THE NARCOTIC DRUG
PROBLEM
[Illustration]
THE MACMILLAN COMPANY
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TORONTO
THE NARCOTIC DRUG
PROBLEM
BY
ERNEST S. BISHOP, M.D., F.A.C.P.
Clinical Professor of Medicine, New York Polyclinic Medical School;
Member Narcotic Committee, Conference of Judges and Justices
of New York State; Committee on Habit Forming Drugs,
Section on Food and Drugs, American Public
Health Association.
Formerly Resident Physician, Alcoholic, Narcotic and Prison Service,
Bellevue Hospital; Formerly Visiting Physician and President of
the Medical Board, Workhouse Hospital. New York Department
of Corrections; Fellow Academy of Medicine, Visiting
Physician St. Joseph Tuberculosis Hospital, Consulting
Physician to St. Mark’s Hospital,
etc., etc.
New York
THE MACMILLAN COMPANY
1920
_All rights reserved_
COPYRIGHT, 1920
BY THE MACMILLAN COMPANY
Set up and electrotyped. Published January, 1920.
TO
MY WIFE,
WHO HAS SHARED MY BURDENS AND HELPED IN
MY WORK, AND WHOSE INTEREST IN AND SYMPATHY
WITH MY WORK HAS MADE MUCH OF IT
POSSIBLE,
THIS BOOK IS INSCRIBED.
PREFACE
This book has been prepared in response to a growing demand that the
author group together under one cover some of the material collected
out of a varied experience with many aspects and phases of narcotic
drug addiction, and with activities in the attempted solution of its
problems.
Some of this experience has been previously presented in many addresses
before scientific and other societies and in articles in the medical
press.
The author is not associated with nor interested in any hospital or
institution active in the care of these cases for financial return or
pecuniary benefit. He is not the exponent or mouthpiece or proponent of
any special or specific “remedy” or “treatment” or method of so-called
“cure.” He has no axe to grind.
He is not a “specialist” in the treatment of narcotic drug addiction.
He is a practitioner of diagnostic and clinical medicine, in whose
professional work the care of the narcotic addict has constituted much
the smaller part of his activities and studies, and that part has been
largely carried on without recompense and often at his personal expense.
Some years ago, through hospital affiliations and duties, the writer
was brought to face this problem of opiate addiction and after a while
saw in it very important and very interesting clinical problems of
physical disease and physical reactions upon which he made observations
and studies.
Hospital connections and the publishing of various articles have
since that time brought him into association with practically all
phases and aspects of activity in the consideration and handling
of the narcotic drug problem. He has listened to discussions of the
subject by promoters; by reformers of various sorts; by those engaged
in legislative, judiciary, administrative, custodial, penological,
sociological, psychological or psychiatrical, medical and other lines
of work, and by narcotic addicts from all classes and types of people
and their friends and relatives, etc., in groups, or as individuals.
Two vital elements seem to the author to have received insufficient
consideration in the efforts to solve the narcotic drug problem. One
of these elements is the sufferings and struggles and problems of the
narcotic addict, and the other is the nature of the physical disease
with which he is afflicted.
This book is an effort to accomplish two things, first to present
the two elements above stated, and second to outline, discuss and
correlate various elements and conflicting activities so that each
of us can appreciate the relation of his own endeavor to the whole
narcotic drug problem, can realize the comparative importance of
his own observations, and can cooperate with the others for the
benefit of humanity, for the welfare of society and posterity and for
the increased health and happiness and economic usefulness of the
individual.
CONTENTS
CHAPTER PAGE
PREFACE vii
I. INTRODUCTION 1
II. FUNDAMENTAL CONSIDERATIONS 11
III. THE NATURE OF NARCOTIC DRUG ADDICTION-DISEASE 23
IV. THE MECHANISM OF NARCOTIC DRUG ADDICTION-DISEASE 35
V. REMARKS ON METHODS OF TREATING NARCOTIC
DRUG ADDICTION 50
VI. THE RATIONAL HANDLING OF NARCOTIC DRUG
ADDICTION-DISEASE 61
VII. RELATION OF NARCOTIC DRUG ADDICTION TO SURGICAL
CASES AND INTERCURRENT DISEASES 85
VIII. LAWS, AND THEIR RELATIONS TO NARCOTIC DRUGS 95
IX. SOME COMMENTS UPON THE LEGITIMATE USE OF
NARCOTICS IN PEACE AND WAR 114
X. GENERAL SURVEY OF THE SITUATION AND THE
NEED OF THE HOUR 122
APPENDIX: HUMAN DOCUMENTS,--STATEMENTS OF SUFFERERS
FROM NARCOTIC DRUG ADDICTION-DISEASE 137
THE NARCOTIC DRUG PROBLEM
CHAPTER I
INTRODUCTION
It is a fact becoming more and more obvious that too little study and
effort to interpret their physical condition have been given to those
unfortunates suffering from narcotic drug addiction.
