Polypharmacologic drug abuse: Presentation and Drug abuse discussion of a case

ROBERT BLAIK, 0.0., MPH Washington, D.C.

The sharp rise in drug abuse in the latter part of This article focuses on an epidemiologic the 1960s, with its attendant costs to society, has led appraisal of the current trends of drug to a flurry of investigations. The problem has been abuse in the United States, presents and approached from several directions: epidemiolog- discusses a case of polypharmacologic ic," clinical with regard to specific types of neurophysiologic and pharmacol- drug abuse, and offers a stress hypothesis abuse, 8- 24 of drug dependence. Although some ogic,25- 34 psychodynamic and analytic, 35- 4 ° phe- childhood experiences seem to play a nomenologic, 4 " 3 and criminologic. 44.45 Even part in determining which subjects will the studies cited here are not all-inclusive, but offer become multiple drug users, the roles of only a cross section of research activity. Despite the investment of fink and energy by the the broken home and of childhood isolation appear to have been scientific community, the deceptive question "How overemphasized. The multiple drug user many addicts are there?" remains unanswered. In an attempt to answer this question, Greene, Night- is not likely to be hedonistic. Instead, he 46 recently coordinated efforts of appears to have found no better means ingale, and DuPont than drugs for reacting to stress, and the the Center for Disease Control, National Institute of physician can be most helpful if he Drug Abuse, and Special Action Office for Drug assumes that a person does not choose to Abuse Prevention in a nationwide epidemiologic as- sessment of evolving patterns of drug abuse. Their become emotionally ill, but needs study summarized the most recent government data guidance in handling stress. available on heroin, marihuana, , am- phetamines, and , and described some major demographic, geographic, and behavioral William Osler once stated that to know syphilis was characteristics associated with the use of each drug. A summary of their observations follows: to know all of medicine. In the mid-1970s, drug dependence is of similar significance. To under- Heroin use occurred in epidemic form in the United States dur- ing the mid-to-late 1960s, beginning in the inner cities of major stand the multifactorial origin, pathophysiologic as- metropolitan centers and then spreading to adjacent suburban pects, and treatment of drug-induced and drug- and smaller communities. There was a decline in heroin-use related illness, an investigators knowledge would prevalence in 1972 and 1973, primarily on the East Coast, which was associated with a sharp reduction in heroin availability. Both have to span the basic sciences, clinical sciences, and the availability of heroin and prevalence of heroin use in this clinical therapeutics relative to every organ system region appear to be increasing currently, probably in association of the body. with the expansion of the Mexican heroin distribution system.... With such an overwhelming demand for concep- Rates of marijuana use within the general population have been rising steadily over recent years, although this upward trend tualization, an overview of the subject appears im- may be levelling off in the school-age population. Marijuana has perative in order to organize existing knowledge become one of the most widely used psychoactive drugs in this country. In excess of 15% of the general population have had and demarcate future lines of inquiry. This article some experience with this drug.... will focus on an epidemiologic appraisal of the cur-. Rates of cocaine use were relatively low in the Marihuana rent trends of drug abuse in the United States, pres- Commission national survey data. Assessment of current subjec- ent and discuss a case of polypharmacologic drug tive impressions regarding a sharp increase in cocaine use awaits the results of the new nationwide drug use survey. It is of interest abuse, and offer a stress hypothesis of drug depen- that this impression is not reflected in data regarding cocaine dence. treatment and cocaine-related emergencies....

