REMARKS ON METHODS OF TREATING NARCOTIC DRUG ADDICTION
Most physicians have at some time or other in the course of their
practice encountered cases of narcotic addiction. Most addicts have
appealed to the physician for advice and help. A very large proportion
of them have at different times made effort to obtain relief from
their affliction through the avenues of various forms of treatment,
advertised and otherwise. Most physicians have at some time or other
made effort to rescue some victim from drug addiction, and as a rule
have given over the effort as hopeless, because even when they had
succeeded in taking his narcotic away from the patient, usually after
an experience trying and exhausting to both, the patient has resumed
narcotic administration--according to the patient, because he had
to--according to the average observer, because he wanted to. Frequently
the patient has refused to persevere to the end of treatment and has
abandoned his attempts before the treatment has reached the point of
cessation of opiate medication--the patient stating that he could
not--the observer believing that he would not, continue, and did not
have the courage or stamina or will to endure the necessary suffering.
The medical profession as a whole has adopted a cynical attitude
towards the possibility of permanent “cure,” and towards the efficacy
of medical treatment, which has tended to send the addict to quacks and
charlatans and various advertised remedies.
It is not my purpose to discuss in this book in detail the various
methods, and treatments and cures advocated and employed in the
handling of the drug addict. This alone would require a volume in
itself.
Three broad lines of procedure have been employed; so-called
“slow-reduction,” “sudden withdrawal,” and withdrawal accompanied by
the administration of various drugs, such as those in the belladonna
group and its alkaloids.
Slow reduction or “gradual reduction” as a “method” is employed by
slowly or gradually, reducing the patient’s accustomed dosage to the
point of discontinuance of opiate medication. Interpreted by a great
many to mean that the fact of reduction is the principal indication in
clinical procedure, successful in the hands of a few who have acquired
unusual technical skill and clinical ability in the interpretation
of addiction manifestations, I believe it to have failed as a method
of cure in the hands of the average. Practically every addict has
attempted it one or more times. As a method of procedure in some
stages and under some conditions of addiction treatment, slow or
gradual reduction of dosage has its value. In my opinion, however,
all other considerations aside, there are very few who are possessed
of sufficient understanding of narcotic addiction and ability in the
interpretation of clinical indications, and have the technical skill
required to carry it through to a clinically successful culmination.
As a method of routine or forcible application it has many serious
objections as well as potentialities for damage to the patient. In
cases whose opiate intake is in excess of actual physical-need, gradual
reduction as often practiced is perfectly easy and unnecessarily
slow down to the amount demanded as a minimum by the patient’s
addiction-disease requirements. Then must come withdrawal, nagging,
exhausting and protracted, if unskillful reduction is persisted in,
and the wrench of actual final withdrawal is nearly as severe from a
very small dosage as from a moderate one, other conditions in the
case, physical and mental, being equal. Prolonged “withdrawal” without
rare technical skill and without unusual and not commonly available
environment and conditions of life, means subjecting the patient to
the continued strain of persistent self-denial and self-control in the
face of continued suffering, discomfort, and physical need and constant
desire for their relief. It is my opinion that this experience has
in many cases tended to deeply impress upon the mind of the patient
so-called “craving” for the drug, and has converted many a case of
simple physical addiction-disease into a more or less mental state
which may be described as “morphinomania” or “narcomania.”
This last observation does not apply to the method of gradual reduction
only, but is equally true of protracted suffering under any other
procedure in which the individual is cognizant of the existence of
means of immediate if only temporary relief.
In the comprehension of this a physician has only to glance back over
his professional experience and recall cases of various conditions
other than addiction which have come to him, and whose histories
present the effect of long protracted suffering and discomfort in the
conversion of an average normal, self-supporting human being into a
dependent neurasthenic.
The histories given by most narcotic addicts of their efforts to get
relieved of addiction, show that following the withdrawal of opiate
drug in many if not most instances has come weeks and months of
weakness, and discomfort, nervousness, sleeplessness, and pain which
have persisted for weeks and months, establishing the basis for the
much emphasized “after care,” of some investigators.
