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Reproduced by the U. S. DEPARTMENT OF HEALTH, EDUCATION,
AND WELFARE, Public Health Service, with porate sion of
the Connecticut State Medical Journal.

RATIONALE OF THE DIAGNOSIS AND TREATMENT OF ADDICTIONS

ABRAHAM WIKLER, M.D., Lexington, Kentucky

 

Reprinted from The Connecticut State Medical Journal
July 1955 Issue, Vol. XIX, No. 7, Page 560
 

 
RATIONALE OF THE DIAGNOSIS AND TREATMENT OF ADDICTIONS

AsRAHAM WIKLER, M.D., Lexington, Kentucky

 

The Author. Chief, Neuropsychiatric Section,

National Institute of Mental Health Addiction Re-

search Center, U. S. Public Health Service Hospital,
Lexington, Kentucky

 

SUMMARY

From the standpoint of the clinical problem in-
volved, drug addiction is defined as “pharmacological
dependence” (both “psychic” and “‘physical’’), and its
diagnosis is based on the demonstration of an ab-
stinence syndrome. Currently, opiates, barbiturates and
alcohol are the most commonly used “addicting”
drugs. Other agents, like cocaine, amphetamine and
marihuana may produce dangerous toxic effects when
used in excessive amounts, but the clinical problem
involved differs from that of addiction, since abrupt
withdrawal of such agents produces neither intensified
“craving” nor distressing physical. disturbances. Treat-
ment of drug addiction may be divided into two

hases; withdrawal of drugs and rehabilitation. With-
drawal of opiates can be accomplished most readily by
the. substitution of methadone by the oral route, and
rapid reduction of methadone dosage over a period of

1

seven to ten days following a short period of “stabili-
zation.” Barbiturates should be withdrawn by gradual
reduction, over a period of three weeks or more, fol-
lowing a short period of stabilization on pentobarbi-
tal. The problem of the management of alcohol with-
drawal requires further investigation. The rehabilita-
tion program includes confinement in a drug-free
environment for four to six months, vocational train-
ing and occupational therapy, and formal psychother-
apy when possible.

The rationale of the diagnosis and treatment of drug
addiction is discussed from the standpoints both of
empirical evidence and of theoretical formulations of
the psychological and physiological mechanisms of
addiction. Abstinence phenomena are viewed from
the standpoint of the “counter-adaptation” theory, and

attention is directed to the important role which,

among other factors, previous pharmacological de-
pendence may play in the genesis of subsequent
relapse. Areas for future research, both of a psycho-
logical and a physiological nature, are indicated in re-
lation to both the “nonpurposive” and “purposive”
abstinence phenomena that characterize the clinical
problem of drug addiction.

 

prs in any field of medicine is measured, not
only in terms of the efficacy of methods available
for the relief of human suffering, but also the degree
to which treatment is based upon scientifically
acceptable explanations of the genesis of particular
illnesses. Viewed from both of these standpoints,
considerable “progress” in the management of addic-
tions appears to have been made in recent years, but
many problems of major importance remain to be
solved. It is the purpose of this discussion to indi-
cate the extent of our present knowledge in relation

to currently used methods of diagnosis and treat-
ment of opiate and barbiturate addictions. Although
some allusions will be made to alcoholism, this prob-
lem will be considered only to the extent that it has
been investigated at the Lexington hospital.

DEFINITION OF ADDICTION

The United Nations Expert Committee on Drugs
Liable to Produce Addiction has defined drug addic-
tion as follows: “Drug addiction is a state of periodic
or chronic intoxication detrimental to the individual

From the National Institute of Mental Health Addiction Research Center, Public Health Service Hospital, Lexington, Ky.
Based on a lecture delivered before the Clinical Congress of the Connecticut State Medical Society, New Haven, Septem-

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and to society, produced by the repeated consump-
tion of a drug (natural or synthetic). Its character-
istics include: (1) an overpowering desire or need
(compulsion) to continue taking the drug and to
obtain it by any means; (2) a tendency to increase
the dose; (3) a psychic (psychologic) and some-
times a physical dependence on the effects of the
drug.” Undoubtedly this definition is very useful
for the purpose of facilitating international control
of traffic in potentially harmful drugs. However,
for the needs of the practicing physician, “drug
addiction” should be defined in terms of the problem
with which he is called upon to deal. In general, the
problem involved is the management of persons who
display pronounced disturbances in behavior when
they are deprived of certain drugs which are con-
sidered to be harmful to the individual, society or
both. In this sense, “drug addiction” is synonymous
with “pharmacological dependence,” and is said to

exist when abrupt and complete withdrawal of cer- |
tain agents is followed by an “abstinence syndrome,’ |

which may consist only of “craving” and persistent

seeking out of drugs, or these _purposive’’ abstinence . : a ee .
, anxiety, tachypnea, hypertension, anorexia, insomnia,

phenomena may be associated with more transitory
“nonpurposive” changes involving the neuromnscu-
lar, autonomic and endocrine systems. Both “pur-
posive” and ° ‘nonpurposive” abstinence phenomena
are associated with the regular, continuous use of

