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Addiction or Drug-Dependence?
Addiction or Drug-Dependence? ERWIN
N.
• Recently the WHO Expert Committee on Addiction Producing Drugs modified considerably terminology and definitions in regard to "addiction and habituation."l These two terms had been used in the definitions previously formulated (1952 2 and 19573 ) and were being replaced now by a single term "drug-dependence." According to the same committee, however, "drug-dependence" is only a general term which has to be qualified by specifying the particular type of drug-dependence. The report speaks of "drug-dependence of morphine type," "drug-dependence of barbiturate type," "drug-dependence of cocaine type," "drug-dependence of amphetamine type," and "drug-dependence of cannabis type." It appears from the above that within the framework of this definition the accent is rather on the agent involved in the abuse than on the individual-the addict (in the classical sense of the word). Even the social and socioeconomic aspects implicated in drug abuse are classified according to the agent involved. Perusal of case histories shows that to many an addict, the type of drug is completely immaterial. Quite a number-some say the majority-of addicts change drugs frequently." A not unimportant reason for this may be that following the natural law of least resistance, addicts will try to obtain drugs not subject to narcotic laws with their restrictions and limitations. However, this switching of drugs by the addict does not only occur in the search for more accessible agents. In Mexico, for instance, where everything can be bought with money, the American Beatnik expatriates use alcohol, marijuana, LSD, Demerol, heroin, amphetamine, and barbiturates in succession. They claim that they do not get "hooked" to any of them. 5.6 This interchangeability is as one can see not restricted to a specific group of substances comparable in pharmacological effect or chemical structure. There is no predictable pattern in July-August, 1965
TERRY,
M.D.
this variability. The sometimes almost paradoxical usage in terms of pharmacological effect shows that the concepts of "stimulation" and "sedation" cannot be used in their ordinary sense. One deals here with a specific effect apparently only experienced by the addict, which itself perhaps is pathognomonic. The original pharmacological effect may be lost completely and becomes unimportant as it is submerged by the psychic effect common to all substances used in addiction. One is almost tempted to conclude that one can only speak of addiction if such paradoxical effect takes place. The possibility of substituting drugs in addiction serves also as a further indication that the dynamics of addiction evolve at a personality level where pharmacological aspects such as analgesia, sedation or stimulation may playa very necessary and, initially, possibly even a casual though only indirect role. Therein lies the true significance of an addictive agent, namely, that in so disposed individuals it loses completely its original specific pharmacological characteristics which are superseded by a psychic action apparently taking place at a somewhat higher level. This latter effect is the one really looked for by the addict and apparently found to be the same in principle with all drugs used. Full scale addiction, or to use the new term "drug-dependence" is not really a separate disease entity but usually represents a symptom in a number of personality'" or psychiatric disorders,9-14 whether the pharmacologic agent is a narcotic, an alcohol, a barbiturate or whatever." Major psychoses generally do not playa role in the genesis of addiction.9.l5.18 Isbell and Fraser17 put it quite clearly: "The writers have yet to see an addict who could not easily be shown to have been psychiatrically abnormal prior to addiction, provided an adequate psychiatric examination had been made." The shift of accent in the definition of ad241
PSYCHOSOMATICS
diction by the WHO Expert Committee on Addiction-Producing Drugs is not merely a matter of semantics. Addiction is a medical problem. This should under ideal circumstances include not only the somewhat questionable "cure" of the addict but also perhaps to a larger extent the prevention of addiction. By putting the emphasis on the substance involved in addiction it becomes, and in particular as far as prevention is concerned, more a matter of administrative responsibility by law-enforcement. It would appear to date that this approach to addiction can not be shown to be particularly effective, neither in its prevention nor in its discontinuation. SUMMARY
The definitions and terminology recently fonnulated by the WHO Expert Committee on Addiction-Producing Drugs in which an emphasis on the agent involved can be found are compared to current concepts of addiction centering on the individual addict, the variability of agents used by the addict, and the fact that addiction represents only a symptom of underlying psychopathology. BIBLIOGRAPHY
1. Wid IIIth Org. Techn. Rep. Ser., 1964, 273, 13. 2. Wid Hlth Org. techno Rep. Ser., 1952, 57, 9 (section 6.1). 3. Wid Hlth Org. teclm. RqJ. Ser., 1957, 116, 9 (section 8). 4. Isbell, H., and Fraser, H. F.: Addidion to analgesics and barbiturates. Pharmacological Reviews 2 19.'50. 5. Arch. Cell. Psychiat., :\[ay, 196.3. 6. Personal Communication, S. Cohen. 7. Bell, D. S. ct al: ]. Nerwus and ,\lental Dis. 133:489, 1961.
