PART I The Nature of the Opiate Habit
CHAPTER6 CURE AND RELAPSE
In the preceding chapters the theory has been proposed and elaborated that addiction is generated in a specific type of experience with withdrawal distress. From this experience the beginner acquires the behavior, attitudes, and impulses that make him an addict and compel him to recognize himself as such. The tendency to relapse is obviously an integral aspect of addiction, for if it did not exist addiction would not constitute a social problem and breaking the habit would be a simple matter readily accomplished in a few weeks. Implied in the suggested explanatory scheme is the idea that this pervasive and persistent impulse to relapse is a consequence of the persistence of impulses, cognitive patterns, and attitudes originally learned from experiences with the withdrawal distress. Since addicts are tempted to resume the use of drugs long after all withdrawal symptoms have vanished, it is not suggested that relapse occurs because of these symptoms in any direct sense. The argument is rather that the craving for drugs originally established in connection with these symptoms becomes functionally independent of them and of any and all chemical or physiological properties of the drug and its effects. As an independent cortical function the behavioral tendencies designated as a craving for drugs persist in a modified form in the abstaining addict and predispose him to resume his habit.
The addict's impulse to relapse is qualitatively very different from his desire for the drug when he is physically dependent on it. In the latter situation the user's need is urgent, immediate, and continuous, since he knows that he is constantly threatened by withdrawal if he omits a regular injection. The impulse to relapse_ depends for its efficacy on more subtle long-range influences and is, not urgent and immediate. The addict who is taken off drugs sometimes resumes his habit at the first opportunity, but frequently he does not. Under certain circumstances and provided he has adequate motives, he may deliberately postpone his relapse for weeks, months, and sometimes for years. An addict who was on parole when I began my interviews with him in the fall told me repeatedly during the winter that he intended to start using drugs again in the spring before his parole expired. He was living at the time in a kind of half-way house which afforded little privacy, and he did not relish the idea of traveling during the winter months. He planned when he resumed his habit to go to the southwest part of the country. Late in March he did just what he had planned to do and tried very hard to get himself a shot before be left town.
Another addict who served in the army in France during World War I said that he did not use morphine while he was there, even though it was readily procurable, because of the notorious lack of privacy of army life: "There were too many people around and not enough privacy. When he returned to the United States he at once resumed his habit.
The statistics of relapse are further indications that the relapse impulse is not an overpowering compulsion requiring instant gratification. It is more in the nature of a persistent, intermittent, but unrelenting and subtle pressure. Cocteau exclaimed, "The patience of the poppy! He who has smoked will smoke again. Opium can afford to wait."
Some idea of the nature of the relapse impulse may perhaps be obtained by considering the difficulties experienced by tobacco smokers in quittng a habit which is far less-powerful than opiate addiction. Like the urge to take another shot of morphine, the urge of the abstaining cigarette smoker to have a cigarette is usually not constant or overwhelming and can be resisted. Nevertheless, over a period of time, it tends to win the battle. The opiate addict's craving and his tendency to relapse, it should be emphasized, are not rational impulses any more than are those of the cigarette smoker. The cigarette smoker does not smoke and does not resume smoking after a period of abstinence for the purpose of exposing himself to the risks of lung cancer and emphysema, although he knows this is the effect of what he does. Neither can he be said to weigh the risks against the satisfactions and to conclude logically that the risks constitute a fair price to pay. The same reasoning applies to the drug habit, for the addict does not relapse because he enjoys the prospects of again undergoing the ordeal of withdrawal. What he does is to give way to an irrational impulse or desire, permitting it to seduce him by means of a variety of stratagems which have the effect of neutralizing the negative import of withdrawal as well as the many other burdensome and unpleasant features of addiction.
An important feature of the mechanics of addiction is that the positive satisfactions involved in taking a shot are assured and immediate; in contrast, the negative effects of the habit are remote and indirect and can sometimes be avoided or postponed. It is a commonplace to observe that even a small immediate and certain gratification may counterbalance the effect of a dire but remote and contingent threat..
There are two separate and somewhat different theoretical problems involved in dealing with relapse. The first is to determine the source of the tendency the second and more difficult problem is to try to describe the mechanisms which lead to relapse. The first of these theoretical problems has already been dealt with in preceding chapters; the second is the concern of this one.
It may be observed in passing that the linkage between withdrawal distress and the craving for drugs which prompts resumption of the habit is strongly suggested by a curious phenomenon that has been noted frequently in the literature. This is that addicts who have been off drugs for long periods of time frequently experience what may be called pseudowithdrawal symptoms on occasions when they are strongly tempted to resume use. At a conference on drugs in California, for example, an addict in the audience approached me and said that in the course of the afternoon I s programs he had been gripped by a powerful "yen" to have a shot of the drug that was being talked about so much. I asked him what he felt. He reported that he broke into a cold sweat and felt a peculiar sensation in the pit of his stomach. As he himself pointed out, these are also among the initial symptoms of withdrawal. This phenomenon seems to fit neatly with the idea that the relapse tendency is a residual aspect of the craving that is established in a conditioning process in which the withdrawal symptoms play an indispensable role. Having become functionally linked with each other in the initial conditioning process, each subsequently tends to elicit the other; withdrawal elicits desire, and desire withdrawal, .
