Introduction
Terminology
The use of drugs
Historical perspective
The drug traffic
The pharmacology
The addictive experience
The course of addition
The addict
Precipitants of addiction
The control of addiction Legal Controls
Treatment
What of the future?
Author: D. S. BELL,
Pages: 21 to 32
Creation Date: 1970/01/01
Drug addiction should be considered within the larger perspective of the normal use of drugs for social purposes. In widely varying cultures and with pharmacologically dissimilar drugs the pattern of normal use is sufficiently consistent and widespread to indicate that drugs serve an essential social function. An historical review suggests that the patterns of addiction have not altered significantly in recorded time. Sudden or massive epidemics of addiction generally follow the exposure of a population to a drug, the use and control of which are not incorporated in its culture.
Clearly no single cause can be advanced to explain addiction; many factors are involved, from the simpler issues of the pharmacology of the drugs to the more complex problems of the personalities and social interactions of the addicts. Moreover, treatment, control and prevention are complicated by the fact that the addict "enjoys" his illness and tends to resist treatment or change, and family members may be equally obstructive. One thing at least is clear: the use and abuse of drugs, particularly of alcohol, is so widespread and pervasive that many of the effects of addiction are not recognized as such. In the absence of sufficient knowledge, a substantial mythology has been created that inevitably retards or misguides action. This paper will present a general review of addiction, sometimes within a positive framework that is decidedly personal.
In 1964 an Expert Committee of the World Health Organization [ 1] recommended the use of the term "dependence' in preference to the longer-established term "addiction ". Thus drug dependence can be qualified in each case by the specific drug involved, for example, "Drug Dependence of the Morphine Type ". It has been claimed that the concepts associated with the customary use of the word "addiction" are often incorrect and have become associated with prejudiced and punitive attitudes by society and the law. Even if this be so, it is unlikely that the worthwhile aim of modifying public opinion will be achieved by such a simple stratagem.
The original version of this article first appeared in Current Affairs Bulletin Vol. 41, No. 7, February 26, 1968, published by the Department of Adult Education in the University of Sydney. Its present form incorporates certain minor revisions by the author.
Psychiatrist in charge, Psychiatric Research Unit, Rozelle, N.S.W. 2039, Australia.
Moreover, the new terminology, which has not been accepted by the United Nations Commission on Narcotic Drugs [ 2] , has its own intrinsic deficiencies. "Dependence" refers to a number of unrelated syndromes; people who are "dependent" may be so because of circumstances or because of a personality disorder which makes them excessively reliant on other people, without necessarily making them susceptible to drug dependence. Both psychological and physiological dependence may occur in drug addiction, but only psychological dependence is an invariable part and characteristic of this disorder. Physiological dependence can be viewed as an accidental accompaniment, a pharmacological property of some drugs of addiction.
The failure to recognize this has given rise to some of the myths surrounding addiction. For example, the fact that opium and its derivatives always produce physiological dependence in the course of repeated administration gave rise to the erroneous conclusion, contributed to at first by a WHO Expert Committee [ 3] , that the opiates will produce addiction in any person. Hence the lurid tales of people forced to become heroin addicts by a single injection, or of girls forced into prostitution by the same fiendish device. The truth, demonstrated in clinical medicine on innumerable occasions when morphine is given over long periods to relieve pain, is that the opiates will produce psychological dependence, and hence addiction, in only a small proportion of people. Conversely, the likelihood of addiction to stimulants was dismissed for too long because they do not produce an appreciable degree of physiological dependence.
To substitute the inherently confusing word "dependence" for a long-established term, avowedly to clarify issues, is hardly acceptable. In this paper the term addiction is retained deliberately to mean the abuse of drugs to the extent that the health, family or social life, or the occupation of the individual is harmed.
To place drug abuse into perspective, drug use for social purposes should be fully understood. Surprisingly little has been written about the value of drug use for society and the individual. Drug use has been taken so much for granted that the concept of a social function is usually overlooked. For many the use of drugs, including alcohol, is thought of as a weakness - even a sin. Drug abuse in these terms becomes a greater sin, and the distinction between use and abuse is blurred. Prohibition in the U.S.A. was designed to prevent the abuse of alcohol and it failed because the means adopted prohibited its normal use, which society simply refused to abandon.
The social uses of drugs may be implied from the traditional rules that form part of the culture of each society. An almost invariable tradition is that drugs are used in group situations; some primitive cultures restrict drug use to religious occasions. Commonly drugs are used to promote gregarious social functions, which may be contrasted with another traditional valued social function - to assist in inflaming hatreds against an external enemy of the group. On different occasions the same drug may be used for a variety of purposes consistent with the aims of the society of the users; marihuana is normally used to promote a pleasant happy state, but it was used deliberately to promote homicidal impulses in members of a political group of professional murderers in Persia. Aberrant social groups, such as the "flower people ", may use drugs as unacceptable to their parent society as the social aims they profess, but the drugs are still employed to promote the aims of their groups and are used in a conformist manner in a group setting.
Cultures also embody rules that attempt to control drug abuse. In contrast to drug use in a social setting, solitary use of a drug is usually censured. In traditional European Jewish culture a very low rate of alcoholism is coupled with a high degree of acceptance and a sparing use of alcohol. Clearly many other factors are involved but is it probably significant that the use of alcohol is mandatory to Jewish religious ceremonies Of special social consequence, such as the wedding ceremony and the family service during the Passover. Before the opium war disrupted the traditional social and administrative controls there was comparatively little abuse of opium in China where it had been known and used since the ninth century.
