THE THERAPEUTIC FUTURE OF MIND-ALTERING DRUGS*

GERALD L. KLERMAN, M.D.

Professor o f Psychiatry, Harvard Medical School, Massachusetts General Hospital, 2 Fruit Street, Boston, Mass. 021 14.

Although we humans share many characteristics with animals, one distinguishing feature is our capacity to anticipate the future. Every known culture has developed some vision of the future embodied in legend o r myth. As civilizations formed, concern for the future first was expressed in religious awe, belief in supernatural powers, and interest in the possibility of life after death. The pyramids of Egypt are one tribute to this faith in the future. Later, concern for the future was developed into a natural philosophy by the Greeks. Plato and other philosophers of the Athenian school were the first to put forth systematic ideas of utopia. In the 17th and 18th ienturies Enlightenment in Western Europe, the revival of Greek learning, combined with .rational and liberal thinking, generated the modern doctrine of progress; the view that science and learning would bring about new technologies for alleviating man’s suffering, enhancing his material comfort, and promoting new social organizations.

The doctr ines of inevitable progress and optimistic utopianism reached their greatest strength in the Victorian era and in the early decades of this century. These beliefs have decreased markedly, what with two world wars, the economic depression of the 19303, the rise of totalitarianism, and the prospect of nuclear annihilation. Within science, the excitement of discovery is accompanied by the hope that knowledge will benefit mankind in an “endless frontier.” In few fields of science is this hope as strong and captivating as in the recently emergent science of psychopharmacology - the study of drugs which alter the mind; man’s thinking, behavior, and feeling. In psychopharmacology, as

*Presented at the P.M.A.-A.S.H.A.-K.S.U. Drug Education Lecture Series and Workshop, Kent State University, Kent, Ohio, March 1, 1971.

Supported by Research Grant-MH 13738 from the Psychopharmacology Research Branch, Division of Extramural Research Programs, National Institute of Mental Health, Health Services and Mental Health Administration, Public Health Service, Department of Health, Education, and Welfare.

in other scientific fields that are in stages of rapid growth, such as molecular biology or ecology, there is a sense of excitement and anticipation. Recent discoveries suggest a future in which new compounds will be synthesized for the treatment of mental illness. Men are seeking new drugs that will have the capacity to alter emotional states and enhance man’s ability to think and express creatively. Recent discoveries suggest a future more complex than that dreamed of by Aldous Huxley in Brave New World or George Orwell in 1984. Yet it could be a future in which technology could easily get out of control. The dream of a u t o p i a c o u l d b e c o m e a n i g h t m a r e of a depersonalized, programmed society. In this nightmare, mind-altering drugs will be used not to enhance human potential and creativity but as instruments of homogenation and mechanization.

B e f o r e e l a b o r a t i n g u p o n t h e s e f u t u r e possibilities, it would be valuable to review current therapies by placing mind-altering drugs in an historical framework.

Historical Background

Ever since the dawn of civilization, men have attempted to relieve their pain and suffering, bodily, mental, o r spiritual, by ingesting various foods, plants, and their derivatives. In fact, a r c h e o l o g i c a l e v i d e n c e sugges ts t h a t t h e inhabitants of the first civilization in the valley of the Mesopotamia, in what is now Iraq, were brewing a beverage similar to beer before they learned how to plant grain o r raise crops. Alcohol, the first known mind-altering drug, still remains the major substance used to modify emotional lives and mental states. Having discovered the capacity of certain brews and ferments to alter their consciousness, men have continually searched for other naturally occurring substances to perform the same function.

In the past hundred years, science has become increasingly successful in developing new mind- altering drugs by isolating the active principles from plants o r by synthesizing substances not found in nature. The 19th century saw the

116 February 1973 Volume XLIII No. 2

introduction of ether, nitrous oxide, and other anesthetic agents which made surgery possible by producing reversible unconsciousness. Soon after, morphine and other analgesic drugs were developed for the relief of pain without complete unconsciousness, and the bromides and the barbiturates became available to induce sleep and to relieve tension and excitement. In the past decade and a half, a marked acceleration has occurred in the number and range of drugs introduced for the treatment of anxieties and emotional stresses as well as for the treatment of major mental illnesses. Most people are familiar with Thorazine, Serpasil, Mellaril, Miltown and other “tranquilizers,” and with the antidepressant or “psychic energizing” drugs, such as Tofranil, which have also become available. Within the larger meaning of the term, these medications are “mind-altering drugs.”