The Desire To Be Cured
Certain paradoxical features of the opiate habit should be indicated here, and the reader's attention should be focused again upon the ambivalence of the user who Dot only bends all his efforts toward maintaining his supply but also hopes to be extricated from the trap into which he has fallen. The original effectiveness of the drug diminishes and eventually disappears with continued use, and at the same time its consumption must be constantly increased. Before long the user consumes large quantities merely to keep himself normal, and when this point is reached, as it usually is within a few months, the addict is trapped. As H. H. Kane said of opium smokers, "Then the good spirit of the pipe disappears, giving place to a demon who binds his victims hand and foot. Smoking no longer gives the pleasure of the first few months, and the victim of the habit continues not for the pleasure obtained from it, but is driven to it by the terrible suffering that surely comes if the pipe is not smoked at the accustomed time.(1) The drug user then sees the folly of the habit and, realizing the transitory character of its pleasures, he desires to escape. Sandoz said of drug users that 11 most of them realize their bondage and its consequences. If their lives were not all they should have been before their addiction, they know now how much worse they have become since.(2)
This desire to be cured is best demonstrated by the large number of cures attempted by the chronic user. Charles Schultz (3) found that the average number of cures taken by each of the 318 addicts who came under his care was four. If one were to include those attempts to quit which were given up after a day or so, or after several hours, there is no question that this average number would have been much larger. I once asked an addict if drug users often tried to go off the drug and his reply was, "Every time they take a good jolt." The same idea was expressed by another user: "A junkie always quits on a full ounce. He never quits when he is out." Kane has described this tendency as follows:
A very odd conceit obtains among many smokers. When you ask them, "Can you stop this?" they will answer with the instant assurance, especially if they have been smoking opium for an hour or two and are well primed with opium, "Stop it? Certainly. For instance, this will be my last smoke for a month," Nevertheless you will find him there smoking as usual the next day, and for many days thereafter. Some men will bid their companions good-night and good-bye night after night, sometimes for months, about as follows: "Well, boys, good-bye. I've bad my last smoke with you. It has given me a world of pleasure and served to while away many a tedious hour, and I forgive it whatever it has done to me. I wish you joy. Goodbye." The next night he will be found smoking again as bard as ever, and at the finish go through the same performance.(4)
I have never met a chronic user addicted for several years or more who bad not tried to free himself Of tbe-babit. Moreover, contrary to the frequently expressed notion that so-called criminal addicts do not desire to be cured, (5) I have encountered professional thieves who voluntarily abstained from opiates for as long as five to eight years in grim determination to throw off the habit. Recognition of the evil effects of addiction, however, bears little relationship to the probability of permanent cure. Otherwise there would be few addicts, for they are keenly aware of, and often bitterly resentful of, the stigma and misfortune attached to being a "dope fiend." Addicts relapse again and again after the drug has been removed at their earnest request. lt is sometimes said, therefore, that the user's desire to be cured cannot be sincere and that he is motivated by ulterior purposes, such as reducing the size of his dosage, recreating the initial pleasure, obtaining admission to an institution during the cold winter months, avoiding the law, or complying with the demands of relatives. This skeptical view is discussed by Schultz:
They do not think their habit is a vice, or that it degrades or injures them. To them it is a pleasure, which they see no reason for giving up, and as a result they are often amused at others' attempts to "reform" them.
If a patient of this type openly declares he is going to revert to drugs (and many do) and boasts about it, enlarging upon the pleasures of his first shot upon discharge, others are apt to do likewise.
This attitude is detrimental to the exercise of self-control and will power on the part of the more sincere patients, as sometimes they will ridicule such a patient's statements that he is going to try to stay off drugs; e.g., one patient declared on discharge that be was "through with drugs." Another patient then told him, "For God's sake, be a man. Get shot up!" (6)
While this account is correct, as far as it goes, it does not imply that the hardened addict has no desire to be rid of his habit. The addict who is least motivated to quit is probably the young user with a recently acquired habit. As the habit is continued there is increasing disenchantment. The long-term addict often more or less gives up the struggle after a series of attempts to quit have failed. Some of them reach a point of disillusionment and despair which leads them to consider or attempt suicide. Users who comment cynically on the impurity of the motives of others who take cures usually insist that their own efforts are sincere. What often happens is that the user begins to quit with sincere but inadequate motives and promptly changes his mind and postpones the attempt. In this respect, opiate addiction is not very different from a great many other bad habits.
While there may be some addicts who never fight the habit but simply accept it and allow themselves to be swept along by it, 1 have never met such a person. An apparent attitude of unconcern is frequently a pose, an adaptation to a hopeless situation. In group association with each other, addicts commonly assume an attitude of bravado and defiance, and they ridicule users who want to quit. Such association often creates shared misconceptions in the mind of each addict about the others. Each privately admits that he wishes he could quit and that be has tried to do so, but each assumes that the others accept their addiction and have no real desire to break it. The group attitude gives the individual user relief from the frustration, guilt and sense of helplessness that come from fighting a long, losing battle and provides supporting rationalizations for continuing the habit.
The hope of cure is not easily extinguished, even in the confirmed and experienced addict; be wants to die as a "square," not as a dope fiend, and he may permit himself to be deceived into believing that his next attempt will succeed. He tries once more and adds to his own disillusionment. If the addict's desire to be cured were not genuine and persistent, it would not have been commercially exploited for so many decades of the nineteenth century. The addict steadfastly maintains that he wants to quit and that he would if he could only feel right off the drug.(7)
The following case from my notes lists the major attempts of one addict to break his habit:
Case 14. Mr. T. became addicted to morphine in 1909 after using the drug occasionally for several years. He was a periodic drunkard and first took morphine to recover from inebriety. An only child, his parents, reasonably well-to-do, left him an adequate income. The following list of cures shows how often he attempted to get rid of his habit.
1. 191o: took a home cure without any real determination to quit. He spent $40 and reduced the dosage without getting off the drug.
2. 1912: took a cure lasting five weeks which cost him $175. The drug was completely removed for a time. He resumed using it immediately upon release.
3. 1916: took another home cure without serious intentions of quitting.
4. 1916: took a free cure lasting twelve weeks. He managed to get off the drug, but drank paregoric a number of times and relapsed at once when released.
5. 1917: took another free cure lasting six months. He resumed using the drug at once when released.
6. 1917: took a free cure in an asylum for three weeks. He was off the drug one week and drank paregoric the other two.
7. 1919: He was jailed for fifty days. This was his only involuntary cure. He resumed using the drug at once when released.
8. 1920: took a cure in private sanitarium at a cost of $200. He resumed use of the drug as before.
9. 1922: six months' free cure in a state asylum. He resumed use of the drug at once.
10. 1922: took the "Keeley cure" at a Cost Of $250. He relapsed at once.