_ opiates, barbiturates or alcohol. The abuse of other
agents, such as amphetamine, marihuana or cocaine

constitutes a distinctly different problem in medical
management. In sufficiently large amounts, ‘these
agents can produce dangerous effects, from which
both the user and society may suffer. However, sud-
den withdrawal of such drugs produces few or no

“nénpurposive” abstinence changes, while “pur-
Posive’ ’ abstinence phenomena are rarely as insistent
‘or difficult to cope with as in the case of opiates,
barbiturates or alcohol. As will be indicated later, it
is probably more than a coincidence that of all the
so-called “‘euphoriant” agents that are available, those
are “craved” most by addicts which, after regular
continuous use, produce “nonpurposive” abstinence
phenomena.

Dracnosis or ADDICTION

In accordance with this definition, the diagnosis
of drug addiction involves the demonstration of an
abstinence syndrome. Because they are more easily
measured, and are less subject to the influence of
uncontrollable factors, the “nonpurposive” absti-

class:

Their demonstration, however, should be carried
out only in a hospital by a physician specially trained
in the recognition of the specific abstinence syn-
dromes that characterize opiate, barbiturate and
alcohol addictions. These are quite distinctive, and
will therefore be discussed separately.

THE OPIATE ABSTINENCE SYNDROME

Following abrupt and complete withdrawal of
morphine, heroin, dilaudid, codeine, methadone,
meperidine or a number of other morphine deriva-
tives and potent synthetic analgesics, a train of |
symptoms and signs ensues which conforms to a
general pattern, though differences in time, course

and intensity of particular disturbances characterize

addictions to individual drugs of the opiate-like
n the case of morphine, the fully developed
abstinence syndrome consists of the following train
of events: yawning, lacrimation, mydriasis, rhinor-
rhea, perspiration, chilly sensations, piloerection
(arms, forearms, axillary regions, abdomen), mus-
cular aching, muscle twitches (especially in the
legs), nausea, vomiting, diarrhea, restlessness,

_ weight loss, ejaculations in men and orgasms in

   

women. Significant laboratory findings include leu-
kocytosis, pronounced drop in counts of circulating
eosinophiles, and increased urinary excretion of 17-
ketosteroids. Such changes can be detected as early
as the 14-20th hour, reach peak intensity between
the 48-72nd hour of abstinence, and subside rapidly
during the next five to ten days. However, minimal
abstinence changes may persist for as long as six
months. At any time during the acute abstinence
period, a single dose of morphine (e.g., 30 mg.) pro-
duces a prompt and pronounced reduction of the
intensity of all of the disturbances listed, which lasts
six to twelve hours, after which the intensity of the
abstinence syndrome returns to the value that it
would have reached at that time if untreated. This
phenomenon may be utilized as confirmatory evi-
dence that the disturbances are indeed morphine
abstinence changes. The over-all intensity of the
morphine abstinence syndrome varies individually,
but is remarkably reproducible in any given subject
under controlled experimental conditions, and varies

within limits with the dosage and duration of
morphine addiction.

The heroin and dilaudid abstinence syndromes
esemble that of morphine except that withdrawal
phenomena appear_and_reach peak intensity sooner,

nence phenomena are used as the basis for diagnosis. (and_they subside more-rapidly. That of codeine is
milder, while the methadone abstinence phenomena,
while mild, are more persistent than in the case of
morphine. Addiction to meperidine, however, pre-
sents unique problems. Abstinence phenomena
(yawning, lacrimation, rhinorrhea, perspiration,
isolated muscle twitches and extreme restlessness)
may appear within two hours after the last dose, and
impel the user to increase the frequency as well as
the amounts of merperidine injected. When a daily
dose level of approximately 3,000 mg. has been
reached, direct toxic effects of the drug, in the form
of myoclonic jerks and/or generalized convulsions
may be superimposed on the abstinence phenomena,

