83 Depressants from opium in 1803 by a German pharmacist — an event that marked the beginning of the modern era of drug treatment, because it was the first time that an active principle was extracted from a drug plant. Morphine is prepared as a soluble white powder that can be mixed with water and injected into the body. Given by injection, it is a far more powerful and dangerous drug than when taken by mouth. Injection of drugs is relatively recent, dating back only to the invention of the hypodermic syringe in 1853. Interestingly enough, the world's first morphine addict was the wife of the man who came up with that device.
Codeine (methylmorphine) is another natural constituent of opium. More active by mouth than other narcotics, it is a weaker pain reliever than morphine, and doctors frequently prescribe it today to treat for moderate pain.
In the late 1800s, chemists began to experiment with variations on molecules of morphine and other compounds of opium. One of the drugs they produced was heroin, a simple derivative of morphine first made available in 1898. Heroin (diacetylmorphine) is more potent than morphine — that is, it produces the same effect in smaller doses — but otherwise the two are very similar. In fact, heroin is promptly converted back into morphine in the body.
Drugs derived from morphine and other opium compounds are called opiates. Today, many hundreds of opiates are known; some are semisynthetic derivatives, like heroin, and others are purely synthetic, like Demerol. In general, all of the opiates produce similar effects. They differ from each other in potency, in duration of action, in how active they are by mouth, and in how much mood change they cause relative to their physical effects. Opiates that are more potent, shorter-acting, and more active by injection lend themselves more easily to abuse.
The main effects of opium and its derivatives are on the brain and the bowel. In the brain, these drugs cause relief of pain, suppression of the cough center and stimulation of the vomiting center, relaxation, and drowsiness. They may also cause mental clouding and inability to concentrate. Although they may induce sleep, they do not do so as reliably as the sedative-hypnotics. Some people become anxious, restless, and wakeful after taking opiates; others fall into a kind of twilight sleep marked by vivid dreams. Opium and opiates cause the pupils of the eyes to contract, sometimes to tiny pinpoints; they also cause nausea and sweating, which can be profuse and uncomfortable. Larger doses often produce vomiting and depression of breathing. High doses of opiates, especially by injection, can causc death by stopping respiration, just like other strong depressants.
Heroin enjoyed brief popularity as a cough suppressant immediately after its invention. This advertisement appeared in a 1903 medical journal. (© 1903 by the New York Times Company. Reprinted by permission
Laudanum gave me repose, not sleep; but you, I believe, know how divine that repose is, what a spot of enchantment, a green spot of fountains and flowers and trees in the very heart of a waste of sands!
— Samuel Taylor Coleridge (1772-1834), from a 1798 letter to George Coleridge
Samuel Taylor Coleridge. (Painting by R. Hancock. Courtesy of the National Portrait Gallery, London)
Because narcotics paralyze intestinal muscles, doctors prescribe them to treat diarrhea, particularly when it is accompanied by painful cramps. Regular use commonly results in chronic constipation.
In medicine today, narcotics are the main drugs used to treat severe pain. They are also prescribed to control bad coughs. In proper doses, when they are really needed, opiates are safe and extremely effective. Anyone who has experienced the rapid relief of terrible pain by narcotics knows what blessings they can be. By allowing sick and injured people to take their minds off pain, to feel better, to relax and rest, they can also indirectly promote healing. Opium and its derivatives have earned a secure place in treatment over many years of medical experience.
Yet narcotics have generated more fear and argument than any other class of drugs. The reason, of course, is their potential to cause addiction, a problem that was probably recognized even by ancient peoples when the only form available was crude opium from poppies.
Narcotics addiction provides the classic model of drug dependence, and many of our current notions of drug abuse are based on it. For example, the fundamental principle that addiction consists of three features — craving for the drug, tolerance, and withdrawal — developed from observations of opiate addicts. Many popular beliefs about narcotics are untrue, however, and the whole subject is highly contaminated by prejudice and emotion.
There is no question that dependence on narcotics, with physical components, can develop quickly with repeated administration. When medical patients receive morphine by injection every four hours, some degree of dependence can occur in as few as twenty-four hours. If the drug is stopped even after a short period of use, mild withdrawal symptoms may occur — including sweating, nausea, weakness, headache, restlessness, and increased sensitivity to pain.
Tolerance to narcotics also develops rapidly and can reach striking levels. The usual pain-relieving dose of tincture of opium (laudanum) is twenty drops in a glass of water, repeated every four to six hours if necessary. In England in the early 1800s, a number of writers and artists were laudanum addicts with phenomenal habits. The poet Samuel Taylor Coleridge, for example, consumed as much as two quarts of laudanum a week. Thomas De Quincey, best known for his Confessions of an English Opium Eater, took up to eight thousand drops a day. Such doses would certainly kill nontolerant persons.
