In 1977, Stanton, based on Love and Addiction, wrote the first in his Redefining Addiction series, whose abstract demolished decades of scientific thought about addiction. It was ignored for 30 years.
By 2017, a series of books and articles in Scientific American by Carl Hart, Maia Szalavitz, and Marc Lewis (all of whom acknowledge Stanton’s primacy in this area) undercut the entire disease model of addiction, while international conferences were organized to rethink the addiction process.
Here is the original idea.
International Journal of Health Services, Volume 7, Number 1, 103-124,1977.
Copyright 1977 Stanton Peele. All rights reserved.
I. Making Addiction a Scientifically and Socially Useful Concept
Addiction is both a more complex-and a more common-phenomenon than either medical personnel or laymen have realized. It is impossible to link addiction as a medical syndrome to any one drug or family of drugs, or to trace it to a specific biological mechanism. As scientists have uncovered more data leading to these conclusions, they have turned away from employing the term "addiction." Yet many drug researchers and workers in the helping professions continue to make incorrect assumptions about both addiction and drug use. In this paper the author attempts to broaden the applicability of the addiction concept in order to give it meaning. With this broader approach, we find that many involvements that people become engaged in follow the pattern of addiction, while some involvements with supposedly addictive drugs do not follow this pattern. The addiction cycle is explored by means of the following psychological definition: An addiction is any compulsive activity or involvement which decreases a person's ability to deal with other aspects of his life to the point where that activity or involvement comprises the dominant source of emotional reinforcement and identity for the person.
A popular TV show about two policemen recently screened an episode in which one of the men was given heroin by the mob. Addicted, he was taken to a hotel by his partner, where he went through the most excruciating withdrawal symptoms. He rampaged around the room, his body and mind wasted by the process of removing the drug from his system. Although he pleaded with his friend to give him more heroin, no matter what the consequences, the friend stood fast. Eventually the man recovered, and he was able to return to the job of apprehending the criminals who had forced him to become addicted.
I happened to be doing a discussion show the following day with several ex-addicts, two of whom had seen the program. They laughed about this public image of what addiction and withdrawal are like. In all their years of taking heroin-and periodically withdrawing from it-they had never experienced or seen anything remotely like what television had presented to millions of viewers as the "normal" course of taking the drug. Given the facts about heroin addiction, their mirth was understandable. Yet how many pharmacologists, drug counselors, and scientists would find nothing amiss in that mythical portrait of addiction?
Most of us, whether scientists or lay people, have a deceptively clear image of addiction, one very similar to the customary TV portrayal. The word calls to our minds the feverishly driven ghetto addict who will do anything to obtain the drug he must have-heroin. Failing this, the addict goes through the horrendous and agonizing throes of withdrawal. Both fearsome and loathsome, addiction is seen as being beyond any normal experience. Thus we feel compelled to postulate some special, unique chemical process to explain it.
From a pharmacological standpoint, it has not been easy to establish a biological and chemical basis for the addiction syndrome. As a result, the definition of addiction still rests on the observable characteristics of tolerance and withdrawal. Increasingly, however, there has been unsettling evidence both that addiction fails to occur in many regular users of narcotics, and that the behavior and feelings of people habituated to supposedly "nonaddictive" drugs closely resemble what we see in narcotic addiction. (The narcotics consist of the opium derivatives, morphine and heroin, and synthetic imitations such as Demerol.)
Faced with such diverse and seemingly contradictory findings, leading drug researchers have been abandoning the concept of addiction. In its place, they have turned to equally ill-defined terms such as "physical" and "psychic" dependence. There is now a split in both the scientific and the broader community on this question. Many people, including professional observers of the drug scene, seem to be unaware of the accumulation of data disconfirming the classical notions of addiction. Thus they continue to accept an unrealistically simple physiological model of drug dependence. Many scientists who are aware of the relevant data have given up on the idea of addiction altogether, and may be missing a crucial means for organizing a large and important area of human behavior under a coherent theory.
In this article, I will review the research which rules out the simple concept of a one-to-one connection between the chemical structures of certain drugs and the appearance of tolerance and withdrawal. Since we must, however, confront the fact that some people do exhibit drug-dependent behavior, I will also try to establish the basis for alternate explanations for both the presence and absence of this syndrome. These explanations lead to a theory of addiction which focuses on the social and psychological setting of the drug user, rather than a theory growing out of assumptions about the properties of drugs. I believe that such a theory can help us come to grips with the disparate evidence about drugs, as well as the larger issue of the occurrence of psycho-pathological dependencies in general.
The History of Addiction
Addiction, as a medical and biochemical concept, is a recent idea. It was first used with something resembling its present meaning-and associated with the narcotic drugs-at the beginning of this century, and then primarily in the United States. As late as 1929, reputable scientists conducting clinical studies of morphine-dependent subjects suggested that withdrawal was a form of malingering (1). What prevented people from recognizing the addictive nature of the opiates earlier? One obstacle was the fact that many other drugs were regarded as having debilitating and habit-forming effects comparable to those of the opiates. Thus, when the term addiction was finally introduced into pharmacology, it was as likely to be applied to caffeine, nicotine and alcohol, or to patent medicines such as acetanilide and bromide, as to the narcotics. It was not until around the 1920s, even in America, that narcotics were widely conceived to be a special drug menace, and addiction to be something more than a bad habit (2).
To understand this puzzling delay in the evolution of a concept which is second nature to the modern mind, we must first understand on what basis our present scientific notion of addiction rests. There are no definitive means for deciding that addiction exists in a given person. Instead, various indirect or suggestive indicators of the addicted state are relied on. These indicators are the symptoms of withdrawal and tolerance. Tolerance is the need for increased doses of a drug brought about by a diminishing response to a constant dosage; withdrawal is the traumatic bodily upheaval that results from cessation of regular administration of the drug. Both of these syndromes are most readily defined by observations of the behavior of the drug user. When a subject can be noted to show less of an effect from the taking of a drug, he is said to be growing tolerant to that drug. Indications of this adjustment may be his immediate level of activity after administration of the drug, his reported desire for more of the drug, or his ability to function normally while on the drug:
Withdrawal, regarded as the crucial test of addiction, is likewise identified by the drug user's behavior, this time when his regular dosage is cut off. Under these conditions addicts are known to display uncontrolled responses such as involuntary shivering and sweating, watery eyes and rhinitis, restiveness and sleeplessness alternating with almost comatose inactivity, and pupillary dilation and contraction. Vomiting, diarrhea, fever, and frantic thrashing about have also been reported in severe cases (3). Nothing in this syndrome links it inescapably to the narcotics; in fact, all of the behaviors listed can occur in the course of a severe case of the flu. Tolerance, too, is not well defined medically since there is no set pattern of responses which are associated with it and nothing else. Actually, tolerance phenomena appear with nearly every class of drug. Whenever a foreign substance of any chemical potency is introduced regularly into the body, the body adjusts so as to achieve a new equilibrium.
The vagueness inherent in these defining attributes helps explain why it has been difficult historically to connect addiction exclusivelywith the opiates. Consider the following description of a drug user: "The sufferer is tremulous and loses his selfcommand; he is subject to fits of agitation and depression. He has a haggard appearance.... As with other such agents, a renewed dose of the poison gives temporary relief, but at the cost of future misery." The "poison" is coffee, and the account is by two eminent British pharmacologists of the late nineteenth century, Clifford Allbutt and W. E. Dixon. This is their view of tea: "An hour or two after breakfast at which tea has been taken ... a grievous sinking ... may seize upon a sufferer, so that to speak is an effort. ... The speech may become weak and vague.... By miseries such as these, the best years of life may be spoilt" (4).