8. StaHord-Clark, D.: Psychiatry Today, p. 130, London, 1953. 9. Felix, R. H.: Some comments on the psychopathology of drug addiction. Ment. Hyg., 23:567 1939. Studies on codeine addiction. The effect of codeine on behaviour. ppg. 32-49 1940. Pub. Health Rep. Supp. 158, Part IV. An appraisal of the personality types of the addict. Am.]. Psychiat. 100:462, 1944. 10. Kolb, L.: Pleasure and deterioration from narcotic addiction. Ment. Hyg. 9:699 1925. Clinical contributions to drug addiction. The struggle for cure and the conscious reasons for relapse. ]. Nero. & Ment. Dis. 66:22 1927. Drug addiction. A study of some medical cases. Arch. Neurol. & Psychiat. 20: 171 1928. 11. Reichard, J. D.: Narcotic drug addiction; a symptom of human maladjustment. Dis. Nerv. System 4:275 1943. Addiction: some theoretical considerations as to its nature, cause, prevention and treatment. Am. ]. Psychiat. 103:721 1947. 12. Vogel, V. H., et al: ].A.M.A., 138: 1019, 1948. 13. Wikler, A.: Treatment of drug addiction. Conference on therapy, Cornell University, Medical College. N. Y. State]. Med., 44:1,1944. Recent progress in research on the neurophysiologic basis of morphine addiction. Am. ]. Psychiat. 105:329, 1948. 14. Murphee, H. B.: Clin. P/wrmaeol. Therap. 3, 4:475-504, 1962. 15. Pescor, M. J.: The Kolh classification of drug addicts. Pub. Health Rep. Supp. 155: 1, 1939. Prognosis in drug addiction. Am.]. Psychiat. 97: 1419, 1941. Physician drug addicts. Dis. Nere. System 3:2, 1942. A statistical analysis of the clinical records of hospitalized drug addiets. Pub. Health Rep. Supp. 143: 1, 1943. 16. Pfeffer, A. Z.: Psychoses during withdrawal of morphine. Arch. Neurol. & Psychiat. 58:221, 1947. Pfeifer, A. Z., and Ruble, D. c.: Chronic psychos{'s and addiction to morphine. Arch. Neurol. & Psychiat. 56:665, 1946. 17. IsI)(>II, H., and Fraser, H. F.: Addiction to Analgesics and Barbiturates. Pharmacological Redews 2 1950.
Pharma-Research Canada Ltd. 250 Hymus Bled. Pointe Claire, Quebec, Canada
... \Ve are still animals and are meant to use our muscles as well as our brains, each for the benefit of the other. . . . It is simply a matter of physiology. Contraction of the skeletal muscles squeezes the veins and actually helps to pump blood back to the heart. . . . The pumping function of the heart is aided by the diaphragm, which makes of the thorax a suction pump. It is wise to keep the diaphragm free in its motion by avoiding filling the abdomen with fat. . . . At some very remote time in the future nature may rearrange us to enlarge our brains and to diminsh our muscles to suit our way of life. PAUL DUDLEY WHITE, M.D. (Letter to the Editor, New York Times, 2/21/65.)
