The Heroin Stimulus: Implications for a Theory of Addiction

263 Pages·1979·4.48 MB·English

by  Roger E. Meyer M.D.

The Heroin Stimulus
Implications for a Theory of Addiction
The Stimulus
~Heroin
Implications for a Theory of Addiction
Roger E1 0eyer, M. D.
University of Connecticut Medical School
Farmington, Connecticut
and
Steven M. Mirin, M.D.
Harvard Medical School and
McLean Hospital
Belmont, Massachusetts
PLENUM MEDICAL BOOK COMPANY . NEW YORK AND LONDON
Library of Congress Cataloging in Publication Data
Meyer, Roger E
The heroin stimulus.
Includes bibliographical references and index.
I. Narcotic habit - Etiology. 2. Heroin - Physiological effect. 3. Heroin - Psychological
aspects. 4. Narcotic habit - Treatment. I. Mirin, Steven M., joint author. II. Title. [DNLM:
1. Heroin addiction - Etiology. WM288 M613h]
RC566.M48 615'.782 78-13634
ISBN-13: 978-1-4684-3428-6 e-ISBN-13: 978-1-4684-3426-2
001: 10.1007/978-1-4684-3426-2
© 1979 Plenum Publishing Corporation
Softcover reprint of the hardcover 1st edition 1979
227 West 17th Street, New York, N.Y. 10011
Plenum Medical Book Company is an imprint of Plenum Publishing Corporation
All rights reserved
No part of this book may be reproduced, stored in a retrieval system, or transmitted,
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To our families
Contributing Authors
Joseph Albeck, M.D . • Assistant Professor of Psychiatry, University of
Miami School of Medicine, Miami, Florida (formerly Instructor in
Psychiatry, Harvard Medical School)
Thomas F. Babor, Ph.D .• Assistant Professor, Department of Psychiatry,
Harvard Medical School, Boston, Massachusetts
Cecily Barrington, B. A • Formerly Research Assistant, Alcohol and Drug
Abuse Research Center, McLean Hospital, Belmont, Massachusetts
James Ellingboe, Ph.D.· Principal Research Associate in Psychiatry
(Biochemistry), Harvard Medical School, Boston, Massachusetts
Jack H. Mendelson, M.D.· Professor of Psychiatry, Harvard Medical
School, Boston, Massachusetts
Roger E. Meyer, M.D . • Professor and Chairman, Department of Psychia
try, University of Connecticut School of Medicine, Farmington, Con
necticut (formerly Associate Professor of Psychiatry, Harvard Medical
School)
Steven M. Mirin, M.D . • Assistant Professor of Psychiatry, Harvard Med
ical School, Boston, Massachusetts
Paul J. Orsulak, Ph.D .• Assistant Professor, Department of Psychiatry,
Harvard Medical School, Boston, Massachusetts
Mary Randall, M.S .• Formerly Statistician, Alcohol and Drug Abuse Re
search Center, McLean Hospital, Belmont, Massachusetts
Elizabeth A Rider, M.S. W, AC.S. W • Senior Psychiatric Social Worker,
Framingham Youth Guidance Center, Framingham, Massachusetts
(formerly Clinical Social Worker, Narcotic Antagonist Research Unit,
McLean Hospital, Belmont, Massachusetts)
Joseph J. Schildkraut, M.D .• Professor of Psychiatry, Harvard Medical
School, Boston, Massachusetts
Nancy M. Valentine, M.S.N . • Director, Continuing Education in Nursing,
Boston State College, Boston, Massachusetts (formerly Clinical Nurs
ing Supervisor, Narcotic Antagonist Research Unit, McLean Hospital,
Belmont, Massachusetts)
vii
viii CONTRIBUTING AUTHORS
Fred Zackon • Formerly Rehabilitation and Recruitment Counselor,
Narcotic Antagonist Research Unit, McLean Hospital, Belmont, Mas
sachusetts
Foreword
The simple fact that the authors were able to give injectable heroin to
volunteers for addictive self-administration at a Harvard facility may
elude the notice it deserves. On the other hand, resec:irch questions center
ing on whether heroin is linked to a craving for pleasure or relief of pain
might raise the transplanted hackles of those who simplistically see scien
tists as pursuing only transparent trivialities. In truth, this report is about
a historical and pioneering step in clinical research on a major unsolved
problem of the biological-social-psychological roots of addiction. The
research questions posed are clearly relevant both to the design of effec
tive treatments (and treatment policy) and to the basic science search that
could help our understanding of how addictive drugs capture such power
ful control over behavior.