It is easy to dismiss these tum-of-the-century notions as artifacts of the primitive state of a science, but the patterns so carefully described by Allbutt and Dixon are clearly identifiable as tolerance and withdrawal. Although English coffee and tea brews of the period were very potent, we can still see such caffeine-induced phenomena today among people who "get by" on coffee, and now caffeine withdrawal has been substantiated in studies by Goldstein, Kaizer, and Whitby at Stanford (5, 6). Indeed, many drugs have been observed to bring about these states. Brecher (7) has summarized impressively the evidence for the addictive potential of tobacco, as illustrated by the postwar shortage of tobacco in Germany which led many normal middle-class citizens to steal and prostitute themselves in order to obtain the drug. Of course, alcohol is now commonly referred to addictive, with pharmacologists such as Jerome Jaffe (8) classifying the alcoholic's DTs as a variety of withdrawal. And a few years ago John Ingersoll, Director of the Bureau of Narcotics and Dangerous Drugs, stated in a press release that barbiturates produce more severe withdrawal symptoms than heroin. Even "harmless" pharmaceuticals such as tranquilizers, aspirin, and laxatives have been reported to cause withdrawal.
When we review the variety of drugs which have been seen to lead to tolerance and withdrawal symptoms, it is perhaps not surprising that the concept of addiction as a specific property of one class of drugs was so slow in arising historically. In our own time, the continuing discovery of addictive reactions to a wide variety of drugs casts doubt on the currently accepted meaning of addiction. For if addiction does not result exclusively from the action of one type of chemical on the body, then can it be purely chemical or physiological in origin? And how valuable is a concept of one drug's action which is so general that it can describe the effects of nearly every drug at some time or other in one or another person?
Along with the fact that addiction appears with other drugs besides the opiates, there is the equally disorienting realization that it does not occur universally with the opiates themselves. Narcotics cannot always be counted on to addict, even when taken regularly and in high doses. Again, a look at other places and other times will show us that our view is not the only one possible.
Addiction to opium was probably first noted as a widespread social and health problem in China, where the drug was trafficked heavily, beginning in the early 1800s, as part of the British colonial trade. By the 1850s, opium smoking-with its many unsavory effects- was out of control among large portions of the Chinese population. Yet that very opium was imported from India, where for centuries it had been employed for medicinal and ceremonial purposes. Because the drug was so well integrated into Indian society, it was not seen as a social problem there, and in fact rarely produced debilitating dependency.
What can account for this difference in the impact of opium on the Indian and Chinese societies, and even, apparently, in the effect experienced by the individual opium user in each society? The answer lies in the particular history - and meaning - of opium within the two cultures. As a general rule, when a drug is introduced externally to a society with little prior experience of it, especially as an accompaniment to conquest or colonial subjugation, then there is a good chance that the drug will come to symbolize escape and degradation. On the other hand, when a drug is traditionally used in a regulated way within a society, then it will not likely have these negative connotations and will not likely be abused. Richard and Eva Blum (9) examine this theory of the relativity of drug effects in their study of Greek rural society, where alcohol is considered a harmless social lubricant and debilitating alcoholism is unknown. This setting is contrasted with that of the North American Indians, among whom alcoholism became rampant after the intruding European brought liquor to them.
It is worthwhile analyzing the American experience with narcotics from this cultural-historical standpoint. Opium came to this country with Chinese laborers in the mid-nineteenth century, and was used extensively (in the form of morphine) as a pain killer during the Civil War. By 1900 it had reached many mainstream Americans through its presence as an active ingredient in popular patent medicines. During this period, too, heroin was isolated from morphine. Although the narcotics thus became a part of American culture, they were accepted only with great unease, and were soon rejected by the dominant institutions of society. The conflicts Americans felt about pain-killing drugs surfaced with a virulent campaign against the opiates led by the Narcotics Division of the Treasury Department (10, 11).
We all are by now familiar with the counterproductive resu1ts of this campaign: the legal removal of heroin from medical control and supervision (and the consequent usurpation of this role by the criminal underworld); the shift in opiate use from rural and mainly middle class settings to an urban, almost exclusively lower-class (and black) one; and finally, the excessive legal and medical isolation of addicts into a class of pariahs with whom normal people should have no need for contact. Today America has a narcotics problem exceeding in magnitude that of every other western country. However, although there is now a broad recognition that our public health policies toward the narcotics have gone awry, there is far less realization of how this process has also distorted our idea of what the narcotics actually do, and what addiction and addicts are like. In particular, the accepted notions that heroin is automatically and overpoweringly addicting, and that severe withdrawal pain is inevitably the consequence of discontinuing its use, have been disproved by a number of studies.
Let us survey briefly a sample of this body of evidence (to which we will return in greater detail in taking up the question of what does cause addiction):
- Because of the small concentrations of heroin present in street dosages in New York, addicts there often either do not show withdrawal or act it out when there is no possible chemical basis for their behavior.
- Hospital patients receiving narcotics at higher than street-level concentrations for long periods of time often do not experience withdrawal.
- Large numbers of controlled narcotics users have been uncovered. These include physicians taking morphine or Demerol, and ghetto residents who use heroin regu1arly while holding jobs and living normal family lives. Contrary to the addict stereotype, controlled users stabilize their dosage instead of experiencing an upward spiral of tolerance.
The anticipated deluge of heroin addiction in America among returning Vietnam veterans, many of whom had been consuming enormous quantities of heroin overseas, never materialized. Left puzzled by this phenomenon were administrators like Dr. Richard Wilbur, Assistant Secretary of Defense for Health and Environment, who found his medical school teachings - i.e. "that anyone who even tried heroin was instantly, totally and perpetually hooked" -completely useless for confronting the actual situation.
Why have trained observers such as Dr. Wilbur been so unprepared for what was revealed about heroin users in Vietnam, many of whom seemingly almost shrugged off their former habit? It seems that the lurid and inaccurate propaganda about the opiates dating from the early part of the century, reinforced by the continuing sensationalism of the media's portrayal of addicts, has had a great residual effect on our thinking, scientific as well as popular. Most American drug research has also taken its direction from the official dogma of the 1920s. The failure to question the assumptions behind the research has not only impeded our efforts to deal with addiction as a social problem, but has held back our empirical and theoretical attempts to understand addiction.
The Chemical Mystery of Addiction
Although it has been assumed by near consensus opinion that the addictive process has a chemical connection to the opiates, and the opiates alone, no such connection has been demonstrated. As Jaffe writes, "At present, the mechanisms by which the opioids exert their effects remain unknown" (12). Indeed, the characteristic of heroin to which Jaffe links its addictive potential is its ability to bring about "total drive satiation." The user's sex and hunger drives are suppressed, as well as his social, achievement, and other motivations. It is this feeling that the user need do nothing more in order to be contented that makes the opiates so attractive to many people.
The opiates are powerful analgesics because they likewise act to detach a user from sensations of pain. However, in reducing the awareness of pain, and at the same time dulling sensibility and intellectual and emotional responsiveness, the opiates are not unlike several other classes of drugs. Chief among these are the barbiturates or synthetic sedatives, alcohol and its relative, ether, and the various synthetic narcotics. While these substances and the opiates are all dissimilar chemically, they have in common certain gross characteristics brought about by a depressing of the functioning of the central nervous system.
