Tobacco Documents Online

~ s~M .. r.. ..f r M M .r r r. ~M Mr rr. ~r.. MICHAEL S. GAZZANIGA i Books by Michael S. Gazzaniga The Social Brain The Bisected Brain Fundamentals of Psychology The Integrated Mind (with Joseph Le Doux) Psychology Fundamentals of Neuroscience (with Bruce T. Volpe and Diana Stccn) Mind Matters: How Mind and Brain Interact to Creatc Our Conscious Lives MIND ~ AMIIERS How Mind and Brain I nteract to Create Our Conscious Lives Boston 1988 Houghton Mifflin Company Published in association with ttre MIT Press, Bradford Books ~tt66OVOZ

.. M M .. M r. MM .. A. .. s .r rf /. ~... .. I.. , Addiction 141 I I Addiction To put it boldly, addiction is a human phenomenon. While it is possible to create in animals a physical dependency for narcotics and alcohol, it is virtually impossible to addict animals to substances that humans will sometimes commit crimes to obtain. If given the choice, animals will walk away from a' drug that has been foisted upon them. This is true even though the physiological effect of the drug is the same for animals and humans. As we try to untangle the problem of addiction, from a host of popular confusions about its origin and nature;., we come to the inescapable conclusion that~human addiction: is largely a product of the mind, not the body. And, morc, pointedly, only a small percentage of our society become ad-: dicted to drugs. Most people use one or another pleasure-produc-, ing drug at some time, but only a few become addicted. Addiction was originally defined in Roman law as a surrendei or dedication of anyone to a master. In modern culture, it refers to the uncontrollable seeking of an experience, usually througlL use of a substance that either gratifies or relieves pain. We tend to think of alcohol, tobacco, caffeine, and other drugs with either a sedative or stimulating effect as the stuff of addictioii: Although the addictions these substances produce are powerfi>t.~ consider 211 the things around which people organize their livq: . f One can be addicted to sports, trips to Italy, Chinese restaurants, power, passionate sex, and many other sources of gratification. Of course, these latter "addictions" are entirely acceptable behaviors. They give life a sense of well-being and focu'sed interest, making the humdrum aspects of everyday life bearable. Six months in Kansas is acceptable if there is going to be a week in Ravello. Money is saved, plans are made, duties are assigned so that one rapturous week can be spent at the Hotel Palumbo, feasting every night upon gnocchi and calamari with the scents of the Amalfi coast wafting up. The week is addicting. When it is over, plans are once again made for that special experience. It is a peak experience and it must be relived. These acceptable, normal "addictions" are psychological in nature and can be contrasted with the physiological addiction of many drugs. The vacation habit is a "soft" addiction, in that it represents a desire for simple rewards that do not establish physical dependence and that can be delayed in their delivery. But realizing all the ways we humans become ritualized in certain habitual behaviors is to begin to understand what is called "hard" addiction. The Concept of Addiction The concept of addiction is obviously riddled with problems. American society, which seems consumed with the notion of helping the deviant, whether it be the drug abuser or the criminal, has become obsessed with addiction. We have sanitized the problem by suggesting that "hard" addictions can happen to anybody exposed to powerful drugs. Save our children from the devil's grasp, we proclaim, and say no to drugs. Yet +t of what we hear is hyperbole, and it is encouraged by those who profit from a continuance of the drug hysteria. It is hyped by medical researchers who get paid to study drugs. It ir hyped by the social service industry that gets paid to help rehabilitate the addict. It is hyped by politicians who get elected by showing they have a social conscience. 8U66E9V99

.. MI.. MM a. m.. r. .. r r r. r. .. rr M .r N.. I , I 142 Addiction This urgency to solve the problem loses some of its force once we realize that addiction, in the sense of physiological need, is very limited and relatively easy to fix.~Most so-called addicts are not suffering from physiological needs; their cravings are psychological, and one has to wonder whether all the helping agencies that concentrate on the physiological dependencies are not in fact serving the function of reinforcing various forms of dependent or fatalistic psychologically driven behavior Con- sider a study by Professor Stanley Schachter of Columbia Uni- versity. Schachter spent years studying why it was so difficult to wean smokers from their cigarettes. He examined all the data from rehab services and observed that no matter what the treat- ment had been, 60 to 70 percent of the participants returned to smoking. As he puzzled this fact and unearthed relations, between nicotine levels and cigarette use, he also wondered why he no longer knew anyone who smoked. Years before, a seminar room would be so filled with smoke that the blackboard. was barely visible. Now, not only was the air clear, but a. maverick smoker incurred the wrath of all those around hini when he Gt up. What was going on? ~; Schachter formally surveyed his