Journal A0A/vol. 76, August 1977 900/81 Polypharmacologic drug abuse

Rates of abuse of . . . [barbiturates and ] . . . ap- In the multiple-drug-abuse group the first illicit pear to be growing steadily, at least in the young-adult popula- drug experience occurred at a significantly lower tion. Individuals treated for abuse of these drugs appear to have serious, extensive, associated personal, social, and medical dis- age than in the moderate-experimentation group, abilities. The tendency of these persons to use multiple drugs and the first illicit drug tried was more often not (including serious problems with ) increases the risks in- marihuana than in the experimentation group. Be- herent in such behavior.... It has been estimated that there may be as many as 3,000,000 Americans who have serious problems cause of limitations in appropriate sampling, the in association with the abuse of legitimate psychoactive drugs. authors said that generalizations from their data should be considered provisional. Because of the often horrendous difficulties in At a different level of conceptualization from the treatment of the multiple drug abuser coupled with foregoing epidemiologic assessment of predisposi- the increasing incidence of abuse of more than one tions to drug abuse was the work of Greaves, nonopiate drug, 47 some investigators have begun to 49 who offered a broad and critical overview of five leading focus attention on primary prevention efforts to theories of drug dependence, which he listed as identify early life patterns predictive of later abuse of multiple drugs. a) the acquired drive theory; b) the avoidance paradigm theory; c) the metabolic disease theory; d) the conditioning theory; and e) Halikas and Rimmer48 retrospectively analyzed a series of behavioral events in early life in a popula- He expressed the belief that the first four theories tion of 100 regular marihuana users whose patterns "account for drug dependence only after the fact, of drug use spontaneously clustered in two groups, and the fifth is essentially incomplete." He con- multiple drug abuse, defined as use of more than cluded: two drugs other than marihuana, and moderate All theories of drug dependence miss the essential point: that drug experimentation, defined as use of not more persons who become drug dependent are those who are unable to than two drugs other than marihuana. provide themselves with usual forms of euphoric experience, primarily because of personality and attitudinal variables, and Early life experiences which differentiated the thus resort to drug use as a substitutive experience. multiple-drug-abuse group from the moderate- He stated also: drug-experimentation group centered about limit- We seem to have drawn the absolutely backward conclusion about testing events and other problems reflecting inter- the drug-addicted person that he is an actively hedonistic, nal personality characteristics, such as childhood pleasure-seeking, turn-on freak when he never was that. • discipline contacts, adolescent antisocial behavior, He suggested that the only way to treat the drug- police contact, homosexual experiences, self- dependent person is to place program emphasis defeating behavior in adolescence, substantial pa- not on good behavior and ascetic values but "on rental conflicts in adolescence, poor adolescent ad- helping persons to secure their basic pleasure needs justment, truancy and dropping out, and problems in nondrug ways." in high school socialization. Epidemiologic and theoretical conceptualizations Noteworthy also was a wide variety of childhood of drug dependence and abuse of multiple drugs family life experiences that were not found to be serve to suggest certain parameters for understand- significantly associated with multiple drug abuse in ing the complexities of the overall picture. For clini- the study population. The authors stated: cians, though, understanding flows from considera- Neither social isolation in childhood, a disrupted or turbulent tion of the individual case. For this reason the follow- home life, nor parents who served as role models of excessive ing case is presented to show the necessity for holis- personal drug use served to distinguish the polydrug group. tic consideration of polypharmacologic drug abuse.