242
Volume VI
N.
• Recently the WHO Expert Committee on Addiction Producing Drugs modified considerably terminology and definitions in regard to "addiction and habituation."l These two terms had been used in the definitions previously formulated (1952 2 and 19573 ) and were being replaced now by a single term "drug-dependence." According to the same committee, however, "drug-dependence" is only a general term which has to be qualified by specifying the particular type of drug-dependence. The report speaks of "drug-dependence of morphine type," "drug-dependence of barbiturate type," "drug-dependence of cocaine type," "drug-dependence of amphetamine type," and "drug-dependence of cannabis type." It appears from the above that within the framework of this definition the accent is rather on the agent involved in the abuse than on the individual-the addict (in the classical sense of the word). Even the social and socioeconomic aspects implicated in drug abuse are classified according to the agent involved. Perusal of case histories shows that to many an addict, the type of drug is completely immaterial. Quite a number-some say the majority-of addicts change drugs frequently." A not unimportant reason for this may be that following the natural law of least resistance, addicts will try to obtain drugs not subject to narcotic laws with their restrictions and limitations. However, this switching of drugs by the addict does not only occur in the search for more accessible agents. In Mexico, for instance, where everything can be bought with money, the American Beatnik expatriates use alcohol, marijuana, LSD, Demerol, heroin, amphetamine, and barbiturates in succession. They claim that they do not get "hooked" to any of them. 5.6 This interchangeability is as one can see not restricted to a specific group of substances comparable in pharmacological effect or chemical structure. There is no predictable pattern in July-August, 1965
TERRY,
M.D.
this variability. The sometimes almost paradoxical usage in terms of pharmacological effect shows that the concepts of "stimulation" and "sedation" cannot be used in their ordinary sense. One deals here with a specific effect apparently only experienced by the addict, which itself perhaps is pathognomonic. The original pharmacological effect may be lost completely and becomes unimportant as it is submerged by the psychic effect common to all substances used in addiction. One is almost tempted to conclude that one can only speak of addiction if such paradoxical effect takes place. The possibility of substituting drugs in addiction serves also as a further indication that the dynamics of addiction evolve at a personality level where pharmacological aspects such as analgesia, sedation or stimulation may playa very necessary and, initially, possibly even a casual though only indirect role. Therein lies the true significance of an addictive agent, namely, that in so disposed individuals it loses completely its original specific pharmacological characteristics which are superseded by a psychic action apparently taking place at a somewhat higher level. This latter effect is the one really looked for by the addict and apparently found to be the same in principle with all drugs used. Full scale addiction, or to use the new term "drug-dependence" is not really a separate disease entity but usually represents a symptom in a number of personality'" or psychiatric disorders,9-14 whether the pharmacologic agent is a narcotic, an alcohol, a barbiturate or whatever." Major psychoses generally do not playa role in the genesis of addiction.9.l5.18 Isbell and Fraser17 put it quite clearly: "The writers have yet to see an addict who could not easily be shown to have been psychiatrically abnormal prior to addiction, provided an adequate psychiatric examination had been made." The shift of accent in the definition of ad241
PSYCHOSOMATICS
diction by the WHO Expert Committee on Addiction-Producing Drugs is not merely a matter of semantics. Addiction is a medical problem. This should under ideal circumstances include not only the somewhat questionable "cure" of the addict but also perhaps to a larger extent the prevention of addiction. By putting the emphasis on the substance involved in addiction it becomes, and in particular as far as prevention is concerned, more a matter of administrative responsibility by law-enforcement. It would appear to date that this approach to addiction can not be shown to be particularly effective, neither in its prevention nor in its discontinuation. SUMMARY
The definitions and terminology recently fonnulated by the WHO Expert Committee on Addiction-Producing Drugs in which an emphasis on the agent involved can be found are compared to current concepts of addiction centering on the individual addict, the variability of agents used by the addict, and the fact that addiction represents only a symptom of underlying psychopathology. BIBLIOGRAPHY
1. Wid IIIth Org. Techn. Rep. Ser., 1964, 273, 13. 2. Wid Hlth Org. techno Rep. Ser., 1952, 57, 9 (section 6.1). 3. Wid Hlth Org. teclm. RqJ. Ser., 1957, 116, 9 (section 8). 4. Isbell, H., and Fraser, H. F.: Addidion to analgesics and barbiturates. Pharmacological Reviews 2 19.'50. 5. Arch. Cell. Psychiat., :\[ay, 196.3. 6. Personal Communication, S. Cohen. 7. Bell, D. S. ct al: ]. Nerwus and ,\lental Dis. 133:489, 1961.