Very recently a more rapid method of precipi-
tating abstinence syndromes in cases of addiction to
morphine, heroin, methadone and a number of
other opiate-like drugs, except meperidine, has been
developed. This utilizes the remarkable opiate-
antagonistic properties of N-allylnormorphine
(“nalorphine,” U.S.P.; “Nalline,” Merck). In non-
addicted, previously nonmedicated individuals, 5-15

mg. of this compound produces effects that are quite -

similar to smaller doses of morphine, including
depression of respirations. In nonaddicted persons
who have received “therapeutic” doses of morphine,
N-allylnormorphine, in the doses mentioned, antago-
nizes many of the morphine effects (particularly
“euphoria”), but not the depression of respirations.
In nonaddicted individuals whose respirations and
arousability have been seriously depressed by larger
_ doses of opiates, relatively small doses of N-allylnor-
morphine produce a spectacular, though transient
restoration of respiratory rate and depth to normal
or supernormal values, and facilitate arousal. In
opiate addicts (with the exception of those addicted
to meperidine), however, N-allylnormorphine pre-
cipitates well defined abstinence syndromes of short
- duration (1-2 hours) within 15 minutes after sub-
cutaneous injection, even when the addicted indi-
vidual has been rendered comatose and almost apneic

by an overdose of an opiate-like drug. The intensity

of such N-allylnormorphine-precipitated abstinence
syndromes varies directly with the intensity of
addiction and the amount of N-allylnormorphine
administered. If the latter is excessive, dangerously
intense “withdrawal” phenomena may ensue. For
the diagnosis of addiction the initial dose of N-
allylnormorphine should not exceed 3 mg. If yawn-
ing, lacrimation, mydriasis, rhinorrhea, perspiration
and/or piloerection do not appear within 15 minutes

-mg. may be administered by the same route. If such

abstinence phenomena fail again to. make their ap-

pearance, a final dose. of 7 mg. (15 mg. total) may

be given in a similar manner. A positive result indi-
cates that the subject has been using an opiate-like
drug in sufficient amounts, and with sufficient
regularity to have developed pharmacological de-
pendence. This has been demonstrated to occur in
former opiate addicts who have received as little as
15 mg. of morphine, 15 mg. of heroin or 10 mg. of
methadone four times daily for as short a period as
two or three days. A negative result indicates either
that the subject has not developed pharmacological
dependence, or that he has been abstinent for as little
as perhaps one week, since it has been shown that
immediately after subsidence of an opiate abstinence
syndrome, N-allylnormorphine exerts effects identi-
cal with those in nonaddicted, nonmedicated indi-
viduals.

The mechanisms of action of N-allylnormorphine
have not yet been fully elucidated. However, a con-
siderable body of evidence obtained in_ clinical
studies, and in investigations on animals and animal
preparations, justifies the following tentative ex-
planation. Single doses of opiate-like drugs produce
a mixture of “depressant” and “excitant” actions at
all levels of the central nervous system, the pattern
of which differs from that characterizing the effects
of other drugs with somewhat similar actions, like
barbiturates and mephenesin. The depressant effects
of single doses of opiate-like drugs are often fol-
lowed by secondary “rebound” changes in the same
functions, with consequent enhancement of activity.
When multiple, fixed doses of opiate-like drugs are
administered daily for variable periods of time, the
initial depressant effects become progressively less -
noticeable, while the “rebound” enhancement of
functional activity becomes intensified. In part, such
“tolerance” may be ascribed to the development of
hypothetical cellular “counter-adaptations” in the
central nervous system which can be held in check
only by additional opiates, the dose of which must
be increased progressively up to a limiting value in
order to prevent the appearance of an “abstinence

syndrome.” It is further hypothesized thatthe N-
allylnormorphine molecule “competes” with mole-
cules of opiate-like drugs for the cellular receptors
of the central nervous system, that they enter the
cell more rapidly, have a greater “affinity” for the
receptor sites, and that they do not “mask” the

after subcutaneous injection, an additional dose of 5 ~eounter-adaptations. Consequently, N-allylnormor-

i
]
phine can not only antagonize the depressant actions
of opiate-like drugs, but it can also “unmask” the
counter-adaptations which are responsible for the
abstinence syndrome. “At present, the concepts

“counter-adaptation, ” “molecular competition” and

“affinity” are not phenomena that can be measured
independently of those that they purport to explain.
However, they appear to be useful postulates, since
they have served to facilitate the prediction of many
observable effects of single and repeated doses of
various drugs.