While so-called “after care” is unquestionably as important as
convalescence from any other disease, it is my belief that as
understanding of addiction as a clinical disease becomes more general,
and more attention is paid to the study and scientific management of
the disease itself, the stage of “after care” will come to assume less
importance. Addiction is not the only disease which furnishes examples
of cases in which incomplete and unsatisfactory results have been
merely a low-grade continuation of the fundamental disease and have
been interpreted as a protracted convalescence.
“After care,” or convalescence, following satisfactory results of
clinical treatment and complete arrest of addiction-mechanism activity
has no terrors for either physician or patient. It is very short and
does not require any more restraint than any other convalescence,
unless conditions exist following active treatment which should have
been recognized and handled and eliminated earlier from the picture. I
shall discuss this again later.
“Sudden” or “forcible” withdrawal, or immediate deprivation of opiate
drug is still advocated by some investigators, fewer and fewer of
them, however, among medical men. There are cases of, and stages in
addiction-disease and its development where this means of procedure may
be pursued without all of the serious objections with which it must be
regarded as a routine method of general enforcement.
That forcible deprivation of opiate drug may end in death is a matter
of too easily found and authoritative medical record to be ignored. It
has been discussed as one of the possibilities by medical writers over
many years. Even the newspaper reports of deaths and suicides following
sudden deprivation of opiate should be sufficient to give pause to
those who would still advocate this measure as a desirable procedure.
Reference to the previous enumerations of the physical manifestations
of body-need for opiate, or “withdrawal signs,” should be sufficient
for the comprehension of its tortures and easily explains the suicides
which have attended sudden deprivation. Any one who has watched a
well-developed case of addiction-disease in the agonies of opiate
deprivation should hesitate to prolong them if possibly avoidable.
While under some conditions, and in some cases, it may be argued that
“the ends will justify any means,” as a routine procedure of wide
application, it must be stated that both in its immediate torment and
in its end results, mere forcible sudden withdrawal is not a procedure
of election. Some of its supporters still cling to and quote the old
fallacy that after seventy-two hours without opiate a narcotic addict
no longer physically requires it. This fallacy is probably based upon
the estimated maximum time of opiate elimination in normal human
beings and experimental animals. It is most decidedly false doctrine
as applied to the well-developed case of addiction-disease in whom the
mechanism of disease, and not the mere administration or elimination of
opiate has become what should be the dominating consideration.
As stated before, the mere withdrawal of opiate drug does not arrest
the activity of addiction-disease, nor prevent the endurance of the
exhausting and incapacitating and protracted low-grade manifestations
before referred to. Its potentialities of permanent damage, moreover,
are attested by and displayed by many who show for years shattered
nerves, premature old age, etc.
It is perhaps wise to state again in this place that in this book
the consideration of narcotic or opiate addiction, its mechanism
symptomatology and handling, is not to be applied to cocaine and
alcohol use nor to the various other drugs often loosely grouped
with opiates as “habit-forming.” Until a distinct physical disease
mechanism, attended by analogous characteristic and constant physical
phenomena, can be demonstrated as resulting from the action of one of
these drugs or substances, its continued use should not be classed with
opiate addiction-disease.
The third general method of procedure is that in which effort is
made to utilize other drugs than opiates, or other measures than mere
reduction or withdrawal or deprivation to secure cessation of opiate
medication. The efforts have been, in a general plan, either to oppose
or replace the action of opiate by substance or substances seemingly
to have physiologically antagonistic or substitution properties--or to
combat, offset or benumb the sufferings of what is described as the
“withdrawal period.” Such agents have been employed in this disease
for very many years, and in their variety include most of the known
analgesic, sedative, antispasmodic, hypnotic or anesthetic agents and
measures.