The advent of new therapeutic drugs has had a major impact on the treatment of the mentally ill. Acute psychoses, particularly schizophrenic, manic and paranoid states can now be managed and treated rapidly, often without requiring prolonged hospitalization. As a result, the care of mental illness is increasingly shifting from the large mental hospitals to the new community facilities. From the vantage point of treatment, mind-altering drugs have already proven valuable to mankind. The prospect is that, in the coming decades, still other more effective medications will become available.

One dramatic manifestation of this change has been the reduction in the number of patients resident in public hospitals. This reduction first became evident in 1953-1954 and has been noted every year since. This reduction is of significance because it reversed a fifty year trend. Ever since 1900, there had been a steady increase in mental patients at the rate of approximately a ten percent rise per year. Since 1954, however, the curve has reversed direction and the census of mental patients in public institutions is now decreasing. As a result, the reservoir of chronic hospitalized schizophrenics has gradually decreased. This is all the more remarkable since the decrease in institutionalized patients has occurred at the same time that there has been a reduction in the death rate of mental patients and an increase in admissions for treatment. In other words, more patients are being treated more effectively, at least by the criterion that they are being released from hospitals.

However, there are major unsolved problems in

this treatment of a psychotic person with mind- altering drugs. None of the drugs are cures in the sense that penicillin cures bacterial infections. The patient’s symptoms are reduced, but his inability to tolerate stress remains poor. These treatments alter the balance of symptoms, as occurs in the treatment of diseases such Bs diabetes, hypertension, and cardiac disease; no cure is effected, but the individual is maintained at a level of comfort and performance at which he can function in society.

There is growing concern for the large number of improved patients, better but not well, who are frequently readmitted to hospitals. The “closed door” hospital has given way to the “open door” hospital, but we are in danger of creating “revolving doors” through which the patients return over and over again. From one point of view, this is not all bad. After all, this is the treatment pattern in general hospitals. But the cycles of rehospitalization make their impact on the patient and his family. One challenge for ‘the immediate future is to devise new drugs and other therapeutic techniques which will sustain the patients in the community and prevent them from having recurrences requiring hospitalization. Ultimately, we can hope to develop better drugs to treat psychoses on a curative or even preventive basis.

The Immediate Future

One would think that with the increased efficacy of drugs, the treatment of schizophrenia, depression, and neuroses would have brought about a reduction in the need for mental hospitals. Compare the situation in mental health with the developments in the treatment of tuberculosis. In the early 195O’s, the discovery of streptomycin and isoniazid resulted in the closing of many TB sanitariums, but similar closings of mental hospitals have not occurred. Few, if any, mental hospitals have closed. Why is this so? One major reason is change in function. As soon as one mental health problem is dealt with, another social or legal problem is redefined as a medical problem. Here we come to the current social crises in the epidemics of alcoholism and drug dependence. As the effectiveness of the treatment of schizophrenia and the psychoses has increased, mental health attention has shifted to other problems, such as abuse of alcohol and drugs. Thus, the reduction of admissions of psychotics to mental hospitals has been offset by a rapid increase in admission for alcoholism. The most

The Journd of School Health 117

dramatic changes have occurred in drug addiction, particularly increases in heroin addiction among adolescents, but also for increased problems with abuse of amphetamines and barbiturates in all age groups.

This situation well exemplifies the destiny of the mental hospital; to constantly change the patient being served, but to continue to retain its role as the last hope of social deviancy and marginality. Thus, the function of the mental hospital in society remains the same; to serve as the repository for the social outcast whose behavior places him on the borderline between deviancy and acceptance, health and illness. Despite the widely acclaimed goal of shifting the pattern of mental care from the mental hospital to community mental health centers, overall admissions to mental hospitals have not decreased. Instead, there is a significant change in the pattern of admissions. The mental hospitals are treating fewer functional psychoses, but are carrying the burden of the aged, the alcoholic and the adolescent with delinquent and anti-social personality disorders. Thus, the role of the state institution is being redefined; rather than being a treatment center for the psychotic, it is becoming a resource for the social deviant. Behaviors which in one era were regarded as criminal are redefined as medical. And, instead of prisons, hospitals are mobilized to deal with society’s outcasts. This redefinition generates our psychopharmacological challenge. Can we devise treatments more humane than prisons, more effective than punishment, and more rehabilitative than rejection?

Special Problems in Treating Drug Dependence

This shift in the population of mental institutions presents some challenges for the next generation of mind-altering drugs. Can new chemicals be developed for the treatment of conditions such as alcoholism and drug abuse? The treatment of these conditions differs from other mental illnesses in that psychiatrists try to interrupt the cycle of disability and dependence that follows the excessive use of drugs which in themselves may have minimal therapeutic value.