There is an important difference between tolerance to narcotics and tolerance to sedative-hypnotics. As noted earlier, toler-
85 Depressants ance to the active dose of some sedative-hypnotics develops more rapidly than does tolerance to the lethal dose, a process that can — and does — result in fatal accidents. This is not the case with narcotics, however, which makes them safer drugs. Heroin addicts occasionally die of overdoses, but such deaths result from poor quality control in street supplies of the drugs, rather than from the properties of heroin itself. *
Withdrawal from narcotics is also less hazardous than withdrawal from sedative-hypnotics. Alcohol, downers, and the minor tranquilizers can produce violent withdrawal, marked by convulsions and, sometimes, death. Narcotic withdrawal can be intensely unpleasant, but it is not life-threatening.
Also, the physical consequences of long-term narcotics use are minor compared to those of alcohol. People can take opium and opiates every day for years and remain in good health, provided they keep up good habits of hygiene and nutrition. There are many documented cases of opium and morphine addicts who, despite lifelong, heavy habits, survived to ripe old ages, remaining healthy to the end. Thomas De Quincey, for instance, who started taking laudanum for a toothache as a college student, died at seventy-four, still an addict. The worst medical effect of regular opiate use is severe and chronic constipation, which can be distressing, but hardly compares to the cirrhosis of the liver, and degeneration of the nervous system so commonly seen in chronic alcoholics.
Some addicts even claim that opiates help them to resist disease. Many heroin users say they don't get colds or other respiratory infections as long as they take their drug. Since the symptoms of heroin withdrawal resemble those of a respiratory flu, it is possible that the drug somehow suppresses this kind of reaction. No one has investigated this claim of addicts; it would make an interesting subject of research.
The strong craving that characterizes opiate addiction has inspired many critics of the drugs to suggest that narcotics destroy the will and moral sense, turning normal people into fiends and degenerates. Actually, cravings for opiates are no different from cravings for alcohol among alcoholics, and they are less strong than cravings for cigarettes, a more addictive drug.
The antisocial behavior of some opiate addicts seems more a function of personality, cultural background, expectation, and setting than of the drugs. Medical patients who become addicted to morphine in hospital settings usually do not conform to stereo-
Thomas De Quincey (1785-1859), the Victorian writer, author of Confessions of an English Opium Eater. (Fitz Hugh Ludlow Memorial Library)
'For example, an addict used to a certain dose of impure street heroin may buy a packet of the drug that, by accident, hasn't been cut as much as usual; injecting what he thinks is the right dose, he can unwittingly take too much.
types of addicts. They often have little difficulty separating themselves from narcotics once they are better and leave the hospital setting. People who can afford to support opiate habits legally often lead normal lives while also being addicts. There are numerous cases on record of doctors and nurses who were opiate addicts, yet seemed outwardly normal, and fulfilled their professional and social responsibilities.
Apparently, a crucial difference exists between people who become addicted by chance or through medical circumstance, and those who seek out opiates as a means of dealing with life's
--everyday difficulties. As with other depressants, serious depend-
. . . . 1*1 .-v.. ^t ence is most likely to develop when people use the drugs to screen
ljfe out feelings or anxiety, depression, or boredom. Narcotics may be
William S Burroughs, from his particularly seductive because they insulate people from discom-novcl funky (1953) fort and pain, seem to make time pass more rapidly, and create an
- inner world of security and comfort into which users can retreat, temporarily, from reality and its demands.
In today's world, heroin addiction has reached epidemic proportions. It swallows up many people, especially the young, in unproductive lives of great hardship and cost to themselves and society, and is rightly a cause for serious concern. It is not only the downtrodden poor of urban ghettos who become heroin addicts, but the children of all social and economic classes and many of their parents as well.
When ordinary people look at heroin addicts, what they mostly see are victims of grinding social forces. Visible addicts tend to be in trouble, involved with crime, in poor health, purposeless, psychologically damaged, unhappy, and unable to get out of their grim predicaments. Many of these conditions are due more to society's blunders in trying to control the abuse of drugs than to heroin itself.
Heroin is often portrayed as the very worst of all possible drugs, a "devil drug," always productive of evil and somehow especially dangerous. In reality it isn't very different from morphine, an accepted medical drug. Heroin is strictly illegal in the United States,- even doctors cannot obtain it to use on patients. It is legal in England, however, where doctors do use it, sometimes with good results. Because it is more potent than morphine, it is sometimes a better pain reliever in small doses for people who are too sensitive to the nauseating effect of morphine.