901/82 Report of case died of prostatic carcinoma a year before and stated A 41-year-old married white man was referred to "I have not recovered from it yet." At the same time, the hospital by a local general practitioner on Nov. 6, the patient also had lost an uncle and an aunt. 1973, for his third psychiatric service admission be- He said he had felt "hopeless" for the past year. cause of suspected drug abuse. Previous hospitaliza- This feeling was centered mostly on his impotence, tions had revealed agitated depression, adult ad- and he commented "I no longer feel like a man." justment reaction, and essential hypertension. While he admitted suicidal ideation over this period, For the past year the patient said that he had felt he denied suicidal attempts. He stated that at pres- depressed, with difficulty in initiating and maintain- ent he viewed the future as hopeless. ing sleep, loss of interest in activities and people, and Phone communication with the referring physi- suicidal ideation. The following factors were iden- cian showed that the patient was taking Esimil (a tified by the patient as contributing to his depres- combination of 10 mg. guanethidine monosulfate and 25 mg. hydrochlorothiazide), 1 tablet twice a sion. day, and hydralazine, 25 mg., three times a day. In After having worked for about 20 years as a addition, he had been receiving intramuscular injec- machinist, he had been reassigned approximately 1 tions of 50 mg. Demerol biweekly for the past 2 year before to a position of punch press operator months for unremitting cephalalgia. Without the and supply handler in company moves to economize knowledge of the referring physician, the patient and cut back plant activities. The patient felt de- had been seeing another local general practitioner, moted, working at a reduced wage and finding the from whom he had been receiving Demerol injec- new work unpleasant. Furthermore, he had not tions and Demerol and Seconal tablets. He admitted been allowed to work for 6 weeks prior to admission that he had taken sixteen Seconal tablets in the 5 because of enforced medical sick leave due to uncon- days prior to admission. trolled hypertension. At the time of admission the patients wife said The patient said that he had experienced impo- that he had unequivocally abused medicaments re- tence for the past 12 months, only rarely being able ceived from these physicians and that at various to obtain an erection or sustain intercourse with his times she had found drugs under the mattress, in wife. This had depressed him severely as well as cabinets, and in other hiding places. She expressed creating guilt feelings in not satisfying his wife. He the opinion that drug abuse had gone on for the past had been unable to discuss this problem with any- 3 months. She brought in a bag of pills which in- one, including his wife, for the past year. cluded, in addition to those mentioned previously, He reported anxiety and tension also with regard dextroamphetamine sulfate and Quaalude (metha- to financial problems and said he had had intrac- qualone). table headaches over the past 2 years, which had Examination of the patients mental status showed grown worse in 3 months prior to admission and him to be in contact with his surroundings. Consid- now occurred daily. The headaches were described erable anxiety was manifested by moist hands, as bifrontal, nonradiating, and sharp and were asso- restlessness, tense posture, and strained voice. His ciated with dizziness, were brought on by tension, gait was moderately ataxic. He was accessible and and were relieved only by use of narcotics and/or cooperative until the conversation turned to drugs, sleep. but at this point he became noticeably evasive. He In addition, the patient said that his father had appeared defensive and submissive, with slow and

902/83 Journal AOAIvol. 76, August 1977 Polypharmacologic drug abuse

retarded reactive behavior. His speech was mildly speech, and ataxia. The pupils were equal and reac- slurred but otherwise unremarkable. tive to light and accommodation. He said that he felt anxious and depressed. His Determinations of electrolytes, urea nitrogen, and affect appropriately matched his mood. He denied erythrocytes gave results within normal limits. The experiencing feelings of unreality. He admitted to bromide content of the blood was 2.0 mg./100 ml., being worried and restless and said that his mood and the content imperceptible. The val- worsened in the latter part of the day. He said that idity of the latter result was considered questionable. his concentration and memory had been affected in The patients chemical, hematologic, serologic, the last 3 months. Although he denied feeling angry, and coagulation studies were essentially within he looked as if he was going to explode. normal limits. X-ray study of the chest was unre- Overt paranoid delusions, grandiosity, or halluci- markable. The electrocardiogram showed border- nations were not noted. line left ventricular hypertrophy. Study of a 24-hour Screening for cognitive functioning showed the urine specimen for catecholamines and vanillyl- patient to be oriented to time, place, and person. mandelic acid was within normal limits. Recent, intermediate, and remote memory ap- Impressions at admission were of polyphar- peared intact. He could recall only two of five macologic drug abuse, acute intoxication, seven-digit numbers and could transpose only one and agitated depression. of five five-digit numbers. He was unable to go Inquiry into family relations showed the patient to beyond 93 on attempts of serial "7s." Proverbs were be the oldest of three children born to parents ex- answered concretely. He was aware that he had a periencing their first and only marriage. He had two problem with drugs but did not seem to possess the younger sisters, who were 39 and 37 years of age. insight to relate their effect to his life functioning. The husband of the younger sister had committed Other aspects of cognitive screening were unre- suicide 2 years before. markable. The patient described his father as a fair, just, The following aspects of the patients past and mild-mannered man who rarely