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DEPENDENCY: IN THE MEMORY
Falling in love is a learned phenomenon and is located in the memory and not in gross physiological and vegetative reactions (although the memory functions do have their special physiological base). This is also the case with drug dependence. l will illustrate these memory mechanisms with a couple of banal examples.
Suppose that a motorcyclist is out with his fiancee, has an accident, strikes his head on the road, and loses his memory for a while. He would be completely at a loss if his fiancee entered the hospital ward with a bunch of flowers. Since he could not remember that he had seen her before, he could not, of course, be in love with her.
l have myself seen an elderly nicotinist who suffered from senile dementia after more than 60 years of intensive smoking. One day when the patient received his daily two packs of cigarettes from his relatives, he refused them indignantly, with the explanation that he had never been a smoker. When the relatives protested he said, "You must have mixed me up with someone else." He never asked for cigarettes again. When the memory is extinguished, the dependence disappears.
lf, after this discussion, we were to try to formulate a definition of the concept of addiction, it should cover active and passive, direct and indirect, constructive and destructive addictions. lt could be given the following general form: An emotional fixation (sentiment) acquired through learning, which intermittently or continually expresses itself in purposeful, stereotyped behavior with the character and force of a natural drive, aiming at a specific pleasure or the avoidance of a specific discomfort.
Addiction may take many forms and may occur in different phases.
(a) The currency of addiction: ln manifest addictive behavior, addiction is suitably described as active. lf the individual through counterforces (treatment, social control, fear of complications, sanctions, etc.) sacrifices the specific stimulation and remains abstinent, the addiction is, for the time, passive. lf the sentiment disappears completely through deconditioning (reduction or absence of stimulation in response to the behavior), reconditioning, loss of memory, or cerebral damage, the addiction is extinguished.
(b) The stimuli of addiction: lf the stimulation occurs with the help of drugs, a drug addiction is present. lf it occurs through other pleasurable exogenic stimuli, behavior such as gambling, arson, kleptomania, and overeating may arise. The addictions which have arisen from pleasure stimulation may be called direct and will differ from those that arise from very unpleasant experiences—as phobias, compulsive neuroses, paranoid reactions, nail biting, and anorexia nervosa. Since the stereotyped behavior in these cases serves to eliminate discomfort, they may be called indirect addictions.
(c) The relevance of addiction: lf addiction causes a deterioration in the health of the individual and/or the ability to function socially, it may be described as destructive; if it increases these qualities, it is constructive. Among constructive addictions we can include the creative obsession of scientists, authors, artists, and politicians, also the extreme attainment fixation of successful athletes and businesspersons.
According to these definitions, everyone has a number of addictive behaviors. Many sacrifice their lives for their destructive addictions; others receive the Nobel Prize for their constructive ones.
Addiction of the therapeutic type is the only one of the malignant forms of addiction in which women are as numerous as men and may even be somewhat overrepresented. Anxious, asthenic, neurotic, and easily stressed personalities run a greater risk.
Addiction of the professional type usually afflicts physicians who were originally very ambitious and had unrealistically high expectations about their careers. They became disappointed when they realized that they would never reach the goal they had aimed at (Pescor 1942) and fell into drug abuse through self-treatment of somatic problems.
Addiction of the epidemic type is always a breach of norms and is therefore strongly associated with groups at risk for norm breaking, such as active criminals, bohemians, young people, etc. The more the abuse spreads, the less of a breach of norms it becomes, and the greater will be the proportion of ordinary youths who enter the risk zone and are finally drawn into addictive behavior. Finally, an epidemic may in this way change into an endemic, as marijuana smoking has now done in a large part of the United States (Johnson 1973).
Addiction of the cultural type threatens, in principle, the whole population. ln most cultures, women are protected by the norms in regard to intoxicated behavior. Among men, the group with the greatest risk consists of those who have plenty of time, money, access to alcohol, and so on. The high-risk groups for alcoholism are authors, artists, musicians, entertainers, diplomats, commercial travelers, seamen, and people working in restaurants.
The various addictive behaviors still cannot be explained by a single model, but they can be explained by a combination of general biological and social psychological models.
A Theoretical Perspective
Vincent P. Dole, M.D.
The Methadone Maintenance Research Program (Dole and Nyswander 1965, 1966; Dole et al. 1966) began In 1963 with pharmacological studies conducted on the metabolic ward of the Rockefeller University Hospital. Only six addict patients were treated during the first year, but the results of this work were sufficiently impressive to justify a trial of maintenance treatment of heroin addicts admitted to open medical wards of general hospitals in the city.
The dramatic improvements in social status of patients on this program exceeded expectations. The study started with the hope that heroinseeking behavior would be stopped by a narcotic blockade but it certainly was not expected that we would be able to retain more than 90 percent of the patients and that almost three-fourths would be socially productive and living as normal citizens in the community after only six months of treatment. Prior to admission, almost all of the patients had supported their heroin habits by theft or other antisocial activities. Further handicapped by the ostracism of the community, slum backgrounds, minority group status, school dropout status, prison records, and antisocial companions, they had seemed poor prospects for social rehabilitation.
