard to dependence is often interpreted as a sign of a primary character disturbance. l do not consider this to be peculiar, however, as commonsense is usually put aside by the strong pleasure fixation in love and in addiction.