expressed anger, family medical history were pertinent: but said that "...it was awesome to behold" when he (1) He denied use of alcohol or . did. The patient remembered having been frigh- (2) His father had died of prostatic carcinoma at tened of his father because of his temper. He de- age 62, 1 year ago. scribed his mother as a strong person who seemed at (3) He had had the usual childhood diseases. times to dominate her husband. The family did not (4) He had had hypertension for 19 years, and share many activities. He said that, although the this had been treated continually with drugs for the various family members loved one another, "...it was past 5 years. Previous studies of hypertension for often hard to tell because they just didnt show their correctable factors had been inconclusive. feelings." (5) The patient had had an appendectomy in The patient graduated from high school at age 18, 1965 and transurethral resection in 1961. having been a B student with good relations with his Review of medical systems was significant only in peers and no history of disciplinary problems. He the report by the patient of unrelenting cephalagia had attended college for 1 year, then dropped out with dizziness. He had had no other sequelae of and began working. He had continued to live with hypertension, such as tinnitus, blurring of vision, his parents until his marriage 6 years before at age dyspnea, or paresthesias. 35. He had married a woman who was divorced and At admission his blood pressure was 140/100 mm. had four children. They had a set of twins after 11 Hg, the respiratory rate 16 per minute, and the months of marriage. His wife stated that the chil- pulse 80 per minute. His temperature was 97.6 F. dren hardly knew him because he had been in a fog Physical examination showed only hypertensive re- for the past year and that she was threatening to tinopathy, nystagmus on lateral gaze, slurring of leave him if he did not discontinue drug use.

903/84 The patient said that his drug problems had quirement of pentobarbital was estimated to be begun during a hospital admission for transurethral around 900 mg. resection in 1961. He said he received significant It was determined empirically that decrements of amounts of Demerol at that time. After his discharge 100 mg. per day of pentobarbital brought on with- he began going to various physicians and obtaining drawal symptoms, so an extended withdrawal regi- Demerol, at one time using as much as 600 mg. a men covering 30 days was instituted, with decre- day. He stated further that he began using barbitu- ments averaging 25 mg. a day. rates shortly thereafter in order to relax and turned The patients hypertension proved to be as thorny to amphetamines to get a "high." a problem as his drug abuse. His blood pressure In summary, he had had a 13-year history of in- varied between 140 and 200 mm. Hg systolic and tense drug abuse involving narcotics, barbiturates, 100 to 150 mm. Hg diastolic. This was finally con- other , including Placidyl and Quaalude, trolled on a triple drug regimen of hydroch- and amphetamines. lorothiazide, 50 mg. twice a day; propranolol, 60 mg. four times a day, and hydralazine, 75 mg. four Hospital course times a day. Reserpine and methyldopa were av- At approximately 1 p.m. on the day following ad- oided because of their propensity to induce or ex- mission the patient appeared considerably more acerbate depression. Guanethidine was discon- confused than before, with increased slurring of tinued because of the patients complaint of impo- speech and ataxia. The pupils remained equal and tence. reactive to light. A search of his room for drugs was As the patients sensorium cleared, psychotherapy instituted and revealed a container of Placidyl with was begun and followed by numerous family ses- one capsule remaining. Inquiry at the dispensing sions, involving on one occasion all six children in pharmacy showed that a prescription for thirty cap- the patients family. The range of stresses experi- sules had been filled 2 days before. When con- enced by the patient, including his impotence, were fronted, the patient admitted having taken nine cap- discussed in the family conferences. It is significant sules the day of admission and twenty capsules the that after the sessions, in which the patient was able next morning. He denied suicidal intent, saying only to abreact in the presence of his wife to his feelings of that his head hurt. An intravenous regimen was anxiety and guilt concerning the impotence, he went begun for purposes of hydration and augmenting on a weekend leave of absence and reported that he diuresis. Vital signs were monitored every 2 hours, had successful intercourse with his wife for the first with close observation for indications of hypoten- time in a year. By bringing his drug problem into the sion, decreased respirations and hypothermia, open and discussing it candidly with the entire fam- which would herald the onset of what can be a par- ily, the patient received support, and communica- ticularly nasty withdrawal state with Placidyl. tion was enhanced. Osteopathic manipulation was After review of the literature it was decided to employed intermittently as an adjunctive measure to cover the patients withdrawal from Placidyl relieve tension and predispose to the building of a (ethchlorvynol) by substitution of pentobarbital, ac- therapeutic relation by the laying on of hands. The cording to the method of the NIMH Clinical Re- patient was discharged on December 20 to a mental search Center in Lexington. 5 ° The acute intoxica- health center. tion state was allowed to run its course. Before the appearance of withdrawal symptoms, the patient Comment was given a 200-mg. test dose of pentobarbital. No Conceptualizing and treating the problem of signs of intoxication were noted 2 hours later. Then polypharmacologic drug abuse requires an attempt a second test dose of 200 mg. of pentobarbital was to understand holistically the interaction of biologic, administered, and 2 hours later, signs of mild intoxi- emotional, and social factors inherent in the pro- cation were noted. The patients initial daily re- gression of the illness.

