chapter three

the social impact of drug dependence and drug-induced behavior


Western man pays frequent homage to the freedom of his will. Although Western philosophy has always included strains of predestination in one form or another, the belief that man controls his fate runs deep, and even those who question this v w rom. the scientific standpoint are often quick to add that the state should continue to act upon it. Whenever an individual chooses to act irresponsibly, as defined by his society, he is held accountable to other men, to his state, or according to prevailing belief, to his Creator.

But man does not will everything that happens to him, and the precepts of free will and accountability have been tempered in relation to many conditions of existence, Foremost of these, of course, is the notion of sickness. Although the individual may place himself in a position which increases the risk of disease, he does not usually will to be sick; -accordingly, he is generally not held accountable either for his sickness or for its behavioral concomitants. Poverty is another area which has recently been separated from notions of free will and moral worth. There are some who shun worldly possessions in order to enhance their spirituality, but most men do not will to be poor. Since

I

the late 19th Century@ Western society has acted increasingly on the proposition that environmental factors may predispose poverty and socioeconomic immobility. The emergence of the welfare state rests on the belief that man should not be held accountable for, or suffer for that which he cannot prevent.

Disease and poverty are two broad qualifications of a normative order premised on considerations of free will. In addition, our normative system and our law are replete with other exceptions which recognize that an individual may well be overborne by others or by conditions for which he is not responsible. Love, hypnosis, duress, "acts of God," irresistible impulses, uncontrollable rages all may excuse the individual for conduct which might otherwise be considered foolish, unwise, intemperate or even criminal. Of course, there are also conditions which may predispose behavior although we do not excuse them, such as foolishness, immoderation and vanity.

Drugs introduce a new dimension into this uneasy marriage of free will and human and social imperfection. The very phrase "being under the influence" of a drug manifests the fundamental proposition that drugs can alter or control human behavior.

The drug may induce a socially desirable form of control in the seiise that the influence of a drug may restore control which has otherwise been lost. For example, sedative drugs may be administered to a person whose anguish over the death of a loved one is out of control, not to obliterate grief but to modify the person's responses. Drugs may also be used to minimize the effects of "unwilled" behaviors stemming f rom mental illness or aberration. Some examples of the socially sanctioned uses of drugs for behavior control in the context of therapy are: the administration of drugs to mental patients to dampen the intensity of acute behavioral disruption and to enhance their capacity for or" ,la nized responses, the drug-based efforts to increase concentration and reduce aimlessness of hyperkenetic children, and the maintenance of heroin-dependent persons on methadone to stabilize their otherwise anti-social behavior. Drugs have also been used for punishment; that is to alter the behavior of persons in detention, although this development, has met with substantial resistance.

The common thread of these examples is that drugs may be employed to restore the capacity for responsible, willed behavior-. However, public attitude and social policy toward drug use are focused primarily on the fact that drugs may also diminish the capacity of a person to control his conduct in the manner society expects of him. This perception has dominated political rhetoric, literary description, legal doctrine and public understanding about drugs for centuries. With some exceptions, the American normative system stipulates that such loss of control is socially undesirable and in itself constitutes irresponsible behavior. On the other hand, American law has long been ambivalent

about whether a person should be held entirely or partially accountable for such behavior or its consequences, reflecting the basic tension between f reedom of will and human limitations.

Whatever the precise relationship between drug use and self -control, the very possibility of drug-influenced behavior is what distinguishes drug use from other forms of behavior, motivating all societies to regulate it. In American society, however, the extent to which drug use, by itself, can deprive the individual of control over his behavior has been highly exaggerated.

Drugs are fixed in the collective consciousness as substances which can rob man of his sentiency, morals and values. Each drug, whether it be LSD, heroin or marihuana, is widely believed to have the capacity to destroy the will. For decades, the public has held the view that the initial use of psychoactive substances, often tied to the exotic Eastern world, is the opening of Pandora's box: one taste of the forbidden f ruit and control will shortly be lost. The assumed paths from marihuana to herion, f rom. LSD to insanity, f rom heroin to crime, and, in bygone days, from tobacco to alcohol, and from alcohol to skid row, reflect concern not only about social cost but also about the inevitable erosion of will.

This presumed relationship between drugs and -,,,ill is also reflected in the tendencies to ascribe a causal relationship to drugs and almost every type of unwanted behavior, and to attribute to drugs the undes1rable behavior of disapproved social groups. Whenever specific drugs are temporally related to sexual excess, crime, traffic accidents or use of other drugs, the person and his will tend to be forgotten, and the drug itself becomes the villain.

Perhaps the unique expression of drug-induced loss of self-control is the inability of the individual to stop using the drug. The dread of becoming ensnared in the "clutches of addiction" has long dominated public antipathy toward the evils of drug use, reflecting a deep-seated belief that mental, physical and moral debilitation is the likely consequence of habitual drug use. Whatever its ancillary impact or subsequent history, the Harrison Narcotic Act of 1914 embodied above all else a firm public policy judgment opposing the use of "addicting" or "habit-forming drugs." Further, the progression thesis, which has been propounded since drug policy began, although the drugs have changed, and the more recent distinction between bard and soft drugs, suggests how strongly concern about dependence dominates the entire drug issue.

