Concepts of Addiction The US Experience

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Addiction has remained a vague concept in spite of efforts to define it with physiological and psychological precision. The word's Latin root refers to a legal judgment whereby a person is given over to the control of another. In recent centuries the meaning has ranged from a simple inclination toward an activity or interest to an uncontrollable desire to take opium, which historically was viewed as the most addictive of drugs. Opiate addiction is characterized chiefly by the repeated use of the drug to prevent withdrawal symptoms, which include muscle and joint pains, sweating, and nausea. The extreme discomfort of withdrawal passes away after one to three days, although a yearning for the drug may last for a very long time. Some attempts to define addiction in medical terms (e.g., restricting it to opiate withdrawal phenomena) have led to confusion among members of the public because cocaine, according to that restricted definition, would be considered nonad-dictive and, by implication, safer than the opiates.

For the sake of brevity, this essay considers chiefly opium and coca and their constituents and derivatives. The chemicals that could be discussed range from the barbiturates to lysergic acid diethylamide (LSD), but the models of control and therapy commonly applied to these other substances evolved in the past two centuries from experience with the coca bush, opium poppies, and their powerful alkaloids.


The opium poppy appears to be indigenous to the eastern Mediterranean area. The manner of producing crude opium is to scratch the surface of the poppy pod and scrape off the juice that exudes, collecting and drying the material until it is solid. This crude opium can be taken alone or in combination with other substances. Mithradatum, theriac, and philon-ium are three ancient and renowned medicines that contained opium, among other substances, when compounded during the early centuries of the Roman Empire, although in subsequent eras opium was not invariably a constituent.

The smoking of opium, so closely associated with China in the nineteenth and early twentieth centuries, appears to have been introduced to the Chinese in the seventeenth century by Dutch traders who had earlier supplied tobacco for smoking. The Chinese government attempted to outlaw the practice as early as 1729, but through much of the nineteenth century, as supplies came from the region of Turkey and Persia and later mostly from India, the attraction of smoking opium grew. The attempts of some Chinese administrators to cut off foreign opium importation were frustrated by the defeat of China in the so-called Opium War of 1839-42. Near the close of the century, young reformers blamed widespread addiction to opium and consequent lethargy and inefficiency for China's defeat by Japan in 1895. In response to a growing antagonism to opium use, the dowager empress Tzu Hsi instituted a program to eliminate domestic opium production and to seek a reduction in the importation of opium from India. This action was one of three crucial events in 1906 that led to a worldwide effort to control the production and distribution of opium and the opiates.

The second event was the Liberal Party's victory in the British parliamentary elections. The Liberal Party had long taken a stand against sending opium from India to China against the will of the Chinese people and government, although treaty rights to do so had been established by the British military. Complicity in facilitating Chinese addiction to opium deeply offended many Britons, especially those who promoted Christian missionary efforts in China. Previous British governments had argued that opium was not particularly harmful, being the equivalent of distilled spirits among Westerners, and that the opium trade was needed to pay for the British administration in India. After 1906, however, cooperation between the British and Chinese governments in curbing opium production was theoretically possible.

The third major antiopium event of 1906 was the U.S. decision to convene the Shanghai Opium Commission, a decision that reached fruition in.1909, as is discussed in the section on the origin of international control.

Morphine and the Hypodermic Syringe

The isolation of morphine from opium by F. W. A. Sertuener in 1805 marked the beginning of a new era in opium use. Physicians now had access to a purified active ingredient; hence, they were no longer uncertain of the strength of a dose and could investigate the effect of a specific amount. Commercial production followed the isolation of morphine and by the 1830s morphine was commonly available in any area touched by pharmaceutical trade with Europe and the United States. Morphine was administered by mouth, clysis, or absorption through denuded skin, as after blistering. The refinement of the hypodermic syringe and needle at midcentury created a mode of delivery as revolutionary in the history of addiction as had been the isolation of morphine.

Hollow needles and syringes had been employed long before the appearance of the familiar syringe and needle in the nineteenth century, but the growing number of purified chemicals, such as morphine, that could be directly injected into the body stimulated the pace of development and production. At first, injected morphine was considered less likely to be addictive than oral morphine because a smaller amount was required for equivalent pain relief. But by the 1870s this assumption was found to be erroneous, although many physicians continued to use injected morphine for chronic ailments, such as arthritis.