11. 1925: cure lasting six months. Relapsed.
12. 1927: cure lasting three months. Relapsed.
13. 1930: cure lasting six months. Relapsed.
14- 1932: cure lasting three months. Relapsed.
15. 1933: six months' voluntary cure in the Chicago Bridewell. Relapsed.
16. 1934: quit voluntarily while living in the Chicago shelters for unemployed men because of the extreme difficulty of begging sufficient money during the winter months. This was the first time in his life that he ever succeeded in quitting by himself, outside of an institution. He resumed using the drug as soon as warm weather began in the spring of 1935 and was killed by a speeding automobile.
This man was repeatedly interviewed for a period of several months prior to his death, and the cures are described as he recalled them. He said be was not quite sure he had included all.
It will be noted that this addict distinguished carefully between those cures he took with the serious intention of quitting and those he took for other reasons. He told the story with an air of shame and bewilderment. When asked to explain why he had taken so many cures, he was at a loss for an answer, except to remark that he bad hoped each time to remain free. He confessed that his life had been ruined by the drug and all that remained for him was to wait for old age and death. In the meantime, be thought he might as well go on using the drug, since be no longer had anything to lose.
The addict's desire to be cured is readily understood as a consequence both of the social stigma attached to addiction and of the fact that the habit becomes a burden when the beginning euphoria vanishes and physical dependence is fully established. Prior to addiction, the addict generally shares the negative attitudes of the society toward junkies or dope fiends. When he himself becomes addicted he necessarily applies these attitudes to himself and his conduct. The realization that one has become an addict is not pleasant; it is a self-conception that is impressed upon the user when he is trapped by the drug. The - desire - to - quit is so much an integral part of being addicted that it should perhaps be eluded in the definition of addiction. (8)
The addict's wish to be cured indicates his membership and participation in the wider social order that condemns his behavior, When he is tinder the influence of the drug and is functioning normally, these collective ideals exercise their greatest influence, for he is then in relatively full contact with society and responsive to its demands. Moreover, with the drug in his body, be does not at the moment crave more of it and the social pressure which creates the desire to quit operates without opposition. As the effects of the drug wear off, persistent and increasing organic distress separates him from the wider social order. In this situation he changes his mind about quitting. Physical need eclipses all other considerations, as Jean Cocteau has graphically explained:
Let me profit by insomnia to attempt the impossible: to describe the craving for Opium. Byron said: "Love cannot survive seasickness." Like love, like seasickness, the need penetrates everywhere. Resistance is useless. First there is discomfort. Then things get worse. Imagine a silence which corresponds to the cries of thousands of children whose nurses have not come home to give them their milk. An amorous uneasiness translated into the physical world. An absence which reigns, a negative despotism. The phenomenon becomes more clear. Electric moire, champagne in the veins, frozen syphons, cramps, sweat at the roots of the hair, a sticky mouth, mucous, tears. Do not insist. Your courage is a pure waste of time. If you delay too long, you will not be able to take your material and stuff your pipe. Smoke.(9)
The desire to quit represents an integral aspect of the drug habit for obviously a person who is merely habituated and inaware of his dependence upon the drug cannot wish to be cured.
How Relapse Occurs
Addicts occasionally relapse deliberately, but more often they yield without meaning to; that is, they try "just one more shot," but plan not to take the drug often enough to get booked again. This type of reversion is known as "playing around," and it is proverbial that an addict cannot "play around" without being caught eventually. Nevertheless, the user just released from prison or from a cure often decides to take a shot only now and then, for old times' sake. When he is told, "If you keep putting that thing in your arm, you know damn well you will get hooked," he may protest that while it is dangerous for other addicts with less will power to play around, he will not succumb. At that remark, "You laugh right in his kisser," one addict said, for "you know that in a week or so he will be right back on the drug."
The following incident illustrates the unintentional I type of relapse:
Case 15. 1 was talking one day with Mr. K., who had just been released from the penitentiary on parole. He said that he was certainly not going to get hooked until he was off parole. Mr. K. was an intelligent person of a serious and inquiring frame of mind. Another addict, whom Mr. K. did not know, appeared and was introduced. The addict's first inquiry was whether Mr. K. was "hooked." He explained why he was not yet using the drug and said be would not use it until be was off parole in a few months. The other addict laughed and said, "I'll give you two weeks. By that time I bet you'll be hooked." Mr. K. protested and, after the other had gone, remarked on the tendency of persons to judge others by themselves.
I saw Mr. K. often during the next several weeks and each time suspected, from the appearance of his eyes, that he was under the influence of the drug. He did not deny it but said be bad only taken a "little shot" now and then so that his addict associates would not regard him as peculiar and that he would certainly never permit himself to be a fool and get caught. After a number of repetitions of this incident, he finally said, "Well, I'm hooked again, and booked good and strong." Then he elaborated on how "next time" he would not make the mistake of assuming that he could "play around" with impunity. He reproached himself for violating parole and began to talk about taking a cure somewhere and getting off the drug before be was caught and sent back to prison. He felt that there was no possibility of avoiding detection. He was caught and sent back to prison for parole violation.
A similar example is the case of a user who related that he had relapsed several times because of liquor.(10) He had taken to drinking during an abstinence period and finally, becoming disgusted with himself, decided to have a shot of morphine to try to get over his drinking. After obtaining the necessary dose from a doctor, be returned the next day for just one more, still believing that he wanted it only to relieve his hangover. After three or four injections, he realized that he wanted the injections for their own sake. Remarking, "Aw, hell, what's the use? I'm hooked now anyway, he bought a full supply and used it regularly. After several experiences of this kind, he stopped "kidding himself," as he put it, and said that he would never quit in the future unless forced to.
Another addict confided that the longest time he had ever voluntarily abstained was thirteen months. The first several weeks and months involved a struggle because of the debility and other after-effects of the habit. Later his condition improved, and he felt that be had freed himself entirely. He began to feel jubilant and triumphant. During the thirteenth month be took a shot to celebrate and demonstrate his mastery of the drug and was soon readdicted. It is notorious that the drug user's statements of his intentions are very poor indicators of what he is likely to do. This is perhaps because of the conflict between what reason tells him he ought to do and what the irrational compulsion of the habit impels him to do.