We have neglected their disease in its origin and subsequent progress
and formed our conception of its character from fully developed
conditions and spectacular end-results. We have seen some of them
during or after our fruitless efforts at treatment, their tortures and
poor physical condition overcoming their resolutions, until they plead
for and attempted to obtain more of their drug. We have seen others
exhausted, starved, with locked-up elimination, toxic from self-made
poisons of faulty metabolism, worn with the struggle of concealment and
hopeless resistance, and for the time being more or less irresponsible
beings, made so, not because of their addiction-disease itself, but
because they were hopeless and discouraged and did not know which way
to turn for relief.
What literature has appeared on the subject has usually pictured them
as weak-minded, deteriorated wretches, mental and moral derelicts,
pandering to morbid sensuality; taking a drug to soothe them into
supposed dream states and give them languorous delight; held by most
of us in dislike and disgust, and regarded as so depraved that their
rescue was impossible and they unworthy of its attempt.
We have overlooked, ignored or misinterpreted intense physical agony
and symptomatology, and regarded failure to abstain from narcotics as
evidence of weak will-power or lack of desire to forego supposed morbid
pleasure. We have prayed over our addicts, cajoled them, exhorted them,
imprisoned them, treated them as insane and made them social outcasts;
either refused them admission to our hospitals or turned them out after
ineffective treatment with their addiction still fastened to them. To a
great extent the above has been their experience and history.
In great numbers they have realized our failure to appreciate their
condition and to remedy it, and have after desperate trials of quacks,
charlatans and exploited “cures,” finally accepted their slavery and
by regulation of their drug and life, their addiction unsuspected,
maintained a socially and economically normal existence. Some failing
in this, perhaps broken and impoverished, their addiction recognized,
have become social and economic derelicts and often public charges.
From these last, together with the addicted individuals from the class
of the fundamentally unfit, we have painted our addiction picture.
Confined and observed by the custodial official and the doctor of
the institution of correction and restraint, or concealed as family
skeletons in many homes, descriptions of them have given to the
narcotic addicts as a whole their popular status--cases of mental and
moral disorder due to supposed drug action or habit deterioration, and
based upon inherent lack of mental and moral stamina.
It was with the above conception of these addiction conditions that
I began my work in the Alcoholic, Narcotic and Prison Service of
Bellevue Hospital, attracted to the service not by hope of helping nor
by interest in “jags” and “dope fiends” as I then considered them, but
by the mass of clinical material available for surgical and medical
diagnosis and study which was daily admitted to those wards. When I
left the service after sixteen months of day and night observation,
with personal oversight and attempt to care for in the neighborhood
of a thousand admissions a month, my early and faulty conception of
narcotic addicts was replaced by a settled conviction that these
cases were primarily medical problems. I realized that these patients
were people sick of a definite disease condition, and that until we
recognized, understood and treated this condition, and removed the
stigma of mental and moral taint from those cases in which it did not
exist, we should make little headway towards solution of the problem of
addiction.
It is a fact that the narcotic drugs may afford pleasurable sensations
to some of those not yet fully addicted to them, and that this effect
has been sought by the mentally and morally inferior purely for its
enjoyment for the same reasons and in the same spirit that individuals
of this type tend to yield themselves to morbid impulses, curiosities,
excesses and indulgences. Experience does not teach them intelligence
in the management of opiate addiction and they tend to complicate it
with cocaine and other indulgence, increasing their irresponsibility
and conducing to their earlier self-elimination.
Wide and varied experience, however, hospital and private, with careful
analysis of history of development, and consideration of the individual
case, demonstrates the fact that a majority of narcotic addicts do not
belong to this last described type of individuals. It will be found
upon careful examination that they are average individuals in their
mental and moral fundamentals. Among them are many men and women of
high ideals and worthy accomplishments, whose knowledge of narcotic
administration was first gained by “withdrawal” agonies following
cessation of medication, who have never experienced pleasure from
narcotic drug, are normal mentally and morally, and unquestionably
victims of a purely physical affliction.
The neurologist, the alienist, the psychologist, the law-maker, the
moralist, the sociologist and the penologist have worked in the field
of narcotic addiction in the lines of their special interests, and
interpreted in the lights of their special experiences. Each has
reported conditions and results as he saw them, and advised remedies in
accordance with his understanding. With very few exceptions little has
been heard from the domain of clinical medicine and from the internist.
