THE RATIONAL HANDLING OF NARCOTIC DRUG ADDICTION-DISEASE
If anything has been demonstrated conclusively concerning narcotics it
is that the methods of the past, legal, administrative, and medical,
have not solved the narcotic drug problem, nor controlled the narcotic
drug situation, nor been successful in the handling of the narcotic
drug addict.
Some factor or element of great and fundamental importance has
obviously been neglected. This lacking element is general recognition
of the presence of disease processes which cause the symptomatology
and phenomena of body-need for opiate drug. One of the essentials for
the practical solution and management of the narcotic drug problem is
the realization by the medical profession, legislators, administrators
and laity that opiate drug addiction is a definite disease entity, to
be treated as such, and calling for extensive clinical and laboratory
investigation and study such as have been accorded other diseases over
which we have gained the mastery. One of the most needed achievements
in the line of practical remedy is the admission of narcotic drug
addiction-disease to its legitimate place as an accepted part of
the practice of internal medicine and the stimulating of education
concerning it among medical practitioners, medical students and nurses.
As was stated in the last chapter, too much emphasis has been placed
on drug use and drug withdrawal, as if the drug itself were the most
important element in the clinical picture of addiction. In the handling
and treatment of addiction-disease it should be constantly borne in
mind that the ultimate withdrawal of opiate from the addict is simply
one stage, and not by any means the most important consideration
in his rational handling. Its management in most cases is a matter
of scientific clinical certainty and satisfactory accomplishment
by the physician who understands the disease he is treating and
who is clinically proficient in the control of its elements by
indicated therapeutic procedure. The ease of handling the stage of
final withdrawal, the extent to which suffering, nervous strain and
exhaustion can be avoided in it, and its final issue depend greatly
upon the physical and reactive condition of the man from whom drug
is withdrawn. Like the stage of crisis in pneumonia, its course
and conduct and results are largely influenced by the condition in
which the patient approaches the withdrawal. It is of vastly more
importance to measure and control reactions and treat a patient so as
to get him into the fittest possible condition for final withdrawal
and rapid convalescence, than it is to focus attention on the mere
reduction or withdrawal of drug, or on the mere amount of drug used.
Final withdrawal of drug, like an operation of election, is to be
done when the patient is in the fittest condition and ready for it.
With the addict who is well nourished, non-inhibited, and physically
and glandularly reactive, it can be accomplished with little or no
discomfort, in a very short time, leaving practically nothing to demand
a protracted and difficult stage of convalescence or of so-called
“after care.”
It becomes evident, therefore, that the handling of an opiate addict,
preliminary to withdrawal of the drug to which he is addicted is
of greatest importance. The ease of withdrawal and rapidity and
completeness of subsequent recuperation, is largely commensurate
with the extent of organic dependence upon the drug and the physical
condition of the patient. One man using the same amount as another is
dependent upon its effects for the support of his organic processes
to a much greater extent. The evident solution lies in a preliminary
stage, removing inhibition, reducing in so far as possible organic
and functional dependence upon drug, and putting the patient into the
best possible reactive condition. I believe that in many cases it is
imperative for successful issue to train the patient for the shock and
strain of opiate withdrawal and in practically all other cases, though
less imperative, most desirable.
It has been objected that this will prolong treatment. My experience
has been that it very much facilitates withdrawal treatment, and not
only renders it easier and more uniformly successful and complete, but
that it tends to shorten and make less troublesome, and in some cases
practically eliminates, convalescence.
I have therefore instituted as an important part of my procedure, a
Preliminary Stage of study and handling and treatment of my patient
before attempting withdrawal of the drug. During this time I study my
patient, regarding him not simply as a narcotic addict but as a sick
man to be investigated as carefully as a cardiac or any other patient,
and all his organic and functional conditions appreciated, and all of
his functional and glandular actions estimated in their competency
and balance and their reactions both to the drug of addiction and to
the influences of addiction disease mechanism. Conditions long masked
by opiates, and forgotten, even by the patient himself, may seriously
affect treatment, convalescence and prognosis if undetected before
withdrawal is instituted. Their relations to and possible influence
upon addiction and its treatment, and fully as important--the possible
effect of treatment and withdrawal of drug upon them, should be very
carefully estimated. If advisable or possible they should be remedied
before withdrawal of the drug of addiction.
Also such mental or psychical disturbances as may exist in a given
case should be traced to their origin, estimated and reckoned with.