I once discussed relapse with Broadway Jones, the thief who helped Sutherland writeThe Professional Thief.(11) At the time of the conversation he had been off drugs for more than ten years. He denied that he felt tempted to use it again, even when he was with addicted friends who were using it in his presence. He was engaged in legitimate employment at the time and to the outside observer would surely have seemed to be a prize example of a permanently cured addict. I wrote of him at that time as follows in the original edition of this book:
A casual observer might conclude that this was a case in which twenty-five years of addiction in connection with a "life of crime" had left few traces; in other words, one might ask if this man were not a cured addict. In reply, it may be pointed out that he refers to himself as an "ex-user," not a "square John," or non-addict, and looks upon himself as "one of the boys."Two other aspects of his behavior indicate that there is justification for this definition. One is his belief that morphine is a marvelous cure for most of the afflictions of mankind. Secondly, be frequently sees friends who are addicts and talks with them about narcotics and associated subjects. I do Dot maintain that this man must of necessity revert to the habit but only that certain conditions distinguish him from the non-addict and function as predisposing factors toward relapse. The factor of associationper se cannot be regarded as the crucial condition in his case because be is and has constantly been in close association with drug users for more than ten years without relapsing.
Some years later, after close to eighteen years of abstinence, he wrote to Professor Sutherland at Indiana University to ask for money. Surmising that he was readdicted, Sutherland, without sending any money, advised him to commit himself to Lexington for a cure. The next letter from Jones was mailed from the hospital for addicts in Lexington, Kentucky, where he was successfully withdrawn from the drug. He did not relapse again.
Attitudes That Facilitate Relapse
An individual suffering from a chronic illness notes chiefly, if not solely, the alleviation of pain which the drug brings, and therefore uses it for that purpose. On the other hand, the addict soon learns that, no matter what his difficulty, it is aggravated by his need for the drug and at the same time is relieved by its use. The contrast between the misery caused by the absence of the drug and the well-being which follows the injection gives the user an exaggerated notion of the effects of the shot. He begins by taking the drug for a limited purpose and finds that its usefulness constantly increases. Besides relieving withdrawal distress, the addict quickly learns that morphine also relieves almost all other kinds of distress. If he has a job, he says be cannot work well without it; if be feels anxious, ill, or uncomfortable, be feels that be needs more of it. When be has to appear in court be takes an extra quantity to bolster his morale. The significance of the drug is, in short, generalized as a symbol and guarantee of security, not only against withdrawal but against most of the disturbing and unpleasant aspects of life By the same token, the significance of withdrawal distress is also expanded so that the addict eventually responds to many or most of the troubles that beset him as if they were withdrawal distress to be remedied by another fix.
The addict's exalted notion of the virtues of opiates is suggested by the fact that they sometimes refer to it as "G.O.M." or "God's Own Medicine." However, since I have also heard members of the medical profession use the same expression with regard to morphine, which is still evidently the best known analgesic, it may be argued that there is at least some truth in the addict's view of the efficacy of opiates.
The addict may, of course, realize that his personal difficulties are not associated with withdrawal distress. Thus an addict, earning $90 a month on a WPA project, bought an ounce of heroin and remarked to me that it would last him about a month. He actually consumed it in half the time. Part of his explanation was that he bad a foot complaint and simply bad to use more. Other users to whom I mentioned the incident accepted this as a perfectly legitimate and satisfactory explanation. The point is even more directly illustrated by the user who made hypodermic injections into a painful knee in order to alleviate the discomfort. Virtually every addict I interviewed had high regard for opiates as a curative or ameliorative agent. The more intelligent insisted that the potency of opiates was a fact and not a figment of the imagination. On one occasion in conversation with an intelligent addict, I ridiculed the unfounded belief that morphine is good for anything. The addict joined in the laughter, agreeing that the drug was so regarded, then added seriously, "But, you know, morphine is good ' for anything."
When the addict is' taken off drugs, he does not lose his belief in their efficacy, nor does he cease to respond to discomfort and distress as though it were withdrawal distress calling for a shot. Untoward or unpleasant experiences of almost any sort therefore constantly remind the abstainer of the potency of the drug and subtly impel him to take it again. The addicts tendency to interpret all discomfort as withdrawal distress is strengthened by the fact that the initial manifestations of withdrawal, such as nervousness, irritability, depression, and lethargy, cannot be distinguished out of context from the same feelings when they are not connected with the drug or when they occur in a non-addict. Not only does the addict use drugs to alleviate withdrawal and virtually all other ordinary forms of distress but be- may also use them to alleviate discomforts which the habit itself produces, such as those connected with chronic constipation or with excessive dosage.
From considerations of this sort it is easy to understand that the abstaining addict often appears to be a hypochondriac, complaining of a variety of illnesses, pains , and discomforts which he argues did not bother him when be was on the drug because be could banish them at once with a shot. Having reached this point, the abstaining addict may rationalize his relapse by saying that be really does not crave the drug but that he hates to go on suffering- unnecessarily from, a host of complaints. He may contend that his condition is so bad that lie is unable to work unless be resumes use of the drug. This, frame of mind is illustrated by an addicted woman who wished to send an expensive Christmas present to her child, who was being cared for by others. Her dilemma was that she would be unable to work unless she were' on drugs, but that if she were on drugs she would be unable to, save any money.
