Drugs On Our Minds: Historical, Social Perspectives on 'Modifiers of Affect'

There are more theories about why we use drugs than there are drugs. We avoid reality, abandon morality, suppress hunger pains or other unpleasantness, or turn away from God. We sell drugs out of greed or for upward mobility. Drugs cause brain damage, cancer, personality change and constipation, incite police corruption and political upheaval. We make drugs illegal in order to protect children or to support the underworld markets. Every theory grinds the axe of its proponent.

To understand our fascination with drugs in the first place, we need to ask some basic questions, such as "Why do we like to take poison in small quantities?" The truthful answer is always some variation of "To feel better." How does this come about, and why do we have so much trouble with it?

Psychoactive drugs modulate affect by acting upon both the central nervous system and the physical processes which we ordinarily associate with emotion. When we notice the relaxation of our muscles brought about by a benzodiazepine, we think that we are calmer. Drugs also act directly upon circuits that convert implicit and largely unconscious processes into explicit, linear awareness. Examples are the filtering effects of phenothiazides or serotonergics upon hallucinations and delusional or obsessive ideation, so that the cerebral static of what psychoanalysts call "primary process" and neurobiologists call "implicit imagery" is blocked from narrative consciousness.

A young man, confined involuntarily to a state hospital and diagnosed there as manic-depressive, sought to challenge his being medicated against his will. He had been detained because of his relentless pursuit of a woman who did not reciprocate his affections, and was terrified of him. His usual career, however, was that of a soap-box orator, whose message was one of hideous neo-Nazism. In all other respects, his mental status was rational, organized, controlled and cooperative, though his handshake betrayed constant hyperhidrosis, and he seemed at times edgy and pressured. His objection to treatment with lithium? "It takes away my politics!"

Nathanson was one of the first to explore the relationship between psychoactive substances and their effects upon specific affect systems, noting that alcohol is a very efficient and rapid down-regulator for the affect of shame. My own clinical work with juvenile offenders strongly suggests that cannabis is a specific attenuator of anger, in direct contrast with "Reefer Madness" doctrine. (Whether this is a direct influence upon the noradrenergic system, or a by-product of cannabis' remarkable muscle-relaxant action, is unstudied.)

Amphetamines, on the other hand, appear to increase interest and excitement, thereby enhancing attentive focus. Psychedelics, which lower the threshold for implicit imagery, provide a distraction that enables the user to avoid unpleasant shame-affect.

Affect Evolvement

According to current theory, affects evolved as biological systems that intensify response to stimulus change. Sensory neurons produce electrical and chemical signals to affect-generating mechanisms, which in turn modulate behavior. The entire event is then recorded in memory, whose emotional coloring is based upon the affects involved. Perhaps it was only a matter of time before an animal evolving a technology discovered that its sensory, affective and emotional apparati could be neatly bypassed by supplying the necessary neurochemicals from exogenous sources. What we have discovered, for better or worse, is that the same intensity of motivation for action expected to produce feelings of success in the world is instead directed toward obtaining chemicals capable of producing the affective experience.

Let's look at the opiates, as an example. Under stress or challenge, we produce a very long polypeptide molecule, which, when exposed to several enzymes, breaks down into a molecule of noradrenaline, one of insulin, and several endorphins and enkephalins. The first stimulates the sympathetic nervous system and suppresses acute pain, the second mobilizes energy from carbohydrates, the last few put on the brakes and suppress less acute pain. It is as if the entire operation were designed to activate a response to an emergency, facilitate action, then pause to recover lest the organism exhaust itself. The action of the endorphin molecule, which fits mechanically onto its neuroreceptor, like a key in a lock, is to signal that the crisis is over, the battle won, the predator defeated, the deal closed and the mate secured.

To be even more specific, opiates appear to activate the same pathways between orbitofrontal and hippocampal areas as are stimulated in earliest face-to-face encounters between infant and mother, in which smiles are exchanged and feelings of joyous attunement are constructed. In the language of Tomkins' affect theory, joy-enjoyment is triggered by a particular rate of decrease in stimulus intensity. In higher doses, the rush of euphoria is attributed to dopamine release in the mesolimbic areas, found also in the action of cocaine. I am tempted to predict that a rapid infusion of money would produce the same action, but can imagine no ethical experimental procedure to test such a hypothesis.

