FUNDAMENTAL CONSIDERATIONS
My earliest efforts in the handling of narcotic addicts were
institutional. They were along the lines of forcible control, based
upon the theory that I could expect no help nor co-operation from my
patients.
While this theory is undoubtedly true as applied to many of those who
have developed opiate addiction, it is true of them as individuals
whose personal characteristics are such that they require forcible
control for the accomplishment of desirable ends in general. It is not
true of them simply because of narcotic addiction. It is equally true
of these same people afflicted with other diseases. Their successful
handling for tuberculosis, venereal disease, cardiac conditions, or
anything else requires for its successful issue constant oversight
and what practically amounts to custodial care. I shall refer to them
later. They are fundamentally custodial or correctional cases and
success in their handling will never be accomplished in any other way,
whether they are being treated for narcotic addiction or for anything
else, mental, moral or physical.
What appears in this chapter does not solve the problem of the handling
of the narcotic addict of this type. There are many factors and
elements in their mental and physical make-up other than drug addiction
which should be considered, and these factors and elements lie at the
bottom of their irresponsibility and the real difficulty of their
handling.
Experience and the analysis of unsuccessful effort and results showed
that, however necessary forcible control might be in the handling
of some narcotic addicts, it was not successful nor sufficient nor
even the most important factor in the treatment of most cases of
addiction-disease.
I soon came to see that I had an erroneous conception of my medical
and clinical problems and an unjust attitude towards many if not most
of my addiction patients. Studying them--not as drug addicts, but as
individual human beings--I found them in their personal, mental, moral
and other characteristics, as various as people suffering from any
other disease condition. There were no narcotic laws at that time and
opiates were easily and cheaply obtainable. Very many, perhaps most of
those who came to my wards were not forced in either by fear of the
law or by scarcity of opiate supply. They did not have to come for
treatment, but voluntarily presented themselves in the hope of cure.
Something was wrong with my theories.
In seeking for solution I began to realize that the narcotic addict
of average individual characteristics obtained no enjoyment from the
use of his opiate, and that he co-operated as a rule to the extent of
his ability and endurance in efforts to relieve him of his condition,
so long as he had any hope of possible ultimate success. I learned,
trained and experienced physician though I was, that I was far more
ignorant of the clinical manifestations and physical reactions of
narcotic drug addiction than many of the patients I was trying to
treat. It was soon evident to me, moreover, that the man who recognized
my ignorance above all others was my patient. I came to see that what I
had interpreted as lack of co-operation was largely due; first to his
memory of previous experience, second to recognition of my ignorance,
and third to his anticipation of useless and harmful suffering which he
expected from my care and treatment of his case.
Looking back over that period, I am free to confess that my efforts,
though honestly made, amply realized his expectations.
I began to see that I knew nothing of this disease or how to treat
it as a problem of clinical disease. I saw that addict after addict
sneezed and trembled, jerked and sweated, vomited and purged,
became pallid and collapsed, that his heart and circulation were
profoundly and alarmingly disturbed, that he had the unquestionable
facies or expression of intense physical suffering, and the many
constant and obvious signs which attend physical need for opiate
drug. I could not escape the conclusion that here were tangible,
material, incontrovertible physical facts for which I had no physical
explanation. It seemed unreasonable to be satisfied with any
explanation of them that did not have a physical basis; and it seemed
a logical conclusion that the establishment of a basis of physical
disease mechanism could offer the only hope of remedy. I therefore
ignored for the time being my past teachings and ideas of the drug
addict, and I looked to the patient himself, questioning him as to his
experiences and studying the symptomatology and physical phenomena
he presented. In short, I adopted the attitude which must be widely
adopted before the medical problem of the clinical handling of drug
addiction will be solved--in my attitude towards these cases I became
the clinical student and practitioner of internal medicine, treating my
patient to the best of my ability as I would a sufferer from any other
disease, and studying his case.
Struck by clinical facts which did not accord with past teaching,
I tried to seek out from my personal study and observation of the
individual case data upon which to form theories which would accord
with clinical facts and with verified histories and, if possible, give
a basis of help to these unfortunates.
