International Journal of the Addictions
ISSN: 0020-773X (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/isum19
Discussion of the Preceding Five Papers Roger E. Meyer To cite this article: Roger E. Meyer (1976) Discussion of the Preceding Five Papers, International Journal of the Addictions, 11:3, 545-549, DOI: 10.3109/10826087609056169 To link to this article: http://dx.doi.org/10.3109/10826087609056169
Published online: 03 Jul 2009.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=isum19 Download by: [RMIT University Library]
Date: 05 April 2016, At: 02:22
The International Journal of the Addictions, 11(3), pp. 545-549, 1976
Downloaded by [RMIT University Library] at 02:22 05 April 2016
Discussion of the Preceding Five Papers Roger E. Meyer, M.D. Center for Biobehavioral Studies in the Addictions Department of Psychiatry Harvard Medical School Boston, Massachusetts 021 15 and Alcohol and Drug Abuse Research Center McLean Hospital Belrnont, Massachusetts 021 78
The data presented in the five preceding papers suggest certain tentative answers to some general questions regarding the addiction process while generating more complicated and sophisticated questions. In his introductory remarks, Altman asks whether heroin addiction is a symptom related to specific underlying psychopathology or whether it is a discrete behavior. Mirin’s data suggest that our patients have a significant degree of psychopathology which is, however, not ameliorated by heroin administration nor exacerbated by narcotic antagonist treatment. Curiously, chronic administration of heroin tended to be associated with increases in manifest levels of psychopathology rather than symptom reduction. For patients who completed all phases of the study, narcotic antagonists could successfully eliminate heroin self-administration in a closed ward environment without generating an increase in belligerence or depression. Yet, longer term follow-up in the community (as described by Rawlins) confirms that heroin self-administration is a resilient behavior that returns after some 545
Copyright 0 1976 by Marcel Dekker, Inc. All Rights Reserved. Neither this work nor any part may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, microfilming, and recording, or by any information storage and retrieval system without permission in writing from the publisher.
Downloaded by [RMIT University Library] at 02:22 05 April 2016
546
MEYER
months in a familiar environment amidst familiar stimuli. The data are most consistent with the existence of parallel phenomena : our patients had serious levels of psychopathology which existed in parallel with the discrete behavior of heroin self-administration. The heroin addiction and its blockade did not result in psychopathology nor does the psychopathology cause the heroin addiction. While relapse in the community over time is consistent with long-standing character pathology, we have also observed that many stimuli (associated with drug availability and /or stress) in the community are associated with craving for (and likely relapse to) heroin. In the context of our closed environment the availability of heroin during discrete periods of time was the factor which most consistently related to high levels of craving. Patients were not physically or emotionally more symptomatic when they reported high craving scores. Rather, the knowledge that heroin would soon become available (or was available at a given time) was specifically related to the high craving score. It is very likely that the same pattern exists in the community. Indeed, patients have reported to us that subjective craving is highest in geographic areas where drugs have been purchased or when patients are in the company of persons who are either intoxicated or engaged in the process of “shooting up.” Curiously, for some individuals, craving is higher in the vicinity of methadone clinics, drugstores, and in the company of intoxicated friends than when in treatment for opiate withdrawal. What, then, is the nature of craving? Is this concept useful in the formulation of heroin addiction ? What is the relationship of craving to heroin use? In a scholarly review of craving in association with alcoholism, Mello (1974)notes that “craving” does not increase in studies of alcoholics when alcohol is anticipated or being consumed. Thus, on the basis of these and other data, she concludes that craving is not a useful concept in the understanding of alcohol addiction. In contrast, our patients report very high craving scores when heroin is available. These craving scores go down to a moderate degree in response to injections but never to levels of craving reported when heroin is not available. Thus, in the doses administered, heroin did not satiate the feelings of craving. Moreover, patients’ increasing feelings of “being sick” over the 10-day period of heroin acquisition suggested a greater subjective desire for heroin over time. Thus, the addict on his drug of choice is faced with a situation in which craving is high and does not markedly diminish in response to self-administration. Rather, repeated heroin use leads to the maintenance of high craving scores with very little satisfaction from each dose of the drug. It is of special interest that heroin self-administration behavior parallels sub-
Downloaded by [RMIT University Library] at 02:22 05 April 2016
DISCUSSION OF THE PRECEDING FIVE PAPERS
547