highly educated colleagues at Columbia. He also polled residents of Amagansett, a middlo ; to upper-middle-class community on Long Island where he.. summered. He first determined who were smokers and who~ had been smokers. He took into account how long they had° smoked, what they had smoked, and all other variables he coul~ think of for such a study. It wasn't long before the truth begau} to emerge. Inform a normally intelligent group of people aboutF the tangible hazards of using a particular substance, and tbe'; vast majority of them simply stop. That's all, they stop. Th~ don't need treatment programs, support groups, therapeuti, drugs-nothing. People who had been smoking for years on, s daily basis abruptly quit. This suggested that the rehab centets were attracting only those people who were unable to stof,~ Addiction 143 As a consequence, the rehab patients are not a random sampling of the population with an addiction. They are a subculture that cannot easily give up their addictions. Yet it is the patients from these centers who make up most of the studies about addiction and about how hard it is to kick the drug habit. Clearly, the Schachter study strongly suggests that the world is getting a distorted report about the addictive process. About 10 percent of the population fall into addictive patterns with drugs. They frequently switch drugs, as is happening with crack. Heroin users are switching to it, so crack sales are going up, heroin sales are going down. What is not happening is any significant rise in the number of addicts. Similar conclusions can be made from a large drug study on returning Vietnam vets ordered by Richard Nixon. Nixon, who rarely relied on the powers of social science research, thought the country should know how many vets returned as addicts. This was in response to an outcry from Americans who seemed to regard all returning veterans as junk- ics. The director of the study, Dr. Lee Robbins of Washington University, had a large sample to draw on. She chose chose soldiers returning to the United States in 1971. Of the 13,760 Army enlisted men who had returned, 1,400 were found to have urine that tested positive for drugs (narcotics. ampheta- mines, or barbiturates). In short, these 1,400 men were unques- tionably drug users. Of that sample, she retested 495 men eight to twelve months after their return home. The results were crystal clear. Only 8 percent of the men who had been dru positive in their first urine test remained so. Therefore, 92 percenil of those using drugs upon their return home simply quit, walked away from dependence on the substance they enjoyed in Viet- nam. It was the remaining 8 percent that were making their way to the rehab facilities-the hard-core addi This finding is staggering in its implicationsr"tually every study and every statement made about human addiction is based on the image that heavy drug users are victims of their sub- 6UM19V99

.. M.a rM.. M .. Mrs .. r~ t.r,r 1lr. r.r r. rrr I.• 144 Addiction stances. Yet Schachter's work suggests that the vast majority of humans are able to walk away from a drug should they choose to do so. Those who cannot are not so much victims of a ravaging physiological need as they are of a certain psycho- logical character. That psychological profile, no matter how it might be characterized, is what is at issue-not the substance abuse) As we explore the matter more deeply, we shall see that much of this profile can be attributed to the mind of the addict. I I The Effect of Drugs Drugs, of course, are the stuff of the "hard" addictions. Drugs do not require six months of planning to produce the rewards that lead to the "soft" addictions. The martini, the joint, any mind-altering substance is quick and, for the most part, cheap' in our culture. It can be experienced once, twice, three times daily and still be within the realm of social acceptance. Drugs offer a speeded-up version of experience. They overpower some, people and send them into a downward, unhealthy spiral. Some' of these substances will create a physical dependence. Yet, when that dependence is remedied, the cold reality of the psychological, addiction becomes apparent. In order to realize the depths o~ the psychological habit, it is necessary first to understand the relationship between addictive behavior and real physiologicaif dependence. ,';r The American Psychiatric Association defines addiction.?s "dependence on a chemical substance to the extent that a physio% logical need is established. This manifests itself as withdrawa~ symptoms . . . when the substance is removed." This narro:~ definition raises the issue of physiological dependence. It W come to be believed that addicts are tied to a physiologica~ process, and that bodily need drives the addict to eontinuallT_ seek the drug. As I have said, nothing could be further frota the truth. ~ Addiction 145 When an addict phases out his use of a narcotic or alcohol, there is an immediate but medically controllable period when his body must adapt to the absence of the substance. Cellular changes go on, but there is little understanding of what they are. Yet the effect of the drug's removal is visible. For the first twelve hours after stopping heroin, for example, muscle pain, sneezing, sweating, tearing of the eyes, and yawning can occur. From