DRUG ADDICTION

 DRUG ADDICTION: ORGANIC AND PSYCHOLOGICAL ASPECTS
The taking of drugs is culturally patterned behavior. Both the prevalence and the consequences of drug use in any society depend as much upon social norms as upon physiological responses to drugs or general psychological characteristics of drug users. The ends sought through use of drugs are varied: relief from pain, fatigue, or anxiety, the celebration of social solidarity, “kicks,” and enhanced mystical experience. Beliefs about the effects of the substances used and the specific ends sought through such use are closely linked with more general cultural goals and orientations. A particular drug—for example, marijuana (also called hashish and bhang)—may be accepted as an appropriate adjunct to sociability in one society, used as an invaluable ingredient in religious contemplation in another, and banned by law as dangerous in a third.


There is no evidence that addiction to drugs is favorably regarded in any society or culture, but the status accorded the addict varies markedly. In the United States he has been defined as a criminal and stereotyped as a “dope fiend.” In much of Europe, on the other hand, the addict is regarded as an unfortunate person whose problem is primarily psychological and medical. Having stated that great differences exist in cultural orientations to specific drugs or drug effects, we are, however, far from being able to explain them. Opium and hashish have been widely used without extreme devaluation in Muslim society, although the Koran proscribes the use of substances that alter the state of consciousness. In traditional interpretations, it appears that the Koran’s injunction has been limited to alcohol.


To cite another example, a student of culture and personality has suggested that opium smoking was prevalent in China because it afforded a means of achieving the cultural goal of individual harmony with the environment. But opium smoking did not exist in China until it was introduced by European traders in the seventeenth century (Sonnedecker 1963, p. 16). Opium was subsequently forced upon the Chinese by the East India Company, despite protests by the Chinese government. An adequate understanding of drug use within a given culture requires a knowledge of historical facts that is seldom available.


To the extent that the beliefs and practices surrounding drug use reflect different perspectives and value orientations, the social correlates and the consequences of drug use will themselves vary substantially from one country to another and from time to time within any given country. Coffee and tobacco have, in various societies, been proscribed as debilitating or debauching; the smoking of tobacco was a crime punishable by death in Russia, Persia, Turkey, and parts of Germany (Lewin 1924). The term “drug” refers to a wide variety of chemical substances consumed by man, not merely to narcotics or “dangerous drugs.” When applied to substances consumed outside of medical channels, however, “drug” tends to connote something negatively valued. Hence, we do not normally apply the term “drug habit” to the smoking of tobacco, but we do to the smoking of marijuana (a non-addicting drug produced from the hemp plant), even though many more persons may be psychologically habituated to tobacco smoking than to marijuana. Because of common usage, this article is primarily concerned with narcotics addiction.


Historical background
From the earliest record in antiquity through the Middle Ages, it appears that the primary use of opium was medical. The letters and records of European travelers in the Orient during the Middle Ages occasionally refer to opium as a drug used by the people to overcome fatigue, but they do not mention chronic intoxication or indicate recognition of the phenomena of tolerance and dependency (Sonnedecker 1963, p. 16). Available records suggest that opium consumption was not a widespread practice or problem anywhere until the beginning of the seventeenth century, when opium smoking was introduced into China. Although the pleasures of opium smoking and opium eating were extolled by writers like De Quincey and Coleridge in the nineteenth century, in general neither the British nor other Europeans were drawn to opium; it was primarily an article for trade with alien peoples.


Drug use in the United States
Attitudes were in general no more favorable in the United States than in Europe, but for several reasons opiate addiction was a more frequent occurrence in the former (Terry & Pellens 1928, pp. 66–90). Among these was the reliance on patent medicines containing opium and its derivatives. Such medicines were widely used in nineteenth-century America to combat a variety of ailments, especially “female disorders.” Another source of addiction in the United States was the excessive use of hypodermically administered morphine in medical practice. Many soldiers wounded in the Civil War became addicts. Of quite a different nature was the third general influence, the introduction of opium smoking by devotees of the sporting world on the west coast in the last quarter of the nineteenth century. In this instance, opium was used purely for pleasure.


