EXHIBIT No. 5

[From Mental Hygiene, vol. IX, No. 4, October 1925, pp. 699–724]

PLEASURE AND DETERIORATION FROM NARCOTIC ADDICTION

REPRINT NO. 211, THE NATIONAL COMMITTEE FOR MENTAL HYGIENE, INC., 370 SEVENTH AVENUE, NEW YORK CITY. 1925

By Lawrence Kolb, M. D., Surgeon, United States Public Health Service, Hygienic Laboratory, Washington, D. C.

OPIUM

Relief from pain, long-continued distress, or unusual anxiety, no matter by what means accomplished, is accompanied by a pleasant relaxation and a sense of ease. When the distress has been great and the relief sudden, a short period of happiness may ensue, during which the world seems more beautiful than ever before and one wonders why trifling inconveniences should ever cause discontent. Feelings somewhat akin to the above may sometimes be produced by opium in normal persons who are relieved from intense suffering by it. But in referring to the mental pleasure of opium, a distinction should be made between the pleasure that is merely a reflex following relief from anxiety and pain and the pleasure that results from raising an individual above his usual emotional plane. The studies that form the basis of this paper seem to show that normal as well as abnormal persons may receive the first kind of pleasure, while only in rare instances, if at all, does any one except the emotionally unstable, the psychopath, or the neurotic receive the latter. The first, a reflex from relief of conditions that are temporary and accidental, may be termed negative pleasure; the second, a relief from conditions that are more or less permanent or fundamental, may be termed positive pleasure.

In persons who are first receive positive pleasure from an opiate and because of it continue the use of the drug until it becomes a physical necessity, the degree of the feeling wanes as more and more of the drug becomes necessary to satisfy the craving of physical addiction and to maintain comfort. It is the hope of reviving the pleasure in its original intensity that impels some psychopathic addicts gradually to increase the dose or to inject morphine or heroin directly into their veins. As tolerance to larger and larger doses of opiates is established, positive pleasure is decreased or is not aroused at all because, in the state of opium tolerance (addiction), the body cells have learned to function normally when bathed in opium. Amounts that at first gave unusual effects are then necessary to maintain what to an addict is normal functioning and to ward off discomfort. Practically the only pleasure then received from continuing the drug, unless enormous doses are taken, is the pleasure arising from the relief of withdrawal symptoms. This is a poor substitute for the sense of ease and relief that the drug at first gave from the conflicts and tensions that are fundamental with the psychopath. It thus happens that the drug, taken in the beginning because of its power to raise an inferior individual above his normal level, must be taken in the end to keep him from sinking below it and to relieve conditions that the drug itself has produced

After the first stage of addiction, the motive for it is not pleasure, but the avoidance of pain, and those addicts whose supplies of opium are irregular and uncertain pass through periods of comfort and discomfort depending upon whether or not the amount they are able to get is sufficient to satisfy the need the drug itself has created. To the alternating comfort and discomfort is added the worry arising from the activity of the police and the fear that the next dose will not be available. Strongly addicted persons who have to contend with the physical discomforts and social uncertainties above described are restless, discontended, and unhappy; they get less satisfaction out of life than they did before they were addicted because, as physical addiction grows in intensity, and more and more of the drug is necessary to maintain comfort, its power to give temporary relief from the original inferiorities is proportionately lessened until a point is finally reached where pleasure is completely overshadowed by pain. The unhappy state of addicts who reach this stage of addiction causes them to seek cure which in most cases is easily achieved insofar as withdrawal symptoms and the physical necessity for the drug are concerned. The general health then improves, and with the disappearance of the distress caused by the drug, the fundamental psychic distresses for the relief of which it was originally taken again assert themselves. The memory of the pleasure opium once gave, together with the mental associations connected with the use of it, creates in the psychopath cured of his

addiction an almost irresistible impulse to try the drug again. This he usually does sooner or later, and the cycle of events above described furnishes a logical explanation for the repeated cures and the repeated relapses of certain types of addicts. Every psychopathic addict has an experience comparable to that recorded by De Quincey, who first wrote on the pleasures of opium and then on its pains-and that De Quincey was a psychopath seems clearly to be shown by his conduct as a youth and by the two depressions which he mentions in his Confessions.