Prominent among the drugs mentioned have been the preparations and
alkaloids of belladonna, of hyoscyamus, pilocarpine, and some others.
These drugs have by reason of more or less supposed specific action,
alone, or in various combinations or in conjunction with purgatives,
etc., formed the basis for many if not most of the various special
treatments and “cures.” For example, what is described as the “specific
mixture” of one of the most widely-known treatments contains as its
active agents belladonna and hyoscyamus. These drugs are not mentioned
here in condemnation of their employment as therapeutic measures
in the hands of those skilled in the estimation of their values,
indications and actions--and dangers if unskillfully employed. They
have unquestioned therapeutic value in their proper places, as and when
properly indicated, in individual cases. Routinely used, as specific
curative agents, they seem to me to be demonstrating their failure. In
the conception of addiction-disease herein outlined it is difficult to
attribute to them specific properties.
In a paper, “The Rational Handling of the Narcotic Addict” read before
the Section on Pharmacology and Therapeutics, Annual Session of the
American Medical Association, 1916, I stated, “It is not my purpose
to enter into discussion of the various therapeutic methods and
therapeutic measures which have been advocated and employed in the
treatment of narcotic addiction. Their number is legion, and they
include most of the therapies known to lay as well as to medical
literature.
“Their multitude is conclusive proof of lack of conception and of
understanding of addiction-disease in the past. They have been directed
towards incidental and complicating manifestations. They have no more
place in the treatment of the addict than they have in the treatment
of any other disease condition. I know of no medication that can be
called ‘specific’ in the arrest of the mechanism of narcotic drug
addiction-disease. There is no more of a specific remedy for narcotic
drug addiction than there is for typhoid or pneumonia. The wide
advertisement of treatments based on supposed ‘specific’ action of
the products of the belladonna and hyoscyamus and similar groups is
unfortunate. They have in my opinion, no action as curative agents in
narcotic drug addiction-disease which can entitle them to consideration
as specific or special curative remedies. The drugs of this group
are useful in many cases, intelligently applied to meet therapeutic
indications. They exhibit wide variation of action and reaction in
narcotic drug addicts at different clinical stages and under different
clinical conditions, and their dosage presents an extremely wide range
of individual measure. They are dangerous drugs in the hands of the
inexpert or careless, or used in a routine manner or dosage. The status
which they have acquired as specific medication in narcotic addiction
disease I hold to be a medical fallacy which should be strongly opposed
and early remedied.”
The search for panaceas, specifics and routine treatments has
constituted a stage in the therapeutic history of most disease
conditions. It marks the effort to make wide and general application
of a partial comprehension of facts and imperfect recognition
of fundamentals and is successful only as an individual case is
occasionally capable of responding, perhaps by clinical accident, to
the specific routine employed.
Undue insistence and publicity secured for or given to a procedure of
this description, is a real obstacle to the development of clinical
and scientific understanding of the condition treated. It distracts
attention from broad clinical consideration of disease itself, from
scientific investigation into pathology and disease mechanism, from
determination and observation of fundamental facts, whose comprehension
and analysis form the essential factor in the widespread successful
handling of any condition, and from proper conception and appreciation
of the addiction patient and the addiction problem as a whole with its
many and varied aspects.
Various procedures in themselves, however, are not to be utterly
discredited and condemned. They have performed a function in a
transitional stage of education and progress. They can all bring
evidence in support of some “cures.” In their origin and inception
they represent honest effort, study and original thought. In analysis
of them can be seen, in the minds of those who first evolved them,
recognition and application of one or another of the basic elements,
reactions or facts of addiction-disease. Each generation builds upon
and adds to the work of the previous one, discards or adopts according
to its more complete knowledge. We are building upon the various
procedures of the past just as our successors will build upon our work
of the present and will discard or adopt our various instruments and
theories.