Very often they will be found to be not inherent but a result of past
suffering and present worry and fear. The patient’s confidence in
his physician’s ability to treat the disease from which he suffers
should be strengthened, and his doubts and fears allayed. Addiction
patients are well informed concerning opiates and are acquainted with
the manifestations of addiction-disease, and have had experience with
or full information concerning the various methods of cure. They are,
like any other chronic sick person, suspiciously and keenly analytic of
themselves and of the physician, and unless handled with appreciation
of their condition are naturally the prey of constant worry and fear.
Co-operation and confidence between patient and physician vastly
influence the amount of nervous energy expended by both, and in this,
as in other diseases are big factors in treatment and in convalescence.
Another advantage of a preliminary stage is one which has been too
little considered, but which will before long come to demand the same
intelligent attention and measure as is given to the contemplation
of operations in and treatment for chronic other conditions. It
is this--in what condition will withdrawal of opiate even though
skillfully conducted and successfully accomplished, leave the
individual in his value to himself, and to his family and to the
community, in view of co-existing physical conditions? Withdrawal of
opiate drug has been in not a few cases the cause of transforming of
a capable and useful citizen into an invalid incompetent, for whose
ultimate salvation and competent physical and mental function and
organic and glandular control resumption of opiate medication was
determined to be a therapeutic necessity.
Such considerations as this should be all taken, analyzed and
estimated in a preliminary stage and if treatment is only going to
injure a patient he should be instructed how to handle his addiction,
and advised to continue his opiate medication, and not be subjected to
useless expense and trials.
_Basic Principles of Addiction-disease Handling_
Intelligent addicts well know that, other factors being equal, the less
number of times in a day they take their drug, the less inhibited, the
less constipated and more normal they are, and the smaller amount of
narcotic drug they require to maintain them physically and mentally
competent. It is unfortunate that this therapeutic principle so widely
recognized among intelligent addicts has not received full recognition
and therapeutic employment by all of those who handle and treat
addiction-disease. Its probable explanation is very simple--apparently
a period of inhibition follows the administration of narcotic or opiate
drugs; and the length of this period is not in ratio to the size of the
dose administered. Consequently, the fewer number of times in a day a
dose of narcotic drug is administered, the greater amount of competent
metabolism is present--the more adequate is the patient’s elimination
and nutrition--the smaller amount of opiate or its product lies stored
in inhibited and atonic cells, and the smaller amount of antidotal
substance is manufactured for the protection of the body, and to some
extent, the smaller amount of opiate is required.
In caring for the narcotic addict, therefore, one of the most important
therapeutic measures is the regulation of the interval of his narcotic
drug administration. I have repeatedly experimented upon addicts who
were not confined or under restraint in any way. I explained to them
the inhibitory effects of too frequent dosage and instructed them to
use the amount of drug they found necessary for twenty-four hours in
larger doses at longer intervals. This procedure alone, in many cases
transforms the pallid, starved, constipated and deteriorated addict
within a surprisingly short time into a well-nourished, well-reactive
and practically normally functioning individual. With the return of
health, vitality, and normal nutrition and elimination, his body
requires still less drug and he voluntarily and without mental struggle
and nervous strain reduces the amount of drug used. I wish to emphasize
that in these experimental cases there were no other therapeutic
measures employed in the way of medication.
The practical therapeutic application of wide-interval administration
of opiate drug is made possible by the fact that the narcotic addict
can tolerate without harm large doses of the drug of addiction. It is
made controllable by the fact, that, within certain limits, the length
of time over which a dose of narcotic drug will maintain a patient in
narcotic drug balance--or free from the symptomatology of drug need--is
in mathematical ratio to the size of the dose administered. Each addict
requires, under the conditions of his daily life at a given time, to
satisfy the demands of his physical addiction-disease mechanism, and
to maintain him in narcotic drug balance, an amount of drug which can
be estimated in terms of twenty-four hours and which I have called the
amount of minimum daily need. The most important consideration in the
administration of narcotic drug to a narcotic addict is to supply the
amount of minimum daily need and maintain narcotic drug balance with
the least inhibition of function.
