Opioid Analgesics – Redefining drug addiction
The concept of addiction, once thought to be clearly delineated in both its meaning and its causes, has become cloudy and confused.
The World Health Organization has dropped the term “addiction” in favor of drug “dependence,” dividing illicit drugs into those that produce physical dependence and those that produce psychic dependence.
A group of distinguished scientists connected with WHO has called the mental state of psychic dependence “the most powerful of all the factors involved in chronic intoxication with psychotropic drugs.”
Social setting and cultural expectation are better predictors of addiction than body chemistry.
Caffeine, nicotine, and even food can be as addictive as heroin.
The distinction between physical and psychic dependence, however, does not fit the facts of addiction; it is scientifically misleading and probably in error.
The definitive characteristic of every sort of addiction is that the ‘addict’ regularly takes something that relieves pain of whatever kind. This “analgesic experience” goes far toward explaining the realities of addiction to a number of very different substances. The who, when, where, why, and how of addiction to the analgesic experience will be fathomed only when we understand addiction’s social and psychological dimensions.
Pharmacological research has begun to show how some of the most notorious addictive substances affect the body.
Most recently, for example, Avram Goldstein, Solomon Snyder, and other pharmacologists have discovered opiate receptors, sites in the body where narcotics combine with nerve cells.
In addition, morphine-like peptides that are produced naturally by the body have been found in the brain and pituitary gland. Called endorphins, these substances act through the opiate receptors to alleviate pain. Goldstein postulates that when a narcotic is regularly introduced into the body, the external substance shuts off the production of endorphins, making the person dependent on the narcotic for relief of pain.
Since only some people who take narcotics become addicted to them, Goldstein suggests that those most susceptible to addiction are deficient in the ability of their bodies to produce endorphins.
This line of research has given us a major clue to how narcotics produce their analgesic effects. But it seems impossible that biochemistry alone can provide a simple physiological explanation of addiction, as some of its more enthusiastic proponents expect.
For one thing, there now appear to be many addictive substances in addition to the narcotics, including other depressants like alcohol and barbiturates. There are also several stimulants, such as caffeine and nicotine, that produce genuine withdrawal, as Avram Goldstein (with coffee) and Stanley Schachter (with cigarettes) have verified experimentally.
Perhaps these substances inhibit the production of endogenous painkillers in some people, although how this would come about is unclear, since only precisely constructed molecules can enter the opiate-receptor sites.
There are other problems with a too-exclusively biochemical approach. Among them:
- Different societies have different rates of addiction to the same drug, even when there is comparably widespread use of the drug in the societies.
- The number of people addicted to a given substance in a group or a society increases and decreases with the passage of time and the occurrence of social change. For example, in the United States alcoholism is increasing among adolescents.
- Genetically related groups in different societies vary in their addiction rates, and the susceptibility of the same individual changes over time.
- Although the phenomenon of withdrawal has always been the crucial physiological test for distinguishing addictive from nonaddictive drugs, it has become increasingly evident that many regular heroin users do not experience withdrawal symptoms. What is more, when symptoms of withdrawal do appear, they are subject to a variety of social influences.
Another area of research has further clouded the concept of withdrawal.
Although many babies born to heroin-addicted mothers exhibit physical problems, a withdrawal syndrome attributable to the drug itself is less clear-cut than most people have suspected. Studies by Carl Zelson and by Murdina Desmond and Geraldine Wilson have shown that in 10 to 25 percent of the infants born to addicted mothers, withdrawal failed to appear even in a mild form.
Enrique Ostrea and his colleagues indicate that the convulsions typically described as part of infant withdrawal are in fact extremely rare; they also found, as did Zelson, that the degree of infant withdrawal—or whether it appears at all—is not related to the amount of heroin the mother has been taking or to the amount of heroin in her or her baby’s system.
According to Wilson, the symptoms found in babies born to addicts may be partly the result of the mothers’ malnutrition or of venereal infection, both of which are common among street addicts, or they may be due to some physical damage caused by the heroin itself.
What is clear is that the symptoms of addiction and withdrawal are not the results of straightforward physiological mechanisms.