about thirty-six to seventy-two hours after, more severe and uncontrollable muscle spasms occur, along with cramps, restlessness, increased heart rate and blood pressure, sleeplessness, vomiting, and diarrhea. These symptoms gradu- ally decrease over five to ten days. While it sounds awful, it can be no worse than a bad case of the flu. Yet, once the drug has been gradually removed and the physical dependence on it is no longer a factor, 90 percent of addicts will return to their old habit, as we have noted. Their bodies do not crave the substance; their minds do, and mind problems are the most difficult to solve. There is one physiological phenomenon that bears on the addictive process, and that is the development of tolerance for a drug. Tolerance is loosely defined as the adaptation of the nervous system and other bodily organs, such as the liver, to a set dose of a substance. The net effect of the building up of a tolerance is that it takes more and more of a drug to produce a given mental state. Again, the first assumption is that we are dealing with a purely physiological phenomenon. With alco- hol, for example, the liver becomes more efficient at metaboliz- ing the substance, thereby creating the need for more to be consumed in order to achieve a high. This is referred to as metabolic tolerance. There is also something called pharmacody- namic tolerance, where it appears that certain cells in the brain become adapted to a drug's presence and as a result do not respond as vigorously. Yet even with tolerance there is a psychological factor, in that learning also plays a role. In one study, a group of rats MssEM9

M M M M M M~M MW M4MMM am M M MW I I I I I 146 Addiction trained on a maze were injected with alcohol before each practice session. Another group trained on the same maze, only they were injected with alcohol afta each sesn ohc ~nohol before called a test day, both groups were g the test session. The rats cc `e1 hanache alcohol that had been practices performed far b given alcohol afterward. In short, tolerance is aho, plp- nomenon that ties together physiological and psyc gicaPro cesses. Nowhere is all of this more evident than with heroin. Heroin The closer heroin addiction is examined, the easier it is to see both physiological and psychological factors in it. Consider Sam J., who fell into heavy narcotic use in New York City. ecause There it is easy to d~i lo heddi~ of living there,tand the level of the city's comple y. of poverty in some quarters, but bccause of thfi~` p Lf llity of drugs. Obviously, availability is the necessary . Sam started using heroin, the choice of many heavy abusers. He had taken the drug on a dare one Saturday night and had not been impressed. It had made him frie ds dared him ag ~• A few weeks later, the same g oP uickl This time Sam felt the euphoria. Heroi Subwshi hehmbood~ne, had P breaks down into the mind-altering done its damnable trick. Sam was hooked, but he th hC user intelli- gently gently so. He was sure he could be a Saturday nig Unhappily, however, Sam turned out to be one of the 10 percent of people who, afte i being oae a~on or dropping it altogeth ~~ difficult time using After several weeks, Sam began to seek heroin more often. He gradually lost interest i~hisi ~'h ghcs hoolttcachchisbegan easily, and Sam, once a r pec his career as a mugger. His life took a downward spiralunti, by good luck, he was able to take part in a new drug p og M6699tqg Addiction 147 at Rockefeller University in New York. The program did not make sense to him. Another narcotic, methadone, would be given to him free, and he would have a free room at Rockefeller Hospital. The doctors held out hope that this would control his appetite for illicit drugs and allow him to return to a function- ing life. Sam is a composite addict, the sort of prototypical patient we all have images about. However, the Rockefeller program, under the direction of Dr. Vincent Dole, was real. Dole, realizing there was no known mechanism of addiction, or tolerance, or dependence, reasoned that the problem should be dealt with clinically in a pharmacological setting. It was a solution geared to the physiological problems of addiction only: vary the narcotic and see if the patient is better off. The springboard for methadone therapy came from work done in Kentucky showing that narcot- ics of all kinds have different effects on the nervous system. That is, they act at different sites with different durations. Dole hoped to find a drug that would satisfy the body's physiological dependency only and leave the mind alone enough so that the addict could participate psychologically in society. Dole took the dispassionate, biological view that the body needed chemicals in these dead-end cases of addiction. Supply- ing those chemicals seemed highly reasonable and allowed for the possibility that the person, even though continuing to be drugged, could still function. From the start, his idea was not exactly in the mainstream of thought on how to "help," but in retrospect, his work has illuminated many of the problems of the addict. + After a couple of false starts with inappropriate narcotic~, Dole hit on methadone. He was up against the problem of tolerance for heroin in the addicts he was trying to help. If 10 milligrams of heroin is injected into an addict and a nonaddict, the blood concentration of the narcotic over time will be identical for both. The difference is that the addict has built up a tolcrance, and his euphoria lasts for a shorter time. And after an identical