Journal AOA/vol. 76, August 1977 904/85 Polypharmacologic drug abuse

It is much easier to entertain the inputs into these lem by treating the patients chief complaint phar- three areas separately than to describe their qualita- macologically instead of talking with the patient tive and quantitative interaction. For example, the and/or recommending referral for mental health patient may have had a predisposition to alcohol services.) inherent in his genes. His exposure to a father who (3) Finally, a person does not choose to become was "awesome to behold when angry" may well have emotionally ill (and certainly the cultural and educa- left him little short of terrified regarding the expres- tional development of society has reached a point at sion of anger. Perhaps he learned that it was much which drug abuse should be considered an illness). safer for him to "bottle things up" than to take a Instead, the patient does not know how to react to chance on expressing feelings which he associated stress in any other way. with havoc. While that may have been an approp- If one accepts the preceding suppositions, then riate coping mechanism in his childhood, his sub- the goal of therapy should be a holistic effort to help merging of intense feelings as an adult might the patient learn a more appropriate response to strongly predispose him to drugs under the pres- stress than the self-mutilation and disgust which sure of other stresses. Finally, as a result of an un- come from the use of drugs. happy home life, he may have internalized a poor self-image and considered the untoward effects of drugs an appropriate punishment for disappointing 1. DuPont, R.L., and Greene, M.H.: The dynamics of a heroin his parents. epidemic. Heroin abuse has declined in Washington, D.C. Science 181:716-22, 24 Aug 73 Inherent in these comments are the following 2. Levengood, R., Lowinger, P., and Schooff, K.: Heroin addiction in the suppositions, comprising a stress hypothesis of drug suburbs. An epidemiologic study. Am J Public Health 63:209-14, Mar 73 dependence: 3. Parry, H. J., et al.: National patterns of psychotherapeutic drug use. Arch Gen 28:769-83, Jun 73 ( I) As a product of the interaction of biologic, 4. Greene, M.H., and DuPont, R.L.: Heroin addiction trends. Am J social, and emotional factors, a person learns a Psychiatry 131:545-50, May 74 process of reacting to stress, especially when that 5. National Commission on Marihuana and Drug Abuse: Drug use in America. Problem in perspective. GPO No. 5266-00003. U.S. Government stress is associated with all the uncomfortable feel- Printing Office, Washington, 1973 ings for which such names as frustration, anger, 6. Raynes, A.E., Levine, G.L., and Patch, V.D.: The epidemiology and treatment of polydrug abuse. Read before the North American Congress rage, hate, anxiety, and fear are inadequate. on Alcohol and Drug Abuse, San Francisco, 1974 (2) If, as a function of this interaction, a human 7. Nail, R.L., Gunderson, E.K.E., and Arthur, R. J.: Black-white differ- being learns that safety lies in keeping feelings in, ences in social background and military drug abuse patterns. Am J Psychiatry 131:1097-102, Oct 74 then he is predisposed to becoming a drug abuser, 8. Wikler, A.: Diagnosis and treatment of drug dependence of the bar- for if emotional abreaction must be ruled out be- biturate type. Am J Psychiatry 