RELATION OF NARCOTIC DRUG ADDICTION TO SURGICAL CASES AND INTERCURRENT
DISEASES
It is a common idea in the minds of both surgeons and physicians that
an addict to narcotic drug is a difficult case for surgical handling
and is a poor surgical risk. Numerous instances of surgeons refusing to
operate upon a narcotic addict until the addict should have “stopped”
the use of the drug, voice the almost prevailing attitude.
Very many, if not most, internists and practitioners view with gravest
concern the presence of addiction in a serious illness coming under
their care.
That the addict has borne this undeserved reputation as a poor surgical
and medical risk, and that this reputation has been seemingly merited
by previous medical and surgical experience, is not to be laid at the
door of the existence of addiction in the patient. It is to be laid at
the door of insufficient medical comprehension of addiction-disease and
its mechanism in its material manifestations, and in its functional and
organic influences, and at the door of inadequate clinical study into
the analysis, estimation and control of these. Like much else that has
been for generations generally accepted as true about narcotic drug
addiction, the belief is erroneous that the addict is a poor surgical
and medical risk because he is an addict.
As a surgeon once stated “These addicts have no resistance, and
they go right out.” Swayed by the old conception of addiction, this
more than ordinarily humane and generous-hearted man had not the
slightest suspicion as to why the addicts that he had operated upon
had displayed no resistance and had tended to “go right out.” He had
in his mind simply the then prevailing and practically unquestioned
conception of the narcotic addict, and he had not the slightest
suspicion that a definite physical disease, whose mechanism should have
received intelligent clinical handling and control was complicating the
surgical cases of the addicts who went right out. He had based, as all
of us once did, his opiate medication on his materia medica conception
of therapeutic dosage instead of on the demands of an addiction-disease
mechanism. It is rumored that more than one illustrious life, full
of past accomplishment and potential future benefit to humanity and
society, has ended in this way.
The above statements do not apply to surgery alone. They are equally
true of medical conditions. Dominated by their teachings as to opiate
dosage in ordinary therapeutics, and by the older “habit” conception of
addiction, with little or no instruction as to the dosage indications
of addiction-disease, most practitioners, institutional and private, do
not adequately conceive and have no basis for determination of opiate
dosage in this disease. They do not believe that the addict physically
needs nor do many of them realize that the addict can physically
tolerate what seems to them such dangerous and lethal amounts, and they
tend to ascribe his statements of usual dosage to mental “cravings”
to which they refuse to pander. Many appreciate that such patients
have often to be very carefully watched to prevent their suicide and
that many of them die, but fail to comprehend that these events may
be ascribed to inability to longer endure the suffering and physical
incompetency of body-need for opiate medication.
The recent epidemic of influenza and pneumonia furnishes examples
of the importance of recognizing addiction-disease mechanism in
intercurrent diseases. A number of instances have come to my attention.
One of them is of particular interest because of the graphic picture
presented by a series of sphygmographic tracings showing the physical
organic dependence upon opiate in the circulation of an addict. It may
be said in passing that these tracings and others made upon addicts
in partial or complete opiate withdrawal parallel similar tracings
by other clinical observers, and also those made by experimental
laboratory workers upon addicted dogs.
The subject of these tracings was a man well-known and prominent in his
community, 63 years of age, suffering from pneumonia with marked and
persisting cardiac and circulatory deficiency which did not respond to
the administration of the usual circulatory stimulants even in very
large doses. I was called in consultation. Found the patient very weak
and exhausted, with facial expression of protracted suffering and
anxiety and despondency. Morphine in usual therapeutic doses had been
daily administered for relief of pain, restlessness and sleeplessness,
being insufficient however to control those manifestations. Pulse
was, as shown in tracing number 1, very weak and intermittent. It
was impossible to account for the whole clinical picture and history
on the grounds of a typical pneumonia, present or resolving. Opiate
addiction was suspected and the patient questioned. He had been
suffering from opiate addiction-disease for many years, his addiction
developing unsuspected by him as a result of medication for a painful
and protracted condition many years previous. He begged to be allowed
to die without his wife and son being told of his affliction. The
following tracings made upon him are very instructive and significant,
and cannot be interpreted upon any grounds of psychical explanation of
addiction phenomena.