Much relapse is, of course, directly produced by the withdrawal symptoms themselves. When an active addict is locked up in jail for a day or two or even for a couple of weeks and then released, he is still often in a weakened condition or still undergoing withdrawal. Severe and abrupt withdrawal is sometimes advocated on the grounds that it will serve as a deterrent to relapse but the actual effect may well be the opposite. A prolonged, gradual withdrawal, on the other hand, although it is more humane and less dangerous than the cold turkey method, prolongs suspense and anxiety and probably enhances the addict's feeling that be needs the drug. Schultz has commented on this point:
There is nofeeling of sudden relief from intense suffering as in the abrupt withdrawal treatment; on the contrary they feel that an injustice is being done them when they are taken "off shots" as opposed to the feeling or relief and gratitude when taken off with the abrupt treatment. They resent being taken off treatment and psychologically this suspicious, resentful frame of mind and the suggestion which is impressed upon them by each injection that the narcotics are essential to relieve their symptoms, is not one conducive to the patient's abstaining from narcotics when discharged.(12)
"Cured" addicts often relapse when they are in the best of health, much better than they were when using the drug. I have been told by addicts discharged from Leavenworth that poverty stricken addicts enter prison in an extremely emaciated and starved condition, as a result of the bitter financial struggle to maintain their habits. In fact, some are so bony that they find it difficult to make injections into their shrunken veins. Under the regular prison routine, they put on weight and gradually achieve sound, normal health. Often one of these ex-addicts will rub the veins of his well-rounded arm and exclaim with satisfaction, "Boy, will I be able to hit that when I get out!"
Another influence that lures the-cured addict back to his drug may be called a cognitive factor. It consists of the knowledge the addict acquires about the effects of opiates from his personal experienced When he is on drugs he knows that he can regulate how he feels at will. From direct experience he knows what the drug can do. It is useless for the non-addict to argue with the user about such matters of direct experience, since the addict has
had the experiences and the non-addict has not. The addict's "knowledge" is sometimes merely an erroneous belief or a rationalization, but if it appears as knowledge to him it tends to function as if it were. Such knowledge contributes to relapse, and since people can not be cured of the knowledge they have, this intellectual or cognitive element' is probably close to the heart of whatever there is in addiction that is permanent and incurable. A nineteenth-century addict, S. T. Morton, who had not used opiates for two years wrote the following:
There is one thing which the habitue wishing to be cured would perhaps anticipate with dread: that is an insatiable craving for the old stimulant, and a consequent prolonged and weary resistance of temptation I can only say that, greatly to my surprise, I have felt no craving for it at any time since the beginning of the treatment. This may seem a strange statement to any one under the sorcery of the drug, and conscious of its fearful grip. There is of course the knowledge from experience of the marvelous potency of opium in annulling all discomfort and distress of body or mind, but this is all. The sense of profound satisfaction, ever present at the release from its slavery, as well as a lively appreciation of the great danger of again tampering with it, is sufficient to leave the tempt at ion-whatever it may be-from such knowledge, powerless.(13)
This remarkable statement brings out clearly One of the common experiences of addicts prior to relapse. They seem to have no desire whatever for the drug. Yet the impulse to relapse in the above case was present, but in a different form, as revealed in the words, "knowledge from experience of the marvelous potency of opium in annulling all discomfort and distress of body or mind." The anonymous author underestimates the significance of this factor, for, when the "sense of profound satisfaction" at having quit has worn off, this knowledge is still present, subtly attracting the user to his favorite drug. Given a certain situation, certain misfortunes, or a certain mood, and the ex-user may decide to throw caution to the winds and have "just one pop." For those who are disposed to regard the praise bestowed on opiates by this anonymous addict as sheer exaggeration, a reminder of the traditional view of medicine may be pertinent. Alonzo Calkins has this to say:
Opium has been denominated, and in no extravagance of hyperbole, the grand catholicon for human ills. Laudation here has scarcely been exhausted, even in the excess. In the "Opiologia" of Wedelius, opium is the "medicatamentum coelitus demissum,"-the heaven-born gift. Tillingius styles it the "anchora salutis sacra,"the bower-anchor of health. Sydenham says that "medicine without it would go at a limping gait"; and John Hunter, in an exuberance of enthusiasm, exclaims, "Thank God for opium!" Van Swieten in his estimate does not fall behind: "Opium le plus efficace de tous les medicaments et sans quoi ]'art de guerir cesserait d'exister, est le remede de quoi le Tout-Puissant a fait present pour le bonheur et la consolation de l'humanite souffrante. (14)
Boredom and Disgust in the Cured Addict
One addict whom I interviewed a number of times was imprisoned for a few weeks in the Chicago Bridewell Prison on a charge of theft. When he came out, he returned to precisely the same locality in which he had been living. I expected him to relapse at once and was amazed that he did not do so. A number of weeks passed. He denied that he felt any great temptation or craving but admitted that he did not intend to practice abstinence
permanently. His state of mind when off the drug appeared markedly worse than during addiction. He was inordinately bored and extremely inert, spending most of his time sleeping. He was no longer interested in reading magazines, and his conversation was unanimated and dull in comparison to the sparkle which bad characterized it before. Later he obtained a temporary job distributing hand bills and, becoming fatigued by the walking he had to do, felt the need of a shot after work. Sometime later, when he had developed minor, though irritating, complaints, he took nembutal hypodermically. Seeing the fresh drops of blood on his bed, I had assumed that be was re-addicted. It was a week or so before be admitted having had a few little shots, and still another week before be announced that he was "hooked" again. He now resumed his alert, active attitude; his indifference, apathy, and dullness were gone, He had found. a, motive for living and was himself again, conniving and stealing as before.
It cannot be assumed in- the case of this addict, who- abstained for only a few weeks, that be bad recovered from the withdrawal of the drug. Erich David, for example, remarks concerning the time element in the treatment of addiction:
As we have seen, after six weeks the patient is generally physically well, but he still feels the lack of stimulation furnished him thus far by morphine. The days seem endless, but be has not yet the energy to busy himself with work. He has not yet regained completely the capacity and desire for work, and just because of that, be will inevitably be seduced to a relapse by the recollection of his former greater capacity and the oppression of his complete lack of energy. That be is not yet mentally fully recovered, we can easily prove by giving him some easy scientific book to read and asking him to give a report on it after a few days. The patient will not yet be capable of doing that. If it is at all possible for him to read the book through intelligently, it will take him weeks and weeks to finish his task.
