Care and treatment of drug addicts
ORIGINS OF ADDICTION
Author: Kenneth W. Chapman,
Pages: 25 to 28
Creation Date: 1958/01/01
ORIGINS OF ADDICTION
The reasons for drug use are widely variable and include not only individual and social differences but other determinants such as culture, economics, and individual health states, both physical and mental.
In some eastern countries, for example, the average rural villager has no medical personnel, no one to turn to in illness, and no relief from pain but opium either smoked or eaten. The chronically ill are easy prey to such drugs. On the other hand, it is not unknown in western countries for physicians carelessly to administer narcotics and through neglect cause a patient to become an addict.
It is probable that through personal interest, association, or group pressures many individuals become acquainted with the drugs and find in them a pleasurable sensation which they try relentlessly to recapture.
For half a century or more discerning students of addiction have recognized that drug addiction is only a symptom of an underlying personality and/or emotional disorder reflecting the inability of the individual to adjust to life without narcotics rather than a specific disease entity peculiar to that individual. The remarkable characteristics of the opiates, in particular, in reducing anxiety related to fear of pain, hunger, or sexual urges without seriously impairing the senses make them a suitable substance for relief from emotionally conditioned pain.
The passive-aggressive may find in opiates needed support for his weak ego defences. The magical thinker finds brief escape from reality in the world of fantasies through drugs. To certain" acting out "individuals, the taking of drugs may express their hostility both towards hated parents and their social surrogates. These by no means exhaustive examples will serve to indicate the breadth and complexity of the individual personality problems leading to drug addiction.
Other intimate problems of the individual play an important part in many circumstances. Frustration in some members of minority groups may be relieved through drugs. Hunger may be assuaged by narcotics. The use of opium by overworked parents to quiet their hungry or troublesomely active children is a recognized factor in several countries.
The prevailing attitudes of the cultural and social milieu will also play a part in the development of addiction as well as influence the psychiatric factors. For example, opium smoking acceptable within certain subcultural groups of the Asiatic continent provokes little, if any, anxiety in its habitués. Certain religious attitudes or distortions of doctrine support this attitude while condemning alcohol. On the other hand, European and American countries have taboos towards drugs while accepting alcohol. For some distorted persona- lities, violation of these taboos affords an outlet for social hostility and satisfaction of need for guilt feelings not possible in "eastern cultures ".
Over the years, hypotheses have been advanced concerning the physiological factors in addiction. Some of these relate addiction to certain deficiencies or diatheses in neural and chemical mechanisms. Advocates of such theories feel that the "field theory " of human behavior is insufficient to explain drug addiction in many individuals. In this regard, the work of Hoffer et al.1 proposing metabolic errors as an explanation for schizophrenia is of interest since this diagnosis is not uncommon in drug addicts. The "tranquilizing" drugs also offer possibilities of organic explanations, in addition to the environmental-psychological reasons for addiction.
Although we have spoken only of opiates at this point, one might well discuss hashish (marihuana), which is more commonly used in Mediterranean countries and also in Latin America, where it is not uncommon in rural areas to offer visiting friends a smoke of hashish as a "highball" is offered in other countries. Finding certain pleasurable sensations, the addiction-prone hashish smoker will seek a constant use to the detriment of himself as a useful citizen, husband or father. It has been hypothesized that he may be using it to negate his sexual anxiety or to heighten his sexual desire for a long-accustomed partner. On the other hand, and of etiological importance, is the fact that not all of his fellows smoke to abuse though they may all be poor, frustrated, and hungry. In this connexion it may be of interest to remember the statement of experienced Egyptian physicians that the cannabis drugs act like alcohol as far as sex is concerned; namely, to heighten the desire but inhibit the act.
In the western cultures, marihuana is a problem largely confined to certain social groups. Periodically, delinquently inclined groups of youths will take to smoking this drug. The dangers attendant on this activity are difficult to assess because of the many unsupported distorted stories of orgies which are a welter of confusion of fact and fiction. Aware of this, a number of youths are suspected of offering as an excuse for their delinquent acts the smoking of a few marihuana cigarettes.
The "why" of the use of a particular drug in a particular cultural or social setting is, if anything, less tangible than the reasons for drug use. Of probable significance are cost, availability, and custom, although certain ethnological mass psychological characteristics could play a part. The explanation of the varying use of heroin, morphine, the synthetics, and marihuana from time to time and place to place in the west is most difficult. One is tempted to formulate a concept of "psychic contagion".
