Creating the American Junkie: Addiction Research in the Classic Era of Narcotic Control

  • Caroline Jean Acker
Johns Hopkins University Press, $41.95, 276 pp, 2002

Creating the American Junkie by Caroline Jean Acker is a fascinating exploration of the development of opiate addiction in the United States at the turn of the century. A major theme of the book is that at the turn of the century opiate addiction became marginalized sociologically by ill-fated attempts to reduce the availability of the drug. These efforts not only included attempts at intervention of supply by government and the adoption of government laws to punish use and sale of narcotics (Harrison Act of 1914), but also by a confluence of medical, pharmacological, psychiatric and social factors that led to the marginalization of opiate users. However, in the course of this unfortunate social experiment, the true nature of addiction, the role of social factors and the first seeds of appropriate treatment, neuroscience of addiction, and medication development for addiction were formed. Thus, while the effort of addressing addiction moved inevitably to creating an 'American Junkie', this process provided the enlightenment to learn what place addiction has in our society, and how society contributes to addiction.

Before a 1909 act that forbade importation of opium for smoking, opiates were used largely in opium dens, and while dependence presumably resulted, individuals could maintain habits and continue to function in society because of the general lack of physical toxicity of opiate drugs. However, increasing charges of opiate dependence precipitated by medical use (iatrogenic addiction) combined with a general social movement (vice commissions) to restrict 'hedonic' social behavior such as prostitution, drug taking and even dancing led to both medical and government experts supporting the legal restriction of opiate use. This resulted in the Harrison Act of 1914, which was the first law to prohibit possession of a drug; it made the possession or use of morphine or heroin illegal except as authorized by a physician. Support for the Harrison Act was two-fold: to deny the use of opiates to those who did not need them for pain control (recreational users), and to remove the responsibility for opiate addiction from the medical profession. The hypothesis under test was that removal of readily available opiates would leave only the psychopathic user and they would quickly diminish. Unfortunately, as we now know, the reverse happened. Opiate addiction moved to a different urban milieu of illicit drug sales, clandestine networks of fellow users, likelihood of arrest and societal marginalization.

Consistent with the overall supply-limitation theme, both private and government funding instituted a major research effort, also ill-fated, to develop a non-addicting opiate-like drug for treatment of pain. While this effort failed, it actually laid the foundation for standardization of addictive liability for a drug and the first physiological characterization of opiate addicts. This effort also laid the foundation for current efforts at medication development for psychiatric illness and treatment of drug addiction.

The characterization and treatment of opiate addicts by the medical profession also contributed, according to Acker, to the marginalization and stigmatization of the opiate addicts as deviant personalities who were better served by incarceration than by a modern community-based treatment approach. Again, however, much was learned about opiate addiction from these early attempts at characterizing addicts. The use of a psychopathic diagnosis at the time contributed to the deviant hypothesis but in fact laid the foundation for the modern concept of addiction as a disease. In addition, while the Addiction Center in Lexington, Kentucky, ultimately resembled more a prison than a treatment center, much was learned about what did not work in treatment.

Finally, Acker describes the evolution of the social psychology view of addiction where eventually social psychologists broke out of the psychopathic defect constraint to consider not only a cognitive component but also an ethnographic approach. Addiction finally is placed in the context of social roles, cultural factors and socioeconomic status.

The book is a compelling journey through drug-addiction history and how social experiments can not only fail completely but actually exacerbate a condition due to lack of proper knowledge and research. Nevertheless, one can see the ray of hope that carries through this excruciating exercise as exemplified by psychiatrists, physiologists, pharmacologists and social psychologists as they struggled to understand one of the most intractable disorders of modern times: drug addiction. There are many lessons to be learned from this book, not only about the destigmatizing of drug addiction, but also the destigmatizing of mental disorders, the destigmatizing of other societal 'ills' such as prostitution, and even laying the framework for understanding the difficulties of directed medication development.

Perhaps most importantly to this reviewer, this book lays a firm foundation for re-evaluating our approach to the study of addiction. “Compulsive uncontrollable drug use with impairment in social and occupational function” is a relatively well-accepted phenotype-like definition of drug addiction, but it really says little about the dysregulation of emotional states in the context of critical social psychological elements that drive addiction. While the book makes it clear that opiate addicts are not inherently social deviants and psychopaths, what is clear is that they take opiates ultimately to feel 'normal'. How genetic, neurobiological and socio-cultural factors—and drug taking itself—lead to the “not normal” state that is ultimately self-medicated remains the challenge for the 21st century.