It is the similarity between the addictive effects of the opiates and the other depressant drugs, including the fact that these various drugs are often interchangeable for addicted users, that argues most tellingly against the idea that some particular molecular bonding explains addiction. For these different drugs cannot chemically affect the cells of the body in identical ways. Yet alcohol and barbiturates are cross dependent - i.e. each serves to suppress the withdrawal syndrome in a person who is habituated to the other. Some investigators believe that the accumulated evidence indicates that withdrawal from alcohol involves essentially the same physiological process as withdrawal from the opiates (13). And narcotics addicts, although they may choose heroin as their drug of preference, show a remarkable readiness to become addicted to other depressant drugs. For example, many nineteenth-century opiate addicts in America were formerly alcoholics (10), and, when World War II cut off illicit narcotics supplies to the United States, heroin addicts turned en masse to barbiturates (14). O'Donnell (15) found that narcotics addicts in Kentucky in many cases became alcoholics after narcotics were outlawed.
Another source of data for refuting the link between addiction and heroin is provided by animal researchers. In a long series of systematic experiments, they have uncovered an intricate network of cross-dependence and cross-tolerance among the opiates and the many synthetic narcotics (16). From 1929 to 1941, a number of such researchers working under the auspices of the National Research Council's Committee on Drug Addiction participated in an effort to synthesize an analgesic which would not have the addictive characteristics of the natural narcotics. That no synthetic analgesic has been found which satisfactorily fulfills this requirement should not be surprising. The search for a non-habit-forming analgesic so far has witnessed the invention of the hypodermic needle, the discovery of heroin, and the development of the synthetic sedatives (barbiturates). The early synthetic narcotics like Demerol and synthetic analgesics recently made popular, like methadone, have done nothing to change this record. All of these drugs have been and continue to be used addictively.
Despite their findings that habituation and withdrawal occur with a mass of drugs besides morphine (including not only depressant drugs but such stimulants as cocaine, nicotine, and caffeine), animal researchers have been among those least inclined to challenge certain popular assumptions about addiction. In fact, this body of research has been remarkably monolithic for the fifty years of its existence. Basic to the work of Maurice Seevers and Abraham Wikler-perhaps the two seminal theoreticians in this field-and their disciples is the assumption that heroin is at the center of addiction. Also present throughout this work is the feeling that a theory which explains addiction must have a physiological centerpiece. Thus, the belief goes, we will understand addiction when we find that a drug or set of drugs touches off some special metabolic process, cellular adjustment, or chemical change in the brain. Yet research is rarely geared toward making such a basic discovery, but instead tends to focus on observable animal reactions to drugs. Hypotheses have then been generated on the basis of these data about what biochemical mechanisms underlie addiction. Because none of these hypotheses is supported by direct evidence, none has achieved broad acceptance (17).
When research has been performed which bears directly on the chemical action of the opiates, there is a danger that it will be invested with more decisive meaning than the findings in themselves justify. Here again it is the social setting in which research takes place which determines the attention given its results. An example of the public's - and the scientific community's - desire to confirm their belief in the necessary addictiveness of opiates was the widespread acclaim that greeted an article in Science about the binding of opiate molecules in the lipid extract of mouse brain (18). The article actually represents one step of a long line of research. On the basis of what has been found out to date, it is clear that differing amounts of binding take place depending on the type of narcotic utilized, but why this is so and what implications it has are not clear. Moreover, it is not known how the binding of opiates compares with binding which may take place with other drugs. Finally, it is not yet possible to determine what binding means in terms of the behavior of the animal in which binding takes place. In other words, this basic scientific work on drugs brings us no closer to identifying what we observe as addiction in human beings with the specific effects of heroin or morphine, or the narcotics in general, than we have been until now. But it was cited by many psychologists, sociologists, and social workers as proof that a physiological basis for heroin addiction had been discovered.
There may be some fundamental reasons why the results of studies with animals will never provide any answers about addiction. Consider the work done in the laboratory on the self-administration of drugs by monkeys, for example. Because a monkey will become habituated to a drug in that setting, do we learn that a human being, given equivalent doses of a drug, likewise will henceforth administer the drug to himself regularly? Obviously not. Any number of considerations prevent it. One investigator, Tomoji Yanagita (19), has laid out what these considerations are. Finding that monkeys consistently "succumb" to taking drugs in the laboratory while people are far less patterned in their responses, Yanagita postulates that the absence of social inhibitions, the stress of the laboratory environment, and the constant availability of drugs at no "cost" to the monkey may account for the differences. Yet it is the effects of these social and motivational factors which not only prevent human beings from reacting so predictably to drugs, but which also make addiction as we know it a purely human problem.
One issue that is often cited in favor of a biochemical interpretation of addiction is that animals and human infants born of addicted mothers do become addicted. What other explanation, the argument goes, can account for these psychologically simple organisms being susceptible to the narcotics? In fact, this phenomenon gives us an insight into the motivations and perspective of the adult human addict. For animals--especially those whose normal range of activities is drastically curtailed by laboratory confinement-and infants just removed from the womb are so limited in their choices and experience that it is predictable that the lulling effects of narcotics will dominate their lives. And it is for adolescents or adults whose outlooks are similarly constrained that a narcotic is so alluring as to overwhelm them. In understanding why this is so and how it takes effect we can find the key to addiction.
Human Motivations in Addiction
There has been one tradition of research into addiction which has not only made clear (as I have cited) that narcotic use by itself does not guarantee addiction, but has also shown the way toward integrating social and motivational factors into the addiction picture. This is the work which has been done with actual heroin users. Starting with Lawrence Kolb in the 1920s, investigators have found that heroin addiction does not occur in everyone who has ever been exposed to the drug. Kolb (20), noting that psychological problems and confused lives in most cases preceded the onset of addiction, believed that certain troubled individuals "receive from narcotics a pleasurable sense of relief from the realities of life that normal persons do not receive...." In considering addiction fifty years later, we cannot do better than to start with this insight, which provides an explanatory link between the "total drive satiation" produced by narcotics and what we observe as drug-dependent behavior.
More recent are the field studies of patterns of heroin use among addicts. Pioneering in this work was Alfred Lindesmith (21), who interviewed street heroin addicts in the 1940s. Lindesmith took as his point of departure a modified conditioning approach. Conditioning theories based on experiments with animals regard the avoidance of the onset of withdrawal pain (through the readministration of an opiate) to be an invariate reinforcer. Lindesmith added a particularly human element to the equation. In his view, a person becomes addicted if he is aware that the withdrawal pain he experiences is due directly to his no longer receiving heroin. Only in this way can the person identify withdrawal and connect it with his need for more of the drug.
Lindesmith's work is valuable for having introduced a sense of humanawareness and motivation into our understanding of the addiction process. However, it is limited in that it allows for the influence of only one simple cognition: the knowledge that one is receiving an opiate and that not receiving it will produce withdrawal. Yet there would seem to be a host of additional attitudes, feelings, and predispositions which could affect a person's reactions to a drug. Lindesmith himself remarks tangentially that hospital patients may be protected from becoming addicted-even when they know they are getting an opiate-because when withdrawal occurs they deal with it as a side effect of their treatment. In other words, people's conceptions of themselves and their reasons for using a drug can prevent them from becoming addicts. Zinberg's observations of hospital patients (22) have shown that, while knowingly receiving morphine at higher than street-level doses, they rarely even experience withdrawal.