125:758-65, Dec 68 cause it is too dangerous, drugs appear phenom- 9. Smart, R.G., and Fejer, D.: Illicit LSD users. Their social backgrounds, drug use and psychopathology. J Health Soc Behav 10:297-308, Dec 69 enologically an appropriate response for dis- 10. Milkman, H., and Frosch, WA.: On the preferential abuse of heroin charge of horrible feelings. The "high" of taking and . J Nery Ment Dis 156:242-8, Apr 73 amphetamine appears to be a better feeling than the 11. Keller, J., and Red fering, D.L.: Comparison between the personalities of LSD users and nonusers as measured by the Minnesota Multiphasic lethargy of self-hate. Then, given that one is "high" Personality Inventory. J Nery Ment Dis 156:271-7, Apr 73 and does not know how to come down without 12. Greaves, G., and Goodyear, C.: Some characteristics of persons in drugs, the taking of a barbiturate becomes a logical acute drug-induced distress. Psychol Rep 31:678, Oct 72 13. Massengale, O.N., et al.: Physical and psychologic factors in glue choice. The trip of lysergic acid diethylamide (LSD) sniffing. N Engl J Med 269:1340-4, 19 Dec 63 appears preferable to the only too well traveled road 14. Carney, R.E., Ed.: Risk-taking behavior. Concepts, methods, and ap- plications to smoking and drug abuse. Charles C Thomas, Publisher, of shame and guilt. When the situation is viewed in Springfield, 1971 this light, visiting several physicians for different 15. Goodwin, D.W., Crane, J.B., and Guze, S.B.: Alcoholic "blackouts." A review and clinical study of 100 alcoholics. Am J Psychiatry 126:191-8, Aug types of drugs appears to make sense (and, tragically 69 all too often, physicians contribute to the drug prob- 16. Weiner, S., et al.: Familial patterns in chronic . A study of a

905/86 father and son during experimental intoxication. Am J Psychiatry 44. Greenberg, S.W., and Adler, F.: Crime and addiction. An empirical 127:1646-51, Jun 71 study of the literature. Governor of Pennsylvanias Council on Drug and 17. Goodwin, D.W., Powell, B., and Stern, J.: Behavioral tolerance to Report Series. No. 1. Harrisburg, Pa., 1973 alcohol in moderate drinkers. Am J Psychiatry 127:1651-3, Jun 71 45. Federal Bureau of Investigation: Crime in United States. Uniform 18. Selzer, M.L.: The Michigan alcoholism screening test. The quest for a crime reports, 1972. GPO No. 2701-00010. U.S. Government Printing new diagnostic instrument. Am J Psychiatry 127:1653-8, Jun 71 Office, Washington, 1973 19. Tamerin, J.S., et al.: Alcohol and memory. Amnesia and short-term 46. Greene, M.H., Nightingale, S.L., and DuPont, R.L.: Evolving patterns memory function during experimentally induced intoxication. Am J of drug abuse. Ann Intern Med 83:402-11, Sep 75 Psychiatry 127:1659-64, Jun 71 47. Gould, L.C., and Kleber, H.D.: Changing patterns of multiple drug 20. Goodwin, D.W.: Two species of alcoholic blackout. Am J Psychiatry use among applicants to a multimodality drug treatment program. Arch 127:1665-70, Jun 71 Gen Psychiatry 31:408-13, Sep 74 21. Zimberg, S., Lipscomb, H., and Davis, E.B. : Sociopsychiatric treatment 48. Halikas, J.A., and Ftimmer, J.D.: Predictors of multiple drug abuse. of alcoholism in an urban ghetto. Am J Psychiatry 127:1670-4, Jun 71 Arch Gen Psychiatry 31:414-8, Sep 74 22. Knox, W.J.: Attitudes of psychiatrists and psychologists toward al- 49. Greaves, G.: Toward an existential theory