The notion of addiction is of relatively recent origin, emerging as a recognizable medical entity during the 18th Century. Before that time, the focus of social control in this country as in other societies, was on the disordering consequences of the drug experience. Aggressive behavior, loss of psychomotor control or other disordered behavior

TABLE 111-1. (Cont.)

FOOTNOTES to TABLE 111-1.

I In choosing substances to be included in this table, the Commission did not attempt to be comprehensive. Selections were made in order to illustrate the full range of dependence liability and capacity for influencing or inducing behavioral change.

2 Capacity of drug to induce continued use on the basis of psychological reward. Relative judgments are based on use of maximum tolerated dose, as measured by laboratory studies and confirmed by refined clinical experience.

3 The actual prevalence of chronic use among the using population. The relative prevalence of chronic use of specific substances is determined by a wide range of sociocultural variables, including such factors as social custom, availability of the substance, susceptibility of particular populations to patterns of chronic use and availability of more potent substances.

4 Potential for disruption or impairment of social functioning after a single dose. Relative judgments are based on consumption of doses sufficient to produce marked pharmacological effects.

5 Drug-induced behavioral response, as measured by potential impairment of social functioning, accompanying chronic administration of dependence-producing doses.

0 Short-term behavioral responses, measured by disruption or impairment of social functioning, accompanying interruption of drug taking after chronic administration of dependenceproducing doses.

7The relative judgments regarding methadone are based on parenteral administration and oral administration in naive subjects. The Commission expressly notes that oral administration to opiate-dependent persons in a maintenance setting has a significantly different impact on behavior.

8 Includes related drugs such as psilocybin, DMT.

9 Inapplicable. Because of extremely low reinforcement potential, chronic use patterns do not generally occur, and no abstinence syndrome has been described.

10 Includes drugs which are structurally related and roughly similar in effect to mescaline, such as DOM ("STP").

induced by the drug experience must also be taken into account in the formulation of drug policy.

While drugs have a capacity to affect behavior, they do not do so uniformly. Table 111-1 provides an overview of the relative capacity of selected drugs to induce dependence and influence behavior. However, drugs do not affect behavior independently. Non-drug factors play an equally crucial role in determining the behavorial concomitants of drug use. The personal characteristics of the user, his expectations about the drug experience and about society's attitudes and possible responses, the setting in which the drug is used, as well as broader sociocultural factors, are all major determinants of drug effect and of the individual's capacity to control the effects of the drug through the exercise of his will.

We will now examine the social consequences of drug-using behavior. First, we will establish a framework by analyzing drug dependence and drug-induced behavior from a psychopharmacological standpoint, providing detailed explanations for the concepts presented in Table 111-1. Then we will consider the actual and potential impact on the public safety and the public health and welfare of the patterns of drug-using behavior discussed in the previous Chapter. Finally, we will sketch the implications of this analysis for social policy. These guidelines will serve as a backdrop for the application of the policy-making process in Chapter Four.

I

DRUG DEPENDENCE

Since the psychoactive properties of naturally-occurring substances were first discovered and sought, the excessive, chronic or compulsive use of these substances has been an identifiable and predictable human condition. Until the 19th Century, however, this phenomenon was viewed primarily in moral, rather than medical or scientific terms. One 18th Century observer likened the use of opium in Eastern countries to the use of "wine and spiritous liquors I'll civilized Europe (where it is) the support of the coward, the solace of the wretched and the daily source of intoxication of the debauchee" (Crumpe 1793).

This is not to say that the physical consequences of chronic drug use went unnoticed. As early as 1701, a London physician, in The My8te?4e8 of Opium Revealed, addressed "The Effects of Sudden Leaving Off the Use of Opium After a Long and Lavish Use Thereof," where he described a withdrawal syndrome (Jones 1701). However, neither Dr. Jones nor his contemporaries regarded this condition as fundamentally different from that associated with excessive wine drinking or the excessive eating or chewing of other substances such as tobacco. The, physical concomitants of the "opium habit", like those for tobacco and wine, were associated by some with a defect of individual will and by others with some unknown property of the drugs.

Isolation of morphine from opium and the subsequent development of the hypodermic syringe clarified the distinction between the opium habit and the alcohol and tobacco habits. Two previously held theories were now discarded: first, that the opium habit was dependent on oral ingestion of the drug, and second, that the withdrawal effects arose. from resinous substances in the opium. Vivid literary descriptions, the, introduction of opium-smoking by Chinese immigrants, and the widespread use of opium and morphine during and after the Civil War soon stimulated the attention of medical professionals. The "army disease" or morphinisin was now recognized as a distinctive medical and social problem.

During the last three decades of the 19th Century, medical professionals strove to understand, describe and treat this sickness. Meanwhile, the public was becoming acquainted with the habit-forming properties of the opiates, as the population of opiate-dependent persoils increased. State laws at once, began to reflect them popular fear of drug habits, as did the labelling requirement of the Pure Food and Drug Act of 1906. Simultaneously, the social aspects of chronic opiate use aroused the popular imagination. The stereotype of the "dope fiend" emerged, and with it a highly restrictive public policy, one rooted in considerations apart from the, pharmacolo(vic effects of the prohibited drugs.