1 Hoffer, A., Osmund, H. & Smythies, J. (1954 ), J. Merit. Sci., 100 29.
It would appear that the multifactorial determinants in the field of drug use make a clearly and easily defined approach to the problem exceedingly difficult. The lack of common cultural, religious, legal, and social denominators prevent easy generalizations.
LEGAL FRAMEWORK FOR TREATMENT
The legal framework in which the addict is treated varies widely and seemingly without relation to culture or social attitudes. To trace the laws - written or unwritten - cover-ing treatment is almost impossible in some countries. Much depends on the attitude of the enforcement personnel, public opinion of the drug addict, and the tolerance or lack of tolerance by the medical profession, to name a few of the obvious significant determinants.
Almost all the countries concerned with drug addiction and the treatment of the addict deal with them within the broad framework of the definition of legal use of narcotics, which is, briefly, for medical and scientific purposes only. The latter can be dismissed from consideration as their scope is fairly obvious. Medical use, on the other hand, has wide interpretation.
In the United States, for example, this is generally construed to include only the relief of pain and suffering incident to physical illness and not the satisfaction of addiction. Drugs may be used, however, in the withdrawal treatment of addicts, providing no supply is given to the patient and the treatment (with rare exceptions) is carried out in hospitals. Several European countries make a similar proscription against the support of addiction. Allowance is made for the person who (although otherwise physically fit) cannot be successfully withdrawn from drugs or who cannot make a satisfactory social adjustment with drugs.2
A number of states in the United States and several other countries provide for voluntary commitment under civil laws. These procedures are rarely used in most instances. There are civil procedures which allow for voluntary commitment but, because of civil rights in some countries, there is doubt of the validity of detention of patients under such laws.
Involuntary civil commitment is possible in 37 of 48 states in the United States3 and in some European countries - for example, Germany - if the patient is dangerous to himself and others. It is used infrequently in these states although, at the same time, this method is more and more frequently recommended as a solution to the problem of treatment since it provides an unstigmatized long-term period of care and post-hospital supervision.
2 The Duties of Doctors and Dentists Under the Dangerous Drugs Act (1956), Home Office, H.M.S.O.
3 U.S. Council of State Governments Report 1954, E/CN.7/296 (April 1955).
In essence, civil laws allow for an indefinfite period of treatment in a hospital under the usual safeguards for medical records and disclosure of court records. Additional advantages include parole under conditions of supervision and treatment for long periods with the opportunity for the immediate re-hospitalization in case of relapse. However, once off drugs the addict may plead for release and, in many cases, achieve freedom. To complicate the problem further, the New York State Supreme Court has ruled, for instance, that the judge has no authority to commit an addict when there is no law against being an addict. Commitments under penal laws, on the other hand, are usually for definite periods (sentence), with limited conditions for experimental release (parole or probation), and the requirement of formal court proceedings for re-institutionalization in case of relapse. Commitments under penal laws do not, therefore, generally allow the kind of flexibility needed in treatment, nor do they provide the kind of medical treatment required.
Commitment under penal laws for treatment of addiction is accomplished in few countries. The United States has been the notable example since 1935, and constructed two special federal hospitals for that purpose, one at Lexington, Kentucky, and the other at Fort Worth, Texas. Iran provides camps in several provinces for this purpose, at which the addict stays for thirty days for withdrawal and re-education. Singapore also has recently developed such a treatment centre for addicts arrested and sentenced. Several other countries have planned, though not yet built, similar hospitals for the treatment of "criminally committed" addicts. An Egyptian law of 1928 makes such a provision as does a recent law in Greece. The majority of the countries, however, do not provide treatment facilities for convicted addicts.
An interesting combination of "criminal" and "civil" commitment has been developed in Washington, D.C., U.S.A., for addicts not under other criminal indictment. Under this procedure addicts may be forced to get treatment at a federal hospital and continue after-care follow-up in the city of Washington, D.C., for a period of two years.
Most countries recognize physical illness of any sort as justification for either special treatment or excuse from withdrawal treatment. The variations are so numerous and depend on so many diverse circumstances that it is impracticable to enumerate or explain them.