THE BARBITURATE ABSTINENCE SYNDROME

Following abrupt and complete withdrawal of
short-acting barbiturates, such as secobarbital, pento-
barbital or amobarbital, a series of phenomena
develops, the intensity of which is related directly
to the degree, continuity, and duration of drug
intoxication, with the usual individual variations. In
persons who have received 1.0 Gm. or more of such
barbiturates daily for six weeks or longer, tremu-
lousness, weakness, postural hypotension and syn-
Seana anorexia and insomnia appear regu-
larly by the end “of the first day of abstinence. In
addition to these phenomena, one to four general-
ized-convulsions may be expected in approximately
80 per cent of such individuals on the second or
third day, in association with pronounced abnormal-
ities, often of the paroxysmal “spike and dome”
variety in the electroencephalogram. In roughly 60
per cent, psychoses, most often indistinguishable
from alcoholic delirium tremens, can be expected
to occur between the fourth and seventh days, with
spontaneous recovery within a week thereafter.
Replacement on barbiturates serves to suppress all
of the abstinence phenomena, except the psychoses
which, once well under way, tend to run their
course, although occasionally rapid recovery occurs
after prolonged sleep has been induced by anesthetic
doses of a barbiturate. It has also been established
experimentally that in subjects who have received
/ 0.6-0.8 Gm. of short-acting barbiturates daily for
similar periods, only anxiety, tremulousness, postural
faintness, anorexia, insomnia and weight loss are
likely to appear on abrupt withdrawal of the agents
concerned. In about 10 per cent of those taking 0.6

8 Gm. daily, convulsions may develop, and a
similar incidence of mild, transitory psychotic
“episodes has been observed. Data are not yet avail-
able to enable the prediction of the nature and
intensity of abstinence phenomena, if any, that can
be expected to occur in individuals taking less than

+

0.6 Gm. daily. In general, however, it appears that

_ the intensity of abstinence phenomena is related

directly to the degree and duration of chronic. in-
toxication that existed before withdrawal.

At present, little is known concerning the mecha-
nisms that are involved in the genesis of the bar-
biturate abstinence syndrome. The fact that con-
vulsions occur after withdrawal of drugs with anti-

_convulsant properties, suggests again that “counter-

adaptations” may develop at cortical or subcortical
cellular levels during chronic barbiturate intoxica-
tion. On the other hand, alternative hypotheses can
be advanced, based upon recent evidence that bar-
biturates exert selective depressant actions on the
brainstem reticular activating system, and the role
of this and the diffuse thalamic projection system in
the genesis of seizures. Unfortunately, practically no
studies have been made on the neurophysiological
changes that occur during recovery from the initial
depressant effects of barbiturates. Carrying out of
such investigations would entail technical difficulties
of formidable proportions, but they appear to be
necessary for the ultimate resolution of the problem.

THE ALCOHOL ABSTINENCE SYNDROME

Very recent experimental studies support strongly
the view that “rum fits” and delirium tremens, cur-
rently regarded by many as toxic effects of alcohol,
are, in fact, alcohol abstinence phenomena. In addi-
tion, this syndrome includes other well known but
less dramatic changes such as tremulousness, nausea,
perspiration, insomnia, vomiting, diarrhea, hy per-
reflexia, fever, hypertension and transient visual and
auditory hallucinations. These may occur several
hours after the last previous drink during chronic
alcoholic intoxication, but they are suppressed tem-
porarily by another drink. If, on the other hand,
alcohol is withheld, and other “sedative” drugs are
not administered, they increase in intensity over a
period varying from one to several days. Thereafter
they may subside, or classical delirium tremens may
supervene, with or without antecedent seizures. The
intensity of the alcohol abstinence syndrome appears
to be related directly to the degree and duration of
continuous alcoholic intoxication prior to abrupt
withdrawal. Sufficient data are not yet available to
enable one to quantify this relationship, but in a
group of six former opiate addicts who received up
to 489 cc. of 95 per cent alcohol daily for as long
as 87 days, abrupt withdrawal of alcohol was fol-
lowed by seizures in two. cases, transient hallucina-
tions in two, and classical delirium tremens in two
(possibly three) instances, while otler abstinence
phenomena could be demonstrated in nearly all of
the subjects. In general, the alcohol and the bar-
biturate abstinence syndromes are very similar, but

some differences are notable. Thus, demonstratable —

abstinence changes appear only after 14 hours or
more following abrupt withdrawal of barbiturates,
while alcoho! withdrawal changes may appear be-
tween drinks during chronic alcoholic intoxication,
and increase in intensity progressively when alcohol
is withheld. Seizures appear to occur more com-
monly, and paroxysmal abnormalities in the electro-
encephalogram are far more prominent and persist-
ent after abrupt withdrawal of barbiturates than in
the alcohol abstinence syndromes. Also, psychoses
become manifest only after a lucid period of four to

nee

seven days following abrupt withdrawal of barbitu-
rates~-while-a~ Continuum of transient hallucinosis
with clear sensorium changing imperceptibly to the
confusional, disoriented, agitated, delusional and
hallucinatory state characteristic of delirium tremens
may begin within a few hours after the last drink of

alcohol.