M.~ M M M ~ an MM M ~ 4M Ift am VU ~ M ~ W I I 148 ^ddiction single dose is administered, the addict will go into withdrawal within a couple of hours, whereas the nonaddict may not experi- ence withdrawal at all. What Dole figured out was how to adjust the dose of methadone so that it was above withdrawal level for the addict at all times. Because he was not in withdrawal, he could function. Methadone does not produce withdrawal symptoms because of the way it is metabolized in the body. Addicts are given between 50 and 100 milligrams per day. The drug is admiiiistered orally, causing absorption through the intestines and the liver, which essentially buffers its action. After methadone reaches the intestine, it is taken by the blood to the liver, which, on the first pass-through, retains approximately 85 percent of the drug. Then, each time blood circulates through the liver, more drug is released from storage. Thus, methadone enters the blood- stream slowly just like a time-released cold capsule. This grad- ual input is important, since the effect drugs render on our consciousness comes most easily when there is a quick rise in the blood level of the drug. The brain seems to need a shock, which could sensitize it in some way to the next dose. But with a chronic, low-level change by means of an agent such as methadone, the psychological effect seems much less intense, if it is present at all. t As already mentioned, the psychological reaction of addicts : to methadone is completely different from the reaction to heroin.; In a period of a few weeks, they stabilize and begin to livq~ productive lives. They are still on a narcotic but not one that produces euphoria. Their craving for heroin stops. Actually,.' most of the outpatients in the Rockefeller program did try street, heroin after the methadone took hold, but once or twice proved; enough. The heroin no longer had a euphoric effect and had± little psychological value. With the high doses of inethadon~. ~, in place, their tolerance for narcotics in general was high enougl~ to render the shot of heroin ineffective. ~ It almost goes without saying that the methadone solutiow , Addiction 149 engendered much criticism. There were claims that methadone didn't work as reported; that the addicts returned to the streets to find other drugs that produce a high; that they were selling narcotics at the methadone clinics. It is fair to say there were numerous examples of each of these failures. There was also the serious problem of stopping methadone addiction. While withdrawing from heroin is a week's trauma, coming off metha- done can take months and is usually compounded by several relapses into heavy narcotic use. In fact, in one major follow- up study, while there was markedly reduced criminal behavior and illicit drug abuse on the part of those patients carefully maintained on methadone, those who went off fared poorly. Still, at this writing it is one of the only ways known to be successful in controlling the problem of the committed heroin addict. A 1985 study showed that if a support system is part of it, the methadone treatment is highly effective in removing these addicts from a Gfe of crime and uselessness. This is not a perfect world. The methadone-stabilized patient exemplifies the range of psychological variables that make up an "addicted" patient. In reviewing this scenario, we must remember that the vast major- ity of heroin and other drug users walk away from heavy use. Those who end up as part of the 10 percent who become addicted are a special subset of the general population. Dole reported that there were aIl types in the group he assessed after the patients were stabilized. They tended to have similar attitudes about Gfe before entering the treatment program, but once controlled, the still-addicted patients were as diverse as the cured, nonaddict group. Other observers disagree with this appraisal and instead report that addicts tend to be the type that seldom admit they have a problem. They have lots of rationalizations for their habit. For example, they maintain that what they are doing is entirely Pleasurable, and that everybody needs some form of release. They reason that there is nothing wrong with getting high

~.W mm" =am lml M M Mom M Mm M M M W f I I I I i S0 ^ddicdon now and then. Their reasons for not facing reality are endless, and they always maintain that no problem in their lives is of their own making. If the car breaks down or if the court takes away their children, it is someone else's fault, never their own. There is in the addict no sense of personal responsibility. To the extent such evaluations are accurate, they raise the question of whether the addict is one who forever sees the world as beyond his control. The environment makes things happen to him; he can't make things happen in the environment. Given that outlook, he sees the effect of drugs on him as only one more piece of evidence that he is merely a pawn in a preordained scheme of things. Alcohol Most of us are fortunate enough not to have to deal with the problem of heavy drug use. The main addiction