Now it just so happens that a certain plant wraps its seed pods in an alkaloid that contains molecules of precisely the same shape as mammalian endorphins. The outcome is that we can use poppy extract to produce the illusion of feeling successful through stimulating affective centers mediating joy-enjoyment. It therefore becomes unnecessary to exert other effort in our environment to achieve the same result. What is more, opiates are relatively clean drugs, with few untoward effects upon most individuals' bodies other than anticholinergic constipation. The sense of completeness and achievement alleviates pain and hunger. In fact, nearly all of our alarm systems are silenced. We experience no distress, and we do not respond empathically to the distress of others. (Little wonder that children of opiate-addicted parents are so often less forgiving and in less conflict over their hostility toward their parents than children of other chemophiles. Their detachment is more nearly complete.) It is as if we have had a temporary brain bypass, so that we can be exposed to life's problems and pains, even overindulge therein, and not have to endure nor act upon them.We can hereby understand why heroin use is so popular among antisocial personalities, but rarely of interest to psychopaths, the latter's affect systems being chronically under-active to begin with. Most of the former would qualify as having borderline characterological structures and suffer from chronic dysphoria. Their drive for excitement is, in Nathanson's view, an "attack-other" script, designed to alleviate shame-based affective overload. Opiates allow not only direct relief, but also a culturally determined opportunity for the excitement of scoring. Most psychopaths, however, prefer stimulants, alcohol or occasional psychedelics.

It should be apparent that whether a drug is used or abused is entirely dependent upon context. Casanova (who was a physician) is reputed to have said, "In the hands of the wise, poison is medicine. In the hands of a fool, medicine is poison." Until late in the 19th century, doctors held morphine to be God's gift to medicine. Only as opium began to be used for political purposes (i.e., for social control), did it acquire a pejorative reputation. The first law against this family of drugs forbade the sale of opium to Chinese laborers, who were perceived by the new wave of Irish immigrants to have an unfair advantage in being able to work for less, under harsher conditions, if provided the drug (Szasz, personal communication).

From an evolutionary standpoint, Diamond posits that drug abuse may be unique to humans, and likens it to other animal behavior which courts danger, such as the "stotting" of gazelles (affecting a peculiar lurching gait, as if crippled) in the presence of predators, or the growth of extremely ponderous and awkward plumage in birds of paradise. His theory, attributed to the Israeli ethologist Amotz Zahavi, is that flaunting danger can be attractive to potential mates, as if to say "My genes are so terrific that I can get away with anything!" This suggests an entirely new theory for the psychodynamics of codependents of addicts and alcoholics.

However, the assertion that danger or risk-taking is a driving force in motivating drug use overlooks history. The idea that drugs are physically dangerous is only a very recent innovation, after perhaps thousands of years of drug use by many cultures.

Danger and Drugs

When evaluating a drug for "dangerousness," it is really necessary to inquire as to what kind of danger is in question. Physically, most common medicines are dangerous in overdose to most people, some are dangerous in accepted therapeutic doses to a few allergic or hypersensitive individuals. Street drugs are popular precisely because they are, for most users, relatively benign physically, in their immediate direct organic effects. Only the most impoverished children, those who cannot afford less hepatotoxic or renotoxic substances, resort to inhaling hydrocarbons. Even then, use stops as the noxious effects outweigh the pleasurable ones. Likewise, the chronic use of alcohol tends to abate when stomach and liver rebel. Most nonintentional drug deaths are caused by either overdose due to ignorance of the potency of the compound being used, or by idiosyncratic reactions, such as cardiac arrest or anaphylaxis, not unknown in legitimate pharmaceutical circles.

I suggest that the addictive potential of any substance is inversely proportional to its immediately perceived physical danger. We ignore long-term effects, as with carcinogenic tobacco, because our affective systems respond mainly to the immediate antidepressant effect of nicotine. Our perception of danger in drugs, as implanted by our culture, could well make them more attractive to those seeking stimulation or distraction from the dysphoria of lives gone bad. On the other hand, prevention programs that focus upon social and economic dangers are likely to be taken more seriously by potential users who would rather avoid looking stupid than worry about getting hurt.

The real danger of drugs is their potential for social destabilization, of individuals as well as cultures. Social animals use affect as a means of communicating internal states in order to coordinate communal efforts. Affect (or its empathic communication) is the very glue of social organization. It is impossible to modify one without the other. If one's affective system is bypassed, he becomes insulated from empathic influence. The primary complaint of the family of the addict is that he or she has become inaccessible.The development of human language provided us with the first major revolution in affect modulation, a kind of Pleistocene high-tech affect management. Language provides a device for extremely powerful magnification of affective response. As a tool for this purpose, it has been in use for hundreds of thousands of years, after much research and development by pre-Homo sapiens. Looking at drugs as new technology, it will be easier to see why we are so wary of their introduction.

I recently had the privilege of touring a small winery near Macon in France, where the vintner had amassed a remarkable collection of vineyard and wine-making tools and machinery dating back hundreds of years. These included dozens of odd-shaped little hand axes, which had been used to prune vines for centuries. One day, someone invented a simple pruning shear, which enabled one worker to do in a day what had previously taken four. The innovation was met with intense hostility and opposition. The problem, of course, was that the device was at first socially destabilizing. This is a potential problem with any invention. We usually invent tools in order to increase efficiency. However, when labor is no longer necessary, workers are devalued. This is the story of the industrial revolution, and it is always one of the more difficult trade-offs of human civilization. Even our own profession is not without its rift between the psychoanalytically oriented therapists and the psychobiologists.