It is only here and there that the practitioner of internal medicine
has been sufficiently inspired by scientific interest to seriously
consider narcotic drug addiction and to make a clinical study of its
actual physical manifestations and phenomena.
The idea that narcotic drug addiction should be accorded a basis of
weakness of will--neurotic or otherwise, inherent or acquired--and
should be classed as a morbid appetite, a vice, a depraved indulgence,
a habit, has been generally unquestioned and the prevailing dogma
for many years. It is very unfortunate that we have paid so little
attention to material facts and have made so little effort to explain
constant physical symptomatology on a basis of physical cause, and that
there has not been a wider recognition and more general acceptation of
scientific work that has been done.
Despite the years of effort that have been devoted to handling
the narcotic addict on the basis of inferiority and neurotic
tendencies, and of weakness of will and perverted appetite--in
spite of exhortation, investigation, law-making and criminal
prosecution--in spite of the various specific and special cures and
treatments--narcotic addiction has increased and spread in our country
until it has become a recognized menace calling forth stringent
legislation and desperate attempts at administrative and police
control. And though a large amount of money has been spent in custodial
care and sociological investigation on the prevailing theories, and
in various legislation, much of it necessary and much of it wisely
planned, we have made but little progress in the real remedy of
conditions.
It is becoming apparent that in spite of all the work which has been
done--in spite of all the efforts which have been made--there has been
practically no change in the general situation, and there has been no
solution of the drug problem.
In analyzing results of efforts and arriving at causes for failure,
it seems to me that it is always wise to begin at the beginning, and
to ask ourselves whether we have not started out with an entirely
erroneous conception of our basic problem. Is it not possible that
instead of punishing a supposedly vicious man, instead of restraining
and mentally training a supposedly inherent neuropath and psychopath,
we should have been treating an actually sick man? Is it not possible
that the addict did not want his drug because he enjoyed it but that he
wanted it because his body required it? This is not only possible--it
is fact--and the whole secret of our failure has been the misconception
of our problem based on our lack of understanding of the average
narcotic drug addict and his physical conditions.
In my own experience as a medical practitioner I know that
non-appreciation of this fact was the cause of my early failures; and I
further know that from the beginning of appreciation of this fact dates
whatever progress I have made and whatever success I have attained.
In my early efforts as Resident Physician to the Alcoholic and Prison
Wards of Bellevue Hospital, devoid of previous experience in the
treatment of narcotic addiction, directed by my available literature
and by the teachings of those in my immediate reach, I followed the
accepted methods. I tried the methods of the alienist; I tried the
exhortations of the moralist; I tried sudden deprivation of the drug; I
tried rapid withdrawal of the drug; I tried slow reduction of the drug;
I tried well-known special “treatment.” In other words I exhausted the
methods of handling narcotic drug addiction of which I knew. My results
were, in these early efforts, one or two possible “cures,” but as a
whole suffering and distress without relief; in a word failure.
The blame I placed not where it belonged--on the shoulders of my
medical inefficiency and lack of appreciation and knowledge of the
disease I was treating--but upon what I supposed was my patient’s lack
of co-operation and unwillingness to forego what I supposed to be the
joys of his indulgence. In discouragement and despair I held the addict
to be a degenerate, a deteriorated wretch, unworthy of help, incurable
and hopeless. Strange as it seems to me now, possessing as I did good
training in clinical observation and being especially interested
in clinical medicine, in calm reliance upon the correctness of the
theories I followed, I ignored the presence of obvious disease.
As to the existing opinion that the addict does not want to be
cured, and that while under treatment he cannot be trusted and will
not co-operate, but will secretly secure and use his drug--I can
only quote from my personal experience with these cases. During my
early attempts with the commonly known and too frequently routinely
followed procedures of sudden deprivation, gradual reduction and
special or specific treatment, etc., my patients beginning with the
best intentions in the world, often tried to beg, steal or get in any
possible way the drug of their addiction. Like others, I placed the
blame on their supposed weakness of will and lack of determination
to get rid of their malady. Later I realized the fact that the blame
rested almost entirely upon the shoulders of my medical inefficiency
and my lack of understanding and ability to observe and interpret. The
narcotic addict as a rule will co-operate and will suffer if necessary
to the limit of his endurance. Demanding co-operation of a completely
developed case of opiate addiction during and following incompetent
withdrawal of the drug is asking a man to co-operate for an indefinite
period in his own torture. There is a well-defined limit to every one’s
power of endurance of suffering.