The use of alcohol in Western society is deeply enmeshed in its culture and its economics. In France, where wine-producing is economically important, traditions promote the use of alcohol. Not only does France have the highest over-all rate of alcoholism of any nation, but an excessive use that is tantamount to poisoning rather than addiction has resulted in an appreciable incidence of physical disorders amongst the children. The cultural attitude of toleration of drunkenness amongst the Irish, contributing to their high rate of alcoholism, particularly among unmarried males, may also have arisen from an economic cause, namely the grind of poverty. The recognition of this cultural influence in Australia is summarized by the saying that "You don't have to be Irish to be an alcoholic, but it helps."
In the U.S.A. there are an estimated 5 to 6 million alcoholics, with 20 to 30 million persons close to them suffering adversely from their behaviour [ 4] . In fact the size of the problem of addiction to alcohol and barbiturates dwarfs the problem of narcotic addiction in the U.S.A. and in every other country with a Western culture. The selection of alcohol in Western countries as the socially accepted drug has had the unfortunate consequence that alcoholism is regarded as something apart from addiction to other drugs. A wider view, such as that taken by a WHO Expert Committee [ 5] impresses that the basic problems of addiction apply similarly to all drugs of abuse, the apparent distinctions being secondary issues related to the pharmacology of the individual drugs and the cultural and social milieu of the addict.
Regardless of the widely disparate types of drugs adopted by different societies, they are used for identical social purposes. In the Pacific area, societies using kava, an intoxicating beverage and also a sedative, are distinctly separate from those using betel-nut, a stimulant. Other societies that use stimulants are found in South America (coca leaf containing cocaine), around the Red Sea (khat), and in Asia (betel-nut). Marihuana has effects broadly similar to alcohol and is used extensively in Asia, Arabia and Africa. Opium and its derivatives have an extensive use, as distinct from abuse, and it may not be too much to claim that addiction to narcotics in these societies is no more serious a problem than addiction to alcohol in alcohol-using societies.
The reason for the current epidemic of drug addiction is often presented as a consequence of modern life: the soul-destroying pace of the competitive world, the disruption of traditional standards and the elevation of materialistic and hedonistic drives. In fact, the use and abuse of drugs has altered little in its general pattern over the span of recorded history.
The use of opium, marihuana and cocaine was probably known to Stone Age peoples. The cultivation and preparation of opium described on clay tablets by Sumerians about 7000 B.C. are substantially the same as the technique used today. These drugs, and others such as the mushroom hallucinogens, were used mainly for religious purposes or to prepare warriors for battle. Alcohol use was widely established before recorded history [ 6] and biblical injunctions against excessive use show that the dangers were well known. Some of the phenomena attributed to witchcraft by medieval theologians were the consequences of drug intoxication.
As indicated earlier, epidemics of drug addiction usually erupt when a population is exposed to a new drug, the use and control of which is not incorporated in its culture. The destructive effects of alcohol on native populations exposed to European colonizers is only one special example. The European population was also exposed to new drugs when the returning colonizers brought back tobacco and a variety of other drugs. The widespread use of opium in Europe as a drug of addiction followed its importation on a large scale by the East India Company.
Alternatively, a population may be exposed to a drug already known and incorporated in its culture when the culture and the usual controls are disrupted by a conquering civilization: the extensive use of the coca leaf in South America as a drug of addiction followed the disruption of the Inca civilization by the Spaniards. Before this, its use was restricted to the aristocracy, who in turn were restricted to enjoying its effects only in the course of religious ceremonies. Today, the number of users in South America is estimated to be about 8 millions, which is not remarkable considering that in Bolivia and Peru alone the estimated coca leaf production is 10,000 to 20,000 tons a year.
In recent times, an epidemic of stimulant addiction commenced on an equally startling scale in Japan after World War II [ 7] ; stockpiles of amphetamines for the Japanese armed services became available to the public in the disruption of morale and order following the military defeat. It has already been noted that narcotics were not used extensively in China until after the opium wars forced its rulers to accept the British-sponsored opium trade from India.
Many epidemics have resulted from the deliberate exposure of a population to a new drug in the mistaken belief that it is non-addictive. In the last two decades, the ability to synthesize a multitude of new substances, coupled with effective modem promotion techniques, have resulted in numerous examples. The fault cannot be wholly ascribed to the companies that produce or promote them: the epidemic of abuse of lysergic acid diethylamide (L.S.D.) and other hallucinogens has been significantly helped by a small and notorious group of psychologists from Harvard University.
It is less well known that an epidemic of cocaine addiction in Europe in the 19th century was influenced by Sigmund Freud among others, who advocated its use for the treatment of morphine addiction [ 8] . It was undoubtedly effective in cutting short the addiction to morphine, but the subjects simply became addicted to cocaine instead. In the U.S.A. in the 19th century, opiates were used to "cure" alcoholism, and the latest example of this mistaken approach is the attempt to treat heroin addiction with a synthetic narcotic [ 9] . It is of significance that when heroin was first synthesized in 1898 it was hailed as a miracle drug with all of the virtues of an opiate but without any of its dangers [ 10] . Millions of addicts resulted from its free use.