Drugs are a more efficient way of modulating affect, in that they make the usual work of conversation, social discourse and relationships less necessary. Since these activities are part and parcel of culture, and as such are organized around rules codified in religion and morality, it is little wonder that the greatest opposition to drugs and even to their psychiatric use comes from religious and politico-ideological quarters.Governments are not always opposed to substance use by their subjects. Coca leaves were once an integral part of the culture of Central American Indians, whose kings lived at high altitudes in the mountains, and who enjoyed seafood. Their slaves, chewing the leaves for stimulant effects, were able to carry fresh fish from the sea up to the Andean alps, on the run. For the tyrannical Incan kings, coca provided a way of exploiting subjects. As another example, Lifton documents how the Nazis used alcohol in order to numb their Auschwitz physicians against the shame of their atrocities.

In a culture built upon a high degree of cooperation and reciprocity, euphoriant drugs are more likely to interfere with economic relationships. In our own society, the drug user is seen as a disabled and nonfunctioning member, a burden to those who must care for him, because he no longer takes care of himself.

Drug Classes

In psychiatry, most of our pharmacopeia is divided into two classes: the neuroleptics, for their effects upon dopamine-dependent circuitry between hippocampus and limbic system (with consequent "filtering" effect); and the affective modulators, stimulants or deactivators. The SSRIs, at this point, seem to act as both antiobsessive and antidepressant agents.

Most of medicine's affect modifiers are devoted to down-regulation, with two exceptions: the use of methylphenidate to increase interest in children who cannot otherwise sustain it; and of methadone, to induce enjoyment in antisocial individuals, thereby reducing criminal excitement-seeking. Traditionally, methadone treatment is based on the rationale that the individual on maintenance need not commit economic crimes to feed his habit. If this were always true, then methadone clinics would not need their elaborate rules regarding urine checks, daily trips to the clinic and rigid control of "carries." However, the function of the drug as a social stabilizer cannot be overemphasized.

A central problem in any kind of drug research is the differentiation of inherent pharmacological effects from social or cultural phenomena. The problem is even stickier where the substance in question is stigmatized or illegal. Consider the old saw that "marijuana use leads to the use of harder drugs, like cocaine or heroin." The implication is that there is something about marijuana itself that predisposes a user to seek more intense euphoria. Unfortunately, targets of antidrug educational programs are instantly disaffected by such propaganda, as it is so remote from their own experience. Nevertheless, there is a truth which becomes obvious when one looks at the social context of how marijuana is procured in Western cultures. It must be purchased almost exclusively from a dealer in illicit drugs, who has other products to sell. I suggest that expanded interest in illegal drugs is a result not so much of the use of any one of them as of empathic response to the interest-excitement perceived in co-users and sales personnel. We could test this hypothesis with a study of whether those possessing illegal handguns in Great Britain are also inclined to acquire assault weapons. If we focus upon maintenance of social function, we find that the optimum is not an absolute state of social stability, but one which allows gradual change or growth. We view total stasis as tyranny. Psychiatry's critics paint the use of pharmacy as an effort to stifle creativity or individual expression. By contrast, the use of illicit drugs is held tantamount to anarchy, if not treason. How much, then, is not too much?

A rational approach requires careful evaluation of how any agent enables or disables, according to its cultural as well as neurobiological qualities. In order for our approach to remain rational, we must keep in mind our own cultural biases or attitudes. We generally impose these when deciding whether a substance is being abused, by assuming a morally determined level of dysphoria to be a necessary part of life. If we judge a patient's emotional (or physical) pain to be beyond the range of that to be borne in encountering the slings and arrows of daily stress, we justify using and prescribing an appropriate affective down-regulator. If an individual seems to be complaining unduly of being stressed-out and we think he is avoiding necessarily painful conflict or decision, we consider his use of drugs to be abusive. In short, how much is someone supposed to hurt? This is a general rule that cuts across all categories of legal and illegal substances, and which needs to be made explicit in setting drug policy, and in clarifying treatment options.

References:

References

1.

Diamond J. The Third Chimpanzee. New York: Harper Collins; 1992.

2.

Lifton R. The Nazi Doctors. New York: Basic Books; 1986.

3.

Melloy JR. Violent Attachments. Northvale, N.J.: Aronson; 1992.

4.

Schore A. Affect Regulation and the Origin of the Self. Hillsdale, N.J.: Erlbaum Assoc.; 1994.

5.

Szasz T. Ceremonial Chemistry: The ritual persecution of drugs, addicts and pushers. New York: Doubleday; 1974.