i . June 1966 k

Drugs and alcohol barbiturates, each of which was How do they become “trapped by present in concentrations not or- the double addiction”? dinarily considered fatal. To say that the answers to those Potentiation: “The danger incident to the in- questions are not readily available discriminate use of the two agents would be to understate the case. New Top Killer? at the same time is stressed.” Pat answers are non-existent. Facts . The Virginia researchers also are rare. Data are scattered and by J . Horace Strunk ventured, even then: spotty. Observations are guarded “The widespread use of both al- and meager. cohol and the barbiturates would But thanks to a few lonely ex- The editor of Pennsylvania’s Department o f Health appear to make important a more plorers in this “new and sigthorough knowledge of the effects nificant field about which we know Journal reviews the evidence that combined use that may ensue when they are ad- so little,” there are clues and they o f alcohol and mood-changing drugs is now ministered jointly.” form the vague outlines of patterns o – the – major public health problem But those admonitions have been – however nebulous and disjointed all but lost on contemporary gen- they may at first seem. erations. Dr. Joseph W. Spelman, chief Today the need to expound the medical examiner of Philadelphia’s meaning of potentiation into the Department of Health, reports that common knowledge of a frenetic preliminary studies of “coroner’s T HE Secretary of Health recently appealed for expanded research and education in the combined use at the Medical College of Virginia indicated “a synergism between the barbiturates and alcohol.” Mortality society is hardly less critical. The recent deaths of prominent perdeaths” in the city last year-1965 -compare with the findings of the of alcohol and drugs. rates in these experiments jumped sonages caused by the alcohol-drug unique study made in 1961 when The appeal was a welcome of- an average of sixty per cent when potentiation only beg a flood of the the combined use of alcohol and ficial breakthrough in an area of sublethal doses of alcohol were larger questions. drugs was found to be the direct growing concern. given in combination with bar- What is the incidence of death cause or major contributing factor The public shock waves of sud- biturates. from the alcohol-drug problem in 209 cases of suspicious, unatden death from the conjunctive use Potentiation is what another among Americans generally, includ- tended deaths. of alcohol and drugs should have team of research scientists meant ing those of lesser importance to Dr. Spelman himself emphasizes, long since cast an unfamiliar phen- two years later when they con- the news media? however, that the 1961 study was omenon into a household truth. cluded a report on their observa- How many death certificates list stringently limited; that first, only That phenomenon is “potentia- tions in the American Journal of the conjunctive ingestion of alcohol those deaths “of a type coming tion,” and the remoteness of its Clinical Pathology with the state- and drugs as the primary cause of under the purview of the coroner” meaning from the public mind is ment: death? were encompassed by the survey, still lethal. “Examples are presented in What are the portents of the in- and that secondly, less than half of Dictionaries define potentiation which death was apparently due to cidence of combined use? those (only cases of instantaneous as “the combined action of two the combined effects of alcohol and Barbiturates are frequently men- death) were subjected to specific drugs being greater than the sum tioned, but what other drugs are tests. At best, the 209 cases cited Editorial reprinted from Target, Feb.. used in combination with alcohol? of the effects of each one alone.” 1966, Dept. of Health, Harrisburg, Pa. could tell only a small part of the Twenty years ago, experiments by permission. What drives people to the con- epidemiologic story. junctive use of alcohol and drugs? Dr. John A. Dattoli, director of

‘ the State Department of Health’s thirty alcoholic patients a month. Division of Behavioral Problems He freely estimates that fifty per Report on Narcotic and Drug “The frequently cited change and Drug Control, also points to the cent of these patients are suffering, Abuse makes a relevant confession: from a prewar population of white epidemiological limitations. The ma- or have suffered, the double addic- “Adequate data are not available users with a female majority to one jor difficulties, says Dr. Dattoli, are tion of alcohol and drugs in com- for a precise estimation of the in- drawn primarily from minority ethto be found in the official records, bination. cidence and prevalence of the abuse nic groups with male preponderance the death certificates. Dr. Gabos offers an arresting epi- of drugs with psychotoxic side ef- appears to be correct for some geodemiologic sidelight: “In my ex- fects.” graphical areas but incorrect for perience, it seems that the incidence Despite that blanket negation and others where the white still con- I of the combined use of alcohol and also the fact that the Report is deal- stitute the majority of abusers.” 1 drugs is greater among women than ing primarily with drugs other than “There is a possibility that the among men.” alcohol, the White House panelists abuse of barbiturates and ampheta- In those observations, Dr. Gabos offer “some important epidemio- mines among juveniles may be inenjoys the concurrence of Dr. Wil- logic clues” that again have some creasing because they are so much liam W. Unangst, director of Nor- relevance to a study of the alcohol- cheaper, more readily obtainable ristown State Hospital’s alcoholism drug potentiation: and easier to handle.” program and its Center for Alco- “There are large numbers of To those clues add the shocker The inadvertent, justified or in- holic Study and Therapy (CAST). drug abusers who never come to t h a t D r . R o b e r t Greenhouse tentional omissions of such a con- Says Dr. Unangst: ‘ the attention of community agen- dropped at the Pennsylvania Concomitant cause of death as the de- “Half of our alcoholic patients cies.” ference on Alcoholism this year: ceased’s use of alcohol and drugs have been involved also with drugs. “There is an increasing abuse of “Alcoholics in the U.S. are inhave been known to occur. The Alcoholism frequently is the first nonnarcotic drugs concomitant with creasing at the rate of 200,000 a physician may think in such frames step in drug addiction. Many people’ a decrease in the abuse of narcotic year and most of these new alcoof reference as “primary,” “prin- graduate to the realization that derivatives.” holics are young people.” cipal” or “secondary” causes of while there remains a stigma with death. The habits of the deceased the intemperate use of alcohol, there may be of little concern to him, is no such stigma attached to the if, in fact, he has known the de- use of the recently developed tranceased well enough to have any- quilizers and hypnotic drugs. more than a suspicion of addiction. “Actually, in some areas the use On the other hand, and this point of such medication has become a Dr. Dattoli stressed, after listing the status symbol, and housewives openknown and contributing factors of ly compare the relative merits of death the physician may find there Miltown, Librium, Valium, et a].” is just no space on the certificate The specific incidence of comfor an indication of alcohol and bined use among women, or men, drug abuse. or the affluent or the economically Dr. Charles Gabos, director of depressed, or any other category of the Department of Alcoholism, St. the population is, of course un- John’s Hospital, Pittsburgh, reports known. that, on the average, he attends The White House Conference