The illegal traffic in opium is probably the most notorious example of the traffic in drugs; about 200 tons of opium is diverted from legal production annually and only one-tenth is recovered by seizures. There is considerable production in uncontrolled areas, amounting to an estimated 1,000 tons in South-East Asia alone. Large amounts are also grown in India, the Middle East and Turkey [ 11] . Hong Kong is one of the stations in the traffic from South-East Asia and is also one of the most heavily addicted cities of the world [ 12] . The areas in Laos and Burma, where the crop is grown, are protected by large well-armed private armies that are independent of the central governments. Most of the traffic is directed to the U.S.A. where the best price is obtained. Organized crime is involved in the smuggling and distribution of narcotics, but the final sale is conducted by "pushers ", who are mostly addicts themselves. A pound of opium purchased in a hillside village in Laos for $25 may be worth as much as $1000 if it reaches the U.S.A. as 1 oz. of refined heroin [ 13] .
Coca in South America is a cash crop grown on such a scale that economic reasons alone prevent the passage of legislation to control cocaine addiction. Marihuana grows as a weed and its cultivation la so easy that effective control of world production is not possible in the predictable future. Analgesics, sedatives, alcohol and stimulants are manufactured on a large scale for legitimate use and in many countries probably at least half of all that is consumed constitutes drug abuse. Half of the 8 billion tablets of stimulants manufactured annually in the U.S.A. is said to be directed into illegal channels even before it reaches the retailer [ 14] . From the extent of addiction to analgesic drugs containing phenacetin in Australia, it is estimated that at least 4 per cent of the population have already suffered appreciable kidney damage [ 15] .
The enormous profits gained from the sale of alcohol and other drugs has led to the simple reductionist view that the profit motive is the primary cause of drug addiction. It is also claimed that the present situation is perpetuated because the state itself also draws substantial revenue from the sale of drugs. However the profit motive cannot adequately explain addiction.
In fact, excise tax was originally conceived as a measure to prevent addiction and in this it has been partially successful. Restrictive legislation in the United Kingdom after 1917, which included increase in the tax, particularly on spirits, was followed by a sharp fall in convictions for drunkenness. Subsequent experience suggests that the alcoholism rate is inversely proportional to the price of alcohol: alcoholism is almost twice as common in Australia as in the United Kingdom, and alcohol is half the cost. Before the Harrison Narcotic Act was passed in 1914, opium was very cheap in the U.S.A. (it was even added to soft drinks) and addiction was at least eight times as common as it is now. Thus, although the profit motive is involved in the promotion of addiction, it is not "the cause ", but only the inevitable attempt to exploit its possibilities.
The pharmacology of drugs of addiction explains the course of the disorder, but not its origin; addiction may develop to sedatives, stimulants, analgesics, anaesthetics, household and industrial chemicals, narcotics and hallucinogens. The wide range of these drugs suggests that the major actions are irrelevant, even when an action induces unpleasant symptoms, such as the severe constipation common in opiate addiction. Drugs of addiction are also diverse as to their chemical constitution and have only one action in common -that they produce pleasurable effects. The overwhelming need to seek this pleasure is known as psychological dependence.
Addicts are fully aware of the pleasure they experience and seek and, although they themselves readily admit that this is the essential impetus for taking the drug, there is a strange reluctance among others to accept this obvious explanation. The main reason would appear to be that the pleasure-seeking motivation does not fit into the medical model of an illness. A variety of alternative explanations has been formulated, but for reasons described later they are inadequate.
Physical dependence on the other hand relates to the pharmacology of drugs. In the course of the repeated administration of a drug the body adapts to its effects. If the administration is suddenly stopped and a withdrawal syndrome results, the drug may be accepted as having produced physical dependence. Gradual withdrawal over days, or at most a few weeks, allows the physical dependence to resolve without the appearance of a withdrawal syndrome. The effects of precipitate withdrawal of the opiates, known in the vernacular as "cold turkey ", are infamous. The withdrawal syndromes of other drugs are not as well known, and yet are much more common in Western countries and are potentially more serious. Precipitate withdrawal from barbiturates and alcohol can result in convulsions, delirium and a drop in blood pressure sufficiently severe to result in brain damage or death. Physical dependence in fact is the result of changes within the individual cells of the body: cells of a tissue culture can be made dependent on morphine to the extent that sudden withdrawal of the drug from the nurturing medium results in the death of the cells [ 16] .
It has been argued that physiological and psychological dependence are both necessary characteristics of addiction, and that the addiction follows from the desire to avoid the physical discomfort of the withdrawal syndrome. Plausible as it may be, this viewpoint can be dismissed. Some drugs of addiction do not result in appreciable physiological dependence or a withdrawal syndrome; cocaine and the amphetamines are prominent examples. Moreover, the withdrawal syndrome cannot explain how the addiction commenced, nor the relapse of addicts who have long since ceased to have withdrawal symptoms. It is common for addicts to relapse after the lengthy abstinence enforced during detention in an institution.
Tolerance can be defined as a diminishing response to repeated doses of a drug. From the point of view of the drug user successively larger doses are needed to achieve the same effect. It is an unfortunate complication to the addict, who has to go to increasing expense and trouble to secure increasing supplies. Tolerance develops so rapidly to lysergide (L.S.D.) that daily administration for lengthy periods is not possible. Even enormous increases in dosage rapidly reach a limit of practicality. The psychedelic cult has thrown up its own Élite: those who take massive doses in their attempt to defeat tolerance. Usually, however, "trips" are taken only at intervals of a few weeks. Tolerance develops to an obvious degree for the amphetamines and opiates, but is a less prominent characteristic of barbiturates and alcohol.
