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A General Theory of Addiction to Opiate-Type Drugs
Alfred R. Lindesmith, Ph.D.
l formulated my theory of addiction on the basis of an investigation done in Chicago during the years 1934-35 by, at first, observing and interviewing Chicago street addicts. Approximately 50 addicts were interviewed repeatedly over a period of a number of months, and some others were contacted only once or a few times. l did not consult the literature on the subject until l had developed a preliminary hypothesis.
Theories prevalent at the time were generally unsatisfactory, seeming to reflect the ideological commitments and training of their authors rather than the evidence. Most claimed to apply only to limited populations, making it impossible to prove them false by citing negative evidence since such instances were written off in advance. l began my study with the assumption that a scientific theory of addiction ought to be generally applicable regardless of whether the addict was a physician, a medical patient, or a street derelict from the urban slums. lt also was assumed that the theory should be applicable no matter how the drug was taken and that it should apply to addiction in earlier centuries and in countries other than the United States.
After l entertained a few preliminary hypotheses and rejected them when negative evidence was found, l reached a conclusion concerning the dominant and basic characteristics of addiction—the causal process that produces the powerful craving for opiates. When l sought negative evidence or exceptions to this conclusion and its implications, l failed to find them. lnstead, it seemed to me that the theory made sense of what had at first seemed like a chaotic jigsaw puzzle filled with paradoxes and inconsistencies.
ln brief, the theory l formulated is that opiate drug users develop the craving, or become addicted or "hooked," after physical dependence has been established, in the process of using the drug to alleviate the withdrawal distress that begins to appear several hours after the last dose, provided that the user correctly identifies and understands these symptoms (Lindesmith 1947).
After l had formulated this hypothesis and was checking and working out its implications in interviews with users and by consulting the
scientific literature, l stumbled on the same conclusion stated by a prominent German investigator, A. Erlenmeyer, in 1926. (See references.) Being interested mainly in physiological aspects and the medical treatment of addicts, Erlenmeyer did not develop this statement in detail as a theory but simply stated it as a fact and passed on to other matters.
Noting and documenting the organic effects that occur as morphine is used on a regular daily basis, Erlenmeyer describes the process as a "reversal." He adds:
The morphine originally foreign to the body, becomes an
(Cited in Terry and Pellens 1928, pp. 601-602)
He describes the withdrawal syndrome that occurs after the reversal of effects has taken place as a "host of painful sensations, intolerable feelings, oppressive organic disturbances of every sort, combined with an extreme psychic excitement, intense restlessness, and persistent insomnia." He then remarks:
ln such moments the craving for morphine is born and
(Cited in Terry and Pellens 1928, pp. 601-602)
The cognitive feature of my theory, which is also implicit in Erlenmeyer's statement, is designed to explain how it happens that medical patients relatively rarely become addicted even when opiates are administered on a regular daily basis for prolonged periods sufficient to establish physical dependence. lt is widely recognized in medical practice that in the administration of such addicting drugs, keeping patients in ignorance or deceiving them about the identity of the drug are effective tactics in preventing subsequent use. lf withdrawal symptoms occur, they may be explained to the patient as symptoms of a disease, as side-effects of other medication, and so on. lf a patient who has been attracted to the effects of morphine that has been regularly administered is deceived into the belief that the drug was strychnine or arsenic, he or she will lose interest in it.
Similar considerations also apply to the fact that physical dependence in very young children, such as occurs in infants born of addicted mothers, apparently never produces addiction. ln lndia, a lower caste custom that involved keeping very young children quiet by providing them with opium often produced physical dependence. The drug was usually withdrawn by the age of five. No addiction appears to have resulted from this practice, and there was no connection observed between it and adult use.
An important and often overlooked aspect of opiate effects that is basic to the theory and that is strongly emphasized by Erlenmeyer is the changes in these effects that take place gradually during the progression from initial use on a regular basis to the point of physical dependence. Disregarding a few unpleasant effects following from the first
few doses, initial effects may be described as depressant and are perceived by the recipient as generally pleasant in that they relieve pain and discomfort and produce a feeling of relaxation and well being.
lt is these first effects and the impact of a dose that are spoken of as the "high" or "rush" by addicts. As usage continues, these euphoric effects become progressively briefer in duration and harder to obtain. The original sedative effect gives way to and is replaced by an opposite or stimulating effect as the drug begins gradually to be used mainly to alleviate withdrawal distress. Organic changes are of a parallel nature. The first injection creates abnormal bodily changes which tend to return to normal as bodily adaptation occurs. When the latter process is complete, bodily abnormalities occur when the drug is withdrawn and return roughly to "normal" when another dose is taken. ln this situation the user feels approximately normal between shots but still has the solace of brief euphoric episodes at the time of injection, these becoming progressively more difficult to achieve as use continues.