8. StaHord-Clark, D.: Psychiatry Today, p. 130, London, 1953. 9. Felix, R. H.: Some comments on the psychopathology of drug addiction. Ment. Hyg., 23:567 1939. Studies on codeine addiction. The effect of codeine on behaviour. ppg. 32-49 1940. Pub. Health Rep. Supp. 158, Part IV. An appraisal of the personality types of the addict. Am.]. Psychiat. 100:462, 1944. 10. Kolb, L.: Pleasure and deterioration from narcotic addiction. Ment. Hyg. 9:699 1925. Clinical contributions to drug addiction. The struggle for cure and the conscious reasons for relapse. ]. Nero. & Ment. Dis. 66:22 1927. Drug addiction. A study of some medical cases. Arch. Neurol. & Psychiat. 20: 171 1928. 11. Reichard, J. D.: Narcotic drug addiction; a symptom of human maladjustment. Dis. Nerv. System 4:275 1943. Addiction: some theoretical considerations as to its nature, cause, prevention and treatment. Am. ]. Psychiat. 103:721 1947. 12. Vogel, V. H., et al: ].A.M.A., 138: 1019, 1948. 13. Wikler, A.: Treatment of drug addiction. Conference on therapy, Cornell University, Medical College. N. Y. State]. Med., 44:1,1944. Recent progress in research on the neurophysiologic basis of morphine addiction. Am. ]. Psychiat. 105:329, 1948. 14. Murphee, H. B.: Clin. P/wrmaeol. Therap. 3, 4:475-504, 1962. 15. Pescor, M. J.: The Kolh classification of drug addicts. Pub. Health Rep. Supp. 155: 1, 1939. Prognosis in drug addiction. Am.]. Psychiat. 97: 1419, 1941. Physician drug addicts. Dis. Nere. System 3:2, 1942. A statistical analysis of the clinical records of hospitalized drug addiets. Pub. Health Rep. Supp. 143: 1, 1943. 16. Pfeffer, A. Z.: Psychoses during withdrawal of morphine. Arch. Neurol. & Psychiat. 58:221, 1947. Pfeifer, A. Z., and Ruble, D. c.: Chronic psychos{'s and addiction to morphine. Arch. Neurol. & Psychiat. 56:665, 1946. 17. IsI)(>II, H., and Fraser, H. F.: Addiction to Analgesics and Barbiturates. Pharmacological Redews 2 1950.
Pharma-Research Canada Ltd. 250 Hymus Bled. Pointe Claire, Quebec, Canada
... \Ve are still animals and are meant to use our muscles as well as our brains, each for the benefit of the other. . . . It is simply a matter of physiology. Contraction of the skeletal muscles squeezes the veins and actually helps to pump blood back to the heart. . . . The pumping function of the heart is aided by the diaphragm, which makes of the thorax a suction pump. It is wise to keep the diaphragm free in its motion by avoiding filling the abdomen with fat. . . . At some very remote time in the future nature may rearrange us to enlarge our brains and to diminsh our muscles to suit our way of life. PAUL DUDLEY WHITE, M.D. (Letter to the Editor, New York Times, 2/21/65.)
242
Volume VI