To understand addiction in the adult human being, it is useful to look at the way people experience a drug—at the personal and social context of drug use as well as at its pharmacology. The three most widely recognized addictive substances—alcohol, barbiturates, and narcotics—affect a person’s experience in similar ways despite the fact that they come from different chemical families.
Each depresses the central nervous system, a characteristic that enables the drugs to serve as analgesics by making the individual less aware of pain. It is this property that seems to be at the heart of the addictive experience, even for those drugs that are not conventionally classed as analgesics.
Researchers have found that a painful consciousness of life characterizes the outlooks and personalities of addicts. The classic study of this kind was conducted between 1952 and 1963 by Isidor Chein, a psychologist at New York University, among adolescent heroin addicts in the inner city. Chein and his colleagues found a clear constellation of traits: a fearful and negative outlook toward the world; low self-esteem and a sense of inadequacy in dealing with life; and an inability to find involvement in work, personal relationships, and institutional affiliations rewarding.
These adolescents were habitually anxious about their own worth. They systematically avoided novelty and challenge, and they welcomed dependent relationships that protected them from demands they felt they could not cope with. Since they lacked the confidence in themselves—and in their environment—to produce long-range and substantial gratifications, they chose the predictable and immediate gratification of heroin.
Addicts give themselves over to heroin—or to other depressant drugs— because it suppresses their anxiety and sense of inadequacy. The drug provides them with sure and predictable gratification. At the same time, the drug contributes to their inability to cope with life generally by reducing the ability to function. Use of the drug expands the need for it, sharpening guilt and the impact of various problems in such a way that there is an increasing need to numb awareness. This destructive pattern can be called the addictive cycle.
There are many points in this cycle at which a person can be called addicted. Conventional definitions emphasize the appearance of the withdrawal syndrome. Withdrawal occurs in people for whom a drug experience has become the core of their sense of well-being, when other gratifications have been shunted into secondary positions or forgotten altogether.
This experiential definition of addiction makes the appearance of an extreme withdrawal understandable, for some kind of withdrawal reaction takes place with every drug that has a noticeable impact on the human body. This may be simply a straightforward example of homeostasis in an organism. With the removal of a drug that the body has learned to depend on, physical adjustments take place in the body. The specific adjustments vary with the drug and its effects. Yet the same general unbalancing effect of withdrawal will appear not only in heroin addicts but also in people who rely on sedatives to sleep. Both will tend to suffer a basic disruption of their systems when they stop taking the drug. Whether this disruption reaches the dimensions of observable withdrawal symptoms depends on the person and the role the drug played in his or her life.
What is observed as withdrawal is more than bodily readjustment. Different people’s subjective responses to the same drugs vary, as do the responses of the same person in different situations. Addicts who go through extreme withdrawal in prison may hardly acknowledge it in a setting like Daytop Village, a halfway house for drug addicts in New York City, where withdrawal symptoms are not sanctioned. Hospital patients, who receive larger doses of a narcotic than most street addicts can find, nearly always experience their withdrawal from morphine as part of the normal adjustment to coming home from the hospital. They fail even to recognize it as withdrawal as they reintegrate themselves into the routines of home.
If the setting and a person’s expectations influence the experience of withdrawal, then they influence the nature of addiction. For instance, Norman Zinberg has found that the soldiers in Vietnam who became addicted to heroin were the ones who not only expected it but who actually planned to become addicts. This combination of expectation of withdrawal and fear of it, along with a dread of being straight, form the basis of the image addicts have of themselves and their habits.
Viewing addiction as a pain-relieving experience that leads to a destructive cycle has several important conceptual and practical consequences. Not the least of these is its usefulness in explaining a persistent anomaly in pharmacology— the frustrating search for the nonaddictive analgesic. When heroin was first processed in 1898, it was marketed by the Bayer company of Germany as an alternative to morphine without morphine’s habit-forming properties. Following this, from 1929 to 1941, the National Research Council’s Committee on Drug Addiction had a mandate to discover a nonaddictive analgesic to replace heroin. Barbiturates and synthetic narcotics such as Demerol appeared during this search. Both turned out to be as addictive and as often abused as the opiates. As our addictive pharmacopoeia expanded, the same thing happened with sedatives and tranquilizers, from Quaalude and PCP to Librium and Valium.
