THE NATURE OF NARCOTIC DRUG ADDICTION-DISEASE
It is a pertinent question to ask, “What type or class of individuals
become narcotic addicts?” The only correct answer unquestionably
is, any type or class or individual to whom opiates are given for a
sufficiently long time. It has yet to be demonstrated that there is
any warm-blooded animal, which following sufficiently prolonged and
constant administration of opiate drug, is immune to the development of
the symptomatology and constant physical phenomena of addiction-disease.
Color, nationality, social or economic position, age, mental and moral
attributes of whatever sort are no bar to the development of the
condition. These may influence, of course, the conduct and incidental
manifestations of the individual addicted, just as they do in any
other condition. The addicted judge, or the addicted physician, or the
addicted clergyman, or the addicted man of business or other affairs,
or the addicted clerk or industrial worker reacts differently to
the sufferings and trials of narcotic drug addiction than does the
addict of the underworld, or the heroin “sniffer” of idle and curious
adolescence, or the addicted defective, degenerate, or criminal. Also
he reacts differently to everything else. What is true of one man who
has opiate addiction may be absolutely false of another. One narcotic
addict is honest, competent, truthful and intelligent. Another is
dishonest, incompetent, untruthful and incapable of appreciation or
self-control. Neither the one set of attributes, nor the other, is
peculiar to narcotic addicts. They are simply personal attributes
possessed by different men and types of men who may or may not be
narcotic addicts. If the addict of a higher type displays at times
attributes not typical of his preaddicted days, and seems to show a
lowering of his mental and ethical tone, it is well to estimate in
his case the influences of past worry, fear, suffering, strain and
struggle, the attitude of society, medical and lay, towards him, and
the manner in which he has been handled, before blaming it all upon the
mere presence and effects of narcotic drug addiction, or of narcotic
drug. If such changes were inherent in the action of continued narcotic
drug medication, they would be found in all addicts, whereas the fact
is that they most decidedly are not.
As to age in addicts there is no limit. I have seen an infant
newly-born of an addicted mother, displaying the characteristic
physical symptoms, signs and phenomena of body-need for opiate a
few hours after birth. This case is discussed more in detail in the
transcribed testimony of the New York State Legislative Investigation
hearings, (Whitney Committee) pages 1524 to 1529, at which I reported
it. The infant undoubtedly developed addiction-disease prenatally,
reacting in its unborn body against the presence of opiates, supplied
through its mother’s blood, exactly, as is now demonstrated through
experimental laboratory animals and by clinical study upon adults, this
disease is always developed--through physical and constant reaction
of the body to the continued presence of opiates, however supplied.
There have been many such cases, some of which are matters of medical
record. This condition of prenatal development of addiction-disease
exists beyond dispute and certainly cannot be explained upon grounds of
conscious appetite or deliberate self-indulgence. I am told that there
are or until very recently have been old soldiers, veterans of the
Civil War, whose addiction dated from medication for wounds received
during that struggle. The late Doctor T. D. Crothers told me once that
opiate addiction in this country received its first wide dissemination
in that way. This points to the serious consideration of what may be an
urgent and important medical problem of modern warfare.
This brings us up to the origin of addiction. There is only one actual
origin of addiction, and that is the continued administration of an
addiction-developing drug sufficiently long to develop the physical
manifestations symptomatology, and phenomena and body need for that
drug. This statement is the only one which can be made as generally
inclusive. I have many records and histories, much correspondence, and
other data, collected from addicts, relatives, friends and associates
of addicts, physicians, official conferences and workers in the
various fields of narcotic endeavor. My material covers an active
interest of many years duration, and an experience which has dealt
with various types and classes of patients under various conditions.
I have held different beliefs at different times, influenced by the
demands of my immediate position, and by my best interpretation of my
own experience, by the conditions under which I happened to be working
and by the class of people coming to my attention under the conditions
of my work. At one time I believed that all addicts were defective,
irresponsible, degenerated, unreliable and liars, made addicts by
curiosity, environment and morbid appetite. At one time I believed
that the narcotic addict did not physically need narcotic drug under
any circumstances, and that he could get along without it if he only
had the will and the desire to do so. I proceeded on that theory for a
while in the handling of my cases, and have to thank the illicit supply
which is present in all institutions that my mortality was no higher,
for it is agreed and on record by many competent authorities that
forcible deprivation of opiate drug may at times cause death.