The cases that form the basis of this paper seem to indicate that the intensity of pleasure produced by opiates is in direct proportion to the degree of psychopathy of the person who becomes an addict, and that the subsequent depression resulting from long-continued use of the drugs carries him as far below his normal emotional plane as the first exaltation carried him above it. In other words, the two ends of the cycle-exaltation and the depression-tend to balance each other. The phases of exaltation and depression may each be several years in duration, but in longstanding cases of addiction without cures, the phase of depression is continuous, and some addicts seems to have forgotten that opium ever gave them any pleasure. In psychopathic patients who are unable regularly to secure a supply of narcotics sufficient to satisfy their craving, there may be several small cycles of exaltation and depression within the larger one. In other words, they are at times compelled to submit to partial cures -and in the partially cured state a sufficient supply of narcotics may give more intense pleasure for a short time or until a higher degree of tolerance is again established. Also, in these partially cured, inadequately supplied addicts, there may be, following their one hypodermic of morphine, a short period of peace, comfort, and contentment which gradually on the same day fades into a condition of unrest, irritability, and discontent as the effect of the drug dies down.

The unhappy state into which addicts of long standing finally descend is such that a superficial examination of a group of them with low native intelligence or lack of education might lead one to believe that only a small proportion of them ever received pleasure from opium apart from that involved in its power to relieve withdrawal symptoms.

With few exceptions they say: "It only makes me comfortable." This explanation is apparently true for most, if not for all, nervously normal people who become addicted, but it is not true of the abnormal type who make up the bulk of addicts of the present time-and it is probable that no person who deliberately addicts himself fails to derive pleasure of some kind from the drug. When the addiction history of a group of addicts is studied carefully, it is found that practically all of the psychopaths and neurotics among them have for a longer or shorter period experienced some sort of mental pleasure from the use of opiates. But most of the cases are seen by physicians long after the memory of the short period of pleasure has been beclouded by the distress that later ensued. This distress causes them to seek relief, and it is uppermost in their minds. They are, therefore, honest when they claim to take the drug only to prevent suffering.

The examination of intelligent people able to give expression to their feelings is more satisfactory, and it is mostly from these that we discover the secret of how the pleasure that opium induces in psychopaths allures them into addiction in the first place and causes them to relapse time after time.

Whether opium causes pleasure to absolutely stable individuals is difficult to decide. Fourteen percent of the addicts in the series of cases (230 in number) with which this paper deals were classified as having been normal before they became addicted, and a few of these received pleasure from the drug that did not seem to be a mere contrast with the discomfort that it relieved. The examination of those apparently normal cases that received unusual satisfaction from the drug was not, however, as thorough in all of its phases as was desirable, and it is possible that a more extended study of the cases would have disclosed traits of personality or abnormal trends that would have justified placing them definitely among one of the nervously abnormal classes referred to in an earlier paper.1

The case cited below is the most striking of the supposedly normal cases who derived pleasure at first from taking an opiate:

A physician, 28 years an addict, successful in his practice, head of a family and one of the most highly respected citizens in a small town, answered all of the requirements of normality insofar as could be determined. He received the first injection of morphine during an attack of influenza and rheumatism. It relieved his pain, but in addition to this made him "more happy than he had ever been

1 Drug Addiction in Its Relation to Crime, by Lawrence Kolb, M. D., Mental Hygiene, vol. 9, pp. 74-89, January 1925.

before." Such was the state of feeling that he lay awake to enjoy it and would not allow himself to go to sleep for 3 hours. For 2 hours the drug had an exhilarating and stimulating effect upon him. After 3 years, when addiction was firmly established, pleasure gave way to necessity. The only satisfaction he then received from the drug was its power to relieve and ward off distress. It is worthy of note that this case relapsed after each of five cures and enjoyed himself for a short period each time, but a recurrence of acute rheumatism was given as the cause for the relapses, and he now has a severe heart lesion which may be accepted as proof of the rheumatic affliction.

Against apparently stable persons of this kind who receive pleasure from opium are the thousands of persons who have taken an opiate prescribed by physicians without feeling anything but drowsiness and relief from actual pain. It would appear from this that those individuals who are made happy by opium must have some special mental conflict that the drug relieves, even though they are not nervously abnormal in the ordinary sense.

In one series of 12 professional men among these cases who admitted receiving pleasure from opium, 10 had either been drunkards or were neurotic individuals before they became addicted. The father of one of the others had migraine; a sister, epilepsy; and a brother, aged 28, died of apoplexy. The addict himself had apparently been normal, but was always timid and somewhat shrinking in his contact with other people.

Another professional man who derived pleasure from cocaine felt none whatever when he later became addicted to morphine.