TEMINOLOGICAL CONFUSION

In the Vinted States, the public, the medical professions and policy makers all discovered the indix-idual mid social conse(Iiiences of chronic opium use at roughly the same time. A connection between popular vocabulary and scientific terminology was established as the scientific community tended to appropriate lay terins, laden with emotional and imprecise meanings, and to imbue them with scientific meanings. The first of these descriptive terms to emerge was "addictions"

Addiction

The word addiction evolved from the Latin addiccre which, in Roman law, meant the giving oi- binding over of a person to one thing or another, such as a judge assignbig a debtor to his creditor. By the late 16th Century, "to addict" had apparently assumed a broader meaning: to devote, give up or apply habitually to a practice. One writer suggests that the word was generally identified with bad habits or vices (Sonnedecker 1959). With the emergence ol'public and scientific interest in the opium problem, ",,addiction"' and "inania" were commonly used in the press to describe this ascendent vicc.

Within the American scientific community, the terms most comnionly employed during the 19th and early 20th Centiirles to describe the condition were "opium (or morphine) habit" and "morphinism."' In 1903, for example, the, American I'liarmaceutical Association establislied a "Committee oil t1le Acquirement of Drug I fabits." By 1920, however, the scientific community had given the terni addiction its blessing, a development paralleling the popularization of the word 44 narcotics" and the entry of government into the field. "Narcotic addiction" became a household phrase.

As we suggested in Chapter One, "narcotic" soon lost its pharmacologic meaning and came to encompass silly drug assoelated with the populations using the opiates or cocaine; similarly "addiction" came to

be tied in the public mind to the habitual use of any drug. In the press and councils of government, marihuana users and cocaine users were frequently characterized as addicts. Interestingly, the dangers of alcohol "addiction" were widely proclaimed during the intense Public discussion surrounding the adoption of the 18th Amendment although this terminology was strongly resisted by opponents of Prohibition.

Many scientists remained uncomfortable with the imprecise use of the term addiction, and particularly with its strong moral over-tones. Yet, because the condition was so little understood, there was little agreement on a substitute. Throughout the 1920's there remained "considerable confusion ... as to the significance of various terms emploved in consideration of drug addiction in the broad sense of the wo rd" (Seevers 1962). Terry and Pellens, in the introduction to their classic 1928 work addressed this problem:

One further matter requires consideration, namely, the terminology employed. As elsewhere, here also controversial subjects are involved, for different writers have used terms and definitions which in themselves have indicated particular attitudes toward the nature of the, problem. Thus habit, craving, appetite, mania, addiction, addictiondisease, all may be interpreted significantly if desired by those using or reading them. We have tried to select some name for the condition of chronic opium-using that would not carry a partisan, restricted or incomplete implication as f ar as the nature of the conditicm- is concerned. The phrase Chronic ophw? iptox-I'cat;an seenis to fulfill this purpose better than any other but it has the disadvantage of length and is at times an awkward expression. We decided, therefore, not to restrict ourselves to any one terni, but to employ whichever of those in common use today semed best suited to the individual need (Terry and Pellens, 1928).

Most scientific observers recognize that habitual users of many drligs did not experience the same degree of physical discomfort upon abstinence as did chronic opiate, users. Consequent] - y, the main goal was to establish a conceptual framework and a vocabulary which would distinguish the habitual use of other drugs f rom the, chronic rise of opiates. By the late 1920's, a general consensus had emcr@),red that habit-forniiii(I drugs could be separated into those which produced "habituation," and those which produced "addiction."

Habituation

In broad terms, habituation usually characterized recurrent use of those drugs which were not associated with the development of tolerance and an abstinence syndrome; for this reason, the condition was closely linked with weakness of individual will rather than specific

drug effects. Addiction, by contrast, was associated with physical dependence and -with serious individual and social consequences. This dichotomy, because of its public policy implications, was not completely satisfactory f rom either the scientific or legislative viewpoints. For example, the tendency to classify cannabis as an habituating substance was generally resisted by those who sought to prohibit its use, mainly because public policy was so closely identified with the prohibition of drugs of addiction. Well into the past decade, there was still a strong tendency to classify marihuana as an addictive drug.

Many pharmacologists were uncomfortable with the addiction-habitnation dichotomy because many drugs would not fit easily in these categories. They recognized that cocaine, for example, did not produce the classic withdrawal symptoms or tolerance which were so closely intertwined with the notion of addiction; yet, it was clear to them that "cocainism" carried significant consequences for both the individual and society. In addition, the succeeding years witnessed the development for medical application of whole new families of psychoactive drugs. Often these new drugs could not easily be pigeon-holed within the simple dichotomy. Many pharmacologists were concerned that classifying such new drugs as "addicting" would stigmatize them by associating them with the opiates and with the perception of serious social hazards. From this concern emerged a policy-based distinction between the labelling and warning concepts tied to the Pure Food and Drug Act and its successor statutes, and the addiction concept associated with the Harrison Act.

The Search for Precision

For more than three decades, experts attempted to preserve the habituation/addition dichotomy, continually redefining and enlarging its scope in the hope that it would serve the needs not only of science and medicine but also of law and sociology.