The unexpected response of these patients to a simple medical program forced us to reexamine some of the assumptions that we brought to the study. Either the patients that we admitted to treatment were quite exceptional, or we had been misled by the traditional theories of
This paper, prepared by Jack E. Nelson and reviewed by Marie Nyswander, is based largely on an article written by Dr. Nyswander and Dr. Vincent P. Dole, "Methadone Maintenance and lts lmplication for Theories of Narcotic Addiction," Research Publications of the Association for Research in Nervous and Mental Disease. 49-359-66, 1968. Material from this article is reprinted with the permission of the Association for Research in Nervous and Mental Disease.
addiction (Terry and Pellens 1928). lf, as is generally assumed, our patients' long-standing addiction to heroin had been based on weaknesses of charactei—either a self-indulgent quest for euphoria or a need to escape reality—it was difficult to understand why they so consistently accepted a program that blocked the euphoric action of heroin and other narcotic drugs, or how they could overcome the frustrations and anxieties of competitive society to hold responsible jobs.
lmplicit in the maintenance programs is an assumption that heroin addiction is a metabolic disease, rather than a psychological problem. Although the reasons for taking the initial doses of heroin may be considered psychological—adolescent curiosity or neurotic anxiety—the drug, for whatever reason it is first taken, leaves its imprint on the nervous system. This phenomenon is clearly seen in animal studies: A rat, if addicted to morphine by repeated injections at one to two months of age and then detoxified, will show a residual tolerance and abnormalities in brain waves in response to challenge doses of morphine for months, perhaps for the rest of its life. Simply stopping the drug does not restore the nervous system of this animal to its normal, preaddiction condition. Since all studies to date have shown a close association between tolerance and physical dependence, and since the discomfort of physical dependence leads to drug-seeking activity, a persistence of physical dependence would explain why both animals and humans tend to relapse to use of narcotics after detoxification. This metabolic theory of relapse obviously has different implications for treatment than the traditional theory that relapse is due to moral weakness.
Whatever the theory, all treatment should be measured by results. The main issue, in our opinion, is whether the treatment can enable addicts to become normal, responsible members of society, and if a medication contributes to this result it should be regarded as useful chemotherapy. Methadone, like sulfanilamide of the early antibiotic days, undoubtedly will be supplanted by better medications, but the success of methadone maintenance programs has at least established the principle of treating addicts medically.
The efficacy of methadone as a medication must be judged by its ability or failure to achieve the pharmacological effect that is intended— namely, elimination of heroin hunger and heroin-seeking behavior, and blockade against the euphoriant actions of heroin. The goal of social rehabilitation of criminal addicts by a treatment program is a much broader objective; it includes the stopping of heroin abuse, but is not limited to this pharmacological effect. Failures in rehabilitation programs therefore must be analyzed to determine whether they are due to failures of the medicine, or to inability of the therapists to rehabilitate patients who have stopped heroin use. lndividuals who have stopped heroin use with methadone treatment but who continue to steal, drink excessively, or abuse nonnarcotic drugs, or are otherwise antisocial, are failures of the rehabilitation program but not of the medication.
When the Food and Drug Administration asks for proof of efficacy of a new drug it is the pharmacological efficacy that is in question. For example, diphenylhydantoin is accepted as an efficacious drug for prevention of epileptic seizures. Whether or not the treated epileptics obtain employment or otherwise lead socially useful lives is not relevant to the evaluation of this drug as an efficacious drug for prevention of epileptic seizures or as an anticonvulsant. Similarly with methadone.
With thousands of patients now living socially acceptable lives with methadone blockade and with many more street addicts waiting for admission, the question as to whether these patients are exceptional is no longer a practical issue. The theoretical question, however, remains: ls addiction caused by an antecedent character defect, and does the maintenance treatment merely mask the symptoms of an addictive personality? The psychogenic theory of addiction would say so. This theory has a long history—at least 100 years (Terry and Pellens 1928)—and is accepted as axiomatic by many people. What, then, is the evidence for it?
Review of the literature discloses two arguments to support the psychogenic, or character defect, theory: the sociopathic behavior and attitude of addicts and the inability of addicts to control their drugusing impulse. Of these arguments, the first is the most telling. Even a sympathetic observer must concede that addicts are self-centered and indifferent to the needs of others. To the family and the community the addict is irresponsible, a thief, and a liar. These traits, which are quite consistently associated with addiction, have been interpreted as showing a specific psychopathology. What is lacking in this argument is proof that the sociopathic traits preceded addiction.
lt is important to distinguish the causes from the consequences of addiction. The decisive proof of a psychogenic theory would be a demonstration that potential addicts could be identified by psychiatric examination before drug usage had distorted behavior and metabolic functions. However, a careful search of the literature has failed to disclose any study in which a characteristic psychopathology or "addictive personality" has been recognized in a number of individuals prior to addiction. Retrospective studies, in which a record of delinquency before addiction is taken as evidence of sociopathic tendencies, fail to provide the comparative data needed for diagnosis of deviant personality. Most of the street addicts in large cities come from the slums where family structure is broken and drugs are available. Both juvenile delinquency and drug use are common. Some delinquents become addicted to narcotic drugs under these conditions, whereas others do not. There is no known way to identify the future addicts among the delinquents. No study has shown a consistent difference in behavior or pattern of delinquency of adolescents who later become addicts and those who do not.
Theft is the means by which most street addicts obtain money to buy heroin and, therefore, is nearly an inevitable consequence of addiction. For the majority this is the only way that they can support an expensive heroin habit. The crime statistics show both the force of drug hunger and its specificity; almost all of the crimes committed by addicts relate to the procurement of drugs. The rapid disappearance of theft and antisocial behavior in patients on the methadone maintenance program strongly supports the hypothesis that the crimes that they had previously committed as addicts were a consequence of drug hunger, not the expression of some more basic psychopathology. The so-called sociopathic personality was no longer evident in our patients.
The second argument, that of deficient self-control, is more complicated because it involves the personal experience of the critic as well as that of the patient. Moralists generally assume that opiates are dangerously pleasant drugs that can be resisted only by strength of character. The pharmacology is somewhat more complicated than this. For most normal persons morphine and heroin are not enjoyable drugs—at least