These are examples of a few of the various beliefs and ideas I have
held at various times, and upon which I used to generalize, as is the
habit and tendency of those who as yet lack experience or breadth
of experience. I have in time found many of my beliefs wholly or
partly erroneous, or to apply only to selected groups of cases or to
incidental phases and aspects of the main problem. They all have their
bearings on the general situation, and may be of primary importance in
the immediate handling and control of certain phases of it. I have come
now to keep my general statements to the solid rock of basic disease
and draw on my past experience for the measure and estimation of
associated problems and complications as they arise.
The actual origin of addiction is the administration of opiate
drugs continuously over a sufficient length of time. The incidental
details in their early administration to those who become addicted
vary widely. In the origin of some proportion of addicts, we of the
medical profession must sooner or later come to recognize and assume
our part, unconscious and innocent, but none the less beyond question.
What this proportion is is variously estimated by various authorities
and statisticians and investigators. It is now beyond dispute that
many cases of addiction-disease had their origin in medication during
illness, the condition developing unsuspected by either physician or
by patient until its physical manifestations had passed the bounds of
control.
The old fallacy that an opiate might be administered safely to a
sufferer so long as the patient did not know what was being given him
is completely disproven by the evidence of addicted infants, and by the
excellent and exhaustive laboratory experiments upon addicted animals
by such men as Giofreddi, Hirschlaff and more recently Valenti of
Italy whose work, published in 1914, should have widest recognition.
This fallacy has been responsible for many a case of addiction. Very
many opiate addicts have passed into the stage of fully established
addiction-disease before they were aware that they had ever taken an
opiate.
Clinical familiarity with the symptoms and signs of beginning and
developing addiction should be the possession of every physician
and surgeon. It would save from the physical sufferings, and mental
tortures and fears of narcotic addiction many human beings. It has
been my experience when called in as a medical consultant upon medical
and surgical cases whose progress towards recovery seems unaccountably
tedious and unsatisfactory, to detect as the basis for the lack
of function and recuperative power, unsuspected developing opiate
addiction in time to prevent its further progress. Unwisely prolonged
opiate medication makes more opiate addicts than we have realized.
The addict in whom it is most profitable to study addiction origin
and development and handling, if we are to get a clean-cut picture of
addiction-disease, is the individual who is primarily normal, mentally,
morally and physically, whose addiction condition is a result of
ignorant, misguided or unavoidable medication, either professionally or
self-administered. Their number is far greater than is yet generally
appreciated. Many if not most of them are unsuspected and unknown and
they include eminent people in all walks of life. They are social, and
economic assets whose interests and welfare we cannot ignore when we
are considering the disposition and handling of the narcotic addict.
Many of them have gone from one institution to another, and have
attempted, in desperate effort to be cured, each newly-discovered and
announced specific or theory of treatment. They have never derived any
pleasure from narcotic use. For them the narcotic drug has been only
necessary medication to relieve physical suffering and to maintain
economic existence and the support of themselves and their families.
They should be classed as innocent or accidental addicts--normal and
worthy sick people. They earnestly desire treatment and help, and once
their addiction process is completely arrested do not tend to return
to narcotic drug use. Whatever associations they may have had with
the unworthy or unfit of the so-called “underworld” and with illicit
and illegitimate traffic has been the result of desperate necessity,
in their best judgment, in the obtaining of opiate supply when it has
seemed to them to be otherwise denied them, and which was necessary to
them for the relief and avoidance of suffering and for the maintaining
of a condition making possible self-support and the avoidance of
revelation and disgrace.