In most European nations, the central government controlled the practice of medicine and the availability of dangerous drugs through legislation. In addition, by the mid-nineteenth century, European physicians and pharmacists had organized themselves on a national level. By contrast, in the United States the federal government relegated to the individual states control over the health professions, and the professions themselves were poorly organized nationally. No laws controlled the sale of, contents of, or claims for "patent medicines," and there were few local laws restricting the availability of opium, morphine, and, later, cocaine. The result was a thriving and open market in these substances until late in the century, when some states began to enact laws preventing the acquisition of opiates and cocaine except with a physician's prescription. The U.S. Constitution grants the regulation of commerce among the states to the federal government, so no state law could affect the sale of drugs or products across state lines. The consequence was a higher per capita consumption of opium and opiates in the United States than in other Western nations and even, a government official claimed in 1910, more than the legendary consumption of opium in China.

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. But as drugs were increasingly used to treat illnesses it was also understood that an individual could inadvertently become addicted to them - an understanding that has helped to give rise to the biological concept of addiction as an illness.

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 addict was considered to be ingenious in obtaining drugs and to have a will so weakened by addiction and craving for opium that, unless he or she was securely confined, withdrawal would not be successful. It could be assisted by the administration of belladonna-like drugs that counteracted withdrawal symptoms such as sweating. These drugs also caused delirium, which, it was hoped, would have the effect of erasing the addict's memory of the withdrawal. (Scopalamine is given today just before general anesthesia for a similar reason.) The high rate of relapse in the weeks after treatment brought into question the value of detoxification.

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. Grad ual 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. If the level of morphine dropped below that required to "balance" the antibodies, the antibodies would produce withdrawal symptoms. Thus, unless the antibodies and every vestige of morphine could be removed from the individual, maintenance would be required to create a normal physiological balance.

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 reputa tion 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. During the latter part of the therapy a formula, chiefly belladonna and hyoscine, which presumably counteracted the symptoms of withdrawal, was given at half-hour intervals. In the early years of this treatment, prominent physicians such as Richard C. Cabot of Boston allowed their names to be closely associated with that of Towns. In the years immediately after World War I, however, Lambert rejected the treatment as worthless and adopted the position then becoming popular that there was no specific treatment for addiction. Towns, by contrast, continued to operate his hospital in New York, applying the same treatment to alcohol addiction. "Bill W." received the inspiration to found Alcoholics Anonymous while undergoing treatment at the Towns Hospital in 1934.

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.


Cocaine, a central nervous system stimulant, offers a contrast to the opiates, although both have been subject to extreme praise and condemnation. Coca bushes are native to South America, and the leaves have been chewed there for millennia. The amount of cocaine extracted by chewing was increased by the addition of an alkaline substance to the wad of leaves, but the tissue level of cocaine obtained in this way was small compared with that obtained from the purified alkaloid cocaine, identified and named by Albert Niemann in 1860. Cocaine was not commercially available until the early 1880s. Before it was introduced to the market, extracts of coca leaves, often in a wine solution such as Vin Marianni, found favor as a tonic both with physicians and with the public.

Pure cocaine proved extraordinarily popular. Within a year of its introduction in the United States in 1884, Parke, Davis & Co. offered cocaine and coca in 14 forms. Cocaine was expensive, but soon became an ingredient in the new drink Coca-Cola and was found to be a specific remedy for hay fever and sinusitis. Within a few years, reports appeared in medical journals and the popular press telling of ruined careers and bizarre behavior among some users, but eminent experts such as William A. Hammond, a professor of neurology in New York medical schools and a former surgeon-general of the U.S. army, reassured the profession and the public that cocaine was harmless and the habit no more severe than that of drinking coffee.

Within 10 years, however, observers raised serious doubts that cocaine was as safe as had been asserted by Hammond and by cocaine's chief advocate in Europe, Sigmund Freud. By the first decade of the twentieth century, cocaine was no longer considered an ideal tonic but an extremely dangerous substance. In the United States, this new image, now associated with uncontrolled consumption, violence, and distorted thinking, provided powerful impetus to establish a national antinarcotic law, despite constitutional restrictions. In most other nations cocaine production and distribution was already regulated by national pharmacy laws. Through a complex series of events, the United States placed a national prohibition on narcotics use except for medical purposes and initiated an international campaign to control the production and distribution of opiates and cocaine.

The U.S. Response to Addiction

The per capita consumption of narcotics in the United States was officially described in the late nineteenth century as much higher than that of any comparable Western nation, perhaps even that of China. This may well have been the case, but reliable comparisons are often difficult to make, partly because drug use and addiction have been topics relatively neglected by historians.

Concern in the United States over opiate addiction and the rise in consumption, which reached a peak in the 1890s, led to state laws that in most instances made morphine available only by a physician's prescription, although there was no restriction on interstate commerce. Cocaine use increasingly worried the public, who associated it with the underworld and assumed that its use by blacks was a cause of unrest among them in the South. The latter association exemplifies the linkages so easily made by the public between drugs and social problems.