Gradually since then I have gotten together, from my own work and that
of others, and with some success attempted to interpret and explain
and apply, what seemed to me facts about opiate addiction. To my mind
and in my experience these facts offer a beacon-light of hope and
assure ultimate rescue to a very large proportion if not most of those
suffering from narcotic drug addiction-disease.
It is well to state here that of late some of these facts have
secured recognition in medical and lay authoritative announcement and
literature. The Preliminary Report of a special investigating committee
of the New York State Legislature is quoted from elsewhere in this
book, and the report in June, 1919, of a special committee appointed
by the Secretary of the Treasury speaks of, “the more or less general
acceptance of the old theory that drug addiction is a vice or depraved
taste, and not a disease, as held by modern investigators.”
It is on account of “the more or less general acceptance of the old
theory” that it is necessary in this place to discuss some of the
tenets of that theory for the benefit of those whose interests or
emergencies have not led them to investigation of and familiarity with
the scientific and other writings on this subject of recent years.
It has been demonstrated to be a fact that description of narcotic
drug addiction as “habit,” “vice,” “morbid appetite,” etc., absolutely
fails to give any competent conception of its true characteristics, and
clinical and physical phenomena. A large majority of opiate users are
gravely wronged in a wide-spread opinion still prevalent. This opinion,
as previously outlined, is that chronic opiate addiction is a morbid
habit; a perverted appetite; a vice; that only he who is mentally or
morally defective will allow it to get a hold upon him; and that its
main and characterizing manifestations are those of mental, physical
and moral degeneration. Opiate addicts are supposed to have irrevocably
lost their self-respect, their moral natures and their physical
stamina. They are still painted by many, as inevitable liars, full of
deceit, and absolutely untrustworthy--people who are supposed to use a
dream and delight producing drug for the sensuous enjoyment it gives
them, and who do not want to discontinue its use. They are thought
of as physical, mental and moral cowards who, after realizing their
deplorable condition, refuse to exert “will-power” enough to stop the
administration of opiates.
With these views I did my early work on this condition. On these
hypotheses, trying to follow current available literature and teaching,
I treated my patients for a considerable time with results which
superficially interpreted seemed to corroborate both literature and
teaching. Many of them managed to get their drugs even while in the
institution, and practically all of them left uncured with but an
exceedingly small number of possible exceptions.
From my patients themselves, and from watching and studying them,
I later learned the truth, which has since been continually
strengthened--that the so-called “discomforts” we think of them as
suffering upon withdrawal of their drug, are actually unbearable
suffering, accompanied by physical manifestations sufficient to prove
this to be so. I also learned that the supposed delightful sensations
which have formed the background of most pictures painted of them, had
in many, if not in most of the cases with which I came in contact,
never been experienced. If they had ever existed they had long ago been
lost and all that remained in opiate effect was support and balance to
organic processes necessary to the continuance of life and economic
activity. As I have written, these sensations seem to be, “part of the
minor toxic action of the opiate against which the addict is nearly or
completely immune and to the securing of which very many and probably
a majority of the innocent or accidental addicts have never carried
their dosage.” In plain English the sufferer from opiate addiction has,
in many if not a majority of cases, never experienced any enjoyment
as a result of the drug and has endured indescribable agony in its
non-supply.
I do not want to be understood as claiming that opiates will not
produce pleasant sensations, nor that they are never used to the end
of experiencing these sensations. There is a class of the inherently
or otherwise defective or degenerate, who first indulge in opium or
its products from a morbid desire for sensuous pleasures, just as they
would and do indulge in any form of perversion or gratify any idle
curiosity. They are mentally incapable of self-restraint, indulging
jaded appetite with new stimuli. They yield themselves to any and all
forms of self-indulgence and gratification of appetite. There comes a
time when for them opiates, from increasing tolerance and dependence
lose power to give pleasurable sensations and become simply a part of
their daily sustenance, exacting physical agony as a result of their
non-administration. When this occurs they make no effort to control
amount or method or use; and overdosage together with conditions
incidental to and attendant upon their mode of life soon relieves
society of the menace of their membership. As a class they have
been regarded as incurable and hopeless--socially, economically and
personally unworthy of salvage. To whatever extent this may be true,
however, it is not true simply because they happen to have acquired
opiate addiction, but because they are fundamentally what they are,
diseased, degenerate and defective.