This reversal of effects creates some important logical problems and paradoxes for the theorist. lf initial euphoric effects are said to be the key factor, one may ask why addicts seem so miserable and so prone to suicide. lf euphoria is the addict's goal, an obvious way to maximize it would be to stop regular use and, instead, use the drug episodically—say, every other day. This would unquestionably reduce costs, risks, and misery generally and would also permit the user to enjoy the "high" for considerably longer time periods. One might also wonder why, after the user has experienced the miseries and frustrations of addiction, she or he does not kick the habit and take up a euphoria-producing drug that does not produce physical dependence, like cocaine or marijuana.
Since the proposed theory does not view the euphoric effects of opiates as the key factor in addiction, these considerations are not an embarrassment to it. From this standpoint one may describe the initial period of use as the stage at which the user learns to like the drug, and subsequent use, to control withdrawal after the reversal of initial effects, as the stage in which she or he learns to love it.
The proposed theory has been corroborated in a variety of ways which cannot all be dealt with here. Two of these will be briefly indicated.
Since there are addicts who have become physically dependent on an opiate before the sequence of regular use that made them addicts, it is relevant to the theory to ask how they escaped addiction in their earlier experience. The theory implies that they must have been ignorant of what was happening to them, and this was borne out in every instance of this sort that came to my attention from interviews or from the literature. One such addict simply said, "l was hooked and didn't know it."
The second corroboration, of a partial nature, has to do with the fact that, if one deletes the cognitive feature of the theory, it may be called one of negative reinforcement and fitted into the pattern of conditioning and reinforcement theory of psychology. lt was adapted in this way by an experimental psychologist and tested with rats (Nichols 1963, 1965). lt was confirmed in the sense that rats that were made physically dependent on morphine by being compelled to drink a morphine solution with a bitter taste became attached to this drink only when they were permitted to experience relief from
withdrawal distress after drinking it. These rats also chose the bitter morphine drink in preference to pure water often enough after they had become abstinent to reestablish physical dependence. All of the other rats that had been physically dependent on morphine but had had no experience with the relief from withdrawal retained a very strong dislike for the water laced with morphine.
These findings raise a host of complex issues concerning the differences between human beings and lower animals that cannot be covered here. They illustrate that the theory is experimental and could probably be tested and improved through experimentation with human subjects if this were permissible.
Theory of Drug Use
Harvey Milkman, Ph.D.
This theoretical approach is based on the formulation that disturbances in the normally expected mastery of phase-specific conflicts during early childhood may induce severe "primitive" psychopathologies, the addictions being prominent among these. Failure to cope adequately with the rage, overstimulation, and disorganized sensory input of such experiences leaves residual sensory overload and disorganization. The drug user is hypothesized to achieve relief via the specific altered ego states induced by psychotropic drugs. The drug of choice will be the pharmacologic agent that proves harmonious with the user's characteristic mode of reducing stress.
Having once experienced the gratification of a supportive, drug-induced pattern of ego functioning, the user may attempt to repeat this uniquely satisfying experience for defensive purposes, as a solution to conflict, or for primary delight. The compulsion to seek out repeatedly a special ego state will be related to the individual's previous needs for the resolution of conflict or anxiety. lf a particular drug-induced ego state provides a mechanism for easing the discomfort of conflict, an individual may seek out that particular drug when that conflict is reexperienced. Wikler's formulations regarding the selection of stimulants, depressants, and hallucinogens closely parallel our own, i.e., chosen substance is related to style of coping with anxiety or stress.' The user's drug of choice appears to produce an altered ego state which is reminiscent of and may recapture specific phases of early child development (e.g., heroin, first year; amphetamine, second to third year).
We have provided empirical support for this theory through the controlled investigation of ego functions in users of heroin or amphetamine
'A. Wikler. Personal communication (cited in Blachly 1970).