Although strongly disapproved of by the conventional citizenry (local legislation against opium dens became widespread), the practice was taken up by many persons on the fringes of polite society, and it flourished among prostitutes and underworld characters. Imports of smoking opium generally exceeded 100,000 pounds a year between 1880 and 1909, when they were finally cut off. As a consequence of these influences, opium consumption tripled in the period from 1870 to 1909. Simultaneously, the image of the addict changed rapidly as opium use became more widespread in the underworld (Eldridge 1962, pp. 9–10). Prior to the enactment of the Harrison Act, most users of narcotics were, however, conventional members of society.


The Harrison Act, passed by Congress in 1914, was basically designed to eliminate the nonmedical use of narcotics by providing controls and a careful system of accounting for and taxing all drugs defined as addicting that were produced or im ported into the United States. With the enforcement of this act, as interpreted by the narcotics section of the Treasury Department, an addict could no longer secure drugs legally. In the first two decades after passage of the Harrison Act, the number of addicts in the United States markedly declined. Since then, however, a persistent problem of somewhat changing character has emerged in the United States.


Extent of drug addiction
The extent of drug use and drug addiction, historically or currently, is known only in very general terms. Since the use of opiates and of marijuana and the so-called “dangerous drugs” is devalued by the great mass of the population in Western society, and since the possession of these drugs is illegal in many countries, it is not possible to get a direct count of drug users but only an indication of those who come to official attention in one way or another. An ad hoc panel on drug abuse reported in 1962 that discrepancies between estimates provided by federal, state, and local enforcement agencies and other sources of data were so great that they precluded any adequate estimate of the number of addicts in the United States (White House Conference 1963, pp. 290–292).


The Federal Bureau of Narcotics, which has attempted to maintain a register of “active addicts,” listed therein nearly fifty thousand names. There is no way, however, of knowing how many of the persons so listed are actively addicted at any given time or, indeed, how many are still living. From various fragments of available data, it appears that the number of persons in the United States actively addicted to opiates within the past decade is almost certainly not less than 50,000 and probably not more than 100,000. By contrast, it does not appear that any other Western country has as many as five thousand opiate addicts, according to a review of foreign experience by the Joint Committee on Narcotics of the American Bar Association and the American Medical Association (Joint Committee 1961, pp. 121–153).


Great Britain has long reported an addict population of between three hundred and four hundred. None of the Scandinavian countries has more than a few hundred addicts, nor does France or Italy. Only in West Germany does the number of known addicts go much higher, and even there the estimate is well under five thousand (Joint Committee 1961, p. 151).


Among Western countries, a significant fraction of all addicts is found among physicians and other medical personnel. Beyond this fact, very little is known about the social characteristics of drug users and addicts except for the United States. Because the problem is more prevalent in the United States than in any other Western country, and because in recent years detailed studies have been undertaken to establish the characteristics of drug users, the following discussion of patterns of drug use and of characteristics of drug users will be confined almost entirely to the United States.


Changing character of drug use
When the Harrison Act was passed, drug addicts were widely dispersed in American society. Impressions of the dominant characteristics of the addict population varied according to the segment of the population seen in treatment—highly successful individuals, middle-class neurotics, criminals, and degenerates (Terry & Pellens 1928, pp. 513–516). It seems probable that female addicts outnumbered male addicts at the turn of the century. Moreover, the large majority of addicts were native-born whites of mature years. In the following two decades, the new addicts were largely white males. Most of them were introduced to drug use as young adults already somewhat detached from conventional society. They tended to frequent or to take up residence in areas in which illegal drugs could be purchased, chiefly the most disorganized areas of the largest cities (Dai 1937). These were areas characterized by overcrowding, high rates of crime, and other social problems; they were areas that afforded anonymity in the pursuit of illicit activity.