Winick (23) has examined two divergent groups of drug users in their natural settings. Interviewing doctors who had been self-administering morphine or the synthetic opiate Demerol, he found that nearly all had been competent in conducting their practices (in fact, most of the doctors in this group were considered to be outstanding physicians). They were exposed not because they lost their grip on themselves and bungled their work, but because nurses had reported their illicit drug use or federal agents had investigated their prescription records. In the controlled middle-class world of these doctors, where narcotics could be obtained without much difficulty, nothing like the physical, psychological, and "moral" degeneration normally associated with addiction was apparent. These findings about controlled users were broadened in a 1972 survey conducted in a Brooklyn ghetto by Lukoff and Brook (24). This work showed that heroin users are better educated and better off economically than was suspected, actually ranking abovethe average for residents of the area as a whole.
What differentiates between the individual who uses a narcotic in a controlled way and one who uses it in the classically addictive - or compulsive - fashion, sacrificing everything else in his life to the drug habit? Jacobson and Zinberg (25) have provided the most definitive answer available based on interviews they have conducted for the Drug Abuse Council. The controlled user considers only certain circumstances appropriate for taking a drug. He or she is likely to have other friends besides those connected with his or her drug use. Controlled users are also likely to have work or school involvements which are sufficiently meaningful to them that they will not allow a drug to interfere with their performance in that area of their lives. In a parallel with Blum's historical data on cultural norms and drug abuse, Jacobson and Zinberg found that it is more difficult for controlled use to come about when a drug is illicit, because users of illicit drugs do not have a chance to learn from parents and other respected elders how to use these drugs in a socially acceptable way.
Since the Winick, Lukoff and Brook, and Jacobson and Zinberg studies focus on controlled users, they cast mainly a reflected light on addiction. Turning to a second study conducted by Winick (26) which does deal with compulsive users, or addicts, we learn more directly the motivational sources of addiction. By going over the Federal Bureau of Narcotics list of known addicts (compiled on the basis of regular use as determined through repeated arrests and other indicators), Winick was able to calculate that one-fourth of these people cease to be active addicts by the time they reach twenty-six, three-fourths of them by the age of thirty-six. In other words, even without much outside intervention, most heroin addicts do not continue their addictions indefinitely. This process is called "maturing out."
Interpreting the maturing out phenomenon on the basis of his research and his familiarity with New York street addicts as a public health adviser in that city, Winick finds that most addicts tum to heroin in their late adolescence as a way of dealing with unresolved dependency needs. Fearing the challenges and problems of adulthood, they use heroin to evade responsibilities they do not feel capable of handling. Some eventually do achieve the maturity to fill an adult role. Others, failing to do so, become institutionalized in prisons, hospitals, or mental institutions. Either way, they leave heroin behind, in the one case because they no longer need it, in the other because they enter an even more comprehensive dependency.
The most thoroughgoing available portrait of the adolescent street addict is that provided by Chein and his coworkers (27). Their research, conducted in New York in the 1960s, reveals that the teen-age heroin user has a terribly constricted world view. He is forced toward a life organized around obtaining· and taking heroin because he has no other opportunities for building a complete existence. Viewing the world as fearsome and dangerous, he lacks the confidence in himself and the motivation to attempt normal work. The addict feels the same distrust and fear in personal relationships, and thus seeks out other people only for the purpose of gaining immediate benefits, such as obtaining drugs. An interesting sidelight of Chein's work has been his finding that the addictive process, including the appearance of withdrawal, takes place with these addicts even when the heroin content of their fixes is so small as to have an almost negligible chemical impact (28). Chein also notes that only some of the adolescents exposed to heroin enjoy it initially. Of these, a majority - but not all - go on to become addicts. Even among those who do not enjoy it, however, a substantial minority become addicts purely through social pressure.
An investigator who has consistently dispelled myths about heroin over the past decade is Norman Zinberg. He and David Lewis were able to write in 1964, on the basis of their in-depth investigation of 200 narcotic users, that "most of the problems of narcotic use do not fall into the classic definition of addiction.... Indeed, the range of cases that do not fit the stereotype of the narcotic addict is very wide...." (29). For example, some subjects were addicted to the injection ritual rather than to the drug itself. Among those users who were not addicted to the drug were people whose motivations were primarily social, such as those who used the drug to stay close to lover or to be with friends.
Zinberg explored this social side of addiction more deeply when he found that withdrawal patterns themselves are markedly influenced by social considerations. For example, Zinberg and Robertson (30) report that addicts in Daytop Village, a treatment center in New York, do not manifest significant withdrawal symptoms because they are not excused from work duties when they do manifest symptoms. Many of the same patients had undergone extreme withdrawal in prison, where such behavior was expected and, in a way, endorsed. Zinberg (31) also found that withdrawal patterns among soldiers in Vietnam varied from unit to unit, although they were consistent within a given unit. In other words, the men learned how to enact withdrawal as a part of a social learning process. The idea may thus occur that those addicts who do evidence elaborate displays of withdrawal have themselves learned to do so from television and movie depictions!
Taken together, the studies reported here indicate that a number of cultural, social, and personal variables interact to influence whether and when heroin use will result in a full-fledged addiction. These influences have an important impact even on a person's reaction to the physical presence of the drug in his or her body. They deter mine, in part, how potent and how appealing its effects are experienced to be, and how the drug affects behavior both when a user is currently taking it and when he ceases to take it. To prove this, we can tum to one last study of human narcotic use, but one which this time does not involve heroin, street addicts, or self-administration. This classic piece of research was conducted by Lasagna and his coworkers (32) in 1954 to determine differences in the reactions of postoperative patients to morphine and a placebo.
Lasagna employed double-blind controls in his experiment, where neither patients nor technicians knew which substance was being injected at any given time. Under these circumstances, between thirty and forty percent of the patients reacted just as satisfactorily to the placebo as to morphine. Either would relieve their pain. On the other hand, the morphine itself proved effective only from sixty to eighty percent of the time. Interestingly, those who accepted the placebo were more regularly relieved of pain by the morphine. What was most striking in the experiment, however, were the consistent personality traits uncovered in those patients who accepted the placebo substitute and also found the morphine more effective. Using Rorschach tests and interviews, the investigators found that such patients were more anxious and more emotionally volatile, had less control over the expression of their instinctual needs, and were more dependent on outside stimulation than on their own mental processes. They were also more likely to rely on external support in the form of hospital care, medicines, and other institutional involvements (such as with a church).
Clearly, then, whether on the street or in a hospital setting, personality differences can influence the most basic effects produced by a narcotic. And while it would be a tenuous deduction indeed to say that the "reactors" in the Lasagna experiment are potential heroin addicts, it is remarkable how congruent the psychological patterns uncovered in this group are with those found in addicts by Winick and Chein. Exploring why hospital patients receiving narcotics (even those who do get relief from morphine) will almost never seek narcotic sensations once they are released from medical care, we can recognize various psychological and social factors in operation. In the first place, there is no reason to suspect that such unintentional users, when they are not in physical pain, would welcome the oblivion of feelings and conscious ness that narcotics produce. More than this, they simply do not think of themselves as being addicted and hence do not take note of whatever withdrawal reactions they have. And even if they should experience withdrawal, they would never contemplate entering the underworld in which the addict, whose image they despise, operates.