The need to increase the dose has other complications for the addict. Alcohol supplies calories, but is lacking in essential vitamins. As it replaces the normal dietary intake a vitamin deficiency and consequent brain damage supervenes, becoming obvious with the dramatic onset of "the horrors" (delirium tremens). Barbiturates and bromides accumulate in the body until a level is reached which results in mental confusion and delirium. Headache powders and analgesics containing phenacetin damage the kidneys and the preparations can also affect the oxygen-carrying capacity of the red blood cells. The large doses of stimulants taken by the addict who has developed tolerance over some months result in the insidious onset of a mental illness that is clinically indistinguishable from schizophrenia and is often mistaken for such [ 17] : the addict develops delusions of persecution and hallucinations, and may act on the strength of what he believes, even to the extent of homicide or suicide.
Combined action of drugs is commonly sought among addicts. On the face of it, a sedative such as a barbiturate and a stimulant such as an amphetamine should counteract each other. But the terms "sedative" and "stimulant" do not do credit to the possibilities of complex interactions of drugs. The error here is in disregarding the fact that any one drug has not one, but a multitude of actions. Some of the actions of barbiturates and amphetamines are antagonistic, but others combine to enhance the pleasure-giving effect with either alone. It may be inferred from the combinations favoured by some addicts that there is a similar enhanced euphoriant effect from the combined use of amphetamine with alcohol or with narcotics, and of barbiturates with narcotics. Experimentation is common among addicts and is dangerous, as some combinations enhance effects that can be lethal.
The key to understanding addiction is in the study of the intoxicated individual. The first essential event of drug addiction is the experience of the drug-induced pleasure. To the individual this is of such an order that the continued seeking of this pleasure overrides considerations of health, occupation, family and social life. Addicts describe this "super-pleasure" as a feeling of "confidence ", of an ability to do anything and handle any worries, a sense of intellectual and physical power, summarized quite aptly by one patient as "being a bit like God ". The extraordinarily inflated and unrealistic sense of power may be categorized as a feeling of omnipotence [ 18] . Its manifestations may be seen as a commonplace event in any public bar in the drunk who knows all or can fight all. The sober alcoholic usually has superficial and poor relationships with people; during drinking the apparent transformation is marked [ 19] . This behaviour is characteristic of a whole community in' Peru - the Lunahuaná - in which excessive drinking permeates the social life of all its members. Normally suspicious and distrustful, the people when drunk become loquacious, over-friendly and maudlin [ 20] .
An alternative explanation is that the drug relieves tension or anxiety, so that the effect is pleasurable only in comparison with the previous unpleasant state of feeling. Any disagreement between these viewpoints may only be a question of semantics, particularly if it be accepted that the addict is a disturbed individual who has a fundamental problem of obtaining satisfactions and who is subjected to stresses with which he cannot cope.
In looking for a comparable mode of pleasure seeking there are marked similarities to infantile behaviour. A sense of omnipotence in the adult is in fact a regression to a state of infantile thinking and is almost inva- riably accompanied by a loss of competence and effectiveness.
A characteristic of adult behaviour is that it can defer pleasure seeking. Rado [ 21] has observed how the self-regulation of pleasure-seeking demands is corrupted in addiction, and the adult returns to the pre-cultural hedonic responses of the infant with its necessity for immediate relief. The addict, like the infant, has intense swings from the pleasure of satiation to the discomfort of hunger, with little variety or subtlety of feeling between these extremes. The pleasure of the infant and of the addict is gained without the usual adaptive effort and performance required of the adult.
The non-addict may assume that the drug-induced sensation is inconceivably wonderful; the advocates of the hallucinogens make such a claim for the psychedelic experience. Individuals go to such lengths to obtain the drug-induced pleasure that their deeds appear to support their claims.
The same mistaken notion is sometimes found about another form of immature and abnormal behaviour, the sexual perversions. The notion is that the pleasure the pervert seeks must be in proportion to the risks he takes, by comparison far beyond the quality of the heterosexual pleasures of the normal adult. Inquiry establishes the contrary. The perverse pleasure is frequently gained in unpleasant circumstances associated with anxiety, fear and guilt. Perverse sexuality is sought not because it is better than mature sexuality, but because it is the only avenue available for the instinctive sexual drives of these disturbed individuals. Similarly, the pleasures of the drug addict do not convey the outward characteristics of a superlative experience, and an evaluation of the addict's other possibilities for satisfaction show a similar inadequacy.
The symptoms of addiction follow a characteristic cyclic course of elation during intoxication and the "morning after' depression that contrasts so fiercely with the previous feeling of omnipotence [ 22] . The depression may be so marked that it may appear to be the main problem, particularly when evidence of the addiction is successfully concealed. Attempts at suicide are not uncommon in the phase of depression, so much so that no psychiatric group is more prone to suicide than addicts [ 23] and [ 24] .
The cyclic course of elation and depression may be interrupted by any of a number of crises. With those drugs to which tolerance occurs, it becomes progressively more difficult to get a "high' and the increasing expense may make it impossible to continue, at least for a while. The increase in the dose has other complications of inducing psychosis, delirium and physical disorders that have already been mentioned. The intro- duction of new controls or arrest by the police may suddenly cut off the supply of a drug and induce a withdrawal syndrome. But crises that enforce a period of abstinence have the "beneficial" effect for the addict of lowering his tolerance so that in time he can resume his addiction more conveniently.