Methadone, an opiate substitute, is still being promoted as a treatment for addiction. Originally presented as a way to block the negative effects of heroin, methadone is now the preferred addictive drug for many addicts, and like earlier painkillers, it has found an active black market. Moreover, many addicts on methadone maintenance continue to take heroin and other illicit drugs. The miscalculations behind the use of methadone as a treatment for heroin addiction originated in the belief that there is something in the particular chemical structure of a particular drug that makes it addictive. That belief misses the obvious point of the analgesic experience, and researchers who are now synthesizing potent analgesics along the lines of endorphins and who expect the results to be nonaddictive may have to relearn the lessons of history.
The more successful a drug is in eliminating pain the more readily it will serve addictive purposes. If addicts are seeking a specific experience from a drug, they will not dispense with the rewards that that experience provides. This phenomenon occurred in the United States 50 years before methadone treatment. John O’Donnell, working at the Public Health Service Hospital in Lexington, found that when heroin was outlawed, Kentucky addicts became alcoholics in large numbers. Barbiturates first became widespread as an illicit substance when World War II interrupted the flow of heroin into the United States. And more recently the National Institute on Drug Abuse has reported that contemporary addicts readily switch among heroin, barbiturates, and methadone—changing whenever the drug they prefer is hard to find.
One other insight points up how the total experience of an addict includes more than the physiological effects of a given drug. I have found, in questioning addicts, that many of them would not accept a substitute for heroin that could not be injected. Nor would they like to see heroin legalized, if this meant eliminating injection procedures. For these addicts, the ritual associated with heroin use was a crucial part of the drug experience. The surreptitious ceremonies of drug use (which are most apparent with hypodermic injection) contribute to the repetition, sureness of effect, and protection from change and novelty that the addict seeks from the drug itself. Thus a finding that first appeared in a study conducted by A. B. Light and E. G. Torrance in 1929 and that has continued to puzzle researchers becomes understandable. Addicts in this early study had their withdrawal relieved by the injection of sterile water and in some cases by the simple pricking of their skin by a needle—called a “dry” injection.
Personality, setting, and social and cultural factors are not merely the scenery of addiction; they are parts of it. Studies have shown that they influence how people respond to a drug, what rewards they find in the experience, and what consequences removal of the drug from the system has.
First, consider personality. Much research on heroin addiction has been muddled by the failure to distinguish between addicts and controlled users. An addict in Chein’s study said of his first shot of heroin, “I got real sleepy. I went in to lay on the bed…. I thought, this is for me ! And I never missed a day since, until now.” But not everyone responds so totally to the experience of heroin. A person who does is one whose personal outlook welcomes oblivion.
We have already seen what personality characteristics Chein found in ghetto heroin addicts. Richard Lindblad of the National Institute on Drug Abuse noted the same general traits in middle-class addicts. At the other extreme there are people who prove almost entirely resistant to addiction. Take the case of Ron LeFlore, the ex-convict who became a major-league baseball player. LeFlore began taking heroin when he was 15, and he used it every day—both snorting and injecting it—for nine months before he went to prison. He expected to experience withdrawal in prison, but he felt nothing.
LeFlore tries to explain his reaction by the fact that his mother always provided him with good meals at home. This is hardly a scientific explanation for the absence of withdrawal, but it suggests that a nurturing home environment—even in the middle of the worst ghetto in Detroit—gave LeFlore a strong self concept, tremendous energy, and the kind of self-respect that prevented him from destroying his body and his life. Even in his life of crime, LeFlore was an innovative and daring thief. And in the penitentiary he accumulated $5,000 through various extracurricular activities. When LeFlore was in solitary confinement for three and a half months, he began doing sit-ups and push-ups until he was doing 400 of each daily. LeFlore claims never to have played baseball before entering prison, and yet he developed so well as a baseball player there that he was able to try out with the Tigers. Shortly thereafter he joined the team as its starting center fielder.