This lack of stimulation, however, passes after several months, and I am willing to say that after four or five months every withdrawn individual has completely recovered capacity and desire for work. If then assigned the task just mentioned, he will perform it very quickly with utmost satisfaction. This test seems to me the most infallible indication as to whether the time for discharging him has arrived. To retain him any longer in ,in institution, just because it is true that physical alterations with reference to morphine still exist, would be absolutely senseless, since we have seen that the same phenomena are present even after a year. The prognosis is unfortunately very inauspicious. (15)
An addict who read this manuscript expressed the opinion that it was the boredom of abstinence that was hardest to endure. He told of going to baseball games, in which he was normally very interested, and leaving after a few innings. He walked out of movies before they were finished. He could not enjoy life without the drug, so he eventually resumed using it. Another user, who had once abstained for more than ten years, confessed that he had never felt altogether right throughout the period. He used alcohol as a poor substitute for opiates and finally returned to the drug in disgust.
The word "disgust" is one that recurs in the addict's explanations both of why he decides to quit and of why he relapses. When he is on drugs he becomes disgusted with himself, the habit, other users, informers, the police, the public, and so on; when he is voluntarily off drugs he discovers that people are slow to accept him in his new role as an abstainer. This tends to disgust him, as do a great many other aspects of his tentative new identity as a cured addict. These include boredom, lack of motivation, the suspicions attitudes of others, job discrimination, the effects of whiskey and other inferior substitutes for the drug, and lack of communication with former friends.
In a study of relapse and abstinence, Marsh B. Ray quotes an addict's description of how he resumed use:
When I got home I stayed off for two months but my mother was hollering at me all the time and there was this one family in the neighborhood that was always "chopping me up." I wanted to tell this woman off because she talked all right to my face but behind my back she said things like she was afraid I would turn her son on because I was banging around with him. She would tell these things to my mother. I never turned anybody on! She didn't know that but I wanted to tell her. Finally, I just got disgusted because nobody wanted to believe me and I went back on.(16)
[Another user commented pungently]: My relatives were always saying things to me like 'Have you really quit using that drug now?' and things like that. And I knew that they were doing a lot of talking behind my back because when I came around they would stop talking but I overheard them. It used to burn my ass.(17)
The boredom and disgust of the-abstainer may be said to spring from the inability of the ex-user to resume his pre-addiction social identity and role. His experiences as an addict have spoiled his other identity and set up communication blocks between him and those from whom he hopes for support and confirmation of his new role. He recalls, perhaps with some nostalgia, the feverish whirl of activity and excitement that engulfed him when he was on drugs, and be recalls the intimate associations with other addicts and the frank, unfettered talk, especially about everything connected with drugs. By contrast, his life off drugs seems empty and dull, and his personal associations seem unsatisfactory, inhibited, and hypocritical. There is no good easy resolution of this dilemma. The addict is not happy with either of his two possible identities and tends to move from one to the other and back again.
The Influence of Availability and Associations,
Because the addict is generally stigmatized and is often a criminal, be finds it difficult to secure and bold a legitimate job whether he is using drugs or not. If, as in the United States, the user leaves respectable society to join the addict subculture, his associations tend to be heavily or exclusively concentrated within it. It is within this subculture-which includes addicts, drug peddlers, narcotics policemen and informers-that the user learns the folklore of addiction. It is this subculture that makes the drug available to him. His closest associations arc naturally with other users with whom he shares his preoccupation with drugs. Most of his activity and most of his conversations center on the drug habit., which is the organizational basis of the subculture.
When an addict who is part of such a subculture attempts to quit his habit voluntarily, or when be is sent to jail or prison, any attempt that he may make to remain free of the drug is obviously jeopardized if be returns to his old environment and old associates. This, however, is usually what he does because he has no other friends and no other place that he wants to go. Returning to his old haunts, he has no difficulty in finding a supply, and in the process of resuming old associations he strongly tends also to resume his habit. If be has been in prison it is probable that his range of acquaintanceship with addicts, peddlers, and criminals has been broadened, and the probability of his encountering prison acquaintances is increased. Such encounters tempt him to relapse, make the drug available to him, and provide opportunities to make money by illegal means to support his habit.
It is a mistake, however, to think of relapse exclusively in terms of the external cultural, environment. Both the impulse to quit and the impulse to relapse first manifest themselves in the private thoughts of the addict, and both impulses may be translated into action without any direct influence or pressure from others. Thus, an addict whom I interviewed, a former, physician, 'became addicted through medical treatment and for several years was unacquainted with any other addict. During this period he made five attempts to quit and remained free for a year on one occasion. Such instances are fairly common among addicts within the medical profession where the availability of the drug makes it quite possible for a person to use it or stop using it in secrecy and privacy.
The abstainer who wants to relapse often goes out of his way to seek the environment favorable for this project, just as the determined abstainer may deliberately move out of such an environment. This point is illustrated by an addict who was discharged from prison in the spring Of 1937 and went to Chicago with more than a hundred dollars in his pocket. Fearing re-addiction and yet desiring just one shot, he walked the streets for about two weeks looking for some old friend who might help him make the necessary contact. Frustrated on every side, he finally met another addict just released from the same penitentiary. The latter reported the meeting in these words: "He just fell on my neck and asked me for a shot of anything. He said he was sick of booze and blondes and just wanted a shot." From cases such as these it is evident that relapse cannot be explained in terms of the external situation.
An Addict's Rationalizations
The following account of his own experiences by a nineteenth century American drug user is particularly interesting and significant because of the manner in which it exemplifies the addict's rationalization of his addiction and of his relapses, presented in this case with amazing naivete but with obvious sincerity.
Finding then, that a grain of morphine was just the quantity required in my case, I took that amount every day in the evening, while the neuralgia continued, which was for three or four weeks; when this disease left me. Being now free from pain, I ceased taking morphine, as the necessity for it had ceased. This was my first experience with morphine; would to God it bad been my last! And this experience was pleasant, leaving no sting behind. Is it then to be wondered at, that upon my next attack of my hereditary enemy, and in all subsequent attacks, I employed a remedy which had worked so well before, in fact the only remedy I knew for this painful affliction....