Some of the unusual factors associated with extensive narcotics use in the United States (i.e., late professionalization of medicine, an open drug market, and constitutional restrictions on national legislation) began to change in the late nineteenth century. A domestic movement to control dangerous drugs, especially patent medicines, led to passage of the Pure Food and Drug Act of 1906, which required accurate labeling of the narcotic contents of products sold in interstate commerce. The acquisition of the Philippine Islands in 1898 and the necessity of dealing with the opium problem there spurred the most important decision making on narcotics by the federal government. The Philippine experience not only accelerated the passage of national laws but, of broader significance, led directly to a U.S.-inspired treaty to control narcotics worldwide, as well as to the international antiaddiction effort that persists to this day.

Origin of International Control

Under Spanish rule, there had been an opium monopoly in the Philippines from which opium smokers could obtain supplies. The newly arrived U.S. government decided to reinstitute the monopoly and use the profits to help support universal education there. However, U.S. missionary and political leaders strongly rejected the proposal. The impasse led to the creation of an investigating committee appointed by the Philippine government that included Charles Henry Brent, Protestant Episcopal bishop of the Philippines, who would become the key figure in establishing an international campaign against narcotics. The committee examined control measures used in other areas of the Orient and recommended a gradual reduction approach for opium users in the

Philippine Islands. The U.S. Congress took a more severe stance, mandating total prohibition of opium and derivatives, except for medical purposes, for Filipinos in 1905 and all other groups (mainly Chinese) in the Islands in 1908.

It was obvious to the U.S. government that its meager enforcement could not prevent the smuggling of opium into the Philippines. Conflict with China over the treatment of Chinese aliens in the United States along with the crucial events of 1906 in China and the United Kingdom provided Bishop Brent with a rare opportunity. He wrote President Theodore Roosevelt urging that the United States convene a meeting of relevant nations to assist China with its antiopium crusade. Successful control of narcotics traffic would aid the Philippines and the United States, and might also placate China. The acceptance of Brent's idea resulted in a survey of the U.S. domestic drug problem and the convening of the International Opium Commission at Shanghai in February 1909. Brent was chosen to preside over the 13 nations that gathered there. The commission's rather noncontroversial resolutions were used by the United States to convene the International Opium Conference, a treaty-making body, at the Hague in December 1911. The dozen nations represented at the conference, again chaired by Brent, adopted an International Opium Convention in January 1912. This treaty also included provisions for the control of cocaine. Control would be enforced primarily through the domestic legislation of several nations: However, the treaty would not come into force until every nation on earth had ratified. This difficult requirement arose out of the fear of some producing and manufacturing nations that, without universal adoption, the nonadhering nations would be able to dominate a lucrative market.

At a conference in June 1914, it was decided that any nation ratifying the treaty could put it into effect without waiting for unanimity. The United States chose to do so, and enacted the Harrison Narcotic Act in December 1914. World War I slowed ratification, but when the fighting ended, several of the victorious nations, including the United Kingdom and the United States, added the Hague Convention to the Versailles Treaty, mandating that ratification of the Peace Treaty include the Opium Convention. It was as a result of this requirement, and not of any domestic drug crisis, that the United Kingdom enacted the Dangerous Drugs Act of 1920. In later decades, especially in the United States, the origins of this act were forgotten, and the provision of opiates to some addicts allowed under the act was claimed to have solved a serious addiction problem in the United Kingdom. This is an example, common in the area of drug policy, of trying to base solutions to an addiction problem on the laws or practices of another nation without taking into consideration differences in history and culture.

The Establishment of an International Bureaucracy

The League of Nations assumed responsibility for the Hague Convention in 1920. In 1924 the First Geneva Opium Conference addressed the gradual suppression of opium smoking. This was soon followed by the Second Geneva Opium Conference, which expanded international control over drugs by establishing a system of import and export certificates, creating the Permanent Central Opium Board (PCOB) to oversee the new provisions, and adding coca leaves and cannabis to the list of controlled substances. The United States, because it did not recognize the League, relinquished leadership of the international movement, and went so far as to walk out of the Second Geneva Opium Conference because, in its view, the other nations were unwilling to take meaningful steps to curb opium production and refused to ban the manufacture of diacetyl-morphine, more commonly known by its generic name, heroin. Heroin had been introduced by the Bayer Company in 1898 as a cough suppressant and within two decades had replaced morphine as the drug of choice among youth gangs in New York City. Heroin had an advantage over morphine in that it could be sniffed as well as injected and became the most feared of the opiates in the United States. In 1924 the United States banned domestic production of heroin.

In 1931 a conference was held in Geneva on limiting the manufacture of narcotic drugs, and in 1936 another Geneva conference dealt with suppressing the illicit traffic in dangerous drugs. After World War II the United Nations accepted responsibility for narcotics control, and in 1961 the various treaties were combined into the Single Convention on Narcotics. A significant addition to the older treaties was the prohibition of cannabis production.