The "mainliners ", who employ intravenous administration, incur special risks that result in a high death rate. The usual course of addiction is accelerated, tolerance develops more rapidly, each dose gives a more intense experience but the effect is also more evanescent and the subsequent depression is more severe. Such addicts make up their own solutions for intravenous administration, and they soon abandon many precautions, such as sterilization and filtering, and eventually careless technique results in complications such as septicaemia, tetanus, hepatitis, embolism or fatal over-dosage in many cases.
Many factors combine to make it necessary for the addict to conceal the addiction, but the prime motive is to prevent interruption of the supplies of the drug. The alcoholic in a responsible position must conceal his addiction from his colleagues and the "cupboard drinker" does the same at home. The use of illegal drugs involves further need for deception. The long-continued deception produces stereotyped attitudes and defences; in particular a denial of illness that characterizes the chronic alcoholic and other chronic addicts, and which the would-be helper finds particularly irritating.
The necessity to maintain supplies is also the usual motivation of crime committed by the addict. Crime is unnecessary and unusual as long as the addict retains a useful income. The unemployed addict typically commits petty crimes only, such as shop-lifting and break-and-entry to obtain drugs, or the cash to purchase them. More serious crimes of violence are characteristic of drugs such as alcohol and marihuana, which can produce a potentially dangerous intoxicated state. The danger of acts of violence during amphetamine psychosis has already been noted. Contrary to the notion of the narcotic "dope fiend ", the opiates on the other hand produce a tranquil anergic state which inhibits aggressive and sexual activity.
In our society the death rate from addiction is partly disguised as the toll on the road, by far the most important drug being alcohol. Amphetamine psychosis causes an unknown proportion of accidents by interstate truck drivers. Addiction to barbiturates and other sedatives presumably affects the road toll also, but there are no data to allow even a guess as to its extent.
In the preceding discussion it has been shown that no single cause inherent in the pharmacology of drugs or in modern life can adequately explain addiction. Among the welter of other explanations, there is little more of substance than personal opinion.
Biochemical or metabolic theories of addiction enjoy a wide vogue, probably because they present reasons that invite comparison to the respectable model of physical illnesses. They even employ the same terminology, for example, the contention that the alcoholic has an "allergy" to alcohol because of some peculiar metabolic aberration. But there is no single biochemical or metabolic disorder that can be reconciled with the diversity of the chemical constitutions and actions of drugs of addiction. The theories restricted to a special group such as alcoholics do not explain the readiness with which the addict can switch to a completely different drug or the popularity of the combined use with other drugs. The "loss of control' of alcoholics when they take their first drink has been advanced as evidence of a biochemical abnormality. In fact, it has been shown to be a myth as "loss of control" does not occur when alcoholics are given disguised alcohol [ 25] . Premeditation is evident with those alcoholics on disulfuram ( Antabuse), who omit to take the drug for two or three days before they take the first drink of a bout.
Cultural and social attitudes may facilitate, or protect from, the possibility of addiction, but they do not explain the absence of addiction among the greater proportion of the population that is similarly exposed. Particular occupations, such as publican and brewery employee, do facilitate the possibility of addiction because of the ready availability of the drug. Seamen have a high rate of alcoholism. It has been suggested that, in addition to opportunity and an uncritical environment on board ship, a determining factor for the high rate of alcoholism is the gravitation of men with more than the usual incidence of personality disorders to this occupation [ 26] and [ 27] . Medical and para-medical professions have the high rate of addiction to be expected from their ready access to drugs; an estimated 1 in 100 physicians in the U.S.A. is addicted to narcotics. The mistaken notion among jazz musicians that marihuana and other drugs improve their art resulted in considerable addiction in this group.
Fads and fashions that introduce a new drug are particularly effective in promoting epidemics of addiction, mainly because the inevitable time lag before the discovery of the problem and the development of controls allows the addiction to spread in a susceptible population.
Only a proportion of users becomes addicted, despite the influence of culture, occupation and fashion. Some further factor responsible for the addiction must be sought in the addict's make-up. In this writer's clinical experience every addict appears to have a seriously disturbed personality and to have had a disturbed childhood environment. The invariable presence of psychiatric disorder is denied by some investigators, who, because they failed to find the evidence of such disorder, therefore presumed it did not exist. In the case of addiction, such a conclusion is even more risky than usual; denial is a common defence mechanism of addicts and history taking is notoriously unreliable.
It does not seem possible to be any more specific about the psychiatric disorder of addicts. The search for a particular personality type susceptible to addiction has not been particularly helpful. The notion that particular personality types are prone to addiction to specific types of drugs has its attractions, but is not consistent with the facts. Addicts themselves go in the face of such hypotheses by their tendency to concomitant addiction to a variety of drugs and by their ability to switch from one drug to another. The conclusion would seem to be that addiction is associated with a wide variety of psychiatric disorders and is a symptom that is favoured because of the cultural background, attitudes and needs of the individual and the availability of the drug.
Certain "patterns" emerge; histories of the childhood environment of addicts usually describe a wide range of disturbances. Parental discord and separation, overt or covert rejection, are common childhood experiences of addicts. It appears that there is a disproportionately high incidence of addiction among the parents. Only the sketchiest information is as yet available about the subtle specific pressures that may be found in these families.