Heroin was synthesized and has been available, along with aspirin,
for over three-quarters of a century. Yet with all the tools of Western sci
ence, and with the enormous and growing social, personal, and economic
costs of world-wide heroin use, we-surprisingly--<:an point to little sys
tematic clinical study that provides the needed fundamental knowl
edge on which both basic and clinical scientists could design and target
rational therapies.
The present study marks an end to a long period of taboo on the di
rect and in-depth study of human heroin use. The fear and taboo ofnarcot
ics, especially of heroin, as enshrined in both our laws and customs resulted
in a protracted delay in the feasibility of systematic scientific research
with an agent all too widely available in the streets. The overall effect was
that fundamental studies of addictive drugs tended to be sequestered. The
field of addiction owes much to the earlier neuropsychopharmacological
studies of opiates and opioids in animals and man that derived from the
seminal group at the USPHS laboratories in Lexington, Kentucky and to
the basic pharmacology of addictive narcotics in animals that stemmed
from the group at the University of Michigan. But it is only in the past
decade that a growing number of psychiatrists, psychologists, phar-
ix
x FOREWORD
macologists, social scientists, neurobiologists, and epidemiologists have
been encouraged to engage in research, including system!1tic observations
of the tens of thousands of addicts who at long last have had an opportu
nity to engage in a range of available treatments. Building on the scientific
heritage ofthe Lexington and Michigan groups, we today have the oppor
tunity to bring scientific skills to bear on the multiple questions of addic
tion and to advance a step forward from retrospective, sUbjective reports
and isolated study of the "heroin stimulus."
It was the observations of clinical science that warranted the use of
heroin rather than related drugs for this study in which subjective mood,
gross behavior, neuroendocrine and cardiorespiratory physiology, and
other characteristics of drug effects were systematically and directly ex
amined by an interdisciplinary research team. Yet to launch this project,
the team had to undertake enormously complicated problems of working
out the logistic, legal, and administrative hurdles and ethical deliberations
that would permit direct observations of the evolution of addictive be
haviors in man using heroin-the addicts' preferred narcotic. The ethical
sensitivity apparent in the report is not its central topic, but the treatment
of the problem should advance confidence that the tools of science can be
applied to these puzzling, relapsing disorders of addiction in a scientific
and ethically appropriate way. This accomplishment is all the more sig
nificant when we realize our society has lost its access to the major
clinical study population at Lexington because of what some thoughtful
observers believe are as yet un-worked-out ethical constraints on the right
of federal prisoners to volunteer for clinical investigation. The burden
for future studies, then, lies in the innovation of clinical investigatory
opportunities in the academic research and treatment centers across the
country.
Such studies are necessary, for we cannot as yet usefully explain the
power of drugs to elicit addictive behaviors and simultaneously or sequen
tially evoke self-punitive psychological consequences. That the latter are
not solely socially imposed and contingent on the unavailability of
legalized heroin is but one of the fruitful observations clearly elucidated
herein. Indeed, they show that the very presence of heroin in the body not
only produces euphoria, but sets up a tension somehow signaling "heroin
availability," evoking the learned behaviors, if not the physiological re
sponses, which lead to heroin procuring behaviors. That euphoria and
dysphoria coexist, even when an "appetite" is supposedly being sated,
poses fundamental questions both for the psychologist interested in the
structure of affective states and the neurobiologist searching for recep
tors, for endogenous opiates secreted by the brain, or for the linkage and
site of pleasure and pain "centers" of the brain.