The more nearly normal of the abnormal cases referred to above had been addicted 22 years. His father was neurotic and had a strong tendency to despondency; a sister died of apoplexy. The patient himself had a normal, open makeup as a boy insofar as outward appearances and social activities were concerned, but with it there was a feeling of bashfulness and a disposition to be easily discouraged. Like a brother of his, he always shrank from pain and his attitude may be best indicated by his description of what to him were the horrors of treatment for drug addiction. His body, he said, felt as if it were being placed alternately in fire, scalding water, and acid. He was successful in his profession, a respected citizen, and took an active part in politics, but always felt ill at ease when required to take a leading part in any gathering. He found that opium gave him confidence and enabled him to meet people without inwardly shrinking and without feelings of restraint. This was not interpreted by him as pleasure, but he described what he called a condition of ecstasy which once came over him, after a hard day's work, while he was riding to the barn on a load of hay. This was before he started to use the drug, but he has experienced a similar feeling a few times since, following hypodermic injections. It is probable that the feeling he described is akin to that aroused sometimes in normal people by the pleasurable relaxation and satisfaction that supervenes upon the completion of a difficult task.

It frequently happens that the first experience with opium produces more pleasure than any subsequent indulgence arouses. When the first dose is taken for illness, the added factor of relief from physical pain furnishes a ready explanation for this and the rheumatic physician who struggled to stay awake never again experienced the same intensity of feeling. In other cases the explanation probably is that its newness is an added charm.

The following cases are typical of many in the uneducated, abnormal group: A dull, neurotic Italian induced an addict friend to give him a hypodermic of morphine. It was evidently a large dose because it produced dizziness and nausea. In spite of these symptoms, he said: "It made me feel like I was in heaven." patient continued to receive pleasure from the drug for 4 years, or until the time when he presented himself for treatment.

This

A 20-year addict who started by smoking and ruined his life by excessive indulgence in morphine and heroin said, in describing his first experience, that it made his head as light as a feather on his shoulders and gave a sensation "that you go back after, but never quite get again." He enjoyed less intense feeling for about 2: years and for a short period following each of two relapses.

No doubt the enormous doses of morphine or heroin consumed by some psychopathic addicts have been gradually worked up to by them in an effort to revive sensations that the physical factor of increased tolerance has dulled or madeimpossible. At one time the patient above referred to was consuming 60 grains of morphine a day, and he once took 100 one-sixth-grain heroin tablets in 5 hours. The expressions that addicts make use of in describing their sensations illustrate better than anything else the mental pleasure that opium gives abnormal persons.

At the same time they show the neurotic basis of addiction by indicating emotional conflicts or feelings of inadequacy, the relief from which is expressed as pleasure. The following are some of the common statements made:

"It makes my troubles roll off my mind."

"I do not have a care in the world."

"It is exhilarating and soothing."

"You do not care for anything and you feel happy."

"You have a contented feeling and nothing worries you."

"It stimulates you and makes you forget, so you don't care about anything." "It makes you drowsy and feel normal."

"It causes exhilaration and a feeling of comfort."

"A deadening, pleasurable effect."

A clear inference from the foregoing expressions is that opium produces in these cases a feeling of mental peace and calm to which they are not accustomed and which they cannot normally achieve.

The following case indicates more specifically than most of them that the mental calm is pleasurable largely because of its contrast with the trouble and worry that the narcotic properties of the drug temporarily blot out:

Case 110, a married woman, aged 27, with 2 children, suffered cruelty and deprivation at the hands of a worthless, brutal husband. She underwent three operations, became extremely nervous, spent several months in a sanitarium, and worried much about the children, who of necessity had been separated from her. Later on she was sent to the hospital for observation, having been accused of forging a check. Occasionally, before becoming addicted, she passed into a state, sometimes induced by music, during which she "forgot everything and did not worry and had a pleasurable, dreamy sensation as of floating away.' These momentary periods were clearly wanderings from the realities of her existence. She found that morphine also induced them and gave that as a reason for using it. Ether administered during one of the operations produced a similar sensation, and later on she drank and inhaled it for a short time.

A pleasurable sensation of floating away seems to be fairly common during the early period of morphine or heroin indulgence.

A better description of the pleasurable effect of opiates than the average untutored addict gives might be expected from highly educated persons. One of these, typical of others, said it caused a buoyancy of spirits, increased imagination, temporarily enlarged the brain power, and made him think of things he otherwise would not have thought of.

In addition to the mental pleasure produced by opium, some addicts receive a pleasurable physical thrill of short duration and varying intensity immediately following an injection of morphine or heroin. As the intensity of this thrill wanes with increasing tolerance, some resort to injections directly into the veins in order to bring it out in full force again. It is largely this thrill which addicts have in mind when they speak of the "kick" that the "shot" gives them. Most of them describe it as a feeling of warmth that quickly spreads through the abdomen following an injection. The description suggests vasomotor relaxation with increased blood to the parts. In some cases the thrill spreads throughout the entire body and then gives intense pleasure. Striving for a repetition of it naturally leads to larger doses.