of drug dependence. J Nery coholism. Am J Psychiatry 127:1675-9, Jun 71 Ment Dis 159:263-74, Oct 74 23. Mendelson, J.H.: Alcoholism. Some contemporary issues and prob- 50. Nelson, A.S.: Medical management of drug addiction. Ariz Med lems. Am J Psychiatry 127:1680-1, Jun 7l 28:903-10, Dec 71 24. Chafetz, M.E.: A new day of hope for alcoholics. Am J Psychiatry 127:1682-3, Jun 71 25. Arnold, W.H.: The techniques of withdrawal of opiates and barbiturates-sedatives. DHEW, PHS, NIMH, Lexington, Ky. 26. Dole, V.P., and Nyswander, M.: A medical treatment for diacetylmor- Accepted for publication in January 1977. Updating, as neces- phine (heroin) addiction. A clinical trial with methadone hydrochloride. sary, has been done by the author. JAMA 193:646-50, 23 Aug 65 27. Berle, B.B., Ganem, M., and Lowinson, J.: Detoxification of multiple- At the time this paper was written, Dr. Blaik was a third-year drug abusers with sodium amytal. NY State J Med 72:2971-3, 15 Dec 72 resident in general psychiatry, fellow in community psychiatry, 28. Holcenberg, J.S.: Treatment of overdose and withdrawal of abused and doctoral candidate, Department of Epidemiology, School of drugs. Postgrad Med 54:123-7, Dec 73 Public Health, University of North Carolina. At present, he is 29. Jackson, A.H., and Shader, R.I.: Guidelines for the withdrawal of doing his Ph.D. dissertation in epidemiology at Walter Reed narcotic and general depressant drugs. Dis Ner y Syst 34:162-6, Mar 73 Army Institute of Research, Walter Reed Army Medical Center, 30. Pearson, M.M.: Diagnosis and treatment of barbiturate withdrawal. Washington, D.C. Med Insight 5:13-9, Nov 73 31. Smith, D.E., and Wesson, D.R.: A new method for treatment of bar- Major Robert Blaik, M.C., Division of Neuropsychiatry, Walter biturate dependence. JAMA 213:294-5, 13 Jul 70 Reed Army Institute of Research, Walter Reed Army Medical 32. Gay, G.R., et al.: Outpatient barbiturate withdrawal using phenobarbi- Center, Washington, D.C. 20002. tal. Int J Addict 7:17-26, 1972 33. Urbaitis, J.C.: Barbiturate dependence. Am J Psychiatry 126:416-8, Sep 69 34. Reference handbook on psychotropic drugs. Medical Letter, Inc., New Rochelle, N.Y., 1973 35. Wikler, A.: Dynamics of drug dependence. Implications of a condi- tioning theory for research and treatment. Arch Gen Psychiatry 28:611-6, May 73 36. Wieder, H., and Kaplan, E.H.: Drug use in adolescents. Psychodynam- ic meaning and pharmacogenic effect. Psychoanal Study Child 24:399- 431, 1969 37. Savitt, R.A.: Psychoanalytic studies on addiction. Ego structure in narcotic addiction. Psychoanal Q 32:43-57, 1963 38. Hartmann, D.: A study of drug-taking adolescents. Psychoanal Study Child 24:384-98, 1969 39. Gerard, D.L., and Kornetsky, C.: A social and psychiatric study of adolescent opiate addicts. Psychiatr Q 28:113-25, 1954 40. Flynn, W.R.: The pursuit of purity. A defensive use of drug abuse in adolescence. Adolescence 5:141-50, Summer 70 41. Greaves. G.: Behaviorism versus phenomenology. A needless concep- tual muddle. Psychol Rep 30:759-70, Jun 72 42. McPhee, W.N.: Formal theories of mass behavior. Free Press of Glen- coe, New York, 1963 43. Fischer, R.: A cartography of the ecstatic and meditative states. The experimental and experiential features of a perception-hallucination con- tinuum are considered. Science 174:897-904, 26 Nov 71

Journal AOA/vol. 76, August 1977 906/87