The opiate element is as incidental to their fundamental condition as
are the venereal and other diseases from which many if not most of
them suffer. Observations and conclusions upon addicts from this type
of humanity have been given great prominence in the public press and
elsewhere and have had an unwarranted influence in the status of opiate
addiction and the conception of and attitude towards the addiction
sufferer. Because addicts of this class began to use opium or its
derivatives and products to secure sensuous gratification is no reason
for stigmatizing the mass of those afflicted with addiction-disease as
people of perverted appetites. No one should study addiction in them
unless he is possessed of sufficient ability in clinical observation to
separate physical signs of opiate addiction from the manifestations of
defective mentality--and unless he has enough insight and breadth of
vision to see behind end-results, primary causative factors; and unless
he has enough common-sense to refrain from applying to the worthy many
the observations he has made upon the unworthy few.
It is only fair to state in passing, however, that from my experiences
as Visiting Physician in the wards of the Workhouse Hospital, New York
Department of Correction, I am convinced that we all too often casually
include in the above generally considered derelict class of society,
many who under intelligent and humane handling could be restored to or
converted into useful citizens.
There are some above this class, of the type of spoiled and idle youth,
who indulge first in opiates in a spirit of bravado or curiosity. The
tremendous increase in addiction since its spectacular incidental and
morbid aspects became so widely published is largely contributed to
from this class.
There are some who first used opiates to temporarily boost them over an
emergency, post-alcoholic excesses, severe mental strain, etc.
The majority of narcotic addicts, however, and especially those
developing previous to the activities of the past few years, present
a very different history. Mentally and morally they are of the same
average equipment as other people. They form a class which might
be called “accidental or innocent” addiction-disease sufferers.
They had no voice nor conscious part in the early administration of
opiate, realizing no desire or need for it by name, but only wishing
for the unknown medicine which relieved their sufferings. Very many
addiction patients have received their first knowledge of opiate
administration in the withdrawal symptoms which followed the attempted
discontinuance of its use. There is in these sufferers no element
of lack of will-power; no trace of desire to indulge appetite or to
pander to sensuous gratification. In some, before their condition was
recognized, their tolerance for or dependence upon opiate had proceeded
to a point where their bodies’ demand for morphine was imperative and
their withdrawal suffering unendurable. In others, before body need
was completely established--with their stamina and nervous resistance
below par from sickness and suffering--they have been unable to forego
opiate’s supportive and sedative and pain-relieving action, or to
endure the nervous and other symptoms attendant upon its withdrawal
after even a brief period of administration.
As to what the addict is;--the tendency and effect of legislative,
administrative, police and penological activities in general have
been to place the sufferer from addiction-disease in the position
of the criminal and vicious. The tendency of the psychologist and
psychiatrist is to analyze him from the viewpoint of mental weakness,
defect or degeneration, and to so classify and regard him. The average
practitioner of internal medicine, and even the recognized leaders
and authorities in this field of medical science will tell you that
narcotic drug addiction is a condition to which they have given but
little attention and have no clean-cut ideas of its physical disease
problems. The addict himself, whose testimony has been all too little
consulted or sought, will tell you that he is sick with some kind of
a physical condition which causes suffering and incapacity whenever a
sufficient amount of narcotic is not administered.
In the above attitudes and statements the administrative, police and
penological authorities are right in some cases;--the psychologists and
psychiatrists have good basis for their opinions in some cases;--the
addict has physical grounds for his statement in all cases--he is
always sick, sick with addiction-disease.
In my experience with and study of narcotic drug addiction and the
narcotic drug addict, an experience touching practically every phase
of the narcotic situation and giving me opportunity to observe the
condition in practically every type of individual, the one constant
and more and more strikingly emphasized observation has been constant
physical symptomatology and the manifestations of pain and suffering
and of fear. I have in my possession histories of addicts taken from
all walks of life and from all classes and conditions of men. Some of
my histories are of patients who were primarily defective, degenerate,
weak or vicious. Some of my histories are of people of high mentality;
of high ethical and moral standards; of high economic efficiency and
social standing. These histories, stripped of names and possibilities
of personal recognition, would form a very instructive collection of
material for the man, physician, psychologist, sociologist, legislator
or administrator who wishes to study the addict as he really is and to
get some conception of the diversity of the problems which he presents.