We are nearing the end of consideration of routinely applied
procedures, in all diseases. In addiction we are entering upon a
stage of attitude and handling in which there shall be in each case
comprehension of intrinsic elements and appreciation of their relative
importance, and in which there shall be competent interpretation of
symptomatology and competent selection and application of therapeutic
measures, placing our efforts on a rational basis and adapting handling
and treatment to the needs of the individual.
Our stumbling-block in the past has been that our minds have been too
much focused upon the mere use of narcotic drug and upon the stopping
of drug use and too little upon the individual we were treating and the
mechanism of his disease. We have tended to apply our remedial efforts
to narcotic use instead of to narcotic drug addiction-disease.
This may explain the paucity of clinical and scientific information
as to addiction-disease coming from the institutions in which these
cases are gathered. It seems to be the fact that the narcotic wards of
our great charity hospitals and institutions of custody and correction
still in great measure proceed with their handling of narcotic addicts
on the basis of mental or moral degeneracy or deficiency or weakness of
will, or morbid appetite, etc., or apply one or another of the various
remedies or combinations of remedies. Their internes and nurses do not
seem to graduate with a conception of addiction as a definite physical
disease, with clinically significant symptomatology and constant
physical reactions and phenomena. That these institutions have after
many years given us so little information as to the definite physical
symptoms and phenomena which their patients constantly manifest is
in large measure the result of attention directed to control of drug
use instead of to alleviation of physical addiction-disease. There
has been much discussion over various methods of treatment and over
measures for the control of patient and of narcotic drug, and there
has been insufficient study and analysis of the clinical details
of addiction-disease manifestations and their possible therapeutic
significance.
There has been of late, however, signs of change in this situation,
and in this change lies one of the greatest hopes of solution of the
narcotic drug problem. The attitude towards addiction is beginning to
follow the trend of modern medicine in getting away from special or
routine treatments, and the search for specifics and panaceas, and in
aiming at and devoting great effort to the searching out, consideration
of, and treatment of fundamental cause and underlying condition. When
this method of approach is applied widely to addiction-disease, and
the facilities of our great hospitals and institutions of research
properly directed to its furtherance, there will come a re-arrangement
of conception of opiate addiction. Restraint and custodial care,
and psychologic and psychiatric classification will be applied more
sparingly. Many worthy sick people will--instead of being refused
treatment, or turned back upon their own resources after inadequate
treatment--thus adding to the public and private burden of the care of
the unfit--be rationally treated as sick people and returned to health
and self-supporting competency.
The one great point to be kept in mind is that narcotic addicts are
sick; sick of a definite and now demonstrable disease. This disease is
variously complicated and widely variable as it occurs in individual
patients. Although some individuals, afflicted with this disease, may
require custodial or correctional handling--the fundamental physical
disease cannot be properly arrested nor handled successfully by
mental, moral, sociological or penological methods only. Any toxic,
worried, fear-ridden or suffering sick man may show psychological or
even psychiatrical manifestations or complications, but observing and
attempting to control complications only will not cure basic disease.
Even if it should some day develop that a serum can be produced
against the underlying toxins of addiction-disease; and this is not
beyond the bounds of possibility; its usefulness and application must
remain for the present matters of academic speculation. Other than
this possibility, there seems practically no hope of a properly called
“specific medication” in narcotic drug addiction-disease. Even with its
discovery, it is highly improbable that a routine treatment applicable
to all cases could ever be successfully adopted. In the very few
disease conditions in which we can properly be said to have “specific”
medication, routine handling and treatment of all cases is inadvisable
and unsatisfactory.
There is not and probably never will be any specific routine treatment
successfully applicable to all cases of any complex and variable
disease condition. We shall save much public money, and personal
effort and time, and shall save the narcotic addict much suffering and
discouragement, and shall add much to human health, competency and
happiness when we realize these facts as applied to addiction-disease,
and proceed upon them in a spirit of broad humanity and of rational
clinical study and remedy of obvious disease symptomatology. Narcotic
drug addiction-disease is a definite, and in most cases arrestable
disease. It should be widely so regarded and studied and treated.