Failure to maintain narcotic drug balance and a degree below the amount
of minimum daily need renders the addict functionally and physically
incompetent. He is in a condition of physical and nerve incapacity
and exhaustion. He has no physical tone; he has markedly impaired
circulation; he cannot react, he has no recuperative powers; he has
constantly in his body, according to modern theory, unneutralized
autogenous poison which robs him of vitality, reaction and functional
efficiency even though it may not be present in sufficient amounts
to give rise to the violent spectacular and agonizing manifestations
of complete narcotic deprivation. In other words, as I have written
elsewhere, “the reduction of the drug of addiction below the amount
of body-need robs the addict of his most valuable asset in securing
and maintaining recuperative powers.” In no other disease would an
intelligent physician persist in the application of measures which
robbed his patient of recuperative powers and expect satisfactory issue
of the case he was trying to treat. Until the physician and patient are
ready and prepared for the institution of the stage of final withdrawal
of drug, the patient should never be allowed to drop below the amount
of minimum daily need in his opiate intake.
It is evident therefore, that upon the intelligent and competent
estimation, measure and control of physical narcotic drug balance and
inhibition of function depend the reaction, well being and therapeutic
progress of the man who has narcotic drug addiction-disease. These
factors also markedly influence the action of all medication,
including the drug of addiction, upon the body of the opiate addict.
They influence the reaction of the addict’s body to all medication.
Medication cannot be intelligently administered to the opiate addict
unless those who administer it have understanding and clinical
appreciation of the widely varying reaction of the addict under
different conditions of drug balance and inhibition of function.
Failure to recognize and appreciate this fact explains a considerable
portion of the past failures and the past mortality attending specific
and special methods and treatments, and so-called “cures.” The dosage
of medication administered and the time of its administration should
therefore be determined upon with watchful eye to the reaction of the
patient, and with intelligent comprehension of the possibilities in
reactionary change.
The actions and the dosage of therapeutic agents have been largely
determined by experimentation on individuals and animals of average
normal reaction. The toxic, the inhibited and the narcotic addicted
do not display the normal reaction to therapeutic agents. Under some
conditions they over-react both physically and nervously, and under
other conditions they under-react. Detailed consideration of this
matter is not possible in this book. It offers for investigation a
field well worthy of exploration both clinical and laboratory. It
will only state that as the manifestations and influences of toxemia,
functional exhaustion, inhibition, and, in the addicted, of varying
physical drug balance, have become increasingly definite and tangible
and capable of clinical measure and determination, my medication of the
toxic and the exhausted and the inhibited individual, as well as of
the narcotic addicted, has become progressively more effective. These
observations apply to conditions other than opiate drug addiction, and
are worthy of consideration in all toxic, and exhaustion and depression
states.
I have already spoken of the imperative physical need for the drug of
addiction. I have also referred to the amount of minimum daily need for
the drug of addiction. The recognition of factors which influence these
is of great importance. Many of these factors are so commonplace and
so obvious in their relation to the extent of body need that they are
appreciated by most intelligent addicts. Anything which increases the
expenditure of physical and nervous energy increases the addict’s need
for opiate drug. Among the most potent influences are worry, fear and
physical suffering. They consume physical fuel; and an important part
of the addict’s physical fuel is the drug of his addiction. In addition
to this, worry and fear and suffering are also markedly inhibitory
of glandular and peristaltic function. The expenditure of energy in
mental and muscular work also calls for increased supply of the drug of
addiction. I need not enlarge upon this important fact. Its application
to the handling and treatment of the addict is evident. Narcotic drug
should be supplied to meet the physical needs of the individual case,
and only be decreased as intelligent handling of the factors which
determine that need have lessened it.
The method of gradual reduction of dose to the point of ultimate
discontinuance is practical and feasible under conditions and at an
expense of time and money which are possible to but very few addicts.
The forcible reduction of dose without regard to the environmental,
mental, economic, physical or other conditions of the average and
individual addict, and absolutely ignoring the considerations of the
mechanism and symptomatology of his addiction-disease is barbarous,
harmful and futile. Enforced reduction of dose below the point of
body need is not worth what it costs in nerve-strain, suffering, and
physical inadequacy. The extent of addiction-disease and the degree of
progress in its remedy cannot be measured in terms of amount of drug
administered. It must be measured in terms of clinical symptomatology,
just as progress is measured in any other disease. Reduction of dose
below the amount of body need, prior to the stage of final withdrawal,
constitutes a serious therapeutic handicap and is most decidedly
contra-indicated. Withdrawal of opiate from an addict whose physical
reaction and strength and nerve force have been reduced and depleted by
continued reduction of amount of drug without commensurate reduction
in the extent of body need is harder than withdrawal from a reactive
individual with reserve nerve and physical force who may be taking a
much larger dose.