In analyzing the motivational factors acting on the hospital patients, we summarize the human elements in addiction. But in allowing for the role of all these social and subjective variables, so that we deny that the narcotics have any special place among drugs as the source of addiction, are we undermining the very concept of addiction? In fact, many of the best informed commentators on the drug scene now take this position. From Norman Zinberg in Drugs and the Public (written with John Robertson) (30) to Thomas Szasz in Ceremonial Chemistry (33), those holding this viewpoint emphasize the unfounded and often destructive social and legal judgments involved in the labelling of addiction. Such observers feel that some drugs are singled out for disapproval and punishment while other equally harmful and addictive substances are allowed to proliferate. And, because they feel the term "addictive" is applied arbitrarily and illogically, they would rather withdraw it from use.
Changing Notions of Drug Dependence
Among pharmacologists and others who continue to feel that a term is needed to embody the concept of a strong dependence on drugs, there has been in the last decade a large theoretical evolution. In 1964 the World Health Organization Expert Committee on Addiction-Producing Drugs, after twelve years of operation, decided to drop the term "drug addiction" in favor of "drug dependence," and changed its own name accordingly. A 1968 symposium which gathered together leading figures from all areas of drug research makes clear the thinking underlying this development (34). The symposium's chairman, W. D. M. Paton, drew the following conclusions in summation:
- Because of the confusion surrounding its definition and application, the term "addiction" cannot easily be employed. "One of the most important outcomes of the whole symposium," Dr. Paton stated, "has been the evidence, both in animals and man, that strong dependence can arise even though there is little or no evidence of the classical withdrawal syndrome when administration of a drug ceases."
- Instead, a global approach to the problem of drug dependence seems to be demanded. The resulting working definition endorsed by the conference was: "Drug dependence arises when, as a result of giving a drug, forces-physiological, biochemical, social or environmental-are set up which predispose to continued drug use."
- With the removal of withdrawal as a criterion, "the central issue of drug dependence has shifted elsewhere and seems to lie in the nature of the primary 'reward' which the drug provides."
- "By a second, analogous shift of emphasis, the opiates are losing their too dominant position in scientific investigation, and the relevance of drugs such as cocaine, the amphetamines and barbiturates, with different pharmacology yet equally capable of inducing dependence, is being recognized."
- "Finally," according to Dr. Paton, "a third re-orientation is called for, arising from the recognition that these factors differ widely in different countries, varying not only with cultural differences, but with quite simple differences in formulation and accessibility of illicit drugs."
Thus the principle of diversity in drug effects has been recognized, and the two sacred cows of drug research and policy - addiction as purely physiological, and narcotics as the sole source of addiction - have been forsaken. But what has taken their place? In an effort to rescue what was useful in the old addiction concept, scientists like those at the symposium and the World Health Organization have separated drug dependence into "physical" and "psychic" components. Hopefully, they feel, employing these more concrete dual terms will make it possible to allow for the irregular appearance of withdrawal while focusing on a person's subjective experience of dependence.
The result of these developments is that "psychic dependence" is the effect illicit drugs are now said to produce which causes people to use them compulsively. The following declaration (35) by a distinguished group of theoreticians-Nathan Eddy, H. Halbach, Harris Isbell, and Maurice Seevers-makes clear the dominant place psychic dependence has in the theoretical scheme of things:
All of these drugs have one effect in common: they are capable of creating, in certain individuals, a particular state of mind that is termed psychic dependence. In this situation, there is a feeling of satisfaction and a psychic drive that require periodic or continuous administration of the drug to produce pleasure or to avoid discomfort. Indeed, this mental state is the most powerful of all of the factors involved in chronic intoxication with psychotropic drugs, and with certain types of drugs it may be the only factor involved, even in the case of most intense craving and perpetuation of compulsive abuse.... Physical dependence is a powerful factor in reinforcing [italics added] the influence of psychic dependence....
An example of the popularization of physical and psychic dependence can be found in a table of illicit drugs compiled for the World Health Organization by Cameron (36). Typical of presentations of this sort, the table has separate columns under "Dependence" headed "Physical" and "Psychic." In the former column go alcohol and narcotics, the drugs which used to be called addictive. In the latter column go every single one of the eight illicit drugs listed (e.g. marijuana, cocaine, amphetamines, hallucinogens, as well as alcohol and narcotics). The problem in this usage is that instead of eliminating the difficulties associated with the addiction concept, it simply breaks these difficulties into two categories.
The table (36) implies that physical dependence is linked exclusively to alcohol and narcotics, which cannot be proven any more than can the contention that addiction is linked exclusively to these drugs. As for psychic dependence, this term, rather than being too narrowly applied, is made so broad here that it has no meaning. If a concept does not differentiate between major illicit drugs, then it provides us with no additional information about any such drug. And were it not that the table is concerned only with illicit drugs, it would seem that such substances as nicotine, caffeine, and tranquilizers could equally be included in the psychic dependence category. In other words, any substance which people take regularly for other than medical benefits apparently shares this characteristic. Writing elsewhere, Cameron (37) has provided criteria for determining when psychic dependence is present. In making this determination, he maintains that "it is important to ascertain how far use of drugs appears (1) to be an important life-organizing factor, and (2) to take precedence over the use of other coping mechanisms." Again, it is not clear why these criteria can only apply to such illicit drugs as Cameron is concerned with. Indeed, there is nothing in the criteria which limits their applicability to drugs at all.
The enlargement of the addiction concept to make it encompass the dependencyinducing effects of a wide range of drugs has expanded it beyond the point where it can be said to apply to drugs alone. In fact, this seems to have been a logical and necessary development. The only problem is in the persistence with which psycho logical terms like psychic dependence have been used as though they were characteristic of drugs, and then of only some illicit drugs. This is an unworkable carryover from the belief that addiction was a special property of some drugs. Instead, further theorizing about addiction and drug dependence must take us in the direction of an awareness of the personwho becomes dependent and the situations in which he does so, and of the commonality among pathological dependencies of all sorts. Psychic dependence is a characteristic of people who compulsively take drugs, not of drugs that ensnare people. And psychic dependence is present in compulsive experiences which do not involve drugs at all.
New Theories of Addiction
At the same time that most prominent theorists about drugs are abandoning the addiction concept, either in favor of psychic dependence or in reaction against any pejorative and legally prejudicial terms about drug use, the idea of addiction is far from dead. Of course, it is still widely employed in connection with the use of narcotics and other disapproved drugs. Moreover, it is beginning to be applied in many other areas. One now comes across informal references to addiction in connection with work, gambling, overeating, sex, TV viewing, and any other activity which people can engage in compulsively. In thus generalizing the meaning of addiction, usage is reverting to its premodern status. Some of this redefinition is done in a humorous vein-as in, for example, Warren Oates' Confessions of a Workaholic(although many people now refer to the workaholic syndrome). Other writers, like psychiatrist Lawrence Hatterer, are directing serious attention to addictions other than the classical drug-related ones. And clinicians are now successfully borrowing from treatments designed originally for narcotic addiction in their therapies for such diverse health problems as smoking and obesity.
What makes most people regard these popular allusions to addiction as being only literary or symbolic is the belief that a theory of addiction must be biochemical or it is not an actual theory. But it is possible to link both the somatic and behavioral manifestations of addiction to nonchemical sources. To do this, we must have an entirely new paradigm, i.e. a new way of conceptualizing relationships between variables. Attempts to develop such a conceptualization have come from two diverse sources in psychology. The first derives from experimental psychology and conditioning theory; the second, in which I am engaged, is social-psychological in nature.