By making heroin illegal, a society ensures that its heroin addicts will all be criminals. It is clear that drug laws have done nothing to discourage people from becoming addicts. There are as many addicts as ever, and the kinds of addiction are worse than
87 Depressants before those laws were passed. Prohibition of opiates has directly spawned an ugly criminal underworld that supplies heroin to addicts at grossly inflated prices: up to $1,000 a gram for material of questionable purity that may be cut with substances more hazardous than the drug itself. Addicts with habits costing several hundred dollars a day are forced to resort to daily criminal activity in order to avoid the unpleasant symptoms of withdrawal.
It seems obvious that many of the worst features of heroin addiction are due to this social situation rather than to the pharmacological effects of opiates. When you have to come up with several hundred dollars a day to buy a drug you must have to avoid feeling sick, you aren't likely to eat well, sleep regularly, or live in healthy surroundings. Heroin addicts are usually unproductive because they have little time for anything but scoring heroin and then nodding out in isolation.
The aspects of addiction that arc attributable directly to heroin have to do with the high potency of the drug, its short duration of action, and the tendency for people to use it intravenously.* Heroin can be smoked (mixed with tobacco or marijuana); snuffed up the nose; or injected under the skin, into a muscle, or into a vein. By any of these routes it is much more powerful than by mouth. Oddly enough, most people who try heroin for the first time, by whatever route, don't find it pleasant; more often than not, they experience little besides nausea, sweating, and a general feeling of discomfort. After a few doses, however — particularly when it is injected directly into the bloodstream — some people experience an intense "rush" of good feeling that lasts for a few minutes, and then become drowsy.
To hear heroin addicts talk about the intensity of this rush is both fascinating and frightening. Some say it is the most pleasurable sensation they have ever felt, much more powerful than orgasm. People who get this experience from "mainlining" heroin — not all do — find it hard to appreciate other kinds of highs, especially nondrug highs, which tend to be more subtle. The power of the heroin rush to make people uninterested in other experiences and totally committed to heroin is so overwhelming as to be an argument against ever trying the drug at all. One junkie expressed this sentiment in a much-quoted line: "It's so good, don't even try it once."
Nonintravenous heroin doesn't give nearly as intense a rush and so is less addicting. People who snort heroin can do so off and
'The health problems associated with intravenous drug use are discussed in Chapter 12.
There's nothing like a heroin rush. I started shooting heroin when I was fourteen. It's just the most intense, wonderful feeling. I was always interested in getting high. One of my favorite ways when I was little was rolling down big hills. I did it over and over. Heroin has caused me a lot of problems. I'm scared of withdrawal, but I know I have to do it. I'm also interested in meditation and things like that, but I worry that I will always be tempted to feel the heroin rush again, because nothing else I've tried comes close to it.
— seventeen-year-old woman, patient in a private addiction treatment center
on for long periods of time without becoming strongly addicted. Even people who inject it subcutaneously ("skin-popping") can sometimes avoid full-blown dependence, being able to confine their use of the drug to occasional sprees. There is no question that some users can mainline heroin only once in a while, usually shooting the drug only in certain situations — to reduce anxiety in personal relationships, for example, or to boost their confidence before a public performance, or to feel good at weekend parties. In street jargon, this sort of occasional use of heroin is known as "chipping," and it seems that some lucky individuals remain successful chippers over months and even years. Unfortunately, a high percentage of chippers eventually go on to become addicts, so the practice is risky. Most junkies began as chippers, and many never thought they would become addicts.
Once physical dependence develops the need to avoid withdrawal becomes a powerful motive for taking more of the drug. Three to eight hours after his last dose, a heroin addict will begin to feel sick, and unless he takes another fix these feelings will grow more and more intense.
It's too bad that heroin has become the most popular street opiate. Whole opium, when eaten, is a much safer drug — less concentrated, longer acting, and easier to form stable relationships with. Because it is a gummy solid, it cannot be injected directly into the bloodstream, and though people can certainly become addicted to it — as they did in England and Amc-rica in the 1800s — the risk is much less. Taking opium orally doesn't give a rush, and high doses cause unpleasant nausea, encouraging users to moderate their intake. Smoking opium puts drugs into the blood and brain more directly and has a higher potential for abuse.
Many junkies are as addicted to giving themselves intravenous injections as they are to the effects of heroin. Some of them experiment with shooting other drugs, and some combine other drugs with their heroin. For instance, some addicts mix heroin and cocaine into a "speedball" that gives an intense euphoric effect. Of course, this practice is dangerous, much more so than combinations of stimulants and depressants taken by mouth.
Treatments of narcotics addiction are not very satisfactory. The physical component of an opiate habit can be broken fairly easily by withdrawing people gradually and treating symptoms as they develop. As with cigarette addiction, however, the relapse rate is very high, and junkies often go back to being junkies even after being drug-free for months or years.