Drug use and minority group status. By the early 1950s, many of the areas in which illicit narcotics had long been available were occupied by new waves of migration from the southeast section of the United States, from Puerto Rico, and from Mexico. The new residents were at a considerable disadvantage economically and were poorly equipped to cope with the demands of an industrial society. Many adolescents and young adults were exposed to the availability of marijuana and heroin in their home neighborhoods. Opportunities for drug use were afforded, whether or not the individual was favorably oriented toward drug use. In some neighborhoods, as many as 10 per cent of all males in late adolescence were officially recorded as drug users (Chein et al. 1964, pp. 40–41).


In recent years nearly three-fourths of all addicts recorded on the register of the Bureau of Narcotics have been Negro, Puerto Rican, or Mexican-American in extraction. One-third of these recent drug users have been under 25 years of age. Thus there has been a marked shift in the character of the problem of drug addiction in the United States in recent years; it is now entwined with minority group status. While the psychological needs and frustrations of minority group members undoubtedly contribute to the attractiveness of drugs, addiction among them cannot be adequately explained or dealt with in terms of individual psychology.


Becoming a drug user
It is obvious that narcotics must be available before there can be narcotics users; it is perhaps less obvious that an individual must learn the techniques of drug use and to some degree the proper way to perceive and enjoy drug effects before he becomes a regular drug user. The process of becoming a user is closely related to patterns of association and access to drugs.


In the period between initial enforcement of the Harrison Act and World War ii, most persons who became addicted to opiates through nonmedical channels probably did so either by virtue of close affiliation with another addict or in the course of thrill-seeking behavior (Dai 1937, p. 173). Following World War ii, however, a high proportion of those who became drug users had been introduced to the use of narcotics in the slum areas in which their families lived. These recent addicts have tended to come from family backgrounds and life circumstances conducive to the production of psychopathy. There is much evidence, however, that psychological difficulties are far more widespread than is illicit drug use. Recent research in New York City and Chicago suggests that the use of heroin and other opiates, in most instances, is learned through association with peers in the subculture of “street-corner society.” The norms of this subculture are generally inconsistent with and often openly hostile to those of conventional society. The orientation on the part of substantial numbers of adolescents is manifested in delinquency and in the search for and exploitation of “kicks” (Finestone 1957a).


In general, the prevailing sentiment toward drug use, even on the part of residents of slum areas, is decidedly negative. Most children learn that heroin and marijuana are considered “bad” by most adults. In areas of highest drug use, however, rejection of the standards of conventional society, distrust of policemen, and relatively favorable attitudes toward drugs tend to be much more widely prevalent, even among a cross section of school children, than in other areas of the city (Chein et al. 1964, p. 102). A substantial proportion of young people are likely to have friends or associates who use marijuana or heroin.


The subculture of addiction
Many young people have their initial drug experience with marijuana reefers provided by older companions. The neophyte who likes the experience and wishes to move toward regular use must have a more stable source of supply than can be provided by chance encounters with other users. He is likely to spend more time with persons who use marijuana and to avoid those who strongly disapprove (Becker [1953b] 1963, pp. 62–72). This reduces the need for secrecy in smoking marijuana and enhances the pleasures of use. Simultaneously, changing contacts help to negate the popular stereotype of the marijuana “addict.” It becomes apparent that marijuana does not completely transform the personality; the new user learns a series of positive beliefs about the beneficial effects of marijuana, beliefs constantly being reinforced by their verbalization within the group (Becker [1953b] 1963, pp. 72–78).


The use of heroin is a step further along the path of alienation from conventional values. Here the prevailing attitudes, even in delinquent subcultures, are much more negative. Here there is the promise of a bigger kick but also at much greater cost. Most of those who try heroin for the first time, however, are aware that addiction does not come from a single or an occasional trial. It is likely that few anticipate that they will be “hooked.” Some—no one knows what proportion— manage to use the drug for a time on an occasional basis and then stop altogether without ever becoming addicts (Chein 1964, p. 159). Others, especially those for whom heroin use leads to a marked increase in feelings of adequacy, move quickly to the subculture of the addict, where “connections” can be made and where the drug itself becomes the central fact of existence.