In 1931, two experts, attempting to introduce some coherence into the subject, defined habitation as "a condition in which the, habitu6 desires a drug but suffers no ill effects on its discontinuance." Addiction was defined as "a condition developed through the effects of repeated actions of a drug such that its use becomes necessary and cessation of its action causes mental or physical disturbances." Addiction was further subdivided into "true addiction" which involved the "physical disturbances" associated with the withdrawal syndrome, and "psychic addiction, which was associated with the "feeling of exhilaration and euphoria [constituting] an almost irresistible goad to its continued use" (Tatum and Seevers 1931).

Six years later another expert redefined the basic terms as follows:

By habituation is meant the physical phenomenon of adaptation and mental conditioning to the repetition of an effect. Habituation to opiates is probably more intense than habituation to other substances. In a, sense habituation represents Psychical dependence.

Addiction to opiates embraces three intimately related but distinct phenomena, namely tolerance, habituation, and dependence. These phenomena which make up the psychosomatic complex known as addiction are intricately interwoven and interdependent (Hirnmelsbach,1937).

Over the years, successive definitions and redefinitions became more and more elaborate. In 1957, the Expert Committee on AddictionProducing Drugs of the World Health Organization (World Health Organization, 1957) attempted to specify the ways in which addiction differed from habituation:


Rrug addiction

Drug addition is a state of periodic or chronic intoxication produced by the repeated consumption of a drug (natural or synthetic). Its characteristics include:

(1) an overpowering desire or need (compulsion) to continue taking the drug and to obtain it by any means;

(2) a tendency to increase the dose;

(3) a psychic (psychological) and generally a physical dependence on the effects of the drug;

(4) detrimental effect on the individual and on society.


Drug habituation

Drug habituation (habit) is a condition resulting from the repeated consumption of a drug. Its characteristics include:

(1) a desire (but not a compulsion) to continue takin- the drug for the sense of improved well-being which it engenders;

(2) little or no tendency to increase the dose;

(3) some degree of psychic dependence on the effect of the drug, but absence of physical dependence and hence of an abstinence syndrome;

(4) detriniental effects, if any, primarily on the individual.


Despite the loophole provided in subsection (3) to permit the elassification of cocaine as a drug of addiction, the WHO definitions continned to tie that term primarily to physical dependence, thereby perpetuating the impression that the social detriments of chronic drug use arise primarily from physical depedence or addiction.

Despite a concerted effort within the expert community during the 1950's to rationalize the ill-suited terms addiction and habituation, the confusion remained. As the World Health Organization noted in 1965:

Both terms are frequently used interchangeably and often inappropriatAly. It -is mot, uncommon to apply -the. term addiction to any misuse of drugs outside of medical practice, with a connotation of serious harm to the individual and to society, and often with a demand that something be done about it. Such broad use can only create confusion and misunderstanding when abuse of drugs is discussed from different viewpoints.

The difficulties in terminology become increasingly apparent with the continuous appearance of new agents with various and perhaps unique pharmacological profiles, and with changing patterns of use of drugs already well known. These developments must be considered in their relation to, but may not be adequately characterized by, current definitions of addiction. There is scarcely any agent which can be taken into the body to which some individuals will not get a reaction satisfactory or pleasurable to them, persuading, them to continue its use even to the point of abuse-that is, to excessive or persistent use beyond medical need. Probably the only exceptions are agents that have incidental or side effects that prevent such use-for example, cumulative or early toxic effects, to which the individual does not become tolerant (Eddy, et al., 1965).

Two basic problems inhere in the concepts of addiction and habituation. First, the nature of chronic drug-taking behavior, involving a range of individual-drug interactions, is entirely too complex to be compartmentalized into two mutually exclusive categories. Determining the point where the lesser (habituation) becomes the greater (addiction) is bound to be arbitrary, since, as is true in all biological responses, there is a wide range of variation in the same individual and between individuals.

Second, the terms, from their inception, were designed not only to describe a form of drug-using behavior but also to comprehend the relationship between that behavior and the society. The need to accommodate definitions to social consequence is reflected precisely in subsection (4) of the 1957 WHO definitions quoted above. That the chronicity of drug-taking behavior and social harm were not directly correlated became particularly obvious in the early 1960's when an anti-smoking crusade was launched. In this connection, the word addiction was commonly used to describe the tobacco habit despite the absence of significant drug-induced behavior arising from its use.

Drug Dependence

In the early 1960's, the search for more suitable concepts and terminology was intensified. In rapid-fire succession, inost experts in the field and most professional organizations discarded the terms addiction and habituation and substituted instead the concepts of physical and psychological (or psychic) dependence. After endorsement by two WHO expert groups and the relevant committee of the National Academy of Sciences-National Research Counsel, the WHO officially adopted this position in 1965, defining drug dependence as follows:

Drug dependence is a state of psychic or physical dependence, or both, on a drug, arising in a person following administration of that drug on a periodic or continuous basis. The characteristics of such a state will vary with the agent involved, and these characteristics must always be made clear by designating the particular type of drug dependence in each specific case; for example, drug dependence of morphine type, of barbiturate type, of amphetamine type, etc. (Eddy, et al., 1965).