PROGRAMMES OF TREATMENT
Although many countries have expressed an interest in the development of national programmes for the treatment of addicts, few have implemented their plans. Of these few, the United States and Iran have proceeded the farthest. Since 1935, the United States has had the two previously mentioned federally owned and operated hospitals for the treatment and rehabilitation of addicts. Several of the states - notably California and New York - have developed special in-patient facilities of a similar type. California opened a hospital in 1930 and closed it in 1940; the New York hospital was opened in 1952. In addition, a few large cities, such as Chicago, Illinois, and Detroit, Michigan, have special ambulatory psychiatric clinics for addicts for after-hospital care. Iran, in a special programme inaugurated in November 1955, established treatment centres in its several provinces to pro vide withdrawal and short-term rehabilitation for addicts. In many countries-such as Germany, Denmark, and Argentina-addicts are treated in state mental hospitals when beds are available. In most countries, addicts can obtain treatment in either private sanatoria or on an ambulatory basis from private physicians.
Despite the rather general acceptance of the concept that drug addiction is but a symptom of an underlying psychiatric disorder, there is still a special focus on withdrawal techniques in treatment. As Kolb & Ossenfort4said in 1938, "The bulk of the literature on the treatment of drug addiction is concerned only with the withdrawal stage . . . Some of these methods are harmful . . . a large proportion are useless, and all are successful, provided the opiate is withdrawn and the treatment is not so strenuous as to kill the patient, a result that is too often achieved ". A comprehensive summary and discussion of such techniques has been made by Pablo Wolff.5
A brief outline of the principal methods of withdrawal and that plan which is currently considered the most scientific and humane may be useful.
There are generally two main categories: (1) The gradual withdrawal of narcotics over a period of time; (2) The abrupt cessation of the administration of narcotics with or without supportive non-narcotic drug or other therapeutic techniques.
The gradual withdrawal of narcotics can be divided into:
The prolonged reduction with gradual diminution of the dosage of the drug of addiction over a period of weeks, months or even years. To ease the discomfort, adjunctive drugs such as barbiturates, bromides, scopolamine, atropine, hyocyamine, and more recently chlorpromazine, promazine, reserpine and meprobamate have been used.
The rapid reduction in narcotic dosage over a period of seven to fourteen days. Supplemental therapy may include those in ( a) above.
The substitution of other addiction supporting narcotic drugs in ( b) above, the withdrawal of which entails less severe symptoms than those encountered with the drug of addiction. This method used in the federal hospitals in the United States is as follows: the patient is given, depending on the severity of withdrawal signs and level of addiction, up to 20.0 mg of methadone (either orally or hypodermically) three times a day. After the first day the dosage is rapidly reduced to zero over a period of three to ten days.6
The methods of abrupt withdrawal include:
Abrupt cessation of drug administration with or without supportive therapies such as intravenous fluids, cardiovascular stimulants in case of severe collapse.
4 Kolb, L. & Ossenfort, W. F. (1938), The Treatment of Drug Addicts at Lexington Hospital, So. Med. J. (Bgham., Ala.), 31, 914.
5 Wolff, P., The Treatment of Drug Addicts, Bull. Hlth Org., (1945/46) L. of N., XII, No. 4.
6 Vogel, V. H., Isbell, H. & Chapman, K. W. (1948), J. Amer. Med. Assoc., 138, 1019.
As above in 2 ( a) and the use of adjunctive non-narcotic drugs as in 1 ( a), such techniques usually only mask the symptoms of withdrawal.
As above in 2 ( a), except that electroshock or insulin shock is used periodically.
"Patented" methods such as Démorphéne which include a variety of drugs, the essential one of which is believed to be disteareoglycerophosphate of choline.
However, there has been little scientific evaluation of most of these methods, and an over-emphasis on their respective efficacy in preventing relapse. A lack of understanding that addiction to drugs is but a symptom of the basic personality derangement is of paramount importance in this regard.
Most therapists treating addicts recognize the need for adjunctive and supportive treatment beyond somatic therapy. Reports from the literature in Europe and the United States lay repeated emphasis on the necessity of some form of psychotherapy to meet this need. Even the brief treatment programme accorded opium smokers in Iran recognizes the need to strengthen the ego and reinforce through persuasion, law enforcement, public pressure, etc., the knowledge of the bad effects of opium. In Egypt, those hospitals treating hashish smokers place great emphasis on group therapy. Reports from Germany emphasize that psychotherapy should be started at the beginning of treatment and maintained for weeks in the institutions and for months afterwards on an out-patient basis.