One pattern is the rabidly teetotaller parent who constantly lectures the child about the evils of drink, generating a special interest rather than an aversion. The cycle of extreme swings between alcoholism and teetotalism may continue for many generations. A common variation is a drunkard father and a martyred teetotaller mother who beget a brood of children, some abstinent and some drunkards. Teetotalism and alcoholism are opposite methods of handling the same basic conflict Viewed in this light, the common history of abrupt swings from complete abstinence to addiction is more understandable. It also serves to explain the cultural pattern of certain groups which have extreme attitudes of rejection of drug use and yet a high incidence of excessive use. An example is the association between the classic temperance movement and the pattern of excessive drinking in the U.S.A. [ 28] .
The influence exerted by the parents does not appear to be accidental or even involuntary. In many cases it is evident that they gain vicarious gratification from the aberrant behaviour of their children, seeking this gratification by encouraging their children to antisocial activity that they cannot indulge themselves [ 29] and [ 30] .
Some mothers divorce or separate from alcoholic fathers early in the marriage, and yet still manage to raise a son who is the facsimile of the absent deviant father. It is not uncommon to find that a parent has introduced an adolescent child to the drug of addiction, such as slimming pills, sleeping tablets or alcohol, in circumstances that made addiction possible. Parents of addicts generally avoid becoming involved in the group therapy of their children and may continue to provide money, or even the drug themselves, long after it has been pointed out that this merely perpetuates the destructive process.
The addict who is married is usually involved with a partner who has something to gain from the disorder. To date, the most carefully studied group has been the wives of addicts. They appear to select husbands with specific problems. Women who divorce a drug addict and remarry are likely to pick another man who is an addict or a deviant [ 31] . What is more, it is usual for the women to recognize the drug problem of the intended spouse before marriage. It seems that they become involved with weak men whom they can dominate and who make only minimal adult heterosexual demands on them [ 32] . The spouses of addicts, like the parents cited above, commonly refuse to become involved in group psychotherapy [ 33] and may materially encourage continuation of the addiction. Some of the mechanisms involved have been brilliantly illustrated in the game "Alcoholic ", described in Games People Play by Eric Berne.
A complex formulation has been evolved of the multitude of factors that make the addict: a disturbed personality, a childhood environment that was not only disturbing but included specific patterns of behaviour that encouraged addiction, some of them cultural in origin and others psychiatric in nature, coupled with relationships at the time of addiction with people who encouraged it for their own vicarious needs, and availability of the drug. Still unexplained is the fact that many addicts control their drug use for lengthy periods at some time in their lives. Abuse of a drug may commence after months or years of moderate use and addicts may suddenly switch to abstinence or moderate Use that lasts for years. Some additional factor is required to explain the altered susceptibility -of an individual through time.
Sudden outbreaks of addiction to new drugs predominantly affect the young; the group that is most susceptible is 16 to 22 years of age. It is usual to dismiss this phenomenon as being too self-evident to require explanation; youth is rebellious and addiction is merely a protest symbol. A WHO Expert Committee [ 5] refers to "pleasure-loving youth ". Youth is, and pro- bably always has been, decadent and weak - at least in the eyes of adults. Clearly these opinions reflect more prejudice than thought.
The problems peculiar to youth are the result of the critical role transition from child to adult. For most people, this is the most trying time of life. The comfort of childish dependency is forsaken for independence. And the sudden flood of sexual drives presents homo-sexual and heterosexual problems as well. The incidence of drug addiction at this period is probably symptomatic of the failure of disturbed individuals to cope with these problems.
Similar observations have been made of people who have had lengthy mental illnesses, usually schizophrenic psychoses, after taking lysergic acid. It has been assumed by many that the psychoses were due to the drug, but it would appear more likely that taking the drug and the psychoses were both the result of a common precipitating factor. This has been described as a life crisis in which greater pressure was placed on the patient to assume a more demanding and responsible adult role or in which a previously existing prop to the patient's self-image as a mature and adequate adult was lost (34). It is ironic that the cult of the "hippies" should stress love, when the major problem that the drug abusers are avoiding is their inability to love fully and adequately.
Excise tax and restrictions on the sale of drugs have been the traditional methods of government for controlling drug abuse. Controls have been criticized from many points of view. It has been claimed that they do not prevent addiction; that criminality associated with addiction is the consequence of legal restrictions on drug taking; that legalization of addiction would actually reduce the number of addicts, and presumably that drug-satiated addicts could lead normal productive lives.
The situation in the U.S.A. has been scathingly compared with that in the United Kingdom [ 35] , where drug addicts were not subject to the criminal law to the same degree and where drugs could be prescribed by any physician. Addiction, particularly to narcotics and crime associated with addiction appeared to be more common in the U.S.A., and the inference was that the controls created the problems. Subsequent experience has shown that the system in the United Kingdom was not sufficient to prevent outbreaks of addiction. In 1964 emergency legislation was rushed through the House of Commons to deal with an epidemic of addiction that had been growing; largely unnoticed, for years and which has in fact continued to grow [ 36] .
The punitive and restrictive legislation of the Harrison Narcotic Act in the U.S.A. was, by comparison to the permissive English system, a success. The widespread sale of opiates, and addictions, were controlled to the stage that they had practically disappeared during World War II. The resurgence of narcotic addiction after the war has been almost exclusively in the slum areas of the great metropolitan cities, areas affected by chronic unemployment, crime and an aberrant sick culture. Some of the current notions about the opiate addict confuse the product of the slum environment with the effects of the drug.