But there came a time when matters took a different turn, when my relations with morphine were not of so friendly a nature, and when my reflections became of a more somber hue.... [He tells of becoming ill.] Before I had fully recovered from the effects of the fever, the neuralgia set in, in the chronic form; and I was never free from pain a single day for four months, except when under theinfluence of morphine. In the meantime I had become an inmate of a water-cure, but had not as yet received any benefit from the treatment. At the end of four months the neuralgia suddenly ceased, and 1 immediately laid aside the morphine, as I had done always before on the subsidence of the pain. Although I had been using the drug in moderation, never exceeding a grain to a grain and a half daily, yet having taken it continuously for four months, I found a difficulty in thus suddenly leaving it off which I had never experienced before. I felt as weak as a child, and as though I was failing to pieces. All the secretions of my system, which under the influence of morphine had been locked up, were now poured forth abundantly. Perspiration was profuse. Yet it was a cold and clammy sweat, and I was compelled to go to bed and cover up with blankets in order to keep warm in the middle of a July day. I had a gnawing sensation in my stomach which demanded for its satisfaction mustard, pepper, and other hot and stimulating condiments. And for eight days and nights I never closed an eye in sleep. But in a little over a week the system had fully reacted, and I began to feel pretty comfortable. I had not yet become a confirmed opiumeater, but I bad made a narrow escape. I had been standing on dangerous ground.... The neuralgia returned before I had been free from it a month. Being still at the water-cure, I brought to my aid all the resources of hydropathy. I tried cold baths and warm baths, and a most rigid diet, all to no purpose; and after suffering as none but a neuralgic invalid can stiffer, I again resorted to the old remedy, and the only remedy for this protean malady. It may be that I resumed the use of the drug without proper reflection; but when does a man in severe and agonizing pain ever reflect? Although I suffered, suffered severely, when last I abandoned the use of morphine, still I did not suffer as much from that cause as I was now suffering from neuralgic pain. I thought I was choosing the lesser of two evils....
I now struggled both against the disease and against the remedy. I tried bard not to become an opium-eater. I tried hard to sever the links of the chain rapidly forging about me, links which were every day becoming more adamantine. And at one time, and that within four months of the date of my last resumption, taking advantage of a temporary cessation of pain, I almost succeeded. Yet I did not succeed. After this period my pains increased, calling for increased doses of morphine.
I had now become a conformed opium-eater. I had been taking morphine every day continuously for several months.(18)
He then goes on to describe his relapses after temporary abstinence:
My health had now become pretty well established. But it was for a brief period indeed. About the beginning of July of this year symptoms of my old malady began to make themselves felt. I took every precaution to ward off the attack. I tried all the resources of allopathy, homeopathy, and hydropathy, together with a most rigid regimen; for above all things I did not wish again to become an opium-eater. But what was to be done? Although my condition before when taking morphine habitually was a truly deplorable one, still it was more tolerable than my condition was now, without it.
While using it moderately I could give some attention to business; I had still some enjoyment to life, especially intellectual pursuits, for it seemed to stimulate the intellectual faculties to increased activity.
And barring all considerations of this kind, I was free from pain while under its influence. Now I was wholly incapacitated for business of any kind, and enjoyment was out of the question. I had no pleasure in existence, life was a burden. I fought the enemy long and desperately; I fought him with the energy of despair, until, overcome with suffering, I finally succumbed. Then I took morphine for a single day, making a truce with the enemy, as it were, for that short period, only to renew the battle the day following. Then on the third day I took morphine again. In this way I kept the enemy at bay for several weeks, making it a rule never to take morphine two days in succession, thus giving the system time fully to recover from the effects of one dose before taking another. I thought that in this way I incurred less danger of falling back again into my old habits. But the time came when this rule could no longer be observed, and I took morphine every day, but once a day for a while, and, by the time winter had set in, twice a day, or oftener, as required. Thus in about a year from the time I had gone through the tremendous crisis described a little further back, I was again in the gall of bitterness. Indeed, I had come to that condition in which I cared but little whether I lived or died. I had become, in short, perfectly reckless of consequences....
[Relapse No. 2] It was about six weeks since I had taken the last morphine. My health in the meantime had not improved to that degree which I thought I had a right to expect. I was free from neuralgic pain it was true, but I was still nervous and irritable, and exceedingly uncomfortable in every way. That cold and clammy perspiration still continued. It seemed to be more profuse than it badbeen three weeks before. Other symptoms there were too, whichalong with this, indicated a state of great relaxation of the generalsystem. I saw that tonic remedies were called for, and I took quinine,but without any effect whatever. Mine is one of those constitutionsupon which quinine never seems to have any effect. At length thetime came when I must go to work, though in no fit condition forit. Shorthand reporting is a pursuit requiring in those who practiceit the best condition of physical and mental capacity. The mentalfaculties which it calls into action are put to the utmost stretch, andthe physical health must be such as to give them adequate support.However, the attempt must be made, and I made it. I very soonfound that without assistance from some quarter I could not succeed. What was to be done now? I ventured to take a grain of morphine. The effect was marvelous. I could report, now, verbatim,never losing a word. And I could do any amount of labor at transcribing, the drudgery of the stenographer. I now liked to work, theharder and the more of it the better. The morphine had such a bracing tonic effect! . . . I found myself necessitated to take it everysecond day in order to be able to work, and I was determined notto take it oftener, for I knew that in this way alone could I preservemy freedom. I thought that in the meanwhile, perhaps in two orthree weeks, .1 my system might rally, and so become able to work itself out of its relaxed condition when the morphine could be dispensed with.
Here, and here only do I acknowledge guilt in my dealings with morphine: that is, in taking it merely to remove languor of the system, and brace it up sufficiently to enable me to attend to business, at a time when I was not suffering actual pain. Had I bad my time fully at my own command I would doubtless have acted differently. But I was the victim of circumstances. Work I must, and in my then condition I could not work. Say, ye caviliers, what in like circumstances would you have done? It seemed as though I bad now lost that wholesome fear of morphine which I had once entertained.... So I played with morphine as a child plays with fire.