The average addict must support himself and his family. His physical
well-being and economic efficiency should be considerations in
the welfare of the community in which he lives. Legislative and
other investigation has shown that we are entirely unequipped both
institutionally and professionally for the successful immediate
withdrawal of opiate from even a small proportion of our present
census of the opiate addicted. In view therefore, of the practical
impossibility of immediate successful withdrawal treatment, and in
view of what is known and can be demonstrated and taught in the
accomplishment of final withdrawal, I do not hesitate to state that,
until we are prepared and in a position to skillfully and competently
handle the stage of final withdrawal to assured successful issue, it
is much wiser to supply to the addict who is not a public menace the
drug of his addiction to the extent of his physical needs, and to teach
him how to use the drug of addiction in such a way as will maintain
his physical and economic efficiency, than it is by enforced reduction
of dose to deprive him for a long time of working ability and his
family of his support. Furthermore, the addict who is insufficiently
supplied with the opiate of his addiction, turns in desperation to the
use of things far more harmful to him than the drug of his addiction.
This he does in the vain hope of obtaining mental and nervous and
physical stimulus and support and some surcease of his misery. The
many wrecks of addicts to be seen trying through insufficient supply
of narcotic drug, self-poisoned with other drugs which they have
purchased, alcohol, bromides, coal tar products, cocaine, and of late
hyoscine--their addiction disease unrelieved and undiminished--are
sufficient argument against mere reduction of dose, below physical body
need.
The personal attitude of the physician towards opiate addicted patients
is of great importance. The medical man who is to treat a case
suffering from addiction-disease successfully to the end of relieving
this condition, or who is treating addiction-disease as an intercurrent
condition complicating another disease, must first of all make his
patient realize that the physician himself knows something about
addiction as a disease. He must never give his patient any hint or
reason to suspect that he regards opiate addiction as a habit, a vice,
a degrading indulgence which can be to any curative or even therapeutic
extent, combatted by the exercise of will-power.
In their desperation and ignorance, the vast majority of addicts
have repeatedly exercised will-power in self-denial of their drug to
the limits of their physical endurance, and they know the futility
and suffering of attempts based simply and solely upon the exercise
of will-power. Experience has taught them actual facts concerning
the physical action of narcotic drugs and concerning the results of
insufficient supply of narcotic drug in a man who is addicted. The
addict knows that he does not take a drug because he enjoys it. He
knows that he experiences no sensuous gratification or other pleasure
from its administration. He knows that he uses a narcotic drug simply
and solely because he has to use it to escape physical incompetence and
physical agony. As I said before, almost without exception the narcotic
addict has proceeded of his own accord, or under the direction and
advice of others, on the theory of exercising will power, and resisting
temptation. With the few exceptions of those made in a very early stage
and before addiction mechanism had become strongly developed and rooted
in his physical processes, such efforts on the basis of this theory
have been useless.
It is practically impossible to argue successfully on the basis of
theory with the man who has experienced facts. Narcotic addiction
furnishes a class of patients who know more about their own disease
than any other class of people. They can accurately estimate the extent
of understanding and knowledge possessed by the man who is treating
them, and they are desperately critical. Almost without exception,
except for some of the true “underworld,” they desire above all else
to escape from their condition. I know that this is not the popular
conception and for the present may be by some regarded as heresy.
Therefore, it is of essential importance that between the doctor who
treats an addict of average intelligence and that addict must exist
co-operation and understanding. As soon as this patient realizes two
things--that the doctor does not believe his expressed wish to be
cured, and that he interprets the patient’s desire for relief from
suffering as simply a desire for more opiate and the expression of
habit, vice or degraded appetite which should be controlled by the
exercise of “will-power,”--there is an end to that patient’s confidence
in that doctor, and to the help that that doctor can give to that
patient. As I have written elsewhere, the opiate addict of average
intelligence will co-operate with his medical adviser to the extent of
his physical endurance, so long as he has any belief in that adviser’s
understanding of his condition, and ability to help him.
In my own work, and as a result of my own experience I have found
that as a rule the extent to which an intelligent addiction patient
cooperates with me has been a measure of the understanding and
technical ability with which I handled him, rather than a measure
of his desire to be helped. It is held by many that a majority of
addiction-patients are not possessed of average intelligence and are
not honest in their statements. I will simply say that even in the
Alcoholic and Prison Wards of Bellevue and in the narcotic wards
of the New York Workhouse Hospital I came more and more to seek in
faults of medical and nursing handling the explanation of apparent
lack of cooperation. In the Annual Report of the New York Department
of Correction for 1915, in commenting upon the work of the narcotic
wards, is stated, “In ratio as there has been at any given time
among our interne and nursing staff comprehension and understanding
of the manifestations and underlying principles of narcotic drug
addiction-disease and of its rational handling in the individual case,
our results have been good or bad.”