In order to save the new notion of dependence from the fate of its predecessors, WHO added the following important caveat:

The specification of the type of dependence is essential and should form an integral part of the new terminology, since it is neither possible nor even desirable to delineate or define the term drug dependence independently of the agent involved. It should also be remembered that it was the desire to achieve the impossible and define a complex situation by a single term ("addiction" or "habituation," respectively) which has given rise to confusion in many cases. Therefore, the description of drug dependence as a state is a concept for clarification and not, in any sense, a specific definition.

However, the requirements of law and interdisciplinary communication have doomed this attempt to keep dependence as a wide umbrella sheltering a series of more technical dependence types. All attempts to provide a more comprehensive definition have been faced with the fundamental truth that dependence is a matter of degree.

For example, federal legislation and that of many states now define a drug-dependent person as:

A person who is using a controlled substance I and who is in a state of psychic or physical dependence, or both, arising from the use of that substance on a continuous basis. Drug dependence is characterized by behavioral and other responses which include a strong com-

'Many drugs with dependence liability, notably alcohol, are not legally classified as "controlled substances."

pulsion to take the substance on a continuing basis in order to experience its psychic effects or to avoid the discomfort caused by its absence.

The problem of degree is submerged in this definition within the terms "continuous" and "strong compulsion." From a legal standpoint, the umbrella definition and vague terms which cannot be applied to individual cases are inadequate, particularly when a finding that a person is drug dependent may result in coercive legal intervention.

The Commission applauds the much-belated attempt by the scientific community to sever its conceptual apparatus from the vocabulary of politics and emotion. "Addiction," like "narcotics" and "drug abuse," has a general connotation of evil, suggesting illicit ecstasy, guilt and sin. Because the public image is conditioned more by cultural perceptions than by medical ones, medically-precise meanings simply cannot be harmonized with common parlance.

We believe that the concept of drug dependence offers a useful, objective way of describing a highly complex range of drug-using behavior. At the same time, the Commission recognizes that the contrasting requirements of law and science may doom "dependence" to the fate of its predecessors. The only way to avoid this result is for the scientific community to engage in a concerted attempt to formulate a narrower umbrella definition which will meet the specificity requirements of law. For example, the broad concept of drug dependence must, for legal purposes, be oriented toward the degree and types of dependence which impair the social f unctioning of the drug-dependent person and pose predictable adverse consequences for the society.

In addition to this qualification regarding the requirements of law, the Commission also emphasizes the responsibility of the expert cornmunity to communicate an understanding of drug dependence to the public, and to modify the exaggerated perceptions which have so long been tied to the concept of addiction.

Excising "Addiction"

The imprint of history on public attitudes is deep. Addiction still provides the lightning rod for public concern about drugs, and is generally identified with "physically addicting" drugs, the prototype being heroin. The "narcotics," morphine and cocaine, were the models for comparative social danger 50 years ago, and heroin is the model today. "Narcotic" use was identified with depravity, immorality, uncontrolled drug use (addiction) and crime 50 years ago, and the same is true today.

Because addiction has been painted as the paramount social and individual danger in drug use, these images and fears extend to some extent to the use of all drugs. Scientific emphasis on the physical attributes of addiction has confirmed and supported the lay fears.

As a general guide for public policy and personal conduct, the fear of addiction is a constant. When asked in the context of the National Survey which drugs are addictive in the sense that "anybody who uses it regularly becomes physically [and/or] psychologically dependent on it and can't get along without it," the public responded affirmatively in the following proportions:


When asked, in an open-ended question, to elaborate on the dangers of proprietary and prescription drugs, the most common response was that they are habit forming. Roughly 50% of the public characterized this as the chief reason for not using prescription drugs. For proprietary drugs, 35% mentioned this concerns a proportion exceeded only by the 40% which feared overdoses. Finally, slightly more than half of those with opinions on the subject have worried that if they took pills they might become dependent on them (48% have worried and 44% have not worried).

These responses bear comparison with the intensity of the fear of addiction. That is, all these drugs are perceived by a large majority of people to be addicting; but specific perceptions about the nature of this plienomenon vary according to drug, often inaccurately. When asked whether they agreed or disagreed with the statements that "you can use (heroin or marihuana) occasionally without ever becoming addicted to it,"only a small proportion of the public agreed:

Alcohol and barbiturates are not viewed as addicting to the same extent as heroin, and the alcoholic is not viewed with the same fear as the "narcotics addict." For example, the Commission-sponsored National Survey in 1971 found that 66% of the adult public believe that 4 9 most people who use alcohol lead a normal life;" only 237o thought the same was true of most marihuana users (Abelson et al., 1972).

These differences in perception stem from social factors rather than from failure to ascribe addiction potential to all drugs. Paraphernalia is an important indicator of true addiction in the public imagination; the needle, the spoon and irregularly-shaped cigarettes stand as symbols of drug addiction. Further, the perception of addictiveness and its severity has been tied to class and ethnic considerations since the creation of modern drug policy. The net result is that although most drugs are thought to be addictive, some are thought to be more controllable and less of a problem than others. These discriminations are at odds with pharmacological truth. To redress this situation, we now turn to an overview of the nature of drug dependence and its social impact.