The United Nations placed drug control under the Economic and Social Council (ECOSOC). The UN Commission on Narcotic Drugs meets annually to review the drug problem and make recommendations on policy to ECOSOC. The commission is the successor to the League's Advisory Committee on Traffic in Opium and Other Dangerous Drugs (1921-40). Also under ECOSOC is the International Narcotic Control

Board (INCB), which oversees the ongoing functioning of treaty obligations and provides technical assistance in the form of statistics and chemical analyses. INCB, established by the Single Convention, succeeds the League's PCOB (1929-67) and the Drug Supervisory Board (1933-67).

The appearance in the 1960s of problems with newer drugs, such as LSD, barbiturates, amphetamines, and tranquilizers, prompted a new treaty, the Convention on Psychotropic Drugs (1971), which aims to expand international supervision beyond the traditional substances linked to opium, coca, and cannabis. In 1988 a convention intended to improve criminal sanctions against international traffickers was submitted to members of the United Nations for ratification.

Recent Responses to Drug Use

Research into the mechanisms of drug addiction and dependence has greatly increased in the past quarter-century. In the nineteenth century, research centered on modes of delivery, the development of the hypodermic syringe, and the nature of opiate addiction. The pattern of withdrawal was described and treatment for opiate addiction sought. Cocaine was offered, for example, as a cure for morphinism and alcoholism. Other cures were drawn from popular medical theories of the time, autointoxication, and other aspects of immunological response.

Confidence in treatment was equaled only by enthusiasm for research, until after World War I when, especially in the United States, a powerful reaction against drug use caused both professionals and the public to reject current treatments — which, in fact, were of little value - and to lose interest in research. The battle against drug abuse came to rely primarily on law enforcement. Research again found support in the late 1960s and the 1970s when consumption rose and there was a certain toleration of "recreational" or "experimental" drug use among youth. However, as fear of drugs and drug users increased, the public grew impatient with treatment and toleration of any drug use and, again, funding for research fell. In recent decades, significant advances have included the discovery of opiate receptor sites in the brain, of the existence of naturally produced opiates, endorphins, and of the existence of chemicals that block opiate receptor sites. Specific treatment for cocaine dependence has eluded investigators.

On an international level, attempts have been made to interdict drugs coming from producing areas; persuade local growers of poppies, coca bushes, and marijuana to grow other crops; arrest local dealers; and spray illicit crops with herbicides. Crop substitution as an international policy dates to the 1920s, when the League of Nations sought to persuade opium growers in Persia to grow other crops, and continues today in major opium-producing areas, such as the "Golden Triangle" in northern Burma. This scheme has not yet cut into the world supply of opium and coca and, of course, is irrelevant to the control of manufactured drugs such as synthetic opiates and stimulants like amphetamine. Spraying the crops of producing nations and other policies advocated by consuming nations raise sensitive questions of sovereignty. Furthermore, producing nations claim, as they did during the first U.S. campaign to control production before World War I, that the problem is not production but the consuming nations' demand for drugs.

In its worldwide campaign against addiction, the United States early in this century asserted that the use of narcotics for anything other than strictly medical treatment was dangerous and morally wrong. This attitude represented the thinking of most North Americans at the time, but it was not a universal view and is not a view always held by the United States. The vicissitudes of moral attitude toward addiction over the past two centuries illustrate that the response to addiction is intimately bound to the social history and mores of a nation or region at any given time. The history of addiction has a medical element, but it is also a reflection of nations' characteristic approaches to individual and social problems. Integration of the history of addictive substances with the social history of nations and regions remains a fertile area for research.

David F. Musto


Bonnie, Richard J., and Charles H. Whitebread II. 1974. The marihuana conviction: A history of marihuana prohibition in the United States. Charlottesville, Va. Clark, Norman H. 1976. Deliver us from evil: An interpretation of American prohibition. New York. Courtwright, David T. 1982. Dark paradise: Opiate addiction in America before 1940. Cambridge, Mass. Lowes, Peter D. 1966. The genesis of international narcotics control. Geneva. Morgan, H. Wayne. 1981. Drugs in America: A social history, 1800-1980. Syracuse, N.Y. Musto, David F. 1987. The American disease: Origins of narcotic control. New York. Parssinen, Terry M., and Karen Kerner. 1980. Development of the disease model of drug addiction in Britain, 1870-1926. Medical History 24: 275-96.

Taylor, Arnold H. 1969. American diplomacy and the narcotics traffic, 1900-1939. Durham, N.C. Terry, Charles E., and Mildred Pellens. 1928. The opium problem. New York.

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