this country who are impairing their capacities to live fully and function The suggestion of a “potentiation right time or, if worse comes to effectively by the use of alcohol and of clues” is inescapable. worse, any pill, any time? The drugs. How many alcoholics or just “so- White House Report again clues the . “Although cancer and heart discial drinkers” – of the new persua- new compulsion : ease are still considered the major sions of nihilistic sophistication find “The two agents (alcohol and public health problems in America, it cool and convenient to avoid barbiturates) are mutually inter- I am inclined to hold that when all ways conducive to the inception or sweating out an alcohol withdrawal changeable in creating or perpetuat- the destructive factors -economic, integrity of inspirational thought syndrome, or even a hangover- ing the dependent state. In fact, social, cultural and emotional – and there results a sustained inner by the conjunctive use of drugs? many alcoholics turn to barbiturates are considered, alcohol and drug conflict between the daily require- How many use barbiturates or in an attempt to conceal their prob- addiction is the greatest threat to ments of work and the need for any of the new synthetic sedatives lem, and avoid the social pressures our society. meditative freedom. . as an alternative to alcohol on those which stigmatize the alcoholic. . .” “When a man dies of a heart at- The integration of these two occasions when alcohol -because The Report suggests also that the tack or cancer his children are not processes is vital to man’s peace of of its odor, ataxic effects, transport use of amphetamines to counteract ashamed to go to school or his wife mind, if not to his best work. And or other incriminating attributes – or “to antagonize the depressant to church; but when a man dies of he finds, inadvertently or otherwise, is less convenient? effects of alcohol and barbiturates” DTs in the gutter, or a mother that the inspirations of syncretic How many -to retain the eu- is a “common type of abuse.” destroys herself by overdoses or thought can be conjured up like phoria, hide the symptoms, relieve Again, Dr. Unangst is less in- potentiation of alcohol and drugs, magic through the use of alcohol the malaise, dispel the depression clined to understate the problem. the scars remain for a full genera- and drugs. Especially is this said to of alcoholism when trapped in the Citing more recent surveys for s u p tion.” be true of those upon whose inintermittent dilemmas of alcohol port, CAST’S director claims: An empathic, if psychological, sights, depth of feeling, gifts or saturation and withdrawal-simply “In the total arena of addiction, approach to the problem of addic- talents there is any demand whatgo for a pill, the right pill at the there may be 10 million people in tion is offered by Dr. James H. ever. Ewing, of Philadelphia’s Mercy- The thesis extends naturally to Douglass Hospital, who contends, the college generation. “College in effect, that man’s freedom to makes tremendous demands on the dream is as important to his mental student for the organized accumuhealth as his freedom to sleep is to lation of great sums of knowledge,” his physical health. Constantly re- Dr. Ewing points out. At the same curring interruptions of the dream time it stimulates a welling up of inceptions and sequences – as have emotions along with new interests actually been effected in experi- in the world and new needs for exments -lead to critical emotional pressive thought. The student is disturbances. trapped between the requirements But man has concomitant needs for cultural information and the to reflect and to meditate in his impulsions of creative, inspirational waking hours as well as to dream experience. He’s in intense conflict; in his sleep. The pressures and ten- and the resolution of the conflict is sions of todav’s societv are not al- in the integration of the two kinds