Several years ago I wrote as follows: “As to the existing opinion that
the morphinist does not want to be cured and that while under treatment
he cannot be trusted and will not cooperate but will secretly secure
and use his drug, I can only quote from personal experience with these
cases. During my early attempts, 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 upon their supposed weakness of will and lack of determination
to get rid of their malady. Later I realized the fact that the blame
rested entirely upon the shoulders of my medical inefficiency and my
lack of understanding and ability to observe and interpret my patient’s
condition. The morphinist as a rule will cooperate and will suffer
to the limit of his endurance. Demanding cooperation of a case of
morphinism during and following incompetent withdrawal of the drug is
much like asking a man to cooperate for an indefinite period in his
own torture. There is a limit to every one’s power of endurance of
suffering.”
Of primary importance, then, if a physician, institutional or
practitioner, is to have any success in handling a case of opiate
addiction-disease, is his attitude towards his patient--divesting
himself of all conception of habit, appetite or vice as explanation
of characteristic physical manifestations and symptomatology, and
approaching the patient as a man with a definite disease requiring and
deserving intelligent clinical handling. The patient will be the very
first to mark a physician’s shortcomings. If he has not confidence in
the doctor’s ability and understanding of his illness the doctor can
help him but little. This statement applies not to addiction-disease
alone but to every medical condition.
There are three clinical demonstrable elements to be determined,
measured and controlled in the actual therapeutic handling of cases of
narcotic addiction-disease. The first of these is the actual amount
of drug which the patient’s body demands to maintain functional and
organic efficiency and to escape physical distress. The second of these
is the extent of auto- and intestinal-intoxication, autotoxicosis
and malnutrition. The third of these, which is both a result of and
a causative element in the other two, is the extent of inhibition of
function.
In the successful handling of a case of addiction-disease, therefore,
the first effort should be to determine approximately the amount of the
patient’s minimum daily physical need for the drug of his addiction.
This need is clinically recognizable and definitely measurable. It
should be met to whatever extent it is present so long as it exists,
and dosage diminished only as competent treatment diminishes the extent
of need. This physical need can be demonstrated and accurately measured
by clean-cut symptomatology. It can be expressed in mathematical
terms of amounts of drug required in twenty-four hours. Work, worry,
strain--anything which consumes physical or nervous energy increases
this need. If this physical need is not met the patient is robbed of
physical tone and physical reaction. He is robbed of metabolic balance
and functional competency. He is, in short, robbed of the basic ability
which his body has to regain health.
In the estimation of this amount of physical need the procedure is
very simple. Have administered to the patient who is manifesting the
symptomatology of drug-need, sufficient drug to remove the symptoms
and restore him to complete physical, functional and nerve balance.
Have the length of time observed which elapses before the symptoms of
drug need reappear. Have this repeated several times and information
is secured as to what quantity of opiate under the existing conditions
will hold that patient in drug-balance for a known length of time.
In this way can be mathematically estimated the extent of physical
drug-need. The average need for twenty-four hours can be easily
computed from the data obtained. It is merely a matter of arithmetic.
The regulation of dosage can also be estimated with approximate
accuracy. As has been stated before, the interval of freedom from
withdrawal manifestations is found to be, in a general way and within
certain limits, in ratio to the size of the dosage. For example, if
in a given case, under given conditions of fear, worry, physical or
nervous strain, pain, etc., as discussed elsewhere--one grain of
morphine will last a given patient at a given time for four hours;
under the same conditions two grains will last for approximately eight
hours. There are limits to the application of this rule. It is stated
as the general operating of an addiction-disease phenomenon which is
useful as a therapeutic guide.