LeFlore exemplifies the kind of personality for which continual drug use does not imply addiction. A group of recent studies has found that such controlled use of narcotics is common. Norman Zinberg has discovered many middle-class controlled users, and Irving Lukoff, working in Brooklyn ghettos, has found that heroin users are better off economically and socially than was previously believed. Such studies suggest that there are more self-regulated users of narcotics than addicted users.
Quite apart from the personality of the user, it is hard to make sense of the effects of drugs on people without taking into account the influence of their immediate social group. In the 1950s sociologist Howard Becker found that marijuana smokers learn how to react to that drug—and to interpret the experience as pleasurable—from the group members who initiate them. Norman Zinberg has shown this to be true of heroin. Besides studying hospital patients and Daytop Village interns, he investigated American GIs who used heroin in Asia. He found that the nature and degree of withdrawal was similar within military units but varied widely from unit to unit.
As in small groups, so in large ones, and nothing defies a simple pharmacological view of addiction so much as variations in the abuse and effects of drugs from culture to culture and over a period of time in the same culture. For example, today the heads of the federal government’s bureaus on both alcoholism and drug abuse claim that we are in a period of epidemic alcohol abuse by young Americans. The range of cultural responses to opiates has been apparent since the l9th Century, when Chinese society was subverted by the opium imported by the British. At that time other opium-using countries, such as India, suffered no such disasters. These and similar historical findings have caused Richard Blum and his associates at Stanford University to deduce that when a drug is introduced from outside a culture, especially by a conquering or dominating culture that somehow subverts indigenous social values, the substance is likely to be widely abused. In such cases the experience associated with the drug is seen as having tremendous power and as symbolizing escape.
Cultures also differ entirely in their styles of drinking. In some Mediterranean areas, such as rural Greece and Italy, where great quantities of alcohol are consumed, alcoholism is rarely a social problem. This cultural variation enables us to test the notion that addictive susceptibility is genetically determined, by examining two groups that are genetically similar but culturally different. Richard Jessor, a psychologist at the University of Colorado, and his colleagues studied Italian youths in Italy and in Boston who had four grandparents born in southern Italy. Although the Italian youths began to drink alcohol at an earlier age, and although overall consumption of alcohol in the two groups was the same, instances of intoxication and the likelihood of frequent intoxication were higher among the Americans at a .001 level of significance. Jessor’s data show that to the extent that a group is assimilated from a low-alcoholism culture to a culture with a high alcoholism rate, that group will appear intermediate in its alcoholism rate.
We need not compare whole cultures to show that individuals do not have a consistent tendency to become addicted. Addiction varies with life stages and situational stresses. Charles Winick, a psychologist dealing with public-health problems, established the phenomenon of “maturing out” in the early 1960s when he examined the rolls of the Federal Bureau of Narcotics. Winick found that one quarter of the heroin addicts on the rolls ceased to be active by the age of 26, and three quarters by the time they reached 36. A later study by J. C. Ball in a different culture (Puerto Rican), which was based on direct follow-through with addicts, found that one third of the addicts matured out. Winick’s explanation is that the peak period for addiction—late adolescence—is a time when the addict is overwhelmed by the responsibilities of adulthood. Addiction may prolong adolescence until a person matures sufficiently to feel capable of handling adult responsibilities. At the other extreme, the addict may become dependent on institutions, such as prisons and hospitals, that supplant drug dependence.
It is unlikely that we shall ever again have the kind of large-scale field study of narcotics use that was provided by the Vietnam War. According to then Assistant Secretary of Defense for Health and Environment Richard Wilbur, a physician, what we found there disproved anything taught about narcotics in medical school. Over 90 percent of those soldiers in whom heroin use was detected were able to give up their habits without undue discomfort. The stress produced by danger, unpleasantness, and uncertainty in Vietnam, where heroin was plentiful and cheap, may have made the addictive experience alluring for many soldiers. Back in the United States, however, removed from the pressures of war and once again in the presence of family and friends and opportunities for constructive activity, these men felt no need for heroin.