TOWARD A FUNCTIONAL UNDERSTANDING OF

DRUG DEPENDENCE

Research has established that repetitive drug use results from the interaction between a drug, the user and the surrounding environment. Understanding this behavior requires a conjunction of psychological, pharmacological and sociological theory. The concept of drug dependence offers a useful framework for such an analysis. This is not to say that it is without ambiguity, but rather that it is functional, and comports with social, psychological and pharmacological notions, rather than overemphasizing one aspect of this intricate drug-personsituation relationship.

Psychological Dependence: The Primary Reinf orcer

To explore the concept of dependence, we must approach repetitive, drug use from a broad psychological standpoint. Ul behavior which is repeated more or less systematically, whether it be dressing in a certain order, watching special television programs, playing poker on Thursday, going to work in the, morning or coining !ionic from work in the evening, has been reinforced. In a sense, a person can be said to be dependent on any of the innumerable liabits of life. The iniportant question, however, is how strongly the bebavior is reinforced and by what factors. Or, put the other way, what is the degree of dependence?

Degree of dependence can only be measured by looking beyond the behavior itself to its role in the individual's existence and to the nature of the adjustments which would be made if he could not beliave in the way he has come to depend upon. For example, the compulsive gambler is preoccupied with this particular behavior, often to the, exclusion of his social obligations. Other persons may be, preoccupied with sexual behavior, sometimes to the point of dominating the person's existence and interfering with the lives of others. For many Americans, TV viewing on Sunday afternoon during football season has become a highly significant part of weekend life. This all suggests that recurrent behaviors will fall on a continuum from lesser to greater dependence in terms of their importance. to the individual.

The same is true for repetitive drug use, with one important addition. While other habits are only indirectly reinforced through the central nervous system, psychoactive drug use is directly reinforced by its effect on the braill.2 This factor also distin(mishes the, notion of vitamin-deficient, diabetic and cardiac-insufficient patients. Psyeboactive drugs also modify the capacity of the nervous system to react to, and to interpret the nature of the stimulus.

Underlying the notion of psychological dependence is the same concept of positive reinforcement which describes behavioral responses


2 With pharmacologically inert substances dependence is based solely on the so-called placebo effect. It is strictly psychogenic and a reasonable measure of the, existing psychological state of the user or of the user's relationship with the giver. Many other substances which have no direct effect on the central nervous .system may, because of a strong peripheral action, reinforce psychologically and create dependence by drug-induced sensory input or by abolishing unpleasant sensations which arise from the the periphery. (For example, relief of burning sensation by counterirritants, intense catharsis, relief of heartburn by antacids and the like.)

Consideration of dependence on non-psychoactive drugs or placebos is introduced here only to show why it should not be confused, as it has been, with the principal issues as they relate to dependence on psychoactive drugs.

to many types of rewards such as food, drink, sex, and acclaim. In this instance, however, the specific reinforcer is a drug whose effects are sufficiently attractive and rewarding psychologically at the first trial to motivate the user to repeat the experience.

The Pharmacological Component: Reinforcement Potential

An individual who has had no experience with psychoactive substances will never become drug dependent. Having once experienced psychoactive effects, many persons will become dependent to some degree. Some drugs are so weak that little harm results. But many are such powerful reinforcers that if every individual in a given society were exposed to all such psychoactive drugs by intravenous administration and then permitted free access to them, a major social problem would ensue.

Lesser animals, such as monkeys or even rats, having once experienced a drug such as cocaine and after being given unlimited access, will self-administer the drug until they die. It should be clearly understood by those who decry the depravity of the compulsive drug user that susceptibility is only relative, and under certain conditions, almost any individual can be made to be drug dependent in the most extreme sense of the term. However, specific drugs are qualitatively different in this respect, and it is therefore important to consider the reinforcement potential of different substances.

Some drugs offer, from a psychopharmacologic standpoint, high rewards and consequently great reinforcement for their continued use. With drugs such as alcohol, heroin, amphetamines, barbiturates and cocaine, there is a significant likelihood that recurrent administration of large doses will result in a high degree of involvement. However, this result is not inevitable. Many factors such as self-concept, peer orientation and religious feelings may mitigate against the use of large doses and f requent administration, thereby reducing the likelihood of a high degree of involvement.

Substances such as amphetamines, when consumed orally, and the minor tranquilizers" appear to have a moderate reinforcement potential. Others, such as marihuana and codeine, appear to have considerably less reinforcement potential. However, just as it is not inevitable that a high level of dependence will occur with heroin and alcohol, it is possible for a person consuming sufficiently high doses to develop a high degree of dependence upon substances such as marihuana and codeine. In such cases, the dependence is reinforced primarily by non-pliarmacologic factors related to the individual and his environment.

Other drugs, such as LSD and mescaline, appear to possess a self limiting quality due to the temporary development of a moderate de-

gree of tolerance to the psychic eff ects and to a phenomenon of psychological satiation arising from the intensity and duration of the drug experience. For these reasons, instances of prolonged, frequent self-administration of these substances are rare. Finally, some drugs, such as the phenothiazines (the major tranquilizers) have a minimal reinforcement potential.'