Drugs, their use and abuse, are increasingly social and medical problems in most industrial societies. Although growing attention is being given to the so-called “soft drugs,” marijuana and amphetamines, heroin dependence remains the most s e r ious p rob lem, with d e l e t e r i o u s consequences to the individual and to the larger society. The treatment of heroin addiction differs

from the treatment of conventional illnesses; the goal is to interrupt the social dysfunction as much as to relieve the individual’s disability or threats to his longevity. Heroin addiction is a way of life and a vocation, and expensive at that. The individual initiated into heroin use may be s e e k i n g e m o t i o n a l r e l i e f f r o m v a r i o u s uncomfortable states often related to his disadvantaged social state. Whatever their initial causes, heroin dependence and addiction, once underway, involve active participation in a deviant subculture, and usually involve anti-social and criminal behavior in procuring the large sums of money needed to support the “habit.” Society’s current interest in the treatment of heroin dependence is motivated by general concern with “crime in the streets” and by specific desires to protect property and person. Also, there is genuine concern with the rising numbers of deaths due to heroin overdosage, particularly among youths, as well as to hepatitis, sempticemia, and the other associated conditions which affect the mortality, morbidity, and social disability of the heroin addict.

Neither law enforcement nor conventional medical techniques have proven adequate solutions to the heroin problem. Hospitalization for detoxification has a limited and short-term value, as demonstrated by the available follow-up studies. Consequently, new techniques have been developed that are creating both controversy and hope. New forms of group therapy - encounter groups and confrontational methods - are being advocated and self-help residential treatment centers such as Daytop, Synanon, and Marathon have arisen. Although no systematic evaluations of these new psychosocial treatment methods have yet been undertaken, hope runs high.

In addition to these group methods, a new drug approach has evolved. Methadone is the treatment evaluated most systematically, and it offers the most promise for large-scale utilization as therapy. Since 1965, methadone has been advocated increasingly as an effective agent in the treatment of hardcore heroin addicts. Methadone is a synthetic opiate derivative developed by the Germans as a substitute for morphine. It “covers” the patient during withdrawal by reducing the psychic discomfort and physiological dysfunctions of “cold turkey,” the abstinence syndrome. It “blocks” heroin-induced euphoric states, and thus reduces or eliminates the psychic temptation for heroin and helps to interrupt the cycle of craving, tolerance, anti-social behavior and detoxification.

118 February I973 Volume XLIII No. 2

Nevertheless, when used to maintain an addict, methadone induces its own form of drug dependence, although it is a form of medically- supervised dependence. This substitution of dependencies may be a necessary compromise, and may well be considerably more desirable than the social and medical consequences of heroin addiction.

The Far Future

Looking ahead to the far future, what is in store for mind-altering drugs as therapy? Whereas in the near future the challenge of mind-altering drugs is to change the treatment of specific diseases, such as the drug dependencies, the challenge for the more distant future will be to develop drugs that can enhance performance and moderate normal emotional states. Here we handle the delicate problem of deciding what we want to change and what utopias we hope to generate.

For thousands of years man has used various plant substances and ferments to enhance his emotional state or to alleviate pain. The most widely used drugs of this type are alcohol and marijuana. What distinguishes these drugs from the medicines used in the treatment of mental illness is their function. Whereas in treatment conventionally defined, drugs are used to alleviate or remove an abnormal state, here they would be used to enhance a desired normal state either to improve performance or to modulate the range of some affect.

What kinds of drugs am I talking about? Drugs which might improve athletic performance! Or sexual performance! Or to enhance mental performance! In this respect, there are imaginative research projects underway to enhance memory and to facilitate learning. Since molecular biochemists have come to the ability to synthesize the molecules of DNA and RNA, there are endless possibilities of genetic manipulation. Since a number of diseases have been shown to be the result of specific genetic abnormalities, there is the possibility of genetic reconstitution; namely there is hope of identifying individuals with disorders such as mental retardation o r phenylketonuria, and perhaps altering their genetic vulnerability in ways more dramatic than predicted by science fiction. But the future may be more utopian than even the science fiction enthusiasts have been able to imagine. In addition to drugs that alter genetic predispositions, there may be drugs that modify moods such as anger and

rage, emotions such as tension, agitation and anxiety, a n d feel ings such as sadness , discouragement, depression and despair. These emotions and moods are all part of the normal repertoire of everday life. In themselves, they are not pathological. They are part of an individual’s capacity to experience emotion as part of his biological heritage, and they play an important adaptive role in facilitating man’s adjustment to his environment.