As in the case of the barbiturate abstinence syn-
drome, little is known of the mechanisms that con-
tribute to the genesis of the alcohol withdrawal

phenomena. Because of the striking similarities of -

the two syndromes, it may be anticipated that similar
mechanisms operate, and that further research of the
sort indicated above is needed.

‘TREATMENT OF ADDICTION

In this section, discussion of treatment will be
limited to that of opiate and barbiturate addiction,
since active addiction to alcohol is rarely encoun-
tered among patients admitted to the Lexington hos-
pital, and studies on the treatment of experimental
alcohol addiction have not yet been made at this
institution.

Treatment of opiate and barbiturate addiction
should be carried out only in an institution specially
designed for this purpose. Facilities should include
not only the usual medical and surgical services, but
also an adequate psychiatric “team,” consisting of
psychiatrists, psychologists and social service work-
ers. Opportunities for vocational training, realistic
occupational therapy and recreation should be avail-
able, and rigorous exclusion of contraband drugs
should be possible. Immediately on admission, the
patient should receive a careful physical and at least
2 preliminary psychiatric examination. In obtaining

the history, special attention should be given to the
type, amounts and frequency of drug intake.
Ideally opiates and/or barbiturates should be admin-
istered for a few days in amounts just sufficient to
prevent the appearance of abstinence phenomena.
During this “stabilizati
examinations can be made, and systematie-therapy
planned. The latter can be divided into two phases:
first, withdrawal of drugs, and second, rehabilitation.
Psychotherapy is utilized in both phases, but with
different emphasis and will therefore be discussed
separately in connection with drug withdrawal and —
rehabilitation.

WITHDRAWAL OF OPIATES

Before the introduction of methadone, this phase
of treatment was managed most successfully by the
method of “rapid reduction.” In brief, this consists
of subcutaneous injections of successively diminish-

ing doses of morphine, or whatever opiate-like drug _

had been used in stabilization, in amounts and with
frequencies of injections calculated to complete
withdrawal within five to ten days without inducing
excessive vomiting, diarrhea, tachycardia or fever.
However, this method demands much of the time of
physicians and attendants, and may prove to be

rather stormy if the intensity of pharmacological _

dependence has been estimated inaccurately. A much
simpler method consists of the substitution of
methadone for the drug used in “sabilation and
subsequent withdrawal of this~synthetic analgesic
by rapid reduction. Formerly, methadone was ad-
ministered subcutaneously in a dose ratio of approxi-
mately 1 mg. of methadone for 3 mg. of morphine
or in equivalent ratios for other opiate-like drugs.
With subcutaneous injections, substitution was
begun by “overlapping” successively diminishing
doses of the “stabilization” drug with methadone
in the course of one day, in order to prevent the

cca

appearance of severe abstinence phenomena durimg _

the transition period. “Stabilization” on methadone
was then continued for five to seven days, after
which the drug was withdrawn in steps over
a period of three to four days, Recently, how-
ever, the methadone substitution method has been
simplified even further, by administering the
drug orally in approximately the same ratios de-
scribed above. In the case of the average opiate
addict admitted to the Lexington hospital, no “over-
lapping” appears to be necessary, and the daily
amount of methadone needed for “stabilization” can
be administered in two divided doses. Rapid reduc-

pennant ae
ériod, the necessary

—d

4
- tural hypotension.
reduction should be suspended. Generally they will

tion of methadone can be begun after two days of
“stabilization,” and completed in seven to ten days.
However, in patients with active pulmonary tuber-
culosis or myocardial disease, withdrawal of metha-
done should. be_carried out with. special | caution,

over a period of perhaps a month or more.
ee
The methadone substitution method offers many °

advantages over the “rapid reduction” technic. The
clinical course is apt to be less stormy, and, as noted
above, the methadone abstinence phenomena are
much less intense than those of morphine. Further-
more, the feasibility of administering methadone
orally obviates the necessity for sterilization of
needles and syringes as well as the administration of
multiple daily injections, and hastens the “weaning”

of the patient away from whatever symbolic signifi-
cance injections may have. On the other Hand:
special care must be exercised to guard against
cumulative depressant effects of methadone, which
are greater than those of morphine, and although the

 

patient’ S complaints are fewer during the withdrawal ,

period, they persist longer than Aficr withdrawal has
been accomplished by the ‘ ‘rapid reduction” method.