jective reports of craving. Patients who went on to test narcotic blockade with heroin had high craving scores while they were testing blockade. Patients who did not test blockade did not have high craving scores. Craving scores of patients who tested blockade fell dramatically at the time that they ceased testing narcotic blockade. If opiates are reinforcing, what is the nature of the reinforcement? Is it primary, or is it secondary? We have observed two patterns of heroin self-administration. In the first two studies, patients self-administered the opiate on a relatively irregular basis, but with greater frequency over time. In the last three studies, patients self-administered heroin on a q 6-hr schedule. Given the half-life of morphine in blood (Spector, 1971), it is possible that patients on a q 6-hr schedule were merely avoiding withdrawal, but this pattern began even before dependence was possible. At this writing it is not possible to differentiate the relative importance of abstinence relief (conditioned or pharmacological) versus primary euphoria in the genesis of relapse. Craving at the outset of a cycle of heroin administration was not associated with manifest signs of withdrawal or self-report of “sick” feelings. Recent data (Perez-Cruet, 1973) suggests that the agonistic effects of opiates may be conditioned. It is possible that patients reports of “craving” are not conditioned abstinence symptoms, but may reflect a range of subjective feelings associated with the availability of heroin. Behavioral data as well as the group interaction studies described in the preceding pages by Babor and psychiatric data described here by Mirin all describe a pattern of increasing belligerence and aggression while heroin use is proceeding. Curiously, we have also observed that testosterone levels are usually depressed at this time (Mendelson et al., unpublished). Patients tend to become socially isolated and withdrawn with a larger threshold of irritability. These data are consistent with the observations that have been made by others (Fraser et al., 1963), but have been for some reason ignored in the general psychiatric literature (Rado, 1933; Khantzian et al., 1974). Finally, what are the prospects for the use of narcotic antagonists in the modification of opiate-seeking behavior ? The behavioral data reported here by Altman tend to predict the follow-up data described by Rawlins. These data are also consistent with the clinical reports of the group in New Haven (Kleber et al., 1971). Patients on narcotic antagonists do not voluntarily go through a process of extinction of the opiate-seeking response. One would expect an increase in craving, an increase in heroinseeking behavior, and an increase in irritability when patients test opiate blockade. None of these have been observed. Because extinction does not take place, relapse is a constant risk at follow-up in the community. The
MEYER
Downloaded by [RMIT University Library] at 02:22 05 April 2016
548
earliest signs of relapse usually involve patients missing a counseling session and then failing to keep pharmacy appointments. When these occur in quick sequence, relapse is inevitable. In some of our patients, relapse was apparently related to increases in life stress, but in others it seemed also to be a function of the emotional distance that these patients had generated between themselves and the treatment facility over time. It is possible that outcome can be improved with longer-acting narcotic antagonists. It is our feeling, however, that programs must consider ways of encouraging narcotic antagonist self-administration behavior in the community and encouraging socially adaptive behaviors through the use of appropriate reinforcers, This is not an easy task. Patients are discharged and accepted in school or vocational training programs which require a delay of 1 to 3 months. For a population which does not take delays easily, this leads to poor social outcome. Ellinwood (1974) has described an ingenious program in North Carolina which has employed contingency contracting for behaviors in the community in which patients do not have to experience delays in working with social agencies. This may be possible in places like North Carolina; it is much more difficult in urban areas. The treatment of the heroin addict on narcotic antagonists resembles the psychiatric treatment of nondrug-dependent impulsive disorders. Because psychiatry in the late twentieth century is faced with the treatment of individuals who deal with distress through acting out (rather than symptom formation), the challenge in this field is consistent with this broader challenge to psychiatry. Narcotic antagonists clearly are not for all heroin addicts. They may be useful in working with motivated patients. It is our feeling that this treatment approach has tremendous implications for our understanding of behavior and reinforcement. In this regard, it may have a significant impact upon general psychiatry and its approach to the treatment of other impulsive disorders. REFERENCES
ELLINWOOD, E.H., JR. Personal communication. FRASER, H.F., JONES, B.E., ROSENBERG, D.E., and THOMPSON, A.K. Effects of addiction to intravenous heroin on patterns of physical activity in man. Clin. Pharmacol. Ther. 4: 188-196, 1963. KHANTZIAN, E.J., MACK, J.E., and SCHATZBERG, A.F. Heroin use as an attempt to cope: Clinical observations. Am. J . Psychiatry 131 : 160-164, 1974. KLEBER, J.D., KINSELLA, J.K.,RIORDAN, C., GREAVES, S., and SWEENEY, D. The use of cyclazocine in treating narcotic addicts in a low intervention setting. Arch. Gen. Psychiatry 30(1): 3742, 1971.