Psycho-Social Components

Reinforcement for continued use may also steni from non-pharmacologic factors. As noted in Chapter Two, drug-using behavior may be influenced and reinforced by a wide range of psychological and sociological variables, and this is no less true of continued use than of initial use. Various conditioniii- theories have been ,advanced to illustrate how people learn to use drugs. adapt theni to their needs and seek the drug when needed. Drug dependence is a dynamic process composed of a sequence of phrases during which the behavior may be reinforced by different factors at different times.

On one extreine, drug-using behavior may be a function of statusdefinition in terms of class, group, ethnicity or geography. Researchers have noted, for example, the antipathy of many niamhuana-smoking youths for glue-sniffing groups (Blurner et al., 1967). Among other drug-using groups, there may be status connotations involved in selecting a particular brand of scotch whiskey or in preferring scotch to bourbon. The cocktail party epitomizes the inainier in which drugusing behavior may be reinforced by non-drug factors. In these examples, the recurrence of druo, use may reflect very little commitment by the user; in other words, repetitive drug-iisiiig behavior may not reflect drug-seeking behavior .4

By contrast, drug use may be reinforced by less emplienieral variables, as a person comes to rely upon the drug effect to get things done


"'Reinforcement potential" is an absolute laboratory concept, within which psychosocial factors are held constant. In this sense, the major tranquilizers are not reinforcing at all since the "normal" population would not choose to repeat the drug experience because of its side effects. However, we should note that the use of any psychoactive drug can be reinforcing given the appropriate Psychological and social reinforcements. Thus, it is meaningful to say that the major tranquilizers are reinforcing to the patients who agree to use them because of their positive rewards as the individual and his physician define them.

' These situations might be distinguished from the type of behavior involving elaborate, ritualistic preparation and administration of .1 driig where the meaning of the behavior rather than the psychological experience (of the drug provide the entire reward. The selection and preparation of a bottle of wine and the rolling of a marihuana joint are example,,. There is also the "needle freak," a person who is enamored of the process of self-injecting any substanee, including water.

or to avoid unpleasantness. For example, an anxious, unhappily married individual or an obsessional, overworked executive may gradually drink more in quantity, frequency and intensity as he or she finds that this behavior blurs awareness of problems and enhances the ability to avoid their resolution. By the same token, a lonely young person may turn to "speed" when it is popular and readily available, finding with more and more, predictability that he feels potent, alert and energetic and that he shares a common bond with his peers who reinforce each others participation in the entire speed ritual.

At the other extreme, the recurring drug-using activity may form the very definitional base of a person's life: "When Fm on the way home with the bag safely in my pocket, and I haven't been caught stealing all day, and I didn't get beat and the cops didn't get meI feel like a working man coming home; he's worked hard, but he knows he's done something. . ." This person's life style is his repeated acquisition and consumption of heroin; and each administration of the drug confirms the success of his life style, representing his wages and his sole reward.

The Development of Dependence: Conditioning

Many models have been proposed to describe the interactions which take place during the development of dependence. As yet research has not delineated or confirmed these models and their implications. However, at least three identifiable phases of the process of initiation and reinforcement have received attention. The initial phase of beginning and continuing drug use is reinforced primarily by social f actors. Pharmacological and psychological factors become increasingly important in the development and maintenance of dependence. Finally, the permanence of the phase following detoxification and "withdrawal" from the dependent state can be affected by social as well as psychological factors.

No one model or theory is uniformly accepted and many questions remain. However, it is instructive to examine some of the current thinking about these factors, and about their interaction in forming and sustaining dependence, without implying thereby that these examples comprise a theory in themselves.

On the basis of participant observation of marihuana smokers, Becker identified a three-step process of social reinforcement leading to continued use: technical mastery of the process of administration, identification of the pharmawlogic effects and definition of those effects as desirable. Becker's investigations revealed that novices generally reported their first exposure to the drug as unrewarding. After being instructed by their companions regarding bow to aerate the smoke (to take deep breaths filling the recesses of the lungs and to

hold their breath for maximal absorption of the drug), these novitiates began to identify vague sensations as the, drug experience. Finally, they were led to translate what in many cases had been unpleasant responses into desirable ones and therefore into reasons for continuing to use marihuana. The end product of this sequence of events was a confirmed marihuana user. Other factors were delineated by Becker to explain the direction, frequency and intensity marihuana-using behavior might take (Becker, 1953).

Social reinforcement alone, however, does not explain subsequent and deep involvement: the weaving of drug use into the fabric of the user's life. One elaborate scheme assesses the role of pharmacologic reinforcement in the context of conditioning theory. Wikler (1970), for example, describes "primary pharmacologic reinforcement" as being either "direct" or "indirect." Direct reinforcement is related to receptors in the body which pre-exist the use of the drug. This corresponds to the concept of reinforcement resulting from stimulation of a reward center in the brain. Indirect reinforcement develops with drug administration and in essence is synonymous with "physical dependence."

During repeated administrations a learning process occurs, which Wikler relates to "direct secondary pharmacology reinforcement" or ("psychic dependence") (Wikler, 1970).