Lindesmith (1947, chapter 4) has noted the critical importance of the individual’s recognition that withdrawal sickness can be warded off by use of the drug. It is at this time that he becomes fully aware of the nature of addiction and of his dependency upon the opiates. Both his patterns of association and his self-image change markedly as he becomes assimilated into the subculture of addict society.


Social backgrounds, personality, and drug use
Certain personality characteristics of narcotics addicts are markedly different from those of normal middle-class persons, and to a lesser degree they are different from those of nonaddicted persons coming from the same social backgrounds as the addicts. One major expression of the personality differences is in attitude. Addicts are characterized by attitudes of pessimism and futility on the one hand and of distrust and rejection of the standards and representatives of middle-class society on the other. These attitudes do not merely characterize addicts, however. As indicated above, Chein found them to be rife among eighth-grade pupils in schools located in areas of high drug use. To a substantial degree, then, they would seem to be prevalent social orientations which are conducive to drug use.


Another major aspect of personality difference between the addict and the nonaddict is the low self-esteem and high degree of social immobilization of the narcotics user by virtue of anxiety. A major appeal of the opiates is that they permit the constricted ego greater scope and freedom (Chein 1964, chapter 9). But again the personality attributes appear to reflect aspects of the social environment in which the addict has been nurtured, particularly the devaluation and deprivation that are experienced by residents, especially minority group members, of urban slums. The same terms relating to personality characteristics have been used to describe slum dwellers elsewhere who were not involved in drug use (Clausen 1957, pp. 263–266). Within the areas of highest rates of drug use, users tend to come from families lacking a stable father figure, lacking warmth between parents, and characterized by vague or inconsistent standards (Chein 1964, chapter 10). All of these factors would tend to contribute to psychopathy in the child; families with such characteristics are in part a product of migration to and life in the urban slum.


The world of addiction
Criminality and drug use
Although narcotics use has long been prevalent in the underworld, prior to the passage of the Harrison Act the great majority of opiate users and addicts in the United States were law-abiding citizens. Thereafter, addiction or occasional use of opiates for nonmedical reasons could be maintained only by criminal means—either the illegal purchase of smuggled drugs or the theft of drugs. Moreover, few addicts could afford the high cost of illegal drugs without resorting to theft or other criminal activities.


In general, addiction to narcotics reduces the inclination toward aggressive or violent behavior (Joint Committee 1961, p. 68). In this respect, heroin is far less likely to lead to violence than is alcohol. It is the lack of the drug, rather than its consumption, that is most closely linked with criminal activities on the part of the addict. Larceny, or theft for money to buy drugs, is the dominant crime of the narcotics offender (Finestone 1957b, p. 71).


At the same time, drug use provides one type of adjustment within a delinquent milieu. Many, perhaps most, of the young drug users growing up in the worst urban slums are involved in delinquency long before they try marijuana or heroin. There is some evidence that those whose drug use is part of a subcultural pattern that begins with delinquency may be psychologically more sound than those whose delinquent behavior did not start until they had become drug users and needed money in order to support the habit (Chein 1964, chapter 6).


The important point to be made is that drug effects, even when harmful, are not the primary cause of criminal behavior. British opiate addicts are not criminals to any significant degree (Schur 1962, pp. 135–140). The meaning of drug use and its linkage with crime depends largely on the laws relating to narcotics and on public attitudes toward addiction.