The argument that the free use of drugs may somehow be beneficial fails even more abjectly. It is inconceivable that the ready availability of drugs would somehow deter the addict from continuing the addiction, and it is abundantly clear that many more would become addicted. And certainly the drug-satiated addict cannot lead a normal productive life. He may appear normal with some drugs, particularly the opiates, but not with alcohol, marihuana, sedatives or stimulants. This does not mean that the opiate addict will lead a normal life. He is tranquil, anergic and absorbed in his internal world of fantasy while under the influence of the drug - avoiding work, sexual or inter-personal relations:
A shortcoming of legal restrictions is that the reasonably successful control of one drug often leads to the emergence of another drug as a substitute. Sometimes it is the result of the mistaken efforts by physicians attempting to treat addiction with another drug. One synthetic narcotic after another has been introduced with the claim, originally advanced for heroin, that it is non-addictive. The same claim has been made incorrectly for each newly introduced stimulant or weight-reducing preparation. Regardless of the claims that are made, each drug has to be used for some time before the evidence of addiction begins to accumulate. The only feasible method of handling this problem is continually to review the situation and to introduce new controls at the earliest opportunity.
There are now serious advocates of the legalized use of marihuana, who argue that it is no more dangerous than alcohol and may even be safer because it does not include tolerance or physical dependence. Bromides have escaped restriction in New South Wales (although restricted in other states in Australia) on the grounds that bromide addiction, if it should develop, is relatively innocuous and that the addict would otherwise turn to drugs that would cause more harm.
However, this belief that addiction to certain drugs is relatively innocuous is inferred from the pharmacological effects of the drugs, not from the psychological effects, which are similar for all. The stress is mistakenly placed upon the drug and not upon the person who takes it. The pharmacological effects of tolerance or physical dependence matter little in comparison with the psychological dependence and behaviour that destroys the occupation, family and social life of the addict. It can reasonably be claimed that any drug that produces addiction is dangerous.
The controversy over marihuana almost at times becomes confused with issues of civil rights. What is ignored by its protagonists is that past experience has already shown that a population exposed to a new drug is particularly susceptible to it. Marihuana thus cannot simply be placed in the same category as alcohol in a society with no culture developed around centuries of its use. It is dangerous enough in societies where it has been used for thousands of years and, in any case, alcohol is harmful enough without adding another drug to compound the effects of addiction. It should be concluded that the psychological effects of marihuana are no less dangerous than other drugs of addiction. The long-term physical effects are very largely unknown: remarkably little controlled clinical study of them has been made. Even the undoubted irritant respiratory effects of marihuana have not been adequately documented. And all our experience with other apparently innocuous drugs prompts one to take a conservative standpoint on marihuana. Phenacetin, for example, had an extensive clinical use for 75 years before its destructive effects on the kidney were even suspected. The conservative stand can be justified on the grounds that until a lot more is known about marihuana and its functions as a drug it is better to assume that it has ill effects.
Educational programmes have concentrated on information-giving to persuade the public of the dangers of drug addiction. They can hardly be said to have failed for the simple reason that very few comprehensive and exhaustive campaigns have been attempted. The Japanese authorities used an educational programme to some purpose, together with strict controls, to overcome the post-war epidemics of stimulant and heroin 'addiction [ 37] . Educational efforts are usually handicapped by lack of information and mistaken notions about drugs and addiction.
An extraordinary fact is that education about addiction has been neglected almost entirely in the curricula of university medical courses. The physician is not only the first person called upon to treat addiction, but the very nature of his profession increases his own risk of becoming an addict. Crash courses in addiction for a variety of professional groups are hastily evolving as a result of the pressure of public concern, but the medical courses of many universities remain set in their conservative course.
Information giving will fail in its intention if it is not accurate. The "dope-fiend" myth [ 38] is easily disproved by experience; numerous business and professional people, respectable housewives and adolescents who abuse drugs know it to be dangerous but receive a false reassurance from the difference between their situation and that of the bogey. The early signs of addiction are ignored because they do not conform with the image of the addict derived from the" skid-row" alcoholic or the deteriorated "junkie". The needless stress on physical dependence can rebound with considerable damage; the fact that there is no physical dependence to marihuana or stimulants encourages people to use them in the mistaken belief that they will not get" hooked ". Because of the unnecessary stress placed on the drug, rather than on the person, the unrestricted use of certain drugs such as the bromides and alcohol is condoned, with considerable damage to exposed susceptible individuals. The recognition that the basic disorder is a property of the individual, and not the drug, will in time alter public opinion and the services for addicts.
An ideal preference to information-giving would be a serious attempt to alter the culture surrounding drug use and abuse. Mention was made earlier of traditional Jewish culture in which alcohol abuse is viewed with contempt. This is the product of an entire social and religious history and clearly it is not possible to recreate the conditions which developed this attitude, but it certainly might be worth an attempt in other ways to create "the climate of social disapproval of the excessive use of alcohol and other drugs" recommended by the WHO Expert Committee on Mental Health [ 5] . It would certainly require first, an extensive, accurately based and directed programme of education.
A special aim of such education would concern the possibility of deliberately moulding the public attitude to the drunken driver. Bodies which have this responsibility aim their publicity at the reasonable man to dissuade him from drinking and driving. The popular notion of "there but for the grace of God go I" influences the tolerant attitude of the courts to offenders. The fact is that the bulk of convicted drunken drivers are pathological drinkers and not ordinary users of alcohol [ 39] . What is generally accepted as "normal drinking", particularly if food be taken at the same time, does not usually result in drunkenness or the blood levels that establish a conviction in court [ 40] . Educational programmes should be altered to hammer home these facts. It is not accurate, and it is also bad psychology if one is selling safety, to picture a nice man with a nice wife and nice children who takes one drink too many before killing them all on the road.