WITHDRAWAL OF BARBITURATES

At present only a “gradual withdrawal” method
has been found useful in the treatment of barbiturate
addiction. As in the case of opiate addiction, this
should be preceded by a “stabilization” period of
several days’ duration, during which adequate
amounts of a barbiturate are administered to sup-
press all abstinence ~phenomena, and induce a state
of mild intoxication. Also as in opiate addictions it
has been found that various barbiturates can sub-
_ stitute for one another, and, in practice, pentobarbi-
t taba appeats to be the drug of choice for “stabiliza-
tion,” since its duration of action is such that four
oral doses daily in the proper amounts can prevent
the appearance of abstinence phenomena, without
producing more than a mild degree of intoxication.
However, abrupt withdrawal of any of the relative-
ly short-acting barbiturates (secobarbital, pento-
barbital or amobarbital) may be followed by the
dangerous abstinence phenomena described above.
Consequently, withdrawal of pentobarbital must be
carried out with caution. In the average case this can
be accompilshed by reducing the “stabilization”
daily dose of barbiturates by 0.1 or 0.2 Gm. each
day, with close observation for early abstinence
changes such as tremulousness, weakness and pos-
If these supervene, further

_ disappear in a day or two, when the reduction _

schedule may be resumed. As a precautionary meas-
ure the patient should rest on a mattress laid on the
floor, lest injuries be sustained if convulsions occur.
Because of the danger of psychotic disturbances, the
patient should be observed at all times by attendants
and physicians trained to recognize early manifesta-
tions. Since fully developed barbiturate withdrawal
psychoses are not readily reversed, it is better to err
on the side of excesssively slow reduction than the
opposite. In severely addicted individuals a month
or more may be required for complete withdrawal
of barbiturates.

If barbiturate and opiate addiction coexist, as is
not infrequently the case, withdrawal of opiates
should be accompished first, while the patient iS
stabilized on barbiturates. Curiously many patients
who tolerated a given daily stabilization dose of
barbiturates well previously will exhibit more evi-
dence of barbiturate intoxication after opiates have
been withdrawn. In such cases the “stabilization”
dose may be reduced somewhat before systematic
withdrawal is initiated.

PSYCHOTHERAPY

During this phase of therapy the physician should
orient his activities toward the primary object at
hand, namely, withdrawal of drugs. His role should
be sympathetic but firm, and discussion of problems
likely to arouse intense emotional reaction should
be avoided. On the other hand, he should be alert
to the development of severe depressive reactions
because of the danger of suicide, especially imme-
diately after all drugs have been withdrawn. Fortu-
nately such disasters have occurred very infrequent-
ly, but milder depressions of temporary duration
are not uncommon. Physicians who are confident of
their own skill in the management of drug with-
drawal generally have much less difficulty with
patients who are quick to “size up” the therapist and
to seize control of the situation, if indecision,
anxiety or hostility are displayed toward them.

The rationale of the methods described can be
considered from several points of view. In some
areas the “cold turkey” method of abrupt withdraw-
al is still used, on the assumption that suffering will
act as a deterrent. That this is not the case is indi-
cated by the frequent relapses of addicts who have
undergone such “treatment” in various institutions,
principally penal ones. Furthermore, there is reason-
able inferential evidence that such suffering may
actually allay any feelings of guilt that are present,
thus justifying relapse on the grounds that the addict
“has paid his debt to society.” Since, in any case,
measurement of relapse rate has been exceedingly
difficult, if not impossible to accomplish, the more
humane methods outlined can be more readily justi-
fied. Of these, the “rapid reduction” method is based
on the empirical observation that the total duration
of the opiate abstinence syndrome is not prolonged
by successively reduced “braking” doses of opiates.
The methadone substitution method is based on the
repeatedly observed fact that when drug A is sub-
stituted for drug B, the agent on which the addict
has been stabilized, and A reproduces the state main-
tained by regular use of B, abrupt withdrawal of A
is followed by the same abstinence syndrome that
would have occurred if the stabilizing drug had

been A. Both of these empirical facts are consistent |

with the “counter-adaptation” explanation of drug
addiction which was discussed earlier. While this
postulate is inferred from abundant evidence of a
physiological nature, there is clinical evidence that
psychological mechanisms also contribute to the
genesis of even the “nonpurposive” abstinence
phenomena. As yet these have not been investigated
experimentally in a controlled manner, but theo-
retical considerations indicate that psychotherapy
may be very useful in the drug-withdrawal phase of
treatment, if properly applied.

REHABILITATION

This phase of the treatment of drug addiction is
designed to prevent relapse, or at least to reduce its
incidence. As currently practiced at the Lexington
hospital, rehabilitation-includes controlled abstention
from drugs, correction of medical and surgical dis-
orders, vocational training, recreational activity and
psychotherapy. Unfortunately, a reliable method
for measuring relapse rate after discharge from the
institution has been very difficult to devise, and at
present it is not possible to evaluate the comparative
efficacy of this, versus other possible programs, on
an empirical basis. Therefore, the rationale of such
treatment can be discussed only in terms of the
assumptions and hypotheses upon which it is based.