Instead of any improvement taking place in my physical condition, such as I had hoped for, matters only grew worse, and to add to my other difficulties, neuralgic troubles began again to make their appearance about this time. It was not long, under this new condition of affairs, before I found m self compelled to take morphine every day, then twice a day, and also to increase the dose.(19)
A later relapse is described as follows:
I bore my suffering as well as I could until the end of the fourth day, and then I had to yield. . . . And in all subsequent trials that I made, I could never hold out against these gastric symptoms beyond the fourth day.(20)
In the initial conditioning experience, repeated hundreds of times as the drug is used to relieve or avoid withdrawal, the patterns of addiction behavior are fixed. These include the user's realization that be is trapped and has become an addict-a new and traumatic self-conception that stimulates rebellion and struggle against the grip of a powerful compulsion. The craving for drugs, generated initially by the threat and the experience of withdrawal, may be conceived as a basically irrational and subliminal impulse or tendency that is left as a deposit or residuum from thousands of shots. When the user is taken off drugs, this basic craving, which has become symbolically elaborated in the user's psychological make-up, persists as a cortical or conceptual complex independent of the various chemical and physiological conditions that are indispensable in its origins. As such, it predisposes the person who has been hooked and is abstaining to resume use of the drug.
Because the craving is an irrational impulse it impels the person to do things that reason tells him be should not do and causes him to be dissatisfied both with being an addict and with being an abstainer and to switch from one status to the other and back again in a recurring cycle.
This chapter has been concerned with identifying and describing bow the basic drive toward the drug works, behind the scenes one may say, to push or seduce the abstaining addict back to his habit Among the most important of these influences are: the changed perceptions of the addict which lead him to respond to virtually all distress as though it were withdrawal distress to be banished by a fix; the neutralization of memories of the miseries of addiction which are relatively remote consequences of taking a shot compared to the invariable satisfactory immediate ones;, the rationalizations of the abstainer that life without the drug is dull, that he is better off using it than not, and that he might as well use it because he is stigmatized anyway; the knowledge or beliefs acquired from direct personal experience of the marvelous potency and versatility of the drug; and, finally, the attraction exercised by associations within the drug using subculture, which, with a few exceptions, provides the only social setting in which full and free communication on all matters associated with the habit is possible without risk to the ego.
1. H. H. Kane, Opium Smoking in America and China (New York: G. P. Putnam, 1882), P. 59.
2. C. Edouard Sandoz, "Report on Morpbinism to the Municipal Court of Boston,"Journal of Criminal Law and Criminology (1922) 53: 38.
3. "Report of Committee on Drug Addiction to Commissioner of Correction, New York City,"American Journal of Psychiatry (1930-31), 10: 471.
4. H. H. Kane, Op. cit., pp- 73-74.
5. Dr. Wilder D. Bancroft, for example, declares, "Nothing will keep a man from taking morphine again if he wishes to.... I doubt whether much can be done in the way of permanent cure for the criminal addict. I am interested in the man who really wants to be cured" (unpublished paper, "The Chemical Treatment of Drug Addicts," presented at the fifth annual conference of the committees of the World Narcotics Defense Association and the International Narcotic Education Association, in New York, 1932). See also the writings of Lawrence Kolb. This invidious distinction between socalled criminal and noncriminal addicts simply discriminates against the impoverished addict. In this country, be is ipso facto a criminal.
6. "Report of the Committee on Drug Addiction to Commissioner of Correction, New York City," op. cit., PP. 532-33.
7. T. D. Crothers states: "Not infrequently the question comes up as to the advisability of treating elderly morphinists and opium users who seem not to be greatly injured by the use of the drug. Often such persons who have long been addicted . . . become very anxious to break away from its influence. The prognosis is usually unfavorable and the treatment unsatisfactory"(Morphinism and Narcomanias from Other Drugs [Philadelphia: W. B. Saunders, 19021, P. 149).
8. It is significant that Dansauer and Rieth cite this desire to quit as evidence that in a number of their cases of habituation the subject bad begun to develop a "craving" for the drug, that is, was becoming an addict ("Ueber Morphinismus bei Kriegsbeshadigten," Arbeit und Gesundheit: Schriftenreihe zum Reichsarbeitsblatt ( 1931) 18: 92--93, case 28; P. 95, case 459; and pp. 96-97, case 616).
9. Jean Cocteau,Opium: the Diary of an Addict, translated 1)), Ernest Boyd (New York: Longmans, Green, 1932), pp. 55-56.
10. This is a fairly frequent cause of relapse. After he has been drunk for a while, the addict usually decides that "it's better to be a junkie than a drunkard," or be decides to have a shot to "get straightened out."
11. Chicago: University of Chicago Press, 1937.
12. Charles Schultz in "Reportof Committee on Drug Addiction to Commissionerof Correction, New York City,"American Journal of Psychiatry (1930-31), 10: 519.
13. "An Experience withOpium," Popular Science Monthly (1885), 27: 339
14. Alonzo Calkins,Opium and the Opium Appetite (Philadelphia: J. B. Lippincott, 1871), pp. 135-36.
15. Quoted by CharlesE. Terry and Mildred Pellens,The Opium Problem (New York: Committee on Drug Addictions and Bureau of Social Hygiene, 1928), P. 594. David's conclusion concerning the length of time necessary for all traces of withdrawal distress to disappear are substantially the same as those reached by researchers at the Public Health Service Hospital in Lexington, Kentucky.
16. Marsh B. Ray, "The Cycleof Abstinence and Relapse among Heroin Addicts," in Howard Becker (Ed.),The Other Side: Perspectives on Deviance (New York: Free Press,1964), P. 172.
17. Ibid., p. 173.
18. James C. Layard, "Morphine," Atlantic Monthly (1874), 33: 68-99.
19. Ibid., PP. 700-7o6.
20. Ibid., P. 707.