of thinking demanded. Such inte- ly does this seem to be true of the phase become the very instruments gration, or syncretic thought, says tranquilizers. of a more serious complication of Dr. Ewing, “isn’t adequately en- Pharmacologists Robert B. For- his disease. The alcoholic patient couraged.” ney and Francis W. Hughes, of the has in some cases become depend- So the college student, “just like University of Indiana’s School of ent on every drug used to alleviate any creative person who is frus- Medicine, in a preface to their re- his suffering.” trated by conflict,” turns to alcohol search report on the synergistic ac- At this point, a provocative oband drugs for the “liberation of his tion of tranquilizers and alcohol, servation of Dr. Unangst extends inspirations of syncretic thought, state thbt: the prognoses of addiction and pothe continued exercise of which The increased use of tranquilizers tentiation to the overall area of seems to be essential to his mental and the “continued, socially accept- emotional illness. Dr. Unangst conhealth.” able widespread use’? of alcohol in- has frequently been known as the tends: But Dr. Ewing hastily points to dicate that “this combination must “drug of choice” for treating the “The separation of addiction the limitations: occur frequently.” symptoms of acute alcoholism. from the overall, total problem of ‘ “The trouble with the use of al- The growing suspicion that tran- But last year, researchers Sidney emotional illness attempts to estabcoho1 and drugs is that while ideas quilizers in combination with alco- Kaye and the late Harvey B. Haig lish a dangerous and arbitrary dichand emotions may be temporarily hol can be as deadly as any other reported on their study of nine in- otomy. Alcoholism is the cancer of freed, the complex mental opera- drug gains credence with Dr. Spel- dividuals who died suddenly and emotional illness. And each of the tions which have to do with con- man’s continuing studies in Phila- unexpectedly following paraldehyde four categories of mental illness, structive elaboration, re-definition, delphia. In the 1961 survey of sus- therapy for acute alcohol intoxica- the neuroses, psychoses, character and refinement of an idea cannot picious, unattended deaths, the bar- tion. All patients were ambulatory, disorders and psychosomatic disbe brought to share in the creative biturates were found to be the drug “abusive” and apparently in good turbances may predispose to, be task. So while the use of alcohol most frequently used in combination health except for the symptoms of compounded by, and ultimately be and drugs liberates certain creative with alcohol. Now, Dr. Spelman re- alcoholism. Deaths occurred a half buried beneath the far greater defunctions, it usually fails to facilitate veals, tranquilizers, with alcohol, hour to four hours after administra- structive forces of alcohol and drug the full, complicated and highly- are pushing barbiturates for the tion of paraldehyde, and autopsies addiction. patterned sequence of mental op- infamy of top killer. revealed no morphologic causes of “While one-seventh of’ all first . erations essential to the creative In combination with alcohol, not death in any case. admissions to public-health hospiact .” even a “safe” drug is safe. Under The irony of the alcohol-drug po- tals in 1960 were alcoholics, a care- While barbiturates and ampheta- most conditions, paraldehyde has tentiation is stated by Dr. C. Nelson ful scrutiny of pre-admission hismines seem to draw primary blame been considered a “safe” drug; in Davis, psychiatrist-in-chief, Malvern tories in two separate Pennsylvania for complicity in the alcohol-drug fact, it has been known as one of Institute for Alcoholic and Psychi- hospitals revcaled that one-half of potentiation, almost any drug is vul- the safest of the hypnotics. Iron- atric Studies: all admissions involved the excesnerable to indictment. And especial- ically, over the past eighty years, it “Man’s proclivity to abuse a sive use of alcohol or drugs, or drug, rather than use it properly both, during the period of emotional when administered for its best phar- decompensation. macological purposes, has the power “It must be concluded that the to completely submerge the drug’s use of alcohol and the injudicious usefulness. use of any drug represents a real- “And so the paradox. The drugs istic threat to those suffering from that are used in the alcoholic’s acute any form of emotional disorder.

“While the addiction may be tion of habituation rather than adtechnically symptomatic, it ulti- diction, and the equally subtle immately is the primary instrument of plication of safety. Not so, say the the patient’s deterioration and de- White House panelists. “Spree use” struction.” appears to be no less hazardous and As though the portents and enig- may engender the same types of mas of the alcohol-drug potentia- antisocial behavior. tion were not challenge enough, the There is, lastly, a further implinewest problem posed by the Con- cation : that far more people survive jurer of Compulsions epitomizes all the combined use of alcohol and contemporary addictive sophistica- drugs than succumb to it. Is sudtions. It’s the “spree use” of drugs, den death the exception? What a behavioral orgy in which the about the apparently great numbers abuser flits from one drug to an- who from day to day go on and on other, uncannily avoiding depend- with their double addiction? Dr. ence on, or tolerance to any single Forney provides the one and only drug. He may run the whole gamut: pat answer: alcohol to barbiturates to ampheta- “They’re lucky, incredibly lucky.” mine to opiate to cocaine and back In the portentous public-health to alcohol. And he gains the added area of alcohol and drug abuse, advantage of being just as sensitive conquest is not likely to temper the to each new dose as to the original zest to explore anymore than soluone. tions will void the challenge to em- There is here the subtle sugges- pathy for some time to come.