FOREWORD xi
The studies represent a systematic test ofthe best developed theories
of addictive behaviors (derived from clinical observation and extensive
animal experimentation) in a search for a rational approach to their con
trol. The major theory that conditioned abstinence-the physiological
memory of the discomforts of withdrawal-is evoked when the addict
perceives the availability of heroin, and that it is this that sustains the ad
dicts' vulnerability to relapse, is tested. The hypothesis that the "crav
ing for the next injection is internally signaled by the unpleasant effects
of withdrawal could not be clearly confirmed in these studies. The re
search design, permitting the addict to determine his own dosage sched
ule, involved the study of heroin injection in both the presence and ab
sence of the narcotic blockading drug, naltrexone. The observational
conditions permitted a matching of subjective and objective reports of be
havior and physiological response. What was striking was the mixture of
euphoric and dysphoric effects in the unblocked situation, and, with the
next dose of heroin clearly available, the emergence of psychopathologi
cal and dyssocial behaviors rather than blissful quietude. In the presence
of the blockade, subjects differed in learning that the heroin reinforce
ment was not available, and these differential learning patterns were sug
gestively predictive of the utility of naltrexone as a treatment when the
authors examined their follow-up and aftercare data.
The trend of a variety of the observations reported points to some
significant questions of our intuitive notions of what it is that sustains
addictive behavior. The sequence of events triggered by the heroin
stimulus clearly evokes both physiological and subjective phenomena and
learned behaviors as well. Craving is a multistructured state, perhaps
resting on multiple biological and psychological processes simultaneously
elicited. The physiological stimulus alone-heroin reaching the brain
does not describe all the events observed. What we might call the
psychological structure of craving suggests a simultaneity of pleasurable
and distinctly unpleasurable effects, concordant physiological responses,
and a factor of anticipation. Since craving was at its highest when heroin
was in the body or during the withdrawal of heroin, and since craving fell
only minimally in response to each injection (even when the addict was
manifestly intoxicated), the effects of the heroin stimulus signal some
thing beyond pure physiology. It is as if the drug elicits anticipation of
something beyond one's grasp-a glimpse of unattained or unsustained
paradise. As the authors put it, "It is as though the addict were chained to
a treadmill with the constant promise oflight (and peace) at the end of the
tunnel." Perhaps the fundamental maladaptive distortion in the heroin
stimulus is that constant heroin might be available.
These intimations of bliss and immortality pose problems for psychol-
xii FOREWORD
ogists (the role of anticipation in memory) and physiologists. They may
bear not only on addictive behavior with narcotics, but on a range of
human behaviors which appear to deny the obvious. I have often won
dered whether the fact that drugs rarely sustain their initial allure and
promise is a malevolent trick of mischievous nature. Perhaps there are
intrinsic biological and biosociallimits upon the extent to which the chem
ically induced moment of pleasure can be sustained and woven into a
fabric of viable social life. But there may also be similar biopsychological
determinants of our yen for sustained equanimity. Thus, we can readily
give up our lease on reality, but apparently it is difficult to gain ownership
of paradise!
That many zealots as well as addicts might share in the belief of the
state of flawless perfection is beyond the scope of this book, but the
power of religion (which can capture and order man's search for tran
scendence) is indeed relevant in the treatment of addictions. The use of
drugs, then, provides striking metaphors of man and his purposes. This no
doubt accounts for the often morbid fascination and irrationality with
which society approaches these topics. But for the scientific study of man
undertaken by the psychoanalyst or experimental psychobiologist, the
careful observations contained in this remarkable study provide an oppor
tunity not only to delineate the overlapping and differential factors from
physiology to learning which are involved in addictive behavior, but
perhaps more fundamentally something of the way by which a variety of
mental states and their social consequences are organized. In brief, such
studies can proceed from the ievel of the molecular and membrane events
to discernment of physiological and SUbjective data to an analysis of the
consequences of these effects-the uses made of drug experience-and
the way these consequences are managed. At bottom, the regulation of
the self and its purposes is the quest of investigative psychiatry, and this
book is a practically relevant and theoretically challenging approach to it.
Daniel X. Freedman, M.D.
Louis Block Professor Biological Sciences and
Chairman, Department of Psychiatry
University of Chicago
Chicago, Illinois