Richard Solomon, known for his earlier work in avoidance learning, has devised (along with coworker John Corbit) a theory of motivation which he calls "opponent process" (38, 39). The opponent-process theory is based on the idea that the central nervous system always tends to balance any affective input so as to maintain an equilibrium state. Whether stimulation is pleasurable or painful, the system will begin to neutralize that stimulation even during the period when it is being applied. Following its application, there will be a counterbalancing sensation-the pleasure at no longer banging your head against a wall, or the feeling of deprivation after something good ceases.
As a particular form of stimulation is regularly experienced, the organism's internal nervous mechanisms are more and more effective in counteracting it, so that the stimulation has less of the impact it originally possessed. At the same time, the second-or countervailing-state grows in its intensity, until it becomes the primary motivator in the sequence. For example, a dog exposed for the first time to a strong electric shock will react with terror, and when the shock is stopped, it will behave in a subdued, suspicious manner. As the dog is shocked day after day, however, its behavior both when receiving the shock and in the period following alters drastically. Instead of being terrified, the dog now acts when shocked as though it is enduring a minor, annoying discomfort. And when the shock ceases, the dog now reacts with intense joy.
Solomon and Corbit's analysis of drug addiction follows the same lines. An originally pleasurable form of stimulation (taking a drug) is no longer pleasurable after repeated administration. Yet the initial stimulation continues to be sought out in order to avoid the pain of the increasingly negative after-effect (withdrawal). In outlining this pattern, the opponent-process model accurately reflects data on the subjective experience of habitual users of drugs, from heroin to tobacco. Such users do not find their drug-taking pleasurable, as they may have early in the formation of their habit, yet they continue to take the drug because desisting causes a discomfort which they cannot bear.
Solomon and Corbit's contribution to addiction theory is incalculable. Working within the framework of a general motivational theory, they have shown that there is nothing mysteriously chemical about heroin (or barbiturate or alcohol) addiction. What is involved is the kind of motivation to be found in every intensely pleasurable or unpleasurable act, such as receiving shocks, parachute jumping, and "falling in love." As Solomon and Corbit put it, ''There is nothing abnormal or strange about addiction. It is only a socially vivid example of the normal emotional and motivational functioning of the efficiently operating, affect-control system" (39). Tolerance as it appears in drug addiction is simply a phenomenon which occurs with regular exposure to any pleasurable event, and withdrawal is the result (physiological, neural, emotional) of discontinuing any such activity.
However, within the invariability of the opponent-process model lies its limitation as a theory. If the opponent-process leading to the point of addiction is so common. and predictable, why then does not everyone get hooked on the same experiences? After all, everyone-or nearly everyone-takes a drink or experiences sexual infatuation, yet people react very differently to these sensations. The same question put another way might be: "Why do some people find a sensation sufficiently pleasurable that it signals the onset of the addictive process?"
I have approached these issues from a social-psychological viewpoint. There is an extensive social-psychological and medical literature which examines the effect of a person's expectations about a drug, and that of the setting in which he takes the drug, on his reactions to the drug (the Lasagna study cited above is one example). In Love and Addiction, which I wrote with the assistance of Archie Brodsky (40), I apply a similar analysis to drug addiction and also to other compulsively destructive patterns of behavior. On the basis of the research summarized in this article, together with my own clinical studies of drug addicts and people involved in a variety of extreme dependencies, I have tried to develop an essential understanding of the experience of addiction, which I, like Solomon, see as occurring in many areas of life in addition to drug taking.
Such an understanding of addiction begins with a profile of the person who becomes addicted. In studies of addiction to heroin and other strong depressant drugs, we find that, as Kolb put it many years earlier, only certain people find the relief from pain and care that narcotics produce to be a uniformly positive sensation. These tend to be individuals whose normal sense of themselves and their position in life is anxious and insecure. In line with Chein's discoveries, they are people who feel limited in their ability to cope with problems in other than escapist and generally unrealistic ways. They see more productive avenues for relating to the world as being cut off from them, and do not have or are not comfortable with competing values favoring achievement and sobriety. They welcome dependency relationships, even as they may react against dependency, because they feel a need for external sources of support for their identity. In all this, it is evident that addicts have extremely low self-esteem. They are also characterized by an outlook which is essentially fearful and which focuses on the negative aspects of life.
People with these psychological traits are predisposed to be addicted. They may become addicted to any of a range of involvements which can serve to prop up their weakened egos, structure their lives, and reassure them by eliminating uncertainty and challenge. To fulfil these functions, the addictive involvement must be predictable, primarily through being repetitious. It is for this reason that drugs, with their consistent pharmacological effects and their ritualistic means for injection, are so prominently a part of addiction. But any involvement which can come to play a central part in an individual's life and which can engage that person's consciousness in a lulling, nonchallenging way can do the same thing.
An addiction occurs when a person turns to such an involvement and finds in it relief from the stresses of life-stresses which an addict finds particularly difficult to deal with. These stresses may be temporary or irregular in nature (such as those faced by the Vietnam soldier) or they may be permanent, such as those produced by a personal feeling of inadequacy, or by a discomfort with the psychological or social position a person occupies. An addiction allows escape from this perpetual uncertainty, this "existential" anxiety. In turning to the addictive object for relief, the addict loses touch with the problems which made unconsciousness attractive in the first place. Hence, whatever problems existed initially are exacerbated by avoiding them for the time the person is enmeshed in the addictive activity. There is on top of this a guilt, perhaps most evident in American and other Protestant cultures, at having sought escape from a predicament, at having been intoxicated or impotent to deal with the situation facing the person.
If an individual does not have alternate ways to express himself or herself, and lacks personal or professional ties which can protect him against the draw of the addictive involvement, he will turn to it again and again as his main source of gratification. Ultimately, the individual may lose touch with the rest of his life to such an extent that the involvement becomes his only recourse, the entire basis of his identity and the sole source of reward for him in life. When this point is reached, a full addiction has been formed. Both tolerance and withdrawal can be defined by this psychological process. It is the accelerating need to return to the addictive object which is labeled tolerance. Withdrawal is the traumatic disorientation that results when a person is deprived of his sole source of emotional sustenance-the constant presence he has become accustomed to in his life in the form of the addiction.
It takes more than a particular psychological profile, however, to bring about an addiction to heroin or to anything else. Social factors have already played a role in producing these personality traits, but they play an even larger role in leading an addict to make heroin the center of his or her existence. In the first place, the person must be in a social milieu which exposes him to, and even encourages the adoption of, this form of drug escape. And in a wider society which disapproves so strongly of addiction, the addict must be willing to accept-or must already occupy-a despised social position. Finally, the process of succumbing to addiction to heroin must take place in a society which sees heroin as addictive and the individual as unable to cope with its effects, and yet which holds out heroin as a form of ultimate escape.
The basic elements of heroin addiction appear also in addiction to alcohol and barbiturates. Certainly the personality profile remains the same, although ethnic categories are likely to vary, e.g. from middle-class America to a black or an Irish subculture. Also varying from the narcotics to alcohol to barbiturates and the sedatives are legality and degree of social acceptability. These dimensions influence the probability that members of one social class will become enmeshed in one drug rather than another. For example, it is more likely for a businessman to become an alcoholic than a heroin addict, and more likely for a housewife to become addicted to sedatives.