The last dose of morphine prior to these tracings was one-eighth of a
grain given at 3:30 P. M.
[Illustration: (Chart of Sphygmographic Tracings)]
First tracing (number 1) was made about 6:00 P. M.
Tracings 2, 3 and 4 were made at about fifteen minute intervals. They
were made following experimental hypodermic injections of morphine
sulphate to determine the extent of opiate need and organic dependence
upon opiate medication, and the amount of opiate required to restore
organic function and tone.
Tracing number 4, taking into consideration the asthenic and exhaustion
condition of the patient, shows full support to circulation with some
overaction.
Tracing number 5 was taken an hour or two after tracing number 4 to
determine the holding power of the dosage administered, after the
circulation had reacted from the immediate stimulation of the opiate
medication. This tracing, interpreted and considered together with the
clinical manifestations at the time, was decided to be about normal for
that patient at that time.
This patient would have died, not from pneumonia with cardiac
complications, but from insufficient control of the mechanism of opiate
addiction-disease.
On balanced and indicated daily morphine dosage, patient made very
rapid recovery and has continued well and active.
Such cases as this, where addiction-disease co-exists or is
intercurrent with other medical or with surgical conditions, are not
as uncommon as may be supposed. That they are frequently unrecognized
the histories of many narcotic addicts demonstrates, and is discussed
later. Board of Health and Insurance mortality statistics are
undoubtedly very incomplete upon this situation. Addiction, regarded
as a habit or indulgence, may easily be overlooked or disregarded as
a cause of death, direct or contributing. It may easily be omitted
from returns made out, however actually important a part in the final
issue may have been played by the influences, upon body function and
upon physical resistance and recuperation, of an unappreciated and
inadequately controlled addiction-disease.
It is earlier stated that the common idea of the addict to narcotic
drugs as a poor risk is an undeserved reputation, and is not to be
laid at the door of addiction existence itself. In very many cases
of opiate addiction, the opposite of the popular belief is true. The
opiate addict, if his addiction mechanism is competently appreciated,
its reactions accurately estimated, and its influences wisely
controlled, is quite other than a bad risk. Indeed the mechanism of
addiction and the opiate which caused it can often be handled in such
a way in the control of glandular, circulatory, nervous and other
function and reaction as to aid in the carrying over of emergencies,
medical and surgical. A case in point is an emergency operation on the
pancreas, performed upon a man in extremis, whose unexpected recovery
and convalescence astonished all observers by being remarkedly rapid
and uncomplicated, due unquestionably in large part to the early
recognition and clinical handling of his addiction-disease, and the
possibilities it created for unusual opiate medication.
It has been my experience at times, when called in medical consultation
upon post-operative cases whose lack of repair and slowness of recovery
could not be accounted for, to discover an unsuspected addiction, and
to find that the lack of repair and slowness of recovery was due simply
and slowly to the want of comprehension of, or to inadequate control of
addiction mechanism existing in the patient.
Many opiate addicts when about to undergo operation, have provided
for possible contingencies by the concealment of, or by outside
provision for, a supply of opiate sufficient in amount to meet their
physical needs. There are very many addicts who have, out of their
past experience and study upon themselves, competently controlled
their own narcotic-drug-disease during treatment for other conditions,
operative or medical. The number of narcotic addicts is not few
who have been cared for medically with nursing attention, or have
undergone operations for the remedy of various surgical conditions,
have recovered, convalesced and been discharged without the physician
or surgeon becoming aware that his patient was addicted. This is
not a comment in criticism upon my professional brethren. In my
own experience such a case is a matter of quite recent occurrence.
A patient treated by me in a hospital, for conditions other than
addiction, one day unexpectedly revealed to me the fact of long
standing addiction. The patient had been afraid to tell me about this
condition until thoroughly convinced of my attitude towards it, and had
secured opiate medication elsewhere.
It seems strange that a condition of as powerful influence over body
function and metabolism as is exerted by the addiction mechanism of
narcotic drug-disease should not long ago have received exhaustive
and complete clinical and laboratory study along the lines of its
manifestations and influences, as well as along the line of reduction
and deprivation of the drug of addiction. In view of the above it would
seem to be of vastly more importance at the present time that the mass
of practitioners of surgery as well as of medicine should understand
and be able to control action and reaction in a narcotic addict as a
result of his addiction-disease mechanism, than it is that they should
attempt the mere reduction or denial of the drug of addiction.