Employment and drug use
To the extent that narcotics or other drugs become the central preoccupation of an individual, as is true of an addict, that individual is likely to be an undependable employee. A substantial proportion of physician addicts are reported to have functioned adequately for long periods while addicted to narcotics, but the great majority of addicts are, at best, irregularly employed (Schur 1962, p. 131). Except for entertainers and physicians, the population from which addicts are drawn in the United States tends to be relatively disadvantaged in the job market. Since possession of a drug calls for more serious penalties than do most forms of theft, there is little incentive for the active addict to work. Even in Britain, however, where addiction and drug possession are not denned as crimes, most addicts have unsatisfactory work records (Schur 1962, p. 134). It is not possible to state to what degree their poor work records reflect the personality problems that gave rise to their addiction or that are a direct consequence of the use of drugs.


Contextual supports
By virtue of his alienation from conventional norms and his stigmatization, the narcotics addict tends, even when he is not using drugs, to have his closest associations with persons who speak his argot and accept him without regard for his criminal record. Many addicts voluntarily undertake “cures” in one of the hospitals established to provide for drug withdrawal and treatment in a drug-free environment. Few appear to be content with continual addiction (Lindesmith 1947, chapter 6; Ray 1961, p. 134), but the rate of relapse to drug use is exceedingly high. Follow-up studies suggest that relapses tend to occur very soon after discharge from a treatment center. Of patients returned to New York City from the Public Health Service Hospital at Lexington, Kentucky, during the period from July 1952 to December 1955, only 9 per cent were voluntarily abstinent six months later and less than 3 per cent were abstinent for a full five years (Duvall et al. 1963). Yet at the end of the five-year period, nearly 25 per cent of the study group had been voluntarily abstinent for three months or more.


Ray (1961) notes that the abstinent former addict is likely to be viewed with distrust by relatives and representatives of conventional society. Even though not using drugs, he may be periodically picked up by the police for questioning. Under such circumstances, he is likely to turn again to his association with other addicts.


Narcotics control
The primary objective of efforts in the United States to control drug use has been to stamp out the trade in illicit drugs. Efforts to mobilize public sentiment against drug addicts and the drug traffic have often relied on the dissemination of markedly distorted information and on attempts to suppress consideration of alternative points of view (Eldridge 1962, pp. 39–40, 78–80). Legislation has provided severe penalties for the sale or possession of drugs, but this approach has neither eliminated illicit drug use nor contributed to the rehabilitation of addicts.


Most addicts engage in small-scale peddling of drugs on those occasions when they are able to purchase more than enough for their own needs. They are then subject to the same penalties for drug sale and possession as are the nonaddicted distributors of narcotics. As a consequence of longer prison sentences, the number and proportion of narcotics offenders, chiefly addicts, in prison populations has more than doubled. Increasingly, professional groups have called attention to the lack of success of punitive measures (Joint Committee 1961; Eldridge 1962; White House Conference 1963).


It is too soon to predict the effect of such re-evaluations, but attention has been focused on alternative approaches. One such approach is the so-called British system of control (Schur 1962). The basic legislation relating to narcotics use in England is not markedly different from that in the United States, except that penalties are far less stringent. Moreover, in interpretation of the law, the medical profession has been left free to deal with addiction as a medical problem. The addict has neither been stigmatized nor forced into criminal activity.


Hallucinogenic and other “new” drugs
In recent years a new group of drugs, the hallucinogens (also called psychedelic or psychotomi-metic drugs), has come increasingly into attention and use, especially among young intellectuals interested in deepening their psychic experiences (Barron et al. 1964). In the case of these drugs, as with alcohol, it appears that the effects are markedly influenced not only by the nature and amount of the drug taken but by the personality and current mood of the subject and by the context in which the drug is used and the expectations held. In a few places, cults have arisen around the use of the hallucinogens. Where this has occurred, some of the opprobrium directed toward illegal drug use has been noted.


More closely linked with the orientation toward thrill-seeking and deviant behavior that characterizes much opiate addiction in the United States has been the increasing use of amphetamine and other stimulants (White House Conference 1963, pp. 286–289). Although many of the new drugs are not addicting, their use is to a high degree expressive of rebellion and problematic behavior. It is not unlikely that experience with an ever-increasing number of new drugs will in time force a re-consideration of both the criteria and the standards underlying legislation for the control of drugs.