Downloaded by [RMIT University Library] at 02:22 05 April 2016
DISCUSSION O F THE PRECEDING FIVE PAPERS
549
MELLO, N.K. A semantic aspect of alcoholism. In H. D. Cappel and X. LeBlanc (eds.) Proceedings of the International Symposium on Alcohol and Drug Research--1973. Toronto: Department of National Health and Welfare, and Alcoholism and Drug Addiction Research Foundation, 1974, in press. MENDELSON, J.H.,MEYER, R.E., ELLINGBOE, J., MIRIN, S.M.. and McDOUGLE, M. Effectsof Heroin on Plasma Cortisol and Testosterone. Unpublished manuscript. PEREZ-CRUET, J. Conditional reflex changes in dopamine metabolism induced by methadone as an unconditional stimulus. In J. M. Singh and H. La1 (eds.) Drii.e Addiction, Vol. 3. Miami, Florida: Symposia Specialist, 1973, pp. 249-250. RADO, S. Psychoanalysis of pharmacothymia (drug addiction). Psychoanal. Q . 2U): 1-23, 1933. SPECTOR, S. Quantitative determination of morphine in serum by radioimmunoassay. J. Pharmacol. Exp. Ther. 178: 253-258, 1971.
ISSN: 0020-773X (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/isum19
Discussion of the Preceding Five Papers Roger E. Meyer To cite this article: Roger E. Meyer (1976) Discussion of the Preceding Five Papers, International Journal of the Addictions, 11:3, 545-549, DOI: 10.3109/10826087609056169 To link to this article: http://dx.doi.org/10.3109/10826087609056169
Published online: 03 Jul 2009.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=isum19 Download by: [RMIT University Library]
Date: 05 April 2016, At: 02:22
The International Journal of the Addictions, 11(3), pp. 545-549, 1976
Downloaded by [RMIT University Library] at 02:22 05 April 2016
Discussion of the Preceding Five Papers Roger E. Meyer, M.D. Center for Biobehavioral Studies in the Addictions Department of Psychiatry Harvard Medical School Boston, Massachusetts 021 15 and Alcohol and Drug Abuse Research Center McLean Hospital Belrnont, Massachusetts 021 78
The data presented in the five preceding papers suggest certain tentative answers to some general questions regarding the addiction process while generating more complicated and sophisticated questions. In his introductory remarks, Altman asks whether heroin addiction is a symptom related to specific underlying psychopathology or whether it is a discrete behavior. Mirin’s data suggest that our patients have a significant degree of psychopathology which is, however, not ameliorated by heroin administration nor exacerbated by narcotic antagonist treatment. Curiously, chronic administration of heroin tended to be associated with increases in manifest levels of psychopathology rather than symptom reduction. For patients who completed all phases of the study, narcotic antagonists could successfully eliminate heroin self-administration in a closed ward environment without generating an increase in belligerence or depression. Yet, longer term follow-up in the community (as described by Rawlins) confirms that heroin self-administration is a resilient behavior that returns after some 545
Copyright 0 1976 by Marcel Dekker, Inc. All Rights Reserved. Neither this work nor any part may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, microfilming, and recording, or by any information storage and retrieval system without permission in writing from the publisher.