In the years since American troops have returned from Asia, Lee Robins of Washington University and her colleagues in the department of psychiatry have found that of those soldiers who tested positive in Vietnam for the presence of narcotics in their systems, 75 percent reported that they were addicted while serving there. But most of these men did not return to narcotics use in the United States (many shifted to amphetamines). One third continued to use narcotics (generally heroin) at home, and only 7 percent showed signs of dependence. “The results,” Robins writes, “indicate that, contrary to conventional belief, the occasional use of narcotics without becoming addicted appears possible even for men who have previously been dependent on narcotics.”
Several other factors play a part in addiction, including personal values. For example, a willingness to accept magical solutions that are not based on reason or individual efforts seems to increase the probability of addiction. On the other hand, attitudes favoring self-reliance, abstinence, and maintaining health seem to decrease this probability. Such values are transmitted at cultural, group, and individual levels. Broader conditions in a society also affect its members’ need and willingness to resort to addictive escape. These conditions include levels of stress and anxieties brought on by discrepancies in the society’s values and by lack of opportunities for self-direction.
Of course, pharmacological effects also play a part in addiction. These include the gross pharmacological action of drugs and differences in the way people metabolize chemicals. Individual reactions to a given drug can be described by a normal curve. At one end are hyperreactors and at the other end are nonreactors. Some people have reported day-long “trips” from smoking marijuana; some find no relief from pain after receiving concentrated doses of morphine. But no matter what the physiological reaction to a drug, it alone does not determine whether a person will become addicted. As an illustration of the interaction between the chemical action of a drug and other addiction-determining variables, consider cigarette addiction.
Nicotine, like caffeine and the amphetamines, is a central-nervous-system stimulant. Schachter has shown that depleting the level of nicotine in the smoker’s blood plasma causes an increase in smoking. This finding encouraged some theorists in the belief that there must be an essentially physiological explanation for cigarette addiction. But as always, physiology is only one dimension of the problem. Murray Jarvik, a psychopharmacologist at UCLA, has found that smokers respond more to nicotine inhaled while smoking than to nicotine introduced through other oral means or by injection. This and related findings point to the role in cigarette addiction of ritual, alleviation of boredom, social influence, and other contextual factors—all of which are crucial to heroin addiction.
How can we analyze addiction to cigarettes and other stimulants in terms of an experience when that experience is not analgesic? The answer is that cigarettes free smokers from feelings of stress and internal discomfort just as heroin does, in a different way, for heroin addicts. Paul Nesbitt, a psychologist at the University of California at Santa Barbara, reports that smokers are more tense than nonsmokers, and yet they feel less nervous while smoking. Similarly, habitual smokers show fewer reactions to stress if they smoke, yet nonsmokers do not show this effect. The person who becomes addicted to cigarettes (and other stimulants) apparently finds the rise in his heart rate, blood pressure, cardiac output, and blood-sugar level reassuring. This may be because the smoker becomes attuned to his internal arousal and is able to ignore the outside stimuli that normally make him tense.
Coffee addiction has a similar cycle. For the habitual coffee drinker, caffeine serves as a periodic energizer throughout the day. As the drug wears off, the person becomes aware of the fatigue and stress that the drug has masked. Since the person has not changed his inherent capacity to deal with the demands his day makes of him, the only way for him to regain his edge is to drink more coffee. In a culture where these drugs are not only legal but generally accepted, a person who values activity can become addicted to nicotine or caffeine and use them without fear of interruption.
As a final example of how the concept of addiction to an experience allows us to integrate several different levels of analysis, we can examine the alcohol experience. Using a combination of cross-cultural and experimental research, David McClelland and his colleagues at Harvard were able to relate individual predispositions toward alcoholism to cultural attitudes about drinking.
Alcoholism tends to be prevalent in cultures that emphasize the need for men to continually manifest their power but that offer few organized channels to achieve power. In this context, drinking increases the amount of “power imagery” that people generate. In the United States, men who drink excessively measure higher in the need for power than nondrinkers and are especially likely to fantasize about their dominance over others when they drink heavily. This sort of drinking and fantasizing is less likely to occur in those who actually wield socially accepted power.