An

The physical thrill apparently sometimes takes a sensuous character. addict with an intelligence quotient of 110, who described the mental effect as "a feeling of comfort so that nothing worries you," said, in regard to the physical thrill, that it was a pleasurable, tingling sensation that passed over the entire body. He linked this sensation with sexual feeling and mentioned that some of his associates gave it the same coloring. Another pyschopath, with an intelligence quotient of 88, described the sensation as a thrill through the body lasting 7 or 8 minutes and resembling the sexual orgasm. The brother of this patient derived intense pleasure from the thrill, but said that it did not in any way resemble sexual feeling.

None of the 31 nervously stable addicts in this series of cases bad experienced anything but a slight feeling of warmth in the abdomen following injections of morphine or heroin. This was considered pleasurable except insofar as it was a part of the general feeling of comfort and relief that is brought on in all addicts when a needed dose wards off oncoming withdrawal symptoms. The apparent immunity to the thrill of normal persons who become addicts may be explained in part by the fact that such addicts do not take 60 grains of morphine daily nor do they inject the drug directly into the veins, but in the psychopaths the degree of pleasure seems to depend upon the degree of psychopathy, and it is possible

71515-56-pt. 6—16

that the sympathetic nervous system of these abnormal cases may be so constituted as to be more susceptible to the influence of narcotics.

COCAINE

Addicts in this series have described cocaine as producing a pleasurable, "flighty" sensation, but in some cases the drug was positively disagreeable because of a state of anxiety produced by it. These latter were the cases who took only a few doses and stopped. In those who took the drug regularly for long periods, there was a combination of agreeable and disagreeable sensations. The psychopath who takes this drug will use too much and suffer anxiety because of it, but mingled with this there is a pleasure partly mental, but chiefly physical. The drug stimulates both mind and body and gives an increased sense of power, which is real to both normal and abnormal persons. This pleasurable stimulation is enhanced in the feeling of some psychopaths because in them the drug also produces mental calm similar to, but not as intense as that produced by opiates. These psychopaths then get from the drug a blotting out of excessive worries, together with stimulation of intellectual and physical processes. This explains such intense satisfaction as that indicated by the remark of a prostitute, one of this series, who said that the drug transported her to heaven. Cocaine increases sex power, decreases appetite, brings on rapid emaciation, causes a nervous feeling that passes over into anxiety, and in addicts who take excessive amounts over long periods, the anxiety gradually develops into persecutory delusions and the physical overactivity may culminate in convulsions.

The verbal descriptions of addicts quoted below give an idea of the pleasurable effects of the drug.

A lawyer who had become a morphine addict said that cocaine gave him energy but no exhilaration.

A normal physician who started cocaine when a medical student, and used it for about 6 years, had 12 fits before he became addicted to morphine in an effort to counteract the "horrible effects of cocaine,” and then after 21 years was cured of the morphine habit. He described the pleasant effect of cocaine as a "hilarious, exhilarating feeling." Morphine never gave him any pleasure.

The other remarks are:

"It gives me more courage."

"It makes my mind 10 times quicker than normal, but also makes me anxious." "Something like drinking, but it does not make me feel fussy like whisky." "Makes me jumpy and scary, but I like it."

"It is pleasurable, but makes me scary and suspicious."

"It gets me nervous, in a high pitch, and makes my mind act twice as quickly." "It gives great pleasure, but makes me feel wild and flighty."

A Negro with an intelligence quotient of 69 said: "It gives me willpower and makes me feel happy, good, and strong.”

Another Negro, intelligence quotient 55, said: "It makes me walk and feel like doing things, and when the drug dies out, I get tired and sleepy."

Cocaine never causes confusion like whisky, or stupor like morphine and heroin. It is a direct antidote to whisky and opiates and is used as such by drunkards and opium addicts. Some addicts report, from their own personal experience and by observation of others, that a helpless drunkard may be roused to normal in a few moments by an injection of it, and unlike morphine or heroin it may be used in large doses along with whisky.

COCAINE AND OPIATES COMBINED

As would be expected, cocaine and an opiate combined give more intense pleasure than either of these drugs alone. The two following cases illustrate this and show how demoralizing excessive indulgence in these two drugs may be: Case 17, a highly intelligent addict, aged 27, was a drunkard who used cocaine for several years and then became addicted to morphine by taking this drug to combat the anxiety brought on by excessive doses of cocaine. He had used as high as an ounce of cocaine in 5 days. The high state of tension and expectancy brought on by it is illustrated by the fact that he was once thrown into a panic during which he ran 10 blocks in surprise and fear before collecting himself, for no other cause than that someone behind him clapped his hands. On another occasion his attitude was so evidently one of fear and suspicion that a detective followed him for several hours until the effect of the drug wore out and he became more rational. The ordinary effect of a dose of cocaine on him was to produce a thrill throughout his body lasting only a few minutes. He was more talkative