The narcotic addict of this type presents primarily and fundamentally a
purely medical problem. Competent and complete arrest of the physical
mechanism of narcotic drug need permanently removes him from the
ranks of the narcotic drug user. The problem of his handling is one
falling within the province of medical practice. His care is purely and
simply a matter of the treatment of disease with medical intelligence
and judgment on the established lines of medical practice in disease
conditions generally. His after-care is simply such management of
convalescence as is needed in ordinary medical cases. The length of his
convalescence will depend entirely, just as in other diseases, upon
the competency and intelligence of his medical handling and upon his
physical condition, reaction, and recuperative ability.
For such a man custodial care and institutional handling under
conditions of enforced restraint are undesirable and harmful. His
withdrawal from self-supporting citizenship should be for the
shortest time commensurate with adequate therapeutic results.
He should be restored to normal personal, social, and economic
environment and activity at as early a time as possible following
his clinical treatment and the arrest of his physical mechanism of
addiction-disease. Given intelligent clinical handling, with rational
therapeutic treatment, and a comprehensive meeting of the indications
of disease in his case, he is no more a subject for unusual restraint
and custodial care than is a case of malaria or pneumonia or other
medical condition. He is in most cases a clinically curable medical
case. He presents the true picture of addiction-disease uncomplicated
by the distracting and confusing incidentals often met with in the
types of cases more commonly discussed. The development of addiction in
a case of this type is a purely physical matter, and is the addiction
which should be considered in the fundamental comprehension of basic
facts.
_Stages of Addiction Development_
Every case of well-developed addiction has followed in its development
a course through several stages, definitely marked by clinical signs
and reaction phenomena. I shall not exhaustively discuss all of these
stages and their phenomena. The ones I shall mention will be recognized
by most of those who have gone through them or have watched them
develop.
1. _Stage of Normal Reaction to Therapeutic and Toxic Doses._
The manifestations of this state in morphine administration for example
are more fully described in our text-books of materia medica than I
can take space for in this book, and are familiar to all physicians.
The narcotic and analgesic effect with therapeutic doses; the euphoric
and inhibitory action of doses in excess of the therapeutic; the
toxic action manifested by the slowed pulse, slowed respiration, and
generally arrested metabolism and function are too familiar to need
elaboration.
2. _Stage of Increased Tolerance._
Following continuous and consecutive administration of morphine (and
the same is true of other opiates) comes failure to secure the effect
which followed the early administration. Larger doses are needed for
the relief of pain or other symptoms, or the original doses give relief
for a shorter time. Toxic manifestations do not follow what would
formerly have been a toxic dose. The patient requires what was formerly
a toxic dose to secure the former therapeutic effect. The phenomena of
this stage are familiar to every observing clinician who has used or
seen morphine used for continued therapeutic action. The patient has
acquired an increased tolerance of the drug and a beginning immunity
to its toxic action. He does not, however, suffer appreciable hardship
from drug deprivation. Discontinuance of the drug causes little or none
of the symptoms to be described as “withdrawal signs.”
3. _Stage of Beginning Addiction._
Following the stage of increased tolerance comes a stage where
discontinuance or lack of administration of the narcotic drug gives
definite signs and symptoms, beginning “withdrawal signs,” due to some
beginning physical body demand for the drug and completely relievable
only by its administration. These signs are identical with the first
appearing withdrawal signs in a case of established addiction but as
yet do not go beyond the beginning manifestations of “withdrawal”
in a completely developed addiction. They are limited to a peculiar
nervousness, restlessness, weakness, depression, etc. They persist for
a few days only if the drug is denied and are endurable.
As to length of time required for the passage through each of these
previous stages or through both of them--dogmatic statement is
impossible. The time is apparently influenced by a number of factors.
Of course the varying inherent resistance or susceptibility of
different individuals to any given disease condition must be considered
in this disease. It varies also with different forms of opiates used
and their modes of administration. The probable physical factors I am
not yet ready to discuss. The recent Report of the Special Committee
of the Treasury Department says, “Any one repeatedly taking a narcotic
drug over a period of 30 days, in the case of a very susceptible
individual for 10 days, is in grave danger of becoming an addict.”
Certainly a physician should look for the signs and symptoms of
tolerance and beginning addiction throughout his opiate administration.