The amount of actual physical body need as capable of approximate
estimation in the above manner should be administered to the patient,
any reduction being guided by the fact that his clinical symptomatology
and physical manifestations demonstrate that the amount required by his
addiction-disease has been reduced. It is much wiser for the progress
of the average addiction case to have the drug administered in the
amount of estimated physical need than it is to attempt to reduce
the amount of drug before his reactions show reduction in physical
drug-need. The success of outcome and the measure of progress in
such a case is not to be estimated by the amount of drug the patient
is receiving, but is to be measured by the patient’s condition and
clinical manifestations. The mere fact that a physician has reduced a
narcotic addict’s opiate intake from a large dosage to a very small
dosage, or indeed has denied him any opiate at all for a considerable
length of time, is no evidence that he is curing or has cured his
patient of addiction-disease. Unless the physical mechanism of
body-need for an opiate has been completely and actually quieted, the
patient may have in his body for perhaps weeks and months after the
last administration of the drug, a physical demand for it. _The taking
of opiate does not constitute opiate addiction-disease_. Also the mere
fact that an addict is no longer taking opiate does not constitute
proof that he is “cured” of opiate addiction. The non-recognition
of this fact lies at the root of much past failure. The general
axiomatic statement might be that an addict should be supplied with
the drug of his addiction to the complete extent of his physical need
at any given time until conditions are right for the undertaking of
assuredly competent opiate withdrawal and complete arrest of his
addiction-disease mechanism.
The mere amount of drug used by a patient in twenty-four hours is
a matter of minor importance compared with the general health,
physical tone, nervous glandular and functional balance, reaction
and resistance of that patient. Also the amount of drug taken by a
patient in twenty-four hours is absolutely no adequate measure of the
strength or stage of development of his addiction-disease. If he does
not get enough opiate he cannot competently functionate; he cannot be
adequately nourished; he cannot sufficiently eliminate. He is subjected
to the influences of constant discomfort and nerve strain in the
endurance of low-grade withdrawal manifestations. He is worried and
becoming exhausted. It becomes apparent that by continued maintenance
of narcotic administration below the amount of physical body-drug-need
the very factors are created which have been described as increasing
body-drug-need. It is difficult to see any therapeutic advantage in
such a situation. Moreover, as has been stated before, it is far easier
to eradicate completely and successfully narcotic drug need in a short
time and without marked discomfort, from a functionally competent and
organically healthy man who is taking a physically sufficient amount,
than it is from a nerve-racked, worried and physically, nervously, and
functionally exhausted wreck who is under-dosed.
It is therefore much wiser to direct immediate efforts to the securing
and maintaining of health, reaction and tone--irrespective of the
amount of drug required--until there is time and opportunity for the
undertaking of competent withdrawal--a stage of handling and treatment
concerning whose physical and clinical phenomena and manifestations and
dangers too few are educated to and familiar with.
In regulating the administration of drug as to size and intervals
of dosage--amounts should be sufficient to allow the patient long
intervals between doses. In the determination of this, it is necessary
to study and experiment with the reactions in the individual case. The
effort, however, should be to have the drug administered the smallest
possible number of times in the twenty-four hours compatible with the
patient’s well-being. For example--if a given patient’s daily need is
three grains a day, it is much wiser to administer this amount of drug
in doses of one grain three times a day or a grain and a half twice
a day as soon as practicable, than it is to have it administered in
larger numbers of smaller doses at more frequent intervals. The reason
is, that, apparently after a dose of narcotic drug is administered
function is inhibited for a length of time which is not in proportion
to the size of the dose administered. On the other hand, as has been
stated, within limits, the length of time over which a dose of narcotic
drug will hold a patient in drug balance and free from the physical
manifestations of drug need is in proportion to the size of the dose.
Therefore large doses at wide intervals permit greatest freedom from
functional inhibition and as well, if not better, supply the demands of
physical drug need.
I have briefly referred to the elements of intestinal and
autointoxication and autotoxicosis. Intestinal and autointoxication,
combined with worry, fear, and anxiety, constitute very
important causative and controlling factors in whatever mental
and physical deterioration has taken place in a case of
narcotic-drug-addiction-disease. Physical, mental and moral
deterioration are to a very small extent direct results of narcotic
drug action _per se_. As long as a narcotic drug addict is maintained
non-toxic, uninhibited and unworried, he is practically at his
individual normal, plus an added physical need. It should not be
necessary to recall to memory many cases of upright, honorable and
competent and apparently healthy men and women who have been narcotic
addicts over very many years, unknown to but very few or none of
their relatives or friends or even physicians. As has been stated
before, their apparent immunity to the supposed stigmata of narcotic
drug action was not due to the fact that they were on a higher mental
or moral plane than their less fortunate fellows, or that they were
possessed of sufficient will-power to resist temptation in the
over-indulgence of their so-called appetite. The facts are that by
experience they found out that if they used narcotic drug in amounts
indicated by the manifestations of their disease, and did not take it
too often and kept their bowels open and did not worry, they were as
normal as anybody else except for the fact that they had to take a dose
of a certain medicine two or three times a day. In other words they
simply learned to manage their disease in a way to avoid complications.