Downloaded by [RMIT University Library] at 02:22 05 April 2016
546
MEYER
months in a familiar environment amidst familiar stimuli. The data are most consistent with the existence of parallel phenomena : our patients had serious levels of psychopathology which existed in parallel with the discrete behavior of heroin self-administration. The heroin addiction and its blockade did not result in psychopathology nor does the psychopathology cause the heroin addiction. While relapse in the community over time is consistent with long-standing character pathology, we have also observed that many stimuli (associated with drug availability and /or stress) in the community are associated with craving for (and likely relapse to) heroin. In the context of our closed environment the availability of heroin during discrete periods of time was the factor which most consistently related to high levels of craving. Patients were not physically or emotionally more symptomatic when they reported high craving scores. Rather, the knowledge that heroin would soon become available (or was available at a given time) was specifically related to the high craving score. It is very likely that the same pattern exists in the community. Indeed, patients have reported to us that subjective craving is highest in geographic areas where drugs have been purchased or when patients are in the company of persons who are either intoxicated or engaged in the process of “shooting up.” Curiously, for some individuals, craving is higher in the vicinity of methadone clinics, drugstores, and in the company of intoxicated friends than when in treatment for opiate withdrawal. What, then, is the nature of craving? Is this concept useful in the formulation of heroin addiction ? What is the relationship of craving to heroin use? In a scholarly review of craving in association with alcoholism, Mello (1974)notes that “craving” does not increase in studies of alcoholics when alcohol is anticipated or being consumed. Thus, on the basis of these and other data, she concludes that craving is not a useful concept in the understanding of alcohol addiction. In contrast, our patients report very high craving scores when heroin is available. These craving scores go down to a moderate degree in response to injections but never to levels of craving reported when heroin is not available. Thus, in the doses administered, heroin did not satiate the feelings of craving. Moreover, patients’ increasing feelings of “being sick” over the 10-day period of heroin acquisition suggested a greater subjective desire for heroin over time. Thus, the addict on his drug of choice is faced with a situation in which craving is high and does not markedly diminish in response to self-administration. Rather, repeated heroin use leads to the maintenance of high craving scores with very little satisfaction from each dose of the drug. It is of special interest that heroin self-administration behavior parallels sub-
Downloaded by [RMIT University Library] at 02:22 05 April 2016
DISCUSSION OF THE PRECEDING FIVE PAPERS
547
jective reports of craving. Patients who went on to test narcotic blockade with heroin had high craving scores while they were testing blockade. Patients who did not test blockade did not have high craving scores. Craving scores of patients who tested blockade fell dramatically at the time that they ceased testing narcotic blockade. If opiates are reinforcing, what is the nature of the reinforcement? Is it primary, or is it secondary? We have observed two patterns of heroin self-administration. In the first two studies, patients self-administered the opiate on a relatively irregular basis, but with greater frequency over time. In the last three studies, patients self-administered heroin on a q 6-hr schedule. Given the half-life of morphine in blood (Spector, 1971), it is possible that patients on a q 6-hr schedule were merely avoiding withdrawal, but this pattern began even before dependence was possible. At this writing it is not possible to differentiate the relative importance of abstinence relief (conditioned or pharmacological) versus primary euphoria in the genesis of relapse. Craving at the outset of a cycle of heroin administration was not associated with manifest signs of withdrawal or self-report of “sick” feelings. Recent data (Perez-Cruet, 1973) suggests that the agonistic effects of opiates may be conditioned. It is possible that patients reports of “craving” are not conditioned abstinence symptoms, but may reflect a range of subjective feelings associated with the availability of heroin. Behavioral data as well as the group interaction studies described in the preceding pages by Babor and psychiatric data described here by Mirin all describe a pattern of increasing belligerence and aggression while heroin use is proceeding. Curiously, we have