Interest in this role of mind-altering drugs was stimulated by experience with psychedelic or hallucinogenic drugs. Unlike the sedatives, tranquilizers, and narcotics, which remove abnormal symptoms, and therefore are used to alleviate pain, mental illness, or emotional suffering, the psychedelics or “hallucinogens” - drugs like mescaline and lysergic acid (LSD) - do not remove symptoms and have not been proven of value in the treatment of mental illness. On the contrary, they were initially of scientific interest because they produced unusual symptoms and dramatic behavior which resembles mental illness. Marked emotional, intellectual, and perceptual changes may follow their ingestion. Persons under their influence may report horrifying anxiety, often bordering on panic, and describe hallucinations resembling those of schizophrenic and other mentally ill patients, thus leading many observers to call these drugs psychotomimetic - resembling psychoses.

Although mescaline was known for fifty years, it wasn’t until after World War I1 that scientists, especially chemists and psychiatrists, gave serious at tent ion to this drug. In 1947, Albert Hoffmann, a chemist working in the laboratories of the Sandoz Corporation in Switzerland, was studying the chemistry of ergot, the fungus of rye, when he accidently ingested some of the derivatives of ergot and during the next few hours, he e x p e r i e n c e d u n u s u a l p s y c h o l o g i c a l manifestations, including alterations in time perception, hallucinations, and changes in his body image. He immediately recognized these changes as having great significance and demonstrated that they were the effects of inf ini tess imal amoun t s of lysergic acid diethylemide, now called LSD.

Hoffmann’s discovery and his subsequent synthesis of LSD ushered in the era of “model psychoses.” The first studies of LSD in the United States were undertaken in 1949. Scientists compared the psychological and physiological actions of LSD with those of mescaline, and noted

The Journal of School Health 119

the many similarities between these different chemicals.

Through studies of the drug-induced states which were regarded as similar to those of psychoses, it was hoped that an experimental analog for naturally-occurring mental illness, particularly schizophrenia, could be provided. It was predicted that by studying the changes in brain physiology and chemistry brought about by these d r u g s , p sych ia t ry c o u l d ga in a n understanding of the cause of schizophrenia and other major psychoses and thus solve a serious mental health problem. These early hopes for a laboratory model for schizophrenia have not been realized. Currently, the consensus among investigators is that the psychic states produced by LSD and related drugs, while unusual and at time pathological, are different from naturally- occurring mental illness. Accordingly, there is considerably less hope today than there was fifteen years ago that research on these compounds would unravel the mystery of schizophrenia o r o the r mental i l lnesses. Furthermore, the hope that these psychedelic agents would be of direct therapeutic value in disorders such as alcoholism, has not been substantiated.

This use of drugs was brought to attention by the consciousness-expanding movement f i rs t promulgated by Leary and Alpe r t with psilocybine and LSD, but it is not to be restricted to those drugs. Although the use of psychedelic drugs such as LSD for therapeutic or research purposes proved a failure, the response of the public to the claims for their effects demonstrates the desire (and perhaps the need) for mind- altering drugs to enhance performance and to promote consciousness and creativity. Studies of patterns of drug use indicate that the majority of prescriptions for minor tranquilizers and stimulants are not for patients in mental hospitals or in the care of a psychiatrist, but for patients who are under the care of general physicians or who receive drugs without the benefit of medical supervision. Persons using drugs in these situations are not only seeking relief of distress, but also often attempt to go beyond their usual psychic consciousness.

In our society, there is not a suitable label for the use of drugs to enhance pleasure or performance. For example, a recent issue of the Journal of Health and Social Behavior was devoted to “recreational drug use,” but we are not yet cer ta in of the acceptabili ty of this

terminology. The fact that we don’t have an established term for such non-therapeutic use of drugs is an indication of our lack of experience with this use of drugs and of our conflict over it.

Social Strains In the U s e of M i n d - A l t e r i n g Drugs

Let us assume that chemists and pharmacologists will develop drugs to moderate anxiety and tension, reduce sadness and depression, and enhance pleasure and performance. What would be our attitudes toward these developments? Recently, when Congress held hearings on the use and abuse of mind-altering drugs, some Senators raised the fear that the mind-altering drugs were reducing the moral sensitivity of the American public and modifying their ability to cope with stress. These Congressional reactions are manifestations of what I call “pharmacological Calvinism.” If a drug makes you feel good, it must, somehow, be bad. In this view, abstinence from all chemical substances is the highest ideal. This view holds forth a utopia of pharmacological stoicism. It advocates a spartan medical approach and is at variance Virith modern technology. The history of Western society recounts that each new mind- altering drug is introduced with considerable resistance. It is important to remember that when coffee and tobacco were introduced, they were the subject of almost as much controversy as currently surrounds marijuana. The dominant Western value system condones and sanctions drug use only for the therapy of defined illnesses, and then only under professional supervision.

