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Polypharmacologic Drug Abuse: Presentation and Discussion of a Case

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Polypharmacologic Drug Abuse: Presentation and Discussion of a Case 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, cocaine, am- phetamines, and barbiturates, 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 amphetamines] . 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 alcohol) 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.
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