They met their issue squarely; they discounted theory and recognized
facts, and they used common sense in the interpretation and application
of what they learned.
The control of auto and intestinal intoxication in narcotic addiction
is as a rule of easy accomplishment if the patient is uninhibited and
in functional balance and is not over-supplied or under-supplied with
the drug of his addiction. The narcotic addict who is non-toxic and in
drug balance and is not harassed by worry or fear needs practically no
more drastic methods of elimination than his non-addicted brother. If
he is over-dosed his elimination is inhibited; if he is under-dosed
his eliminative powers are not capable of response. The element in
the securing of evacuation of the bowel in a drug case, as well as
in a toxic case of whatever description, is sluggish peristalsis; in
other words, it is inhibition of nervous impulse. It is therefore
not necessary to load a bowel up with large amounts of drastic and
irritating cathartics. Indeed this procedure is very harmful and
abortive of ultimate results. An over-irritated intestinal tract is not
a good eliminative organ. To my mind the so-called “typical stool,”
of the so-called “Towns Treatment” with its content of jelly mucus
has no clinical significance other than its evidence of a production
of an exhaustive and irritative mucous colitis and means that however
much purging may be accomplished competent elimination from the colon
is at an end. Its appearance in a case under my care I should regard
as evidence of injudicious treatment. For the bowel elimination of
a case of narcotic-addiction there is needed practically nothing
beyond the ordinary mild and non-irritating catharsis. All that is
needed is to remember that if inhibition of peristalsis has not as
yet been overcome, you may be wise to administer, about the time you
should get an evacuation, strychnine or other peristaltic stimulators
in sufficient amounts to overcome existing inhibition and stimulate
peristalsis.
Inhibition of function, as I have already shown, is a basic factor
in the development and maintaining of the narcotic addiction-disease
state. It is of great importance to recognize, estimate and control
its presence and influence. Inhibition of function is due to nervous
exhaustion from overwork, fear, anxiety and suffering; it follows
for a few hours the administration of opiate drugs; it is a constant
result of chronic constipation and of intestinal and auto-toxemia. The
rationale of its control is evident from the enumeration of its causes.
Until its causative factors have been removed or controlled, its
manifestations must be treated symptomatically--remembering always that
for therapeutic action in an inhibited individual dosage of medicinal
agents varies, and must be estimated from clinical observation
and experiment and not from memory of the text-books. To the man
experienced in their use some of the internal secretory glandular
products are at times helpful. As has been stated above, strychnine or
other peristaltic stimulator is useful.
Finally I repeat again my disbelief in and opposition to the use of any
drug or combination of drugs under the impression that they have or may
have specific curative action against addiction-disease. Although I
at times employ various of the drugs commonly mentioned in connection
with the treatment of addiction, I do so with no belief that they have
“specific” properties in this disease. I use them in the treatment
of addiction as I do in other disease conditions, simply and solely
as they meet individual clinical and therapeutic indications. Petty
took this stand years ago. I do not regard these drugs as curative of
addiction-disease, and I do not constantly use any of them.
I do not use or endorse, a “belladonna” treatment, a “hyoscine”
treatment, nor any other description of specific or routine treatment
in addiction-disease. I regard the drugs of the belladonna and
hyoscyamus groups, pilocarpine, etc., as extremely dangerous drugs to
be routinely or carelessly used in the treatment of addiction-disease.
They are rendered safe only after personal experience and study into
their action and appreciation of the factors and influences which
control their action in the functional, toxic, and narcotic drug
conditions. The routine and unintelligent use of the products of these
groups of drugs in the treatment of narcotic addiction--under the
mistaken impression that they somehow or other have direct curative
action upon the disease condition--has been the cause of a considerable
mortality and an easily understood opposition among intelligent
addicts. Hyoscine or scopolamine and the other members of this group,
ezerine, pilocarpine, the coal tar products, etc., are at times useful
drugs to meet indications in the treatment of a case of addiction.
Increasing intelligence in the handling of the addiction mechanism
itself, however, renders the necessity of their use less and less
frequent and the dosage of them required for therapeutic action smaller
and smaller. They should simply be classed as of use among other
things, peristaltic and circulatory stimulation and support, indicated
eliminants, kindness and consideration, understanding and intelligence
or any of the other therapeutic weapons in our possession.