During the learning process, associations are made between nonspecific encironmental conditions or events and the reinforcements, including the central nervous system changes created by the drug. For example, long abstinent persons can be provoked into a mild withdrawal sickness simply by returning to the community where their dependence occurred (Jaffee, 1970). Similarly, it is conceivable that relapse to drug use by abstinent former users may be influenced by non-drug factors which stimulate associated drug-taking responses.

This kind of conditioning approach carries important implications for treatment. For example, a treatment regimen might usefully associate with the drug certain influences incompatible with its consumption. The therapist might create, verbally and otherwise, a dislike of the situation each time the drug is administered.

In a corollary model some researchers have suggested that bebavioral responses may be learned while a person is under the influence .of a drug and that these responses may be reduced in strength or be. entirely absent in the non-drug state. Such "state-dependent learning's has been demonstrated experimentally in man using amphetamines, alcohol and amobarbitol (Overton, 1968).

Many of the life style concomitants of dependent individuals ha%-e been learned while those persons were in the debugged state. It is ible that certain relationships and activities iiecessary for cop' t,

possi IIW

or for effective life management have become state-dependent. If this is the case, then detoxification and abstinence, may create anxieties

and f rustrations, perhaps unrecognized, because the person is less able to cope than h e was in the drugged state. Relapsing would then afford the individual one option for regaining such capacity. Another option is for the therapist to assist transferrence of these skills from the drugged to non-drugged state.

The Dependence Continuum

We emphasize that the only common denominator of all types of drug dependence is psychological reinforcement resulting from reward associated with the first individual-drug-society interaction and the subsequent increasing desire for repeated reinforcement. In the broad sense of dependence, a considerable segment of the world's population can be said to be dependent oil drugs. This drug-using behavior is not necessarily harmful, and in most instances carries no social stigma.

All repeated drug taking including that which is medically sanctioned is conditioned by positive reinforcement provided by the action of the drug and by the anticipated response of the user's interpersonal referent, whether it be a physician or a social group. In this respect medical and non-medical use share much in common. All drug therapy, regardless of the pharmacological nature of the drug, or whether the substance is self-selected or prescribed, has a psychological component. Were it not so, advertising to the public would lose much of its force, and physicians would lose a valuable aid in the treatment of the sick, or those who believe they are sick.

Consequently, psychological dependence must mean something more than positive reinforcement through drug-based reward if it is to be a functional concept. At this point, then, it becoines necessary to narrow the focus. As is true of non-drug habits, the fact of the recurrence of drug use is unimportant. The crucial question, for the individual, as well as for society, is the degree of dependence and its consequences. For drug use as well as any other behavior, the phase's of dependence actually form a continuum from lesser to greater, from minimal to compulsive. The additional elements f rom the psychological standpoint are the degree to which the individual is committed to or preoccupied with drug-seeking behavior as part of his life style, and the degree of behavioral disruption which would attend the interruption of his drug taking. From a pharmacological standpoint, these elements are related to the f requency, duration, regularity and intensity of the reinforcements.

Determining the existence of psychological dependence on drugs by segmenting the broader dependence continuum requires an arbitrary decision. It will be recalled that the same kind of judgment was made in past years in order to distinguish addiction f rom habituation on grounds other than physical dependence. The strength of reinforce-

ment is critical; yet, this judgment varies not only with the chemical, physical and pharmacological characteristics of the drug, and with the dose, method, frequency and duration of administration, but also with the personal characteristics of the user and the sociocultural context.

Measuring the Degree of Dependence: Psychological Components

The most important factor to consider in describing the degree of dependence is the extent to which drug use has become interwoven in the fabric of the user's life. For some persons, interaction with or avoidance of the world are facilitated by drugs. The more frequently the drug satisfies the person's needs, the greater the likelihood of his commitment to or preoccupation with such use, with a consequent neglect of lower ordered priorities and responsibilities, and a decrement in other social functioning. Personal health, economic relationships and family obligations may all suffer as the drug-seeking behavior increases in frequency and intensity and dominates the individual's life.

A parallel consideration in measuring the degree of dependence is the likelihood of adjustment or disruption which occurs when the individual's drug-using behavior pattern is interrupted. When faced with interruption, the individual may respond with some form of substitute behavior or may experience a disruption of his customary behavior patterns. Because the desire to continue the behavior also suggests a desire to avoid being in a position of abstinence, the notion of adaptation is closely related to that of preoccupation. Some experience with interruption may increase the priority assigned to the behavior.

The disruption which can occur when an individual is deprived of his drug or a substitute varies with the extent of his dependence. Mild behavioral symptoms may be seen in a housewife deprived of her diet pills, such as lethargy, irritability, reduced amount of housekeeping, or an unusual afternoon nap, while, more intense drug-seeking behavior, including aggression, may be seen among compulsive speed users. To a large extent, these symptoms can be exacerbated by the pharmacologic effects of the drug; in other cases they may be products of anxiety or the unmasking of behavior formerly under pharmacologic control.

Many treatment programs for drug-dependent persons operate on the premise that therapy must provide alternative supports for the individual previously preoccupied with drug taking. In large ineastire, the potential for success is related to the intensity with which the individual participates in the design of the program, and on the strength and numbers of supports within the alternative system. As