also observed that testosterone levels are usually depressed at this time (Mendelson et al., unpublished). Patients tend to become socially isolated and withdrawn with a larger threshold of irritability. These data are consistent with the observations that have been made by others (Fraser et al., 1963), but have been for some reason ignored in the general psychiatric literature (Rado, 1933; Khantzian et al., 1974). Finally, what are the prospects for the use of narcotic antagonists in the modification of opiate-seeking behavior ? The behavioral data reported here by Altman tend to predict the follow-up data described by Rawlins. These data are also consistent with the clinical reports of the group in New Haven (Kleber et al., 1971). Patients on narcotic antagonists do not voluntarily go through a process of extinction of the opiate-seeking response. One would expect an increase in craving, an increase in heroinseeking behavior, and an increase in irritability when patients test opiate blockade. None of these have been observed. Because extinction does not take place, relapse is a constant risk at follow-up in the community. The
MEYER
Downloaded by [RMIT University Library] at 02:22 05 April 2016
548
earliest signs of relapse usually involve patients missing a counseling session and then failing to keep pharmacy appointments. When these occur in quick sequence, relapse is inevitable. In some of our patients, relapse was apparently related to increases in life stress, but in others it seemed also to be a function of the emotional distance that these patients had generated between themselves and the treatment facility over time. It is possible that outcome can be improved with longer-acting narcotic antagonists. It is our feeling, however, that programs must consider ways of encouraging narcotic antagonist self-administration behavior in the community and encouraging socially adaptive behaviors through the use of appropriate reinforcers, This is not an easy task. Patients are discharged and accepted in school or vocational training programs which require a delay of 1 to 3 months. For a population which does not take delays easily, this leads to poor social outcome. Ellinwood (1974) has described an ingenious program in North Carolina which has employed contingency contracting for behaviors in the community in which patients do not have to experience delays in working with social agencies. This may be possible in places like North Carolina; it is much more difficult in urban areas. The treatment of the heroin addict on narcotic antagonists resembles the psychiatric treatment of nondrug-dependent impulsive disorders. Because psychiatry in the late twentieth century is faced with the treatment of individuals who deal with distress through acting out (rather than symptom formation), the challenge in this field is consistent with this broader challenge to psychiatry. Narcotic antagonists clearly are not for all heroin addicts. They may be useful in working with motivated patients. It is our feeling that this treatment approach has tremendous implications for our understanding of behavior and reinforcement. In this regard, it may have a significant impact upon general psychiatry and its approach to the treatment of other impulsive disorders. REFERENCES
ELLINWOOD, E.H., JR. Personal communication. FRASER, H.F., JONES, B.E., ROSENBERG, D.E., and THOMPSON, A.K. Effects of addiction to intravenous heroin on patterns of physical activity in man. Clin. Pharmacol. Ther. 4: 188-196, 1963. KHANTZIAN, E.J., MACK, J.E., and SCHATZBERG, A.F. Heroin use as an attempt to cope: Clinical observations. Am. J . Psychiatry 131 : 160-164, 1974. KLEBER, J.D., KINSELLA, J.K.,RIORDAN, C., GREAVES, S., and SWEENEY, D. The use of cyclazocine in treating narcotic addicts in a low intervention setting. Arch. Gen. Psychiatry 30(1): 3742, 1971.
Downloaded by [RMIT University Library] at 02:22 05 April 2016
DISCUSSION O F THE PRECEDING FIVE PAPERS
549
MELLO, N.K. A semantic aspect of alcoholism. In H. D. Cappel and X. LeBlanc (eds.) Proceedings of the International Symposium on Alcohol and Drug Research--1973. Toronto: Department of National Health and Welfare, and Alcoholism and Drug Addiction Research Foundation, 1974, in press. MENDELSON, J.H.,MEYER, R.E., ELLINGBOE, J., MIRIN, S.M.. and McDOUGLE, M. Effectsof Heroin on Plasma Cortisol and Testosterone. Unpublished manuscript. PEREZ-CRUET, J. Conditional reflex changes in dopamine metabolism induced by methadone as an unconditional stimulus. In J. M. Singh and H. La1 (eds.) Drii.e Addiction, Vol. 3. Miami, Florida: Symposia Specialist, 1973, pp. 249-250. RADO, S. Psychoanalysis of pharmacothymia (drug addiction). Psychoanal. Q . 2U): 1-23, 1933. SPECTOR, S. Quantitative determination of morphine in serum by radioimmunoassay. J. Pharmacol. Exp. Ther. 178: 253-258, 1971.