Having identified these dominant themes in Western values, it is necessary to acknowledge some sources of strain and conflict. One strain results from the two exemptions: tobacco and alcohol. These exemptions produce cognitive dissonance; the conflict between our espoused values and actual behavior generates denial, rationalization, compartmentalization, and other mechanisms akin to neurotic defenses. Society’s stance on tobacco and alcohol sharply contrasts t o its a t t i t udes toward marijuana. This inconsistency contributes to the generation gap and produces a major lack of credibility for young people when adults discuss drugs.

A related source of strain is advertising’s commercialization of drug terminology to Madison Avenue; everything is psychedelic. By using the drug trappings, advertisers accept implicitly the appeals of the youth-drug culture. In fact, one of the characteristics of the mass

120 February 1973 Volume XLIII No. 2

media and the fashion industry is the rapidity with which they assimilate the signs and symbols of the youth culture, without necessarily accepting its ideological content. The counter culture becomes absorbed into the establishment’s fashion cycle. This year’s revolution is next year’s camp.

Another source of strain derives from our society’s emphasis on science and technology, which currently represent the highest embodiment of Western values of reason and achievement. Why can’t we apply science and technology to enhance normal performance and promote pleasure? If NASA can send a man to the moon, why can’t NIMH develop chemicals to prevent normal anxiety and depression? Why can’t we have drugs to make us all brilliant, artistic, and creative? Why can’t we have drugs which generate pleasure and improve and enhance our sexual p o t e n c y ? ( T h e m o s t m a r k e t a b l e psychopharmacologic agent to be developed will be a potent aphrodisiac.)

Drug taking is usually par t of a group phenomenon; as such, it has many of the features of a secular ritual. Many young people doubt that reason and science will really achieve the “heaven on earth” promised by modern technology. Coupled with this disillusionment is an emphasis on immediate experience instead of delayed gratification. Achievement is valued less than personal relations, a view embodied in the love mystique.

Conclusions

In Western society, the ethic of achievement and rationality reached its peak in the Victorian era. Since the turn of the century, there have been continual shifts in our value systems. Today, there is little faith in the model of history as veritable progress. Beliefs in Social Darwinism and in the inherent superiority of the white race and of Western civilization a r e under attack. Our sexual mores are rapidly changing. What moral system will replace the established ethic is difficult to predict. But the technological advances will force us to come to grips with basic social issues. What is the utopia we seek?

Thus, we come full cycle back to the idea of the future with which I began this discussion. Whereas in early civilizations the idea of the future involved preparing for a better life in the hereafter, modern man attempts to construct a

future which will improve the quality of his life here and now. For many centuries, this meant improving the quality of material comfort and prolonging longevity. Now, there is increasing interest in the quality of the life to be lived, man’s relation to his environment, the control of population explosion, the betterment of social relations, the achievement of peace, and, in the area of mind-altering drugs, the enhancement of performance and the improvement of memory.

A p p l i e d t o m i n d - a l t e r i n g d r u g s , t h e development of new drugs accelerates this concern for individualism in a romantic manner akin to the revival of romanticism in the early 19th century with the concern for subjective experience, intuitive knowledge, understanding nature, and an emphasis on sensuate experience.

As Reich has observed in his Greening of America, we are entering “Consciousness Three” which involves a turning inward of our attention and a greater concern with the quality of life, of suggestive experience, and of direct, intimate human relations. I t may well be that the emphasis on the substantial achievements of a modern technology of science has served to undermine a concern for those very values which help to bring about these successes of technology.

O n e th ing is ce r t a in , t h e advances in pharmacological technology a re bound to generate new classical compounds whose effects will challenge established values and will force us to reexamine our ideas as to the definition of illness, the meaning of therapy and the nature of the good life.

BIBLIOGRAPHY Balter, M.B. The use of drugs in contemporary society:

published i n Highlights o f the 14th Annual Conference, Veterans Administration Cooperative Studies in Psychiatry, Houston, Texas, April 1, 1969.

Chein, I. The Road to H; Narcotics, Delinquency, and Social Policy, New York, Basic Books, 1964.

Huxley, A. Brave New World, New York, Harper and Row, 1964.

Klerman, G. L. Drugs and social values, The Int’l J. of the Addictions, 5:3 13-3 19, 1970.

Orwell, G. 1984, New York, Harcourt and Brace, 1949. Reich, C. The Greening of America, New York,

Random House, 1970. Valliant, G. E. A twelve-year follow-up of New York

narcotic addicts: I. The relation of treatment of outcome, Am. J. Psychiat., 122:727-737, 1966.

The Journal of School Health 121