An educational programme should be guided by knowledge of the basic desirable functions of drug use, and the safest ways to use drugs. The first step may be to gain this knowledge. It might then be possible to promote a positive attitude to the normal use of alcohol, particularly before driving, and to create an air of disapproval for the drunk who is largely responsible for the road toll.
Although alcoholism and drug addiction are diseases requiring treatment, the medical model of an illness is inappropriate. Ordinarily, the sick patient and the physician are at one in their desire to remove the illness. The intrinsic difficulty in addiction that faces the therapist has been summarized by Rado [ 21] : "The patient does not suffer from his illness, he enjoys it ".
The doctor-patient relationship implies a "contract" which establishes their respective roles, mutual obligations and rules of conduct. Unless the patient co-operates in the terms of his own role, the physician is ineffective. The usual situation that obtains in addiction is that such a relationship or contract does not exist because it is only the physician who views the addiction as an illness and wants to eradicate it. A reliable history is part of the contract and important for diagnosis and treatment, but addicts are notoriously adept at concealing addiction; a reliable history will inevitably lead to attempts to remove his most important source of pleasure. The contract implies that the patient will co-operate in treatment, but the addict uses every possible ruse to foil drug withdrawal.
The only area in which the doctor and patient are likely to be of one mind is in the treatment of the complications of the addiction. The medical management of all the other aspects of addiction has been so futile that treatment is generally permitted to stop short at the stage where the effects of intoxication and drug withdrawal have been managed. The results of present methods of medical management merely permit the patient to pursue the addiction more effectively and efficiently for a longer period.
Attempts have been made to treat addicts in special units. The dash between the aims of the therapists and the patients produces conflict rather than treatment. Patients and their visitors use every imaginable ruse to smuggle in drugs and defeat the purpose of the ward rules. The collection together of patients with the one type of disorder tends to perpetuate and strengthen the addict culture [ 41] . The therapists may introduce restrictive supervision, in which case the ward becomes a prison, and a poor one at that because it was not planned for that purpose. The other alternative is to discharge the offenders, which is a virtual abandonment of treatment. Those who remain are likely to be the addicts who would do well anyway, without any treatment. There is no proof that special in- patient units effect changes in the course of addiction. In fact, comparison of groups of alcoholics given in-patient and out-patient care respectively showed no difference in their eventual outcome [ 42] and [ 43] .
The assessment of existing styles of out-patient treatment services is equally discouraging. The evidence from two carefully conducted studies has shown that addicts given no treatment at all do just as well as those subjected to a variety of treatment methods [ 44] and [ 45] .
Two established observations could be exploited in planning a model for the future treatment services of addiction. The only measure proved to be effective in a 12-year follow-up of New York narcotic addicts was compulsory supervision by a probation officer [ 44] . The second observation is that many young addicts cease their addiction spontaneously as they grow older. Thus if probation is a practical means of encouraging abstinence then dearly the suitable target group would be the young people whom the effort of supervision would protect during the necessary period of time in which many would mature and overcome their problem themselves. To these observations should be added one other - the apparent failure of voluntary treatment systems [ 9] .
A compulsory treatment service should aim at more than preventing relapse into addiction. A suspended sentence could provide the motivation for treatment as well as being a deterrent to addiction. While under the compulsory supervision of a probation officer, the addict could use the existing health services for out-patient psychiatric treatment, or the existing voluntary organizations such as Alcoholics Anonymous, in an attempt to improve his inter-personal relations, working patterns and satisfactions from life. It is likely that the treatment would consist almost entirely of group psychotherapy. The influence of the family of the addict necessarily requires that they be involved. Unfortunately many addicts are irrevocably separated from their families by the time they come to treatment.
The suggested model for a treatment service would employ compulsory hospitalization as little as possible. Failure to observe the conditions of probation would result in admission to a prison psychiatric ward, or to a rigorously supervised closed ward in a mental hospital. The use of this punishment should be flexible the length of time in confinement depending upon the behaviour that precipitated admission and then modified during the stay so that appropriate behaviour might be rewarded. Psychotherapy would continue in the prison ward. After discharge the addict would be given another period of probation. In this way the suggested system allows the flexible use of a wide range of treatment services, voluntary and compulsory, out-patient and in-patient. Multiple admissions will probably be necessary for most patients, but the duration of each stay need be no more than a week or two in most cases. The grounds for compulsory admission could be objective, such as failure to stay in regular employment or to live at a certain address, and could be decided by a magistrate in consultation with the probation officer.
However, the possibility or practicability of completely eradicating addiction can be seriously questioned. The task is as large as the causes of addiction, that is, psychiatric and social disorders. Even should it be possible, the desirability of pursuing such an aim is also doubtful. Addiction may be the aberrant fringe of social processes that are necessary for a productive and effective nation, processes that may need to be sacrificed in the course of the "cure". It is also conceivable that society may not gain anything from the sacrifice because addicts would continue to be psychiatrically disturbed, and would merely exchange one symptomatic disorder for another. For the foreseeable future there would appear to be little prospect of a radical change. Society will have to rely upon conventional controls, rather in the manner of controlling a smouldering fire in a tinder-dry bush. Each small outbreak that suddenly flares up, unpredictable as to time and place, should be countered immediately.
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