Perhaps the most generally applicable statement
that can be made is that by the continuous use of
certain drugs, the addict has developed a “modus
vivendi” which is of value to him, however unde-
sirable it may be from the standpoint of others.
Consequently, re-education in a drug-free environ-

ment appears to be essential if the probability of :

relapse is to be reduced. However, no “controlled”
environment can duplicate the everyday life situa-
tions to which the patient must return. Hence the
period of confinement in an institution should be
limited ideally to that which affords sufficient time
for available methods of re-education to be given a
thorough trial. This will vary from patient to

patient, but currently, a period of four to six months __

 

is considered sufficient. Tn re-education, vocational
training assumes a very important role, since many
addicts have never acquired socially useful skills
which could serve as a basis for self support, or for
sources of satisfaction and preservation of self
esteem. Likewise, the desirability of recreational
activity and improvement in general health requires
little justification.

The problem of psychotherapy is much more
complicated. What the psychotherapist does, says,
looks for, finds, misses, emphasizes or ignores de-
pends to a great extent on the body of concepts
concerning behavior which he accepts as valid and
relevant to the problem at hand, and these, in turn,
determine to a considerable degree the responses
elicited from the patient. Yet validation of such
concepts by the scientific test of predictive utility
has proved to be a difficult task in all areas of
interest to psychiatrists, including that of drug
addiction. Hence, it is not surprising that psychia-
trists differ widely in their views concerning the
psychodynamics of drug addiction and the particular
problems which should be explored in formal
psychotherapy.

Perhaps the most prevalent view is that drug
addiction is not a “disease” but a symptom of an
underlying personality defect. Because of their
“anxieties,” such persons are attracted to drugs
which produce “euphoria.” Pharmacological de-
pendence tends to perpetuate drug use because of
the patient’s fear of withdrawal discomfort, but
otherwise it is unimportant. Relapse after a period
of abstention is due again to the underlying person-
ality defects, the correction of which is the object
of psychotherapy. These defects have been variously
described. From a symptomatological standpoint the
majority of addicts at the Lexington hospital have
been classified as “psychopathic” or “neurotic,” or
in equivalent terms consistently over a period of
almost 20 years. A very recent study, using the
Minnesota Multiphasic Personality Inventory, has
yielded similar results, with more emphasis on
“psychopathy.” In dynamic terms these patients
have been characterized as narcissistic, oral-depend-
ent and passive-aggressive. It is further assumed that

these defects antecede, and are etiologically related’

to drug addiction. - |
However, this formulation fails to account for the
facts that only a small proportion of persons with
such defects are drug addicts, that addicts exhibit
very strong preferences for one or another drug,
and that major addiction problems arise, at least in
the United States, mainly in relation to drugs which

10

produce “nonpurposive” as well as “purposive”

abstinence phenomena. What appear to have been
ignored in the formulation summarized above are

the pharmacological factors—the facts that because.
of the nature of their associations and contacts, .

“psychopathic” and “neurotic” individuals are more
apt to become acquainted with drug effects, that

addicts’ jargon), provides a sense of accomplishment,
much as the acquisition of money by law-abiding
citizens, and serves to enhance the prestige of the
“hustler” in the eyes of himself and fellow addicts.
Under favorable circumstances, particularly if dif-
ferent goals for sustained activity are acquired by
re-education, relapses to drug use may not occur.
But since the manifestations of “natural” needs can
become “conditioned,” those of “synthetic” needs
may also be activated in response to specific stimuli,
and hence previous pharmacological dependence
can become an important factor in the genesis of
subsequent relapse. :

However, while various types of pharmacological
dependence are similar with regard to the recurrent

-cycle of acquired need and satisfaction thereof,

these are quite specific for particular drugs, and that »

the regular use of one or another may alter the users’
goals in life, as well as satisfy previously existing
needs.

In other words, drug addiction, as defined in the

introduction of this paper, must be viewed as a con-
sequence of*experience with drugs in a setting that
endows such experiences with important values to
the user, of which he may or not. be aware. Fur-

thermore, the most enduring experiences are not the

fleeting effects of the first few “trial” doses (which
may or may not be “pleasant”), but the long main-

tained state of pharmacological dependence. Con- .

trary to the “conscious” interpretations of most
addicts, there is much inferential evidence that
“being hooked” serves many “unconscious” pur-
poses, varying in kind and degree from one to
another individual. In some, pharmacological de-
pendence represents a continuous enaction of hostile

behavior toward special figures or society in general.