Unfortunately, the legal circumstances and opportunities for post-institutional treatment are unsatisfactory even in those countries with the most advanced health programmes. Except for addicts on parole or probation from criminal convictions, there is little opportunity even for post-institutional supervision, let alone treatment. Few, if any, public out-patient psychiatric clinics will handle addicts. In the United States, New York City has developed a combined in-patient and out-patient programme for juvenile addicts only under its public health laws. As previously mentioned, Washington, D.C., is about to provide similar services under "civil-criminal" commitment laws.
The question as to the kind of psychotherapy as well as additional therapies, vocational, occupational, etc., has been of greater interest in the United States than in most countries. There has been some experimentation with group therapy in United States government hospitals and the New York City Juvenile Addict Hospital (Riverside), and at the Abassia Hospital in Cairo, Egypt. Time-honoured individual therapies of the various types- e.g., supportive, psychoanalytic, and psychoanalytically oriented psychotherapy- are used by most therapists when such treatment is given. Countries with recognized problems of addiction among the unskilled and untrained have programmes of vocational education and re-education. Institutional treatment of any prolonged duration usually encompasses some form of occupational and recreational therapy.
Those addicts who are convicted of crime usually receive no special treatment, and are sent to prison as are other law violators in their respective·countries. In the United States and Iran, a few such criminals may be sent to special hospitals or institutions for treatment.
In Denmark, criminal addicts are often sent to the Institution for Criminal Psychopaths for treatment.
The use of N-allylnormorphine- which produces abstinence signs in narcotic addicts - has been suggested as a check method for relapse to addiction. This drug is dangerous in unskilled hands and if given incautiously to a heavily addicted person may produce so violent a reaction as to cause death. Furthermore, the test should be done in a hospital.
Certain countries as mentioned before provide for the continued use of drugs by individuals under controlled circumstances who have failed in attempted treatment. The lack of tight control over the licit dispensing of narcotic drugs in many countries makes possible the support of addiction with or without treatment. It is even possible, in many countries, for a physician to maintain an addict on drugs if he chooses under the guise of" medical treatment ". The frequency with which this occurs around the world is unknown but probably not inconsiderable, according to information from knowledgeable people in many nations. The individual economic resources to afford continued medical care made this possible in many cases.
EFFECT OF TREATMENT
Few attempts to follow up large numbers of patients have been made. Thus, Pescor studied several hundred dischargees from the U.S. Public Health Service Hospital at Lexington, Kentucky, by correspondence. Unverified replies indicated that 15% of the patients had been off drugs for one or more years. About 50% of the inquiries were not answered. The U.S. Public Health Service is currently attempting methods to find by personal contact all patients discharged from Lexington in a large city. Efforts will be made to determine the addiction status as well. There will be no attempt to correlate results with treatment. A recent study on drug addicts in Vancouver, British Columbia, has been conducted by Stevenson. The results have not been published.
It has been suggested that addiction in some is but a temporary maturation problem, as in certain delinquent behaviour. Cursory reviews of United States prison statistics reveal the age of the majority of addicts to be in the third or fourth decade. Observers in Iran and Egypt are under the impression that not all young addicts become old addicts. Many of these implications titillate the imagination as to the possibility that drug addiction may be curable if only we had better information.
The identification of addicts both from relapse and epidemiological standpoints is of particular public health interest. Not only could such methods serve to evaluate treatment but also find those in need of treatment as well as determine the effectiveness of control procedures. A simple urine test would be invaluable. Present methods are time-consuming and cumbersome.
A great many questions which are of fundamental importance remain unanswered. We have too little information on the epidemiology of addiction, the fluctuations in incidence, the effect of cultural, legal, and social attitudes and taboos. There is, above all, little information on the effectiveness of any treatment programme to determine optimum methods of approach other than prohibition of drug use. The last, though undoubtedly effective, does not strike at the underlying problem of the desire for drugs and which results, despite the most stringent controls, in a certain number of people using drugs. Prevention is the watchword, but we must have more information in order to be wholly effective.