It is also well to exhaustively inquire into possible past history of
unrecognized addiction in any of its three general stages. Some of
those patients who have demonstrated an apparent unusual susceptibility
and very rapid development will be found on careful analysis to have
experienced an unrecognized or forgotten addiction in some stage of
development. I have interesting data on this point.
4. _Stage of Established Addiction._
In this stage the “withdrawal” symptoms and signs become more evident
as results of opiate deprivation. They proceed through the mild
discomfort and nervousness of the previous stage to the definite
manifestations and constant unmistakable withdrawal phenomena to be
described. The patient endures physical suffering and displays all
the clinical evidence of it. There can be no question of will-power
in this stage, nor of desire for narcotic drug for any other purpose
than to escape physical suffering. Whether the patient was primarily an
innocent and unconscious recipient of the drug, or of the class of the
vicious and weak, he is now fundamentally a sick man, afflicted with
a physical disease. Whether or not he ever experienced any euphoria
or sensuous enjoyment, he now gets nothing of pleasure from narcotic
administration. He gets, _simply_, relief from suffering. The opiate
drug has become his _only_ immediate means of securing and maintaining
a physical efficiency, a semblance of normality. No other drug will
take its place. He can take tremendous doses without toxic effect.
In this stage, if the drug is denied or withdrawn without competent
handling, his suffering and incompetency is not, as in the previous
stage, a matter of days but may persist for weeks or months after no
narcotic has been administered.
The general stages of addiction-disease development as above rather
superficially outlined are not of course sharply marked in their
transitions. They slowly merge one into the next and taken together
constitute a gradual development from normal reaction to opiate to
established addiction-disease.
Most patients are in or nearing the stage of developed addiction when
they are recognized or come for treatment. Developed addiction for
narcotic drug means physical, bodily need for that drug; functional
incompetency and suffering without that drug; comparative normality
and efficiency only to be immediately secured and maintained by the
continued use of that drug.
This is the situation of the sufferer from addiction-disease until such
time as the activity of his addiction-disease mechanism is arrested.
* * * * *
Before I attempt exposition of the mechanism which seems to me best to
explain addiction-disease and offer a basis for its rational handling,
I shall offer several observations bearing upon physical or body
reaction in the state of addiction.
1. Experience of addicts and observations upon them show that the
length of time over which an addiction sufferer is free from his
“withdrawal” manifestations is in proportion to the amount he has
recently taken. Under conditions eliminating various factors, outside
of the addiction mechanism, which may influence this general rule,
the ratio between the amount of recent dosage and the interval of
freedom is almost mathematical. For example, if under given conditions
one grain of morphine will keep an addict free from withdrawal
manifestations for four hours, two grains will do this for nearly eight
hours and three will have the same effect for about eleven hours. It
would almost seem as if there were some substance produced in definite
amount in each individual case at a given time, and neutralized or
opposed by or in some way negatived in its action by a definite amount
of opiate drug.
2. Each addict shows a definite and approximately measurable daily
minimum need for the drug of his addiction. If he is suffering from the
deprivation of his drug, he will require a certain dose, measurable
by its effect upon his symptomatology, before he is made physically
comfortable and physically efficient again.
3. The narcotic drug administered to an addict suffering withdrawal
phenomena and symptomatology will relieve those manifestations exactly
in proportion to the amounts of drug administered. Each addict has a
constant sequence of symptoms attending the so-called “dying-out” of
the drug. These symptoms are relieved in constant reverse sequence by
the administration of the drug, and in exact proportion to the amount
of drug administered, various incidental influences being eliminated.
A small amount of the opiate will relieve the symptoms last appearing;
another insufficient amount will relieve another proportion of the
withdrawal signs, and so on, until the opiate drug administered
balances in amount the extent of the addict’s deprivation, or physical
need.
This is almost mathematical in its working, and the average intelligent
addict, after a few trials, can tell within a very close margin just
how much opiate, in his accustomed form, has been administered by the
extent to which it relieves his withdrawal signs. It almost seems as
if the narcotic drug acted as some sort of an antidote for some poison
present in definite amounts in the addict’s body.