In others, it represents a process of gradual self
destruction. But in many, this state. fulfills a need
which has generally been overlooked, but appears
to be of prime importance to human beings—the
need for continuous activity directed toward attain-
able, but recurring goals. The consequence of fail-
ure to satisfy this need is an intolerable state of
boredom. This may be relieved temporarily by the
use of any of a large number of drugs which alter
affective behavior, but only those that produce
pharmacological dependence can furnish a continu-
ally recurring “synthetic” need that can be readily
satisfied.. The activity necessary for assuring a con-
tinuous supply of drugs (termed “hustling” in the

they differ with respect to over-all changes in
behavioral patterns that different drugs pi
At least in a controlled experimental situation, pro-
nounced differences are observed between the be-
havior of persons actively addicted to opiates and
others to barbiturates or alcohol. In amounts used
by addicts, the latter two agents facilitate loss of
restraint and aggressive “acting out” on slight
provocation, whereas opiates generally produce an
opposite state, characterized by passivity, rather than
overt aggressiveness, and “detachment,” rather than
embroilment in the interpersonal aspects of the
environment. “Primary” needs, such as sexual urges,
hunger and fear of pain may be unaltered or en-
hanced by barbiturates or alcohol, but they are
reduced in intensity by opiates. Both of these classes
of drugs may be said to relieve “anxiety,” but if so,
the “anxieties” relieved are of different sorts. Like-
wise, the term “euphoria” has been applied to
the states produced by these and many other drugs,
but even the addict, untrained in semantics and in
self observation, is quick to note that there are
various kinds of “euphoria.” Analyzed operationally,
the term “euphoria” seems to denote little else than
that in a particular setting, an individual “likes”
certain drug effects very much. Who will “like” the
effects of one class of drugs more than those of an-
other, may very well be related to previously
established preferences for particular patterns of
behavior. The opiate addict, generally speaking,
lacks aggressivness and competitiveness, and prefers
to handle “anxiety-producing” situations by with-

  
 
 

drawing from, or circumventing them. Such indi- ©

viduals would therefore prefer opiates. On the other
hand, since barbiturates, and particularly alcohol,

facilitate “pseudo-masculine” behavior patterns, they
would be preferred by individuals with strong
aggressive and competitive strivings. No doubt the
hy pothesis here advanced represents an over-simpli-
fication of the problem of specificity of drug prefer-
ences, but it may serve as a basis for future research.

At present little is known of the physiological
mechanisms that contribute to the genesis of relapse.
In large part this is due to the fact long enduring,
drug-seeking behavior following termination of
experimental addiction has not been reproduced
- experimentally in animals. Therefore, severe limita-
tions are imposed on the extent to which the struc-
ture-function aspects of relapse can be investigated.
It has been shown, however, that in man bilateral

rontal lobotomy abolishes or reduces the intensity
of “purposive” morphine abstinence phenomena,
without altering the “nonpurposive” changes. How
permanent this effect is cannot be estimated until
reliable methods for measuring relapse rate are
devised. In the light of our current knowledge it
appears that this procedure should be employed only
in the treatment of addicted patients with chronic,
intractable pain after careful weighing of the con-
sequences of continued addiction against the con-
sequences of frontal lobotomy in each individual
case. Electroconvulsive therapy has also been advo-
cated for the treatment of drug addiction, but the

It

published evidence does not permit a critical evalua-
tion of its efficacy, either with respect to the man-
agement of the drug-withdrawal phase of treatment,
or the prevention of relapse. Present methods for
drug withdrawal are quite satisfactory, and electro-
convulsive therapy would seem to offer no particular

advantages. However, the possibility of using this

‘treatment in the prevention of relapse merits further

investigation.

BIBLIOGRAPHY

(Detailed references are included in the general reviews
listed below.)
1. Eddy, N. B. (Guest Editor): Symposium on drug addic-
tion. Am. J. Med. 537, 1953.
2. Isbell, H., and Fraser, H. F.: Addiction to analgesics and
barbiturates. Pharmacol. Rev. 2:355, 1950.
3. Krueger, H., Eddy, N. B., and Sumwalt, M.: The
pharmacology of the opium alkaloids. Pub. Health Rep.
(suppl.), 165:1, 1941.
4. Wikler, A.: Opiate Addiction: Psychological and Neuro-
physiological Aspects in Relation to Clinical Problems. C. C.
Thomas, Publisher, Springfield, 72 pp., 1953.
5. Wikler, A.: “Drug Addiction,” in Tice’s Practice of
Medicine, W. F. Prior Co., Hagerstown, 8:17, 1953.
6. Isbell, H., Fraser, H. F., Wilker, A., and Eisenman,
A. J.: An experimental study of the etiology of “rum fits”

_ and delirium tremens. Quart. J. Studies on Alcohol, 16:1,

1955