From McClelland’s research we can extrapolate a picture of the male alcohol addict that fits clinical experience and descriptive studies of alcoholism neatly. A male alcoholic may feel that it is the masculine thing to do to wield power, but he may be insecure about his actual capacity to do so. By drinking he soothes the anxiety produced by his feeling that he does not possess the power he should have. At the same time, he is more likely to behave antisocially—by fighting, by driving recklessly, or through boorish social behavior. This behavior is especially likely to be turned on spouses and children, whom the drinker has a particular need to dominate. When the person sobers up, he becomes ashamed of his actions and painfully aware of how powerless he is, for while he is intoxicated he is even less able to influence others constructively. Now his attitude becomes apologetic and self-abnegating. The way open to him to escape his further deprecated self-image is to become intoxicated again.
Thus the very way in which a person experiences alcohol’s biochemical effects originates to a great extent in the beliefs of a culture. Where there are low rates of alcoholism, in Italy or Greece for example, drinking does not signify macho accomplishment and the transition from adolescence to adulthood. Rather than deadening frustration and providing an excuse for aggressive and illegal acts, the depression of inhibitory centers through alcohol lubricates cooperative social interactions at mealtimes and other structured social occasions. Such drinking does not fall into the addiction cycle.
We can now make some general observations about the nature of addiction. Addiction is clearly a process rather than a condition: It feeds on itself. We have also seen that addiction is multidimensional. This means that addiction is one end of a continuum. Since there is no single mechanism that sets off addiction, it cannot be viewed as an all-or-nothing state of being, one that is unambiguously present or absent. At its most extreme, in the skid-row bum or the almost legendary street addict, the person’s entire life has been subjugated to one destructive involvement. Such cases are rare when compared with the total number of people who use alcohol, heroin, barbiturates, or tranquilizers. The concept of addiction is most apt when it applies to the extreme, but it has much to tell us about behavior all along the spectrum. Addiction is an extension of ordinary behavior—a pathological habit, dependence, or compulsion. Just how pathological or addictive that behavior is depends on its impact on a person’s life. When an involvement eliminates choices in all areas of life, then an addiction has been formed.
We cannot say that a given drug is addictive, because addiction is not a peculiar characteristic of drugs. It is, more properly, a characteristic of the involvement that a person forms with a drug. The logical conclusion of this line of thought is that addiction is not limited to drugs.
Psychoactive chemicals are perhaps the most direct means for affecting a person’s consciousness and state of being. But any activity that can absorb a person in such a way as to detract from the ability to carry through other involvements is potentially addictive. It is addictive when the experience eradicates a person’s awareness; when it provides predictable gratification; when it is used not to gain pleasure but to avoid pain and unpleasantness; when it damages self-esteem; and when it destroys other involvements. When these conditions hold, the involvement will take over a person’s life in an increasingly destructive cycle.
These criteria draw in all those factors—personal background, subjective sensations, cultural differences—that have been shown to affect the addiction process. They are also not restricted in any way to drug use. People familiar with compulsive involvements have come to believe that addiction is present in many activities. Experimental psychologist Richard Solomon has analyzed the ways in which sexual excitement can feed into the addictive cycle. Writer Marie Winn has marshaled extensive evidence to show that television viewing can be addictive. Chapters of Gamblers Anonymous deal with compulsive gamblers as addicts. And a number of observers have noted that compulsive eating exhibits all the signs of ritual, instantaneous gratification, cultural variation, and destruction of self-respect that characterize drug addiction.
Addiction is a universal phenomenon. It grows out of fundamental human motivations, with all the uncertainty and complexity that this implies. It is for these very reasons that—if we can comprehend it—the concept of addiction can illuminate wide areas of human behavior.
For further information:
Addictive Diseases. Vol. 2. No. 2, 1975.
Blum, R. H., et. al., Society and Drugs / Social & Cultural Observations, Vol. 1. Jossey-Bass. 1969.
McClelland, D. C., et al., The Drinking Man. The Free Press, 1972.
Peele, Stanton, and Archie Brodsky. Love and Addiction. Taplinger Publishing Co., 1975.
Szasz, Thomas. Ceremonial Chemistry: The Ritual Persecution of Drugs, Addicts and Pushers. Doubleday, 1974.