Addiction and Its Treatment

The model of addiction to opium and opiates is the one to which addiction to other substances has been compared. Such addiction has long been viewed in moral terms, with the addict seen as “vicious” or “degenerate,” driven by a “sinful” desire for plea­sure.

The investigation of addiction has experienced a decided shift over the past two centuries or so from the moral view of addiction as “sin” to the biological concept of addiction as disease, prompting some to argue that the “disease” in question was invented rather than discovered. Yet as more and more have adopted the view of addiction as a disease, the ques­tion of susceptibility has arisen, with biologists oscil­lating between the conviction that everyone is equally susceptible and the belief that only some are susceptible for psychological as well as physiological reasons.

Such ambivalence can also be found in legal sys­tems that attempt to distinguish between morally “superior” and morally “inferior” addicts and in the medical profession, where physicians for a century have tried to find among their patients signs that would warn of addictive liability. These questions are still relevant to contemporary addiction research.

During the nineteenth century, once opiate addic­tion became familiar to physicians, a debate ensued over whether the continuous use of opium was a habit or a disease over which the patient had little control. The debate was complicated by a belief that abrupt withdrawal from opium could cause death. Three options were proposed and vigorously de­fended. The first was abrupt withdrawal, recom­mended almost exclusively as a hospital procedure.

The second option was gradual withdrawal, recom­mended because of the presumed ease of the treat­ment as well as the fear that sudden termination of the opiate would result in death. The idea that abrupt withdrawal could cause death was not widely refuted in the United States until about 1920. Grad­ual withdrawal was a technique that favored outpa­tient care and self-treatment by over-the-counter ad­diction “cures.” Critics of this method argued that many addicts could lower their opiate intake only to a certain level below which they could not comfort­ably descend. An example of this threshold is the case of William Steward Halsted, a physician at Johns Hopkins Medical School who had to take a daily amount of morphine, about two to three grains, for the last 30 years of his life.

Halsted’s experience suggests the third option, in­definite opiate maintenance. Of course, the strong, and for some the invincible, hold that opiates had over a user is what led to popular and professional fear of narcotics. Perpetuating addiction was the opposite of curing it, and initially the reason for doing it was simply the difficulty of stopping. Early in the twentieth century, however, scientific reasons for maintenance were advanced. Influenced by the rise of immunology, some researchers theorized that the body produced antibodies to morphine.

Research produced no evidence of antibodies to morphine, but a less specific claim found adherents around the time of World War I. The hypothesis was that continued exposure to a substance like mor­phine caused a pathological change in the body’s physiology that could not be altered by any known treatment, but required indefinite maintenance for normal functioning. This hypothesis was rejected in the antiaddiction fervor just after World War I in the United States, although it was revived by Vincent Dole and Marie Nyswander in the 1960s as a justifi­cation for maintenance by methadone, a synthetic, long-acting opiate.

A treatment for addiction that found wide accep­tance in the first two decades of the twentieth cen­tury, especially in the United States, was described by Charles B. Towns, the lay proprietor of a hospital for drug and alcohol abusers, and Alexander Lam­bert, a respected professor of medicine at Cornell Medical School and later president of the American Medical Association. An insurance salesman and stockbroker, Towns purchased from an anonymous person a general treatment for addictions. Lambert became convinced of the treatment’s efficacy, and he and Towns published it jointly in the Journal of the American Medical Association in 1909. The reputa­tion of the Towns-Lambert treatment can be gauged by the fact that the U.S. delegation attempted to persuade the Shanghai Opium Commission to ap­prove the treatment formally. The commission de­clined to do so.

The treatment, which combined various medical theories of the time, was based on the belief that morphine or other addicting substances had to be eradicated from the body. Therefore, a powerful mercury-containing laxative, called “blue mass,” was administered several times, culminating in the passing of a characteristic stool that brought a pro­found sense of comfort.

In subsequent years, the treatment of opiate addic­tion has focused on achieving abstinence following detoxification, or maintenance using heroin, mor­phine, or methadone. Even when abstinence is achieved, however, relapses are common. In the 1970s pharmacological research led to the develop­ment of naltrexone, which blocks the effects of opi­ates, and several new drugs, most prominently clonidine, that lessen the discomfort of withdrawal.

The popularity of treatment and the growing em­phasis on law enforcement to curb supply and pun­ish users reflect social attitudes toward drug use. These attitudes have, in the course of a long span of drug consumption, evolved from toleration of use during the decades immediately following the intro­duction of new substances, such as cocaine, to ex­treme hostility toward drugs and drug users as the “epidemic” wears on. In the United States, medical and therapeutic approaches initially found favor but have since given way to law enforcement in response to the public’s belated fearful reaction to the effect of drugs on individuals and society. Some countries, such as Indonesia, employ the death penalty against drug suppliers, whereas others rely on less stringent controls.