Abundant evidence of what I have written is easily found among the many
sufferers from the disease of opiate addiction who have maintained for
years a personal, social and economic efficiency--their affliction
unknown and unsuspected. These cases are not widely known but there
are a surprising number of them. When one of them becomes known his
success in handling his condition and its problems is generally
attributed to his being on a rather higher moral and mental plane than
his fellow sufferers and possessed of will-power sufficient to resist
temptation to over-indulge his so-called appetite. We have not as a
rule considered any other explanation nor sought more at length for the
cause of his apparent immunity to the hypothetical opiate stigmata. It
would have been wiser and more profitable for us to have respectfully
listened to his experiences and learned something about his disease.
The facts in such cases are that instead of being men of unusual
stamina and determination, they are simply men who have used their
reasoning ability. They have tried various methods of cure without
success. They have realized the shortcomings and inadequacy of the
usual understanding and treatment of their condition. Being average
practical men, and making the best of the inevitable, they have made
careful and competent study of their own cases and have achieved
sufficient familiarity with the actions of their opiate upon them and
their reactions to the opiate to keep themselves in functional balance
and competency and control. The success of these people is not due to
determined moderation in the indulgence of a morbid appetite. It is due
to their ability to discover facts; to their wisdom in the application
of common-sense to what they discover; and to rational procedure in
the carrying out of conclusions reached through their experiences.
They have simply learned to manage their disease so as to avoid
complications. When I tried to account for some of the things I saw by
questioning these men who had studied and learned upon themselves, I
soon obtained a clearer conception of what opiate addiction was.
When we eliminate the distracting and misleading complications, mental
and physical, and study the residue of physical symptomatology left, we
make some very surprising and striking observations.
We find that we are dealing fundamentally with a definite condition
whose disease manifestations are not in any way dependent in their
origin upon mental processes, but are absolutely and entirely physical
in their production, and character. These symptoms and physical signs
are clearly defined, constant, capable of surprisingly accurate
estimation, yielding with a sureness almost mathematical in their
response to intelligent medication and the recognition and appreciation
of causative factors; forming a clean-cut symptom-complex peculiar to
opiate addiction. Any one--whether of lowered nervous, mental and moral
stamina, or a giant of mental and physical resistance--will, if opiates
are administered in continuing doses over a sufficient length of time,
develop some form of this symptom-complex. It represents causative
factors, and definite conditions which are absolutely and entirely due
to changed physical processes which fundamentally underlie all cases
of opiate addiction, and which proceed to full development through
well-marked stages.
During the past years I have had under my care a number of excellent
and competent physicians of unusual mental and nervous balance and
control in whom there could be no hint of lack of courage, nor of
deficient will-power, nor of lack of desire to be free from their
affliction. Possessing, some of them, unusual medical training and
scientific ability, having added to this the actual experiences of
opiate addiction, they with others have co-operated and aided in
experiment, study and analysis, and the result has been in their minds
as in mine, complete confirmation of the facts above stated.
Primarily, there are two phrases I should like to see eliminated from
the literature of opiate drug addiction. I believe they have worked
great injustice to the opiate addict and have played no small part in
the making of present conditions. It seems to me that to speak and
write as we still often do of “drug habit” and “drug fiends” is placing
upon the opiate addict a burden of responsibility which he does not
deserve. If long ago we had discarded the word “habit” and substituted
the word “disease” I believe we would have saved many people from the
hell of narcotic drug addiction. I believe if it had not been for
the use of the word “habit” that the medical profession would long
ago have recognized and investigated this condition as a disease. A
man, physician or layman, believes that he can control a habit when
he would fear the development of a disease. Until now, however, the
description has been “drug habit.” And the man who acquires one of the
most terrible diseases to be encountered in the practice of medicine
is unconscious of his being threatened with a physical disease process
until this process has become so developed and so rooted that it is
beyond average human power to resist its physical demands.
In the near future, I earnestly hope the true story and the real
facts concerning the opiate drug addict will become universally
known. Without familiarity with them and understanding of them, and
comprehension and appreciation of their disease, we shall never make
real progress in the solution of the narcotic drug problem. From the
present day trend of articles and stories in the newspapers and lay
and medical magazines it cannot be doubted that the time is not far
distant when in the lay press will appear, in plain, sober, unvarnished
truth, the true story of the experiences and struggles of the opiate
drug addict. I have marked a rapidly growing appreciation of fact and
a steadily increasing activity in the investigation of conditions.
This is sooner or later bound to be followed by intelligent public
and scientific demand for competent and common-sense explanation and
solution.