of the American middle class is alcohol. After years of denial, we have finally recognized it as a major problem. To this day, the New Englander arriving at the emergency room with an alcohol- related injury and in an obvious state of inebriation will deny he has had a drink. Even today, drinking is not viewed as acceptable in New England, although everybody does it. At the same time, the New Yorker in the same situation at Bellevue doesn't have this social constraint and freely admits to drinking. Americans like to drink. It accounts for about 3 percent of their personal expenses and is a pattern that starts early in life. It is estimated that over two thirds of males and females drink, and the heaviest drinking is done between the ages of sixteen and twenty-five. The chances of finding a drinker, as opposed to an alcoholic, in any age group are higher among the more aBluent, the more highly educated, and among Italians and Jews. More interesting, the drinking pattern of youths, which shows a high frequency of drunkenness and alcohol-related absence from school or work, in no way helps predict whether or not Addiction 151 they will become alcoholics. In short, in the early years, novices, future alcoholics, and social drinkers all can behave the same. As is the case with sinister drugs like heroin, exposure to and use of alcohol does not mean addiction will follow. For 211 those who start drinking early in life, approximately 5 to 10 percent continue and become alcoholics. The highest rates are for thirty- to fifty-year-old men, and there is a greater incidence among lower socioeconomic groups and among Cath- olics, especially French and Irish. The toll for this widespread alcoholism is seen everywhere. In general medicine and surgery, for example, upwards of 35 percent of all cases are alcoholics. But here again, one has to be cautious in interpreting what this means. Alcoholics may have a host of other problems, including abnormal mental states, and it is these other factors that contribute to their higher medical risk. Alcohol is a depressant drug. In social situations it is frequently used to loosen one up, to act as a stimulant. In fact, however, the alcohol is assumed to have an anaesthetic effect on some part of the brain, thus allowing for the release of inhibitions. At present, the actual mechanism by which alcohol produces the psychologically stimulating effects associated with its use is not known. One of the current theories suggests that alcohol produces morphine-like substances in the brain of some individ- uals, and that these substances give rise to more intense sensations of pleasure, resulting in a greater probability of addiction. This promising lead of tying alcoholism to opiate systems remains to be confirmed. It is known, however, that a genetic factor exists in alcoholism, thereby suggesting that some people ar'e more susceptible to such bodily chemicals than others. Studi~s of adopted children reared apart from their alcoholic parents show that they are five times more likely to become alcoholics than are adopted children of nonalcoholic parents. Another aspect of alcohol abuse is that it does damage through- out the body-notably to the liver, where it can result in cirrho- sis, and to the esophagus, which can lead to esophageal carci- M6s99vog

MMMMMMM Mon , I f 152 Addictian noma. Recent research also links it to brain damage. Rats that have been exposed to chronic alcohol use show marked cellular changes in their hippocampus, the brain structure that is crucial to memory. There is evidence that some degeneration of the cerebellum, which manages motor control, is possible in the seventh decade of life. Also, some heavy drinkers of Italian chianti contract a disease that attacks the corpus callosum, the nerve cable between the two cerebral hemispheres. +' There are other brain abnormalities that may develop with alcohol use, and these are the result of improper diet. If the brain does not get sufficient vitamins, severe damage can occur. Korsakoff's syndrome, a disease that afliicts heavy beer drinkers;A is common in Boston and in Ireland, but not in London. Suppos-~ edly, this is because American and Irish brewers pasteurize their beer, which kills the vitamins. One wonders how well a vitam'u l, enriched beer would sell in the United States. Theories about the causes of alcoholism are many. In addition l to the evidence for genetic influences, deficiencies in the metabab lism of certain enzymes have been proposed, and there is e~ dence that some personality traits are associated with alcoholism~ Whatever the cause, treatment theorists agree on one pointy once an alcoholic, always an alcoholic. To some extent, thc~K ke are totally apart from other drinkers. While most social drin ~ have a drink every night, alcoholics drink in spurts. They ~ on a binge and then abstain for days or weeks at a time. Onf~ about 30 percent of them spontaneously seek help for theit' problem. Alcoholism is difficult to treat because of the social acceptab'iH ity of drinking. The alcoholic faces temptation every day, everji where. For this reason, many alcoholics are not treated unii! the stage when they begin to hallucinate and become deliriou~: The treatment itself is entirely psychological and must be activid continued throughout the life of the