Neglect of this study and absence of this conception is the chief
cause of past failure. We have tended to regard and handle and treat
and legislate concerning narcotic addicts simply as narcotic addicts,
instead of appreciating that different individuals and different types
and classes of people who may suffer from addiction-disease present
entirely different problems, and require entirely different handling.
If we are going to consider all narcotic addicts as in one class we can
with justice only consider those characteristics which are common to
all members of that class. There is just one fact and characteristic
that stands out as of striking and paramount importance in every one
of my histories--it is the fact of physical suffering upon complete
withdrawal of opiate drug, or a supply of that drug which does not
meet the requirements of the physical body-need. Whatever or whoever
the narcotic addict was before his use of opiate drugs--whatever had
been the character and circumstances of the initial administration of
narcotic drug--after a time, as I have repeatedly written elsewhere,
after addiction-disease has once developed, the history of every opiate
addict is that of suffering and of struggle. After addiction-disease
is once developed the addict loses whatever euphoric sensation he may
possibly have experienced, and all that narcotic administration spells
for him is relief from suffering. Without the drug of his addiction
he endures intense physical suffering and misery. Without the drug
of his addiction he cannot pursue a social, economic, or physically
endurable existence. He may have been primarily defective, degenerate,
depraved or vicious; his primary administration of the drug may have
been deliberate indulgence, disreputable associations, idle curiosity,
any combination of conditions which may be stated;--he may have been
an upright, honest and intelligent, hard-working, self-supporting,
worthy and normal citizen in whom the primary administration of opiate
drug was a result of unwise, ignorant or unavoidable medication;--he
may have been an ignorant purchaser of advertised patent medicines
containing addiction-forming drugs. Whatever his original status,
mental, moral, physical or ethical, and whatever the circumstances
of his primary indulgence; once addiction-disease has developed in
his body the vital fact of his history is the same--subsequent use of
opiate drug means not pleasure, not vice, not appetite, not habit--it
means relief of physical suffering and the control of physical symptoms.
My present definition of narcotic drug addiction is as follows; a
definite physical disease condition, presenting constant and definite
physical symptoms and signs, progressing through clean-cut clinical
stages of development, explainable by a mechanism of body protection
against the action of narcotic toxins, accompanied if unskillfully
managed by inhibition of function, autotoxicosis and autotoxemia, its
victims displaying in some cases deterioration and psychoses which
are not intrinsic to the disease, but are the result of toxemia, and
toxicosis, malnutrition, anxiety, fear and suffering.
To express this somewhat differently--a narcotic drug addict is an
individual in whose body the continued administration of opiate drugs
has established a physical reaction, or condition, or mechanism, or
process which manifests itself in the production of definite and
constant symptoms and signs and peculiar and characteristic phenomena,
appearing inevitably upon the deprivation or material lessening in
amount of the narcotic drug, and capable of immediate and complete
control only by further administration of the drug of the patient’s
addiction.
In plain English, the sufferer from narcotic drug addiction-disease is
one who experiences the symptoms and signs referred to above and which
will be discussed later, as a result of lack of supply or physically
insufficient supply of opiate drug. I know of no definition along
any other lines which will include all who suffer from narcotic drug
addiction. This symptomatology, and the mechanism or process which
produces it, are the only common and characteristic attributes and
possession of all opiate addicts.
How these are developed and how they may be controlled and arrested is
the demand which the sufferer from narcotic drug addiction, and society
as a whole, are making. Until a competent and acceptable answer to
this demand is in the general possession of those handling narcotic
addiction, all other discussions will remain inconclusive, and all
other considerations incidental, for purposes of definite and final
solution. This is the medical problem of narcotic drug addiction, and
until those who handle narcotic addicts, and those who control the
handling of narcotic addicts, have recognized it, are familiar with it,
and can to some working measure explain and control its sufferings,
physical phenomena and symptoms and signs, they are unprepared to
assist intelligently and competently in the solution of a problem which
now as never before menaces the welfare of society.