Appreciation of the above would make available to narcotic addicts,
suffering from other conditions, hospital and professional treatment
and remedy of those conditions. Under present prevailing conceptions
of addiction, many honest and worthy people addicted to opiates dare
not avail themselves of needed treatment for medical conditions
or operation for surgical conditions because of their uncertainty
regarding the attitude towards and handling of addiction-disease
existing in and carried out by the institution or practitioner to whom
they would ordinarily appeal for help. The addict lives in constant
fear of some injury or illness which may necessitate his coming into
the hands of those whose conception of addiction is not in accord with
the addict’s experience of addiction-disease facts.
As I have emphasized in previous chapters, the actual withdrawing of
opiate from an addict is simply one stage, and by no means the most
important stage in the rational consideration and handling of a case
of narcotic drug addiction. The fact that a patient is using an opiate
drug, and that he uses, within reasonable limits, a larger or smaller
amount of that drug, is a matter of very minor importance as compared
with his general functional, nutritional, and metabolic efficiency.
This is true as a general proposition in the handling of any case of
narcotic drug addiction, and is vastly more true in the handling of
cases of other conditions or diseases, operative or otherwise, that
are complicated by narcotic drug addiction-disease. The physician or
surgeon should realize that the use of a narcotic drug by a patient
under his care is of very little immediate importance compared with
the satisfactory recovery of his patient from the condition for which
he is treating him. The physician or the surgeon who has in his care a
narcotic drug addict whom he is treating for another disease condition
should remember that the patient’s recovery from the condition for
which the doctor was consulted, depends to a great extent upon the
amount of functional balance and organic and metabolic adequacy which
exists in that patient, and he should realize that functional balance
and organic and metabolic adequacy in a narcotic addict are largely
under the control of, and vary with the extent to which that patient is
kept in, adequate narcotic drug balance.
The establishing and maintaining of adequate drug balance, therefore,
is one of the most important elements to be considered in the conduct
of a case of narcotic addiction undergoing operation or treatment
for a condition other than the cure of his addiction. In handling
such a patient, the physician or surgeon should completely put out of
his mind any idea of at the same time trying to “cure” the addiction
with which his patient is afflicted. I have repeatedly heard of many,
and have personally come into contact with cases where the physician
or surgeon was trying to withdraw opiate drug from a patient with
addiction-disease, as an incidental in the course of treatment of other
disease conditions. There are cases of addiction-disease in which this
may be successfully accomplished. In the majority of cases, however,
this procedure is too harmful to be anything but condemned. Not only
will the surgeon or physician ordinarily fail in his attempt to remedy
the addiction condition, but he may very severely handicap his other
work on that patient and very seriously jeopardize the success of his
efforts in the remedy of the condition which he was originally called
upon to treat.
It must be remembered that addiction-disease is a chronic condition,
and that it is practically never indicated as a matter of clinical
emergency, in a case of established addiction, that the opiate be
immediately withdrawn. As has been previously stated, drug withdrawal
is very much like an operation of election to be done when the patient
is ready for it and by whatever procedure is indicated when the proper
time arrives. The getting of the patient ready for it often determines,
just as is the case in the operation of election, to a great measure,
the success of the work and the freedom from complications and sequelae.
Since the final withdrawal of drug is to be regarded as comparable to
an operation of election, and the best time for its execution is a
matter of arrangement and of preceding preparation, it is obvious that
it should not be undertaken with expectation of satisfactory issue in
the course of treatment for an ailment or condition which demands and
expends much physical resistance and recuperative powers. Recuperative
forces should be maintained and directed towards whatever is the
indication of paramount importance at any given time. In the conduct of
a surgical case or a serious medical case, the indication of paramount
importance is recovery from the condition for which the patient applies
to the surgeon or physician. All other conditions present should be
handled in such a way as to interfere as little as possible with
the successful accomplishment of the main issue. The proper control
of narcotic addiction-disease mechanism and of its influences upon
the patient addicted is the important problem presented by narcotic
addiction as met in the field complicating surgical and general medical
conditions.