alcoholic. A list of treatm ~ef±t options from the National Institute of Alcoholism emphasiies the psychological aspect with great clarity. Group therapy, f fi#; AddictiOn 153 ily therapy, educational counseling, and behavior modification are but a few of the avenues open to the alcoholic. It is a long path to recovery, a path full of potholes, and the fifty-billion- dollar-a-year liquor business does not seem threatened by the rate of rehabilitation of hard-core alcoholics. Cocaine In recent years, attention has turned away from alcohol and has centered on cocaine. The current euphemism is that it is a recreational drug that every self-respecting yuppie should have as part of his weekly experience. When originally popularized, it was cited not as addictive but as energizing and imparting a heightened awareness. Cocaine has been the mind-altering sub- stance of choice starting in the late 1970s. Cocaine is a stimulant with a history of being in and out of fashion. It was introduced in Europe only after a method had been developed for isolating cocaine from the coca leaf in 1855. Prior to that, its importation did not result in significant use, in part because the coca leaf does not travel well. In 1880 a Russian nobleman and physician working in Germany reported that it was an effective anaesthetic. By the turn of the century, physicians thought it would be helpful as an antidote to narcotics (like morphine) and alcohol. Sigmund Freud, then a neurologist in a Viennese hospital, picked up the lead and tried it on his alcoholics and drug abusers. He also tried it himself. He was so impressed that he wrote a highly influential review article called "On Coca." He became an avid user of cocaine and wrote another paper about it, "Song of Praise." None of this was lost on the Coca-Cola company, which added an extract of the coca plant to its product between 1896 and 1906. Coke was truly "the real thing." Cocaine has a chemical structure close to that of the local anaesthetics lidocaine and procaine, which are commonly used in dentistry and surgery. These drugs act as anaesthetics by M6699vog

10 MMM MMMMMM MMMMMMM~w I I 154 Addiction somehow changing the membrane of peripheral nerve cells, making it more difficult for them to discharge and therefore to impart their messages to the brain. Here's how scientists think the mechanism works. Nerve cells have a sheath of lipid (fat) around them. When a nerve starts to discharge, channels in the lipid membrane open up to allow sodium ions to flow from the outside of the neuron to the inside. This triggers an electrical current to travel down the nerve. Gidocaine, procaine, and, presumably, cocaine bind with the lipid to somehow block the sodium channels and thereby prevent the nerve from firing. The similar action of the three chemicals suggested that, in addition to cocaine, one of the local anaesthetics might also. produce euphoria if administered to the brain, which has turned out to be the case. Snorting lidocaine gives eN'ects similar to those experienced with cocaine. When introduced into the brain, cocaine primarily affeets the sympathetic nervous system. Cocaine use causes an immediate increase in heart rate and blood pressure, and in large dose4 raises body temperature and causes dilation of the pupils. Thcsc palpable effects go along with what seems to be increased mentl activity, euphoria, sexual desire, and an overwhelming sense of self-confidence and well-being. The drug does not impaif the memory system, which means that when it wears off and the taker reassesses matters, he can suffer a depression that comes from realizing that the same imperfect person is once again housed in the same imperfect body. There is no clear understanding of how cocaine causes the grand effects. Other drugs that alter the sympathetic systetri do not produce the euphoric state. What is known of the behavio~ of cocaine in the body is reminiscent of the observation aboLt ,:~ ~ narcotics. The euphoric effect is created by the sudden change in blood level of the drug. Thus, injecting cocaine intravenousf~ or smoking cocaine paste causes a faster and fuller sensati&t; of euphoria than does taking it orally or snorting it. As wi the narcotics, the overall blood level of the substance can ren~a~tt: Addictaon 155 high while the euphoria disappears. In order to regain the eupho- ria, another blast is called for. It is still too early in this culture's experience with cocaine' to know all its effects. We do know that chronic snorting can cause damage to the nasal septum. It can induce hallucinations and psychotic symptoms, anxiety and irritability and stroke. And it can drive you to the poorhouse. Yet it is everywhere. In 1980, U.S. Customs officials reported seizing sixty-five hun- dred pounds of cocaine, while in 1960 they confiscated only eleven pounds. Currently, it is estimated to be a thirty-five- billion-dollar cash business in the United States alone, which would make it our sixth largest industry. The social reinforcements to cocaine use also contribute to its popularity. In American society, the effects cocaine pro- duces-alertness, increased mental activity, decrease in appe- tite--are all very appealing states of mind. It sounds as if it were designed for the middle and upper classes, all of whom cherish such indulgence. Consider