Heroin maintenance — that is, supplying addicts with pure, legal heroin in some sort of supervised setting — has been pro-
89 Depressants posed as a possible treatment, but our society, unwilling to abandon its prohibitionist mentality, has been unwilling to try it, even as an experiment. Instead, it has supported maintenance with methadone, a synthetic opiate that is active by mouth and has a long duration of effect. Oral methadone is an addicting narcotic but gives little euphoria. It does block the effect of heroin, however, and so may reduce a junkie's motivation to shoot heroin. Some addicts sign into methadone programs only to take a break from the street scene; after a time, they go right back to their old ways. Other addicts, if they are highly motivated, can use methadone programs to help them break their heroin habits once and for all.
The main advantage of methadone maintenance is that it is better than leading a criminal life. The real problem with it is that it doesn't go to the root of addiction. Nor does it show heroin users how to get high in more natural, less restricting ways. It offers them no help with the problems that led them to abuse heroin in the first place. All it does is substitute one narcotic for another,- the addict remains an addict, albeit in a less destructive way.
No matter how you look at it, heroin addiction limits personal freedom. Like a cigarette addict, the junkie cannot go anywhere or do anything without thinking about where his next fix is coming from. Unlike the cigarette addict, he cannot buy his drug for a reasonable price at the corner store, and he will become really sick if he cannot get it.
Nowadays, heroin use is becoming more and more common — invading affluent and respectable segments of society. In some circles it is fashionable to try heroin or use it occasionally, particularly by means of "chasing the dragon," the practice of heating brown Asian heroin on tinfoil and inhaling the vapors. Though the medical dangers of heroin have certainly been exaggerated, the risk of addiction is real.
If you do not try heroin, you will not use it. If you do not use it, you will never become addicted.
Many questions about opiate addiction remain unanswered. How much of it is biochemical and how much is psychological? Opiate molecules interact with special receptor sites on nerve cells in the brain. Might addiction be the result of suppression of the brain's own opiatelike molecules, the endorphins? Why do some people who try opiates find them so compelling that they go on to become addicts, while others do not? Is this a matter of differences in brain chemistry, or differences in personality? Unfortunately, the answers are still hidden.
Given these uncertainties, it is impossible to say who is at
The first opiate I ever took was codeine ... It made me feel right for the first time in my life ... I never felt right from as far back as I can remember, and I was always trying different ways to change how I felt. I used lots of drugs, but none of them really did it for me. Codeine was a revelation, and I've been an opiate user ever since ... Opiates have caused me lots of trouble, but what they do for my head is worth it.
— thirty-four-year-old woman, rock singer
greatest risk of addiction and who is not. There is no assurance that you will not become an addict once you start using opiates regularly, and no way of taking the drugs so as to protect yourself from that possibility. Furthermore, once addiction develops, there is no reliable method of breaking it.
Precautions About Narcotics r tM'
1. Opium and its derivatives are powerful drugs that should be reserved for treating severe physical pain and discomfort.
2. Taking narcotics to reduce anxiety or depression, or just to feel good in the absence of physical pain, can easily lead to habitual use and addiction.
3. Never inject a narcotic into the body for nonmedical purposes.
4. If you ever try a narcotic intravenously and feel overwhelming pleasure, never repeat it.
5. If you begin to use narcotics regularly, by any method, and think you can avoid going on to intravenous use and addiction, remember: most junkies thought that, too.
Margaret O. Hyde's Alcohol: Drink or Drug! (New York: McGraw-Hill, 1974) is a good book written for adolescent readers. Berton Roueché's The Neutral Spirit: A Portrait of Alcohol (Boston: Little, Brown, 1960) is a well-written account of the uses of alcohol from ancient times to the present. A more technical book is Under the Influence: A Guide to the Myths and Realities of Alcoholism by James R. Milam and Katherine Ketcham (Seattle: Madrona, 1981). An account of writers with alcohol problems is Donald Newlove's Those Drinking Days: Myself and Other Writers (New York: Horizon Press, 1981). Evelyn Waugh's Brideshead Revisited (Boston: Little, Brown, 1945; reprinted in paper, 1979) describes the evolution of an English alcoholic. For a view of the use and abuse of alcohol on this side of the Atlantic, see The Alcohol Republic: An American Tradition by W. J. Rorabaugh (New York: Oxford University Press, 1979). The connection between violent crime and alcohol is explored in The Crocodile Man: A Case of Brain Chemistry and Criminal Violence by André Mayer and Michael Wheeler (Boston: Houghton Mifflin, 1982).
Several excellent films dramatize the problem of alcoholism. One classic is The Lost Weekend, about an alcoholic writer played by Ray Milland. Days of Wine and Roses, starring Jack Lemmon and Lee Remick, is an agonizing portrait of a pair of alcoholics
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