In tracing these addictive patterns to legally available and medically prescribed drugs, we are led to the stimulants, such as caffeine, nicotine, and amphetamines, and directly into mainstream America. For rea8ons of suitability to a western and advanced industrial way of life, stimulants (except cocaine) are generally accepted in the United States. People who find in such drugs an addictive escape, while sharing some traits with depressant addicts, do have their own characteristic way of dealing with anxiety and low self-esteem. For example, Nesbitt (41) has found that smokers are more nervous than nonsmokers, but experience less tension when smoking. It seems that nicotine serves to protect people from tension by raising the excitation level of the nervous system, thus modulating smokers' reactions to outside stimuli.
We have seen that it is impossible to establish criteria for addictive dependencies which limit them specifically to chemical substances. In the terms in which I have analyzed addiction, anything which is sufficiently compelling to engage a person's consciousness so that he can temporarily be relieved from awarenesses which he finds painful, can come to preoccupy his life in a way which is addictive. While it does not follow that television viewing, eating, sex, relationships, being ill, and so forth are necessarily addictive, it is true that any of these can be an addiction for a given person. Most often, as in the cases of cigarettes and coffee, such a per on is protected from thinking of himself as an addict because the activity in which he is compulsively engaged is socially accepted, or even approved. It is true that his addiction is simplified because of this, first in the fact that what he is doing is not illegal, and second in that guilt may be less directly induced by disapproval from external authority. Yet guilt is present, as is anxiety, in these as in any addictions.
Addiction can come even nearer to mainstream involvements when we consider that any structure outside of an individual on which he relies for his identity fulfils an addictive function. According to this criterion, people can be involved with institutions to which they are addicted. Consider the religious commune and the adolescent or young adult who spends all of his time either within its confines or doing its bidding. Such a person refers all decisions in his or her life to the ultimate judgment of the commune or the guru who leads it. There is no aspect of the person's life which is not controlled in this manner. Often, in order for the person to leave the commune he must first be confined (unwillingly) while he is subjected to marathon deprogramming sessions after which he furiously rejects the religious group he left. It follows that other, even more widely accepted involvements may fulfil all the criteria of addiction while going unrecognized as such.
One of the main examples of this is the intense relationship between two people which some think of as love. How can a love relationship function as an addiction, as both Solomon and Corbit's and my formulations allow for? In the opponent-process framework, when "a boy and girl fall in love," they experience a prevailing mood of ecstasy when together. When apart, they become lonely and depressed. After a long period of association, they merely feel content and normal together. But at this point, separation would be traumatic and would produce grief and other negative reactions of high intensity and long duration.
As with their other examples of addiction, I see Solomon and Corbit's model of love relationships as being mistakenly unimodal. There are obviously many forms that love relationships can take; for instance, there are wide variations in the reactions that people have to the death of a spouse. Some, while experiencing intense unhappiness, continue to live a normal life and may mate again. Other people give up on life, and may even themselves die soon after the death of a husband or wife. Also, the phenomenon of falling in love differs from culture to culture and over time. The notion of romantic love has not always existed in its contemporary American form. In societies living closer to subsistence levels or where wider-ranging sexual contact among adolescents is sanctioned, male-female relationships often take some entirely different course, where the somatic and psychological qualities of being in love as we think of it may be absent.
In my model, addictive love is only possible where social values hold out the possibility of falling in love as a life solution, where love is seen as a transcendent experience and as a rite of passage into adulthood, and where social life is organized almost entirely around being with the one you love. Under these circumstances, people without an adequately formed ego or life structure may rapidly develop a dependency on a lover which serves to define their lives. Since the basic function of the relationship is to provide reassurance for its participants, the lovers experience great anxiety when apart, which often takes the form of worrying about whether the other partner is sufficiently committed. Eventually, the only solution to perpetual insecurity is a life organized as much as possible around constant togetherness, the need for which is a version of tolerance as it occurs with drugs. And should a separation then occur, either permanently or for longer than usual, the lovers can go through acute psychological and even somatic suffering.
Since addiction may appear in involvements of any kind, just as there may be controlled and healthy involvements of any kind, it is not possible to say that "love" is really an addiction. As with any other type of activity, it is necessary to observe the behavior that is associated with the relationship, the setting in which the lives of the lovers and the relationship takes place, and the needs which each lover requires the relationship to fulfil. One of Solomon's principal contributions to the under standing of addiction is the insight that addiction is not a completely abnormal state, but just an extreme version of a normal state. This perspective also implies that addiction is not an all-or-nothing phenomenon, and that there may be a spectrum along which degrees or aspects of addiction may be present. While there are love relationships which would qualify as total addictions, there are probably many more which contain some of the elements of addiction, but where full-blown tolerance and withdrawal are not necessarily present, just as few street users of heroin today experience the full effects of tolerance and withdrawal. Finally, there probably is a group of people among whom the appearance of addictive relationships is more likely to occur, and in some cases even to be the norm. As with Winick's and Chein's largely lower-class adolescent drug users, middle-class adolescents typically confront a fearful time of emergence from childhood into an adulthood which they may feel unprepared for. For these people, the psychological crutch most easily grasped at may be the young love affair in which addictive elements predominate.
The notion of addiction has a powerful appeal to people; yet the idea of it as an extraordinary biochemical process which is set off exclusively by narcotics is an artifact of cultural predispositions and historical events in twentieth-century America. From its origins, the concept has been unworkable for the purpose of explaining, understanding, and dealing with drug dependence. Its failure to do so has increasingly been documented so that the term now either is used while ignoring the data which have been accumulated about drug dependence or is rejected as unusable on the basis of these data. Still, the scientific community by and large persists in certain assumptions about addiction and drug-dependent behavior which cannot be successfully maintained, but which prevent the concept from evolving in a useful direction. The issues involved include the following:
- Addiction-in terms of its identification, definition, association with certain drugs and groups of people, and even the experience of it by addicts them selves-is in large part a cultural phenomenon influenced by a host of social considerations.
- Addiction is best understood as a behavior syndrome, a social-psychological phenomenon, an experience, a characteristic way a person has of relating to the world.
- The dynamics of addiction are part of a basic human motivational process which may appear in any involvement.
- While addiction is an extreme state, it is continuous with (i.e. has elements in common with) habit, dependence, and related aspects of human behavior.
- Addiction is best dealt with in an individual as a problem of overall life-style.
By ignoring these elements in addiction, scientists, social workers, and law enforcement and public health officials have failed to come to grips with the issue by every measure available. Drug addiction and abuse with the narcotics, alcohol, barbiturates and other depressant drugs, stimulants, hallucinogens, etc., have all worsened while we have expended tremendous sums of money and enormous energy in this area. Our problems with the narcotics are far beyond those of any other advanced techno logical society, and our problems with other drugs are at least on a par with those of other societies. Young people are stepping up their use of drugs, particularly depressant drugs such as alcohol and sedatives. But most disheartening, we follow the same shopworn avenues in our research efforts. Perhaps the major focus of basic research is on the investigation of opiate receptors in the brain and the creation of new narcotic antagonists (drugs which block the effects of the narcotics). Like existing methadone programs which substitute one addictive drug (albeit legal) for another (42), these endeavors miss the point that the only solution to addiction lies with changes in the life of the addicted person.