the Wall Street trader who is working in a highly stressful and frenetic atmosphere. He is a perfect candidate for the cocaine lifestyle. He makes plenty of money and so can afford the drug, and he has every reason to take a stimulant that will keep him alert on the trading floor. At night, coke has the social acceptance of the business commu- nity. It keeps them awake to party after a long day at the office. But quickly the routine turns vicious. Sleep becomes almost impossible, causing greater fatigue and then greater cocaine use to stay awake. Eventually, such individuals must submit to careful medical observation and be brought down with sedatives. Is cocaine addictive? Undoubtedly it is, although the effects are surprisingly varied. Until relatively recently, it was widely believed that cocaine was not addictive in a physiological sense and that the user did not develop a tolerance for it. Proponents had maintained that repeated doses of the same amount of the drug had the same psychological effect, but it is now known that heavy users must drastically increase their dose to achieve

..r .. m... M.r r.rl .. rs M .. m.rl .. rrr r rr ..r w 156 Addiction I f , similar psychological highs. Whereas the average dose for an occasional user is only 25 milligrams, some people can take up to 10 grams per day, according to reports. For a novice, such a dose could result in convulsions and even death. At present, the tolerance is thought to be largely metabolically based. Cocaine, when first used, stays in the blood in a potent concentration for approximately one hundred minutes. With repeated use, it stays in the blood only fifty minutes. Some people respond in quite the opposite way and find that, with continued use, it takes less and less of the drug to produce the desired high. This points up a number of interesting aspects of drug use. First, there is tremendous individual varia- tion in how people respond to drugs. Many scientists assert tHat cocaine somehow prevents the reuptake of the brain neuro- transmitter dopamine. As a consequence, the cells that dopamine innervates remain "turned on" for a longer period of time. Another proposal is that cocaine produces a"kindling effect" in crucial brain structures associated with mood changes. The kindling effect is a concept borrowed from epilepsy research, where it has been shown that slight electrical stimulation of the brain over a long period of time eventually becomes effective in producing seizures. As applied to cocaine, this theory proposes that there is some kind of pharmacological kindling going on where the drug has established an active center in the brain; With chronic cocaine use, the brain center fires off with only a small trigger from the new intake of the drug. This is only hypothetical for now. What is not doubtful, however, is the variation in response seen with chronic use. Cocaine is psychologically addictive. It is habit forming, and for those who take it intravenously or smoke it, it can be ea tremely destructive. In addition to damaging the pulmona~ system, it can produce drug-seeking behavior, which preven , the addict from functioning in society. There is no doubt thg the Saturday night or occasional user can easily survive-yt., cocaine experience. On the other hand, the heavy user Ls:m Addiction 157 for a long struggle with life. Cocaine addicts are now the major- ity of clients at any drug rehabilitation center. In 1975 they were small in number. Starting in 1986, cocaine was modified and sold in a raw form called crack. Unlike traditional prepara- tions, it can give a powerful and quick high when smoked, like the effect of the intravenous blasts that used to be favored. Marijuana Marijuana, or Cannabis sativa, is another drug that is consid- ered psychologically but not physically addictive. Marijuana was barely available in the United States until Prohibition in 1920, when working-class people began growing it or smuggling it in as a substitute for alcohol. In 1937 it was outlaweu in the United States. In the nineteenth century, Baudelaire, a heavy user of hashish in Paris, wrote about the effects of the drug in terms that correspond with more modern experience. He de- scribed the euphoria, uncontrollable laughter, paraesthesia and weakness, perceptual disorders of time and space, and mental confusion and incoherence that can accompany its use. Psychia- trists at that time commonly recommended the drug to their students, so that they could gain insight into mental disorders. Marijuana was the drug of the 1960s. It fulfilled all the needs of the Vietnam years. While much of youth was upset about the war, they wanted a drug that was a thorn in the side of the older generation. Marijuana did the trick. It was illegal, which meant it was fun to deal in. There was some risk involveii, some form of rebellion associated with its use. Smoking it then became a cause in itself, and all the usual arguments were trotted Out to support its legalization• it is not addictive; every culture has its mind-altering drug, so let us have marijuana; pot is simply our generation's equivalent of a worse drug-alcohol. The arguments were partly true. Marijuana is not addictive in the physiological sense. Some claim that for heavy users it takes less and less to achieve the same psychological effects. In M66mu