Elimination and the securing of it in the narcotic addicted has
been referred to in this chapter. The chapter should not be closed
however, without a word of warning against the excessive purgation
with drastic and over irritating agents employed by some in this
condition. Drastic purgation is not at all synonymous with competent
elimination. Competent elimination is not to be measured in terms of
bowel-movements; but in terms of clinical symptomatology of toxemia,
circulation and measure of functional efficiency. Excessive purgation
means over-irritation and over-stimulation of eliminative mechanism,
results in the interference with and exhaustion of function and defeats
true elimination.
Presence of good circulatory tone and absence of congestion in the
eliminative organs is to me one of the most important factors in true
elimination. The addict who is in good functional tone, has competent
circulation, is in narcotic drug balance, and is noninhibited, needs
no more drastic eliminative measures than belong to ordinary rational
therapeutics in the nonaddicted.
As to final withdrawal of the drug, and ultimate arrest of the disease,
I shall say but little in this book.
I follow no “routine” and have no set procedure. I am guided, as in my
handling of the other stages of addiction-disease, by the condition of
my patient and his clinical requirements. There is no one procedure
applicable to all cases of any condition in medicine and surgery. In
narcotic addiction-disease, as in all other conditions of medicine
and surgery, the man who will have the best results is the man who
is possessed of the widest and most varied experience combined with
intelligent observation, technical skill and clinical judgment in the
selection of procedure best adapted to the needs of the individual
case. Familiarity and experience with different methods and procedures
reveals in each and nearly all of them some advantages and some
defects. The wise man and the man whose results will most approach
uniform success is he who can make intelligent selection and use of
whatever is most applicable to the needs of the case he treats, either
out of his own experience and discoveries, or out of his familiarity
with the work of others.
An element in successful withdrawal of narcotic must also remain, as
in everything else, the inherent personal gifts and qualifications of
the individual operator. A man works best with the tools most adapted
to his hand, and operators of different temperaments and of different
experience and training will always disagree on points of procedure and
technique. My own procedure in final withdrawal is determined largely
by my study and measure of my patient and my patient’s reactions,
addiction and otherwise, during my preliminary or preparatory work,
selecting the time for final withdrawal of drug by consideration of
similar factors as would be taken into account in an operation of
election.
After a preliminary stage, or stage of preparation, in which I have
gotten rid of all possible abnormalities, physical and psychical, with
my patient robust and reactive, confident and expectantly happy, with
autointoxication, and inhibition removed and the possible residues of
opiate or opiate product no longer stored in atonic body cells--the
addiction-mechanism, therefore, only kept in activity by the current
intake of opiate, which if properly handled and the patient not
subjected to exhausting strain and struggle and suffering, can be
eliminated in a very short time. With these conditions consummated,
I hasten elimination, keeping well away from exhausting purgation,
maintaining my patient’s circulatory and other functions, and
conducting as rapid a withdrawal as is compatible with my patient’s
reactive condition and the reactions of his disease.
In other words, I endeavor by my conduct of the case to reverse the
process of development of the physical addiction-disease with its
concomitants and complications, as I find it in the individual case,
arresting the addiction-disease mechanism only after I have cleared the
clinical picture in so far as possible of all other considerations.
In a majority of cases by experienced choice of clinical procedure,
combined with judgment and technical skill, the arrest of
addiction-mechanism and the restoration of the narcotic addict to
health and freedom from both opiate need and thought of opiate drug is
a matter of assured accomplishment attended by little if any nervous
strain and physical suffering.
Ability to accomplish this is not beyond the power or any competent
practitioner, whether he reside in a hospital or is in private
practice. All that is required is instruction or information as to
the mechanism of addiction-disease, clinical demonstration of its
manifestations and reactions and the same amount of experience in their
handling as is expected of a man who treats any other disease.
I have purposely refrained in this book from discussion of technical
details of therapeutic procedures, and of various medications, and of
their various indications, contraindications, applications, dosage,
etc. Such discussion, to be adequate and competent, would require much
space and would distract from the general presentation of the problem,
which is the purpose of this volume.
I have learned from experience in teaching and in treatment of cases
that before there has been established appreciation of the whole
personal and clinical problem and picture, and conception of its
disease mechanism, and ability clinically to recognize and interpret
symptomatology, discussion of technical details is premature and
misleading.