What we lose most through misconstruing addiction is the chance to learn about ourselves and the patterns that run through normal life in our society. At the same time, we place a distance between ourselves and those labeled as addicts which exacerbates their recognized addictions. If we could realize that all dependencies and compulsions are part of one behavioral continuum, and that the extremeness which is addiction is at times part of our own lives, we could improve our ability to encourage the well-being of people in all sectors of society.
1. Light, A.B., and Torrance, E.G. Opium addiction. VI: The effects of abrupt withdrawal followed by readministration of morphine in human addicts, with special reference to the composition of the blood, the circulation and the metabolism. Arch. Intern. Med. 44(1): 1-16, 1929.
2. Sonnedecker, G. Emergence and concept of the addiction problem. In Narcotic Drug Addiction Problem1, edited by R.B. Livingston, pp. 14-22. Public Health Service, Bethesda, Md., 1958.
3. Maurer, D.W., and Vogel, V. H. Narcotics and Narcotic Addiction, Ed. 3, p. 95. Charles C Thomas, Springfield, lll., 1967.
4. Lewis, A. In Scientific Basis of Drug Dependence, edited by H. Steinberg, p. 10. J. & A. Churchill, Ltd., London, 1969.
5. Goldstein, A., and Kaizer, S. Psychotropic effects of caffeine in man. III: A questionnaire survey of coffee drinking and its effects in a group of housewives. Clin. Pharmacol. Ther. 10(4): 477-488, 1969.
6. Goldstein, A., Kaizer, S., and Whitby, 0. Psychotropic effects of caffeine in man. IV: Quantitative and qualitative differences associated with habituation to coffee. Clin. PharmacaL Ther. 10(4): 489-497, 1969.
7. Brecher, E.M. Licit and Illicit Drugs, pp. 220-229. Consumers Union, Mount Vernon, N.Y., 1972.
8. Jaffe, J.H. Drug addiction and drug abuse. In The Pharmacological Basis of Therapeutics, edited by L.S. Goodman and A. Gilman, Ed. 5, pp. 284-324. Macmillan, New York, 1975.
9. Blum, R.H., and Blum, E.M. A cultural case study. In Drugs. I: Society and Drugs, edited by R.H. Blum and Associates, pp. 188-227. Jossey-Bass, San Francisco, 1969.
10. Kolb, L. Factors that have influenced the management and treatment of drug addicts. In Narcotic Drug Addiction Problems, edited by R.B. Livingston, pp. 23-33. Public Health Service, Bethesda, Md., 1958.
11. Clausen, J.A. Drug addiction. In Contemporary Social Problems, edited by R.K. Merton and R. A. Nisbet, Ed. 2, pp. 193-235. Harcourt, Brace & World, New York, 1966.
12. Jaffe, J.H. Narcotic analgesics. In The Pharmacological Basis of Therapeutics, edited by L.S. Goodman and A. Gilman, Ed. 4, pp. 237-275. Macmillan, New York, 1970.
13. Davis, V.E., and Walsh, M.J. Alcohol, amines, and alkaloids: A possible biochemical basis for alcohol addiction. Science 167(3920): 1005-1007, 1970.
14. Isbell, H. Clinical research on addiction in the United States. In Narcotic Drug Addiction Problems, edited by R.B. Livingston, pp. 114-130. Public Health Service, Bethesda, Md., 1958.
15. O'Donnell, J.A. Narcotic Addicts in Kentucky. National Institute of Mental Health, Chevy Chase, Md., 1969.
16. Deneau, G.A. The monkey colony in studies of tolerance and dependence. University of Michigan Medical Center Journal 36(4, part 2): 212-214, 1970.
17. Seevers, M.H., and Deneau, G.A. Physiological aspects of tolerance and physical dependence. In Physiological Pharmacology, Vol. I, edited by W.S. Root and F.G. Hofmann, pp. 565-640. Academic Press, New York, 1963.
18. Lowney, L.I., Schulz, K., Lowery, P.J., and Goldstein, A. Partial purification of an opiate receptor from mouse brain. Science 183(4126): 749-752, 1974.
19. Yanagita, T. Self-administration studies on various dependence-producing agents in monkeys. University of Michigan Medical Center Journal 36 (4, part 2): 216-224, 1970.
20. Kolb, L. Drug Addiction: A Medical Problem. Charles C Thomas, Springfield, lll., 1962.
21. Lindesmith, A.R. Addiction and Opiates. Aldine, Chicago, 1968.
22. Zinberg, N.E. The search for rational approaches to heroin use. In Addiction, edited by P. G. Bourne, pp. 149-174. Academic Press, New York, 1974.
23. Winick, C. Physician narcotic addicts. Social Problems 9(2): 174-186, 1961.
24. Lukoff, I.F., and Brook, J. S. A sociocultural exploration of reported heroin use. In Sociological Aspects of Drug Dependence, edited by C. Winick, pp. 35-56. C. R. C. Press, Cleveland, 1974.
25. Jacobson, R., and Zinberg, N. E. The Social Basis of Drug Abuse Prevention. Drug Abuse Council, Washington, D.C., 1975.
26. Winick, C. Maturing out of narcotic addiction. Bull. Narc. 14(1): 1-7, 1962.
27. Chein, I., Gerard, D.L., Lee, R.S., and Rosenfeld, E. The Road to H. Basic Books, New York, 1964.
28. Chein, I. Psychological functions of drug use. In Scientific Basis of Drug Dependence, edited by H. Steinberg, pp. 13-30. J. & A. Churchill, Ltd., London, 1969.
29. Zinberg, N.E., and Lewis, D.C. Narcotic usage.1: A spectrum of a difficult medical problem. N. Engl. J. Med. 270(19): 989-993, 1964.
30. Zinberg, N.E., and Robertson, J. A. Drugs and the Public. Simon & Schuster, New York, 1972.
31. Zinberg, N.E. G.I.'s and O.J.'s in Vietnam. N.Y. Times Magazine 37: 112-124, December 5, 1971.
32. Lasagna, L., Mosteller, F., von Felsinger, J. M., and Beecher, H. K. A study of the placebo response. Am. J. Med. 16(6): 770-779, 1954.
33. Szasz, T. Ceremonial Chemistry. Anchor Press, Garden City, N.Y. 1974.
34. Paton, W.D.M. In Scientific Basis of Drug Dependence, edited by H. Steinberg, pp. 3-4. J. & A. Churchill, Ltd., 1969.
35. Eddy, N.B., Halbach, H., Isbell, H., and Seevers, M. H. Drug dependence: Its significance and characteristics. Bull. WHO 32(5): 721-733, 1965.
36. Cameron, D.C. Facts about drugs. World Health 4-11, April1971.
37. Cameron, D.C. Abuse of alcohol and drugs: Concepts and planning. WHO Chron. 25(1): 8-16, 1971.
38. Solomon, R.L., and Corbit, J.D. An opponent-process theory of motivation. I: Temporal dynamics of affect. Psycho/. Rev. 81(2): 119-145, 1974.
39. Solomon, R.L., and Corbit, J.D. An opponent-process theory of motivation. II: Cigarette addiction. J. Abnorm. Psycho/. 81(2): 158-171, 1973.
40. Peele, S., with Brodsky, A. Love and Addiction. Taplinger, New York, 1975.
41. Nesbitt, P.D. Chronic smoking and emotionality. Journal of Applied Social Psychology 2(2): 187-196, 1972.
42. Lennard, H.L., Epstein, L.J., and Rosenthal, M.S. The methadone illusion. Science 176(4037): 881-884, 1972.