SOME COMMENTS UPON THE LEGITIMATE USE OF NARCOTICS IN PEACE AND WAR
Before commenting upon the legitimate use of narcotics, it is desirable
to emphasize again that the term “narcotics” as used in this volume
refers particularly to the preparations and derivatives of opium,
because as the term “narcotics” has come to be used it is synonymous
in the minds of many with “habit-forming drugs,” a phrase often
loosely used and grouping under its title a number of drugs of widely
dissimilar action and properties.
Although many of these drugs have narcotic properties, their action
upon the human body is in many respects totally unlike the action
of the opiates themselves. Also the condition resulting from their
prolonged and continuous administration is an entirely different
condition clinically and physiologically from that manifested in the
case of opiate addiction-disease. The problems associated with the use
of alcohol, cocaine, chloral, cannabis, the various coal tars, etc.,
differ from each other and all of them are, in their basic medical
principles, of an entirely different character from the problems
associated with the use of opiates. As has been previously stated,
it has not yet been demonstrated that any of them form the basis for
an addiction-disease mechanism such as clinical study and laboratory
experiment seem to demonstrate in opiate addiction-disease.
In considering legitimate as well as illegitimate use of opiates,
therefore, it is important not to confuse them with the drugs above
mentioned and to be sure that in the mind of the reader there shall
not exist any lingering impression that attributes popularly supposed
to be associated with so-called “habit-forming drugs” are of necessity
displayed in the opiate group.
The habitual use of cocaine for example, may be regarded as an
indulgence of appetite and the obtaining of sensation and artificial
stimulation and not as based upon the demands of a specific physical
addiction-disease mechanism. The therapeutics of its discontinuance
are entirely different. Habitual indulgence in cocaine tends to
result in mental and moral deterioration. In the addict of the
so-called “underworld” it is the coincident use of cocaine with its
manifestations of mental, moral and physical deterioration that has
led to the wide and erroneous attributing of characteristics of this
class of cocaine habituates to the average opiate addict. The habitual
use of cocaine is an entirely different matter from the continued
administration of opiate in the case of an opiate addict, and its
manifestations should be completely dissociated from the clinical
picture and problem of opiate addiction-disease.
Some writers, especially those associated with municipal or state
institutions of penology and correction, lay emphasis upon the case
of the so-called “mixed addict.” The crimes of violence with which
addiction has become associated in the popular mind are practically
never connected with the action of opiate drug. They are, however,
characteristic of the cocaine crazed individual. When they are
performed by a so-called “mixed addict” they are the result of cocaine
habituation rather than of opiate addiction. Such crimes of violence as
are committed by the opium or morphine addict are well explained in the
Report of the Treasury Investigation Committee in the following words,
“There are many instances of cases where victims of this disease were
among people of the highest qualities morally and intellectually, and
of the greatest value to their communities, who, when driven by sudden
deprivation of their drug, have been led to commit felony or violence
to relieve their misery.”
This erroneous grouping of so-called “habit forming drugs” is to some
extent responsible for a misconception of opiates and of opiate use and
opiate result to such an extent that, there is unfortunately manifested
at times a lack of appreciation of the very important legitimate uses
of these drugs.
The paramount issue of legitimate narcotic medication is that of the
opiates. Opiates form and must continue to form the most indispensable
medication, emergency and otherwise, for shock, wounds and allied
conditions. It may be safely stated that of all emergency medication,
the opiates would be the last to be surrendered by the intelligent
physician or surgeon. This is true of every day civil practice and its
importance is increased tremendously under conditions of active warfare.
The opiates possess combined actions and powers not found in any
other group of drugs. In therapeutic doses they support the heart and
circulation, they relieve pain, they hold in check excessive activity
of the glands of internal secretion with all their associated phenomena
of exhaustion and collapse; they control spasm and they give sleep.
In no other drugs or group of drugs are these properties combined
as they are in the opiate group. In emergency medication, opium and
its alkaloids, especially morphine, are the medications often most
responsible for the saving of life and reason. It is not necessary to
argue this point with any intelligent physician or surgeon. For the
benefit of the laity, however, and for the benefit of the occasional
fanatic and hysterical reformer it is well to state that without the
use of morphine and other opiates the mortality among the sick and
wounded would be vastly greater, and many of those who might survive
in spite of its non-administration to them would bear for the rest
of their lives physical and mental and nerve consequences of gravest
character. The lives and minds that have been saved by the timely
administration of an opiate drug are incalculable. One has only to talk
with those who have worked under the stern necessities and emergency
conditions of warfare to appreciate this fact. There is no known drug
which will replace clinically and therapeutically the opiate group. At
present it is as indispensable in meeting emergency indications as is
the scalpel of the surgeon.
It would be entirely unnecessary to discuss or to apparently defend
the use of narcotics in peace as well as in war-time medication if it
were not for the fact of recent recognition of the wide existence of
opiate addiction in the civilized world. Combined with this is the
belief, often met, that as a result of prolonged opiate administration,
a certain proportion of soldiers have developed this condition. If
the facts of addiction-disease were widely known and applied to its
proper handling and remedy, there should be no hysteria concerning
and no criticism against legitimate opiate medication; even if
unavoidably continued to the point of creating this condition. That
opiate-addiction is one of the medical problems of war is recognized
and must be openly met. In many cases, just as in private civil
practice, the physician is confronted by a choice of evils. To save
life or reason he must continue opiate medication even into and
past the danger zone of beginning opiate addiction. Lack of popular
recognition, appreciation and comprehension of this fact, in the
present status of narcotic addiction, contains grave dangers of
hysteria and of undeserved and irresponsible criticism. That this
criticism is based on ignorance makes it none the less unpleasant and
hampering to efficient service.
It should be at once and widely taught that the cases of opiate
addiction that follow war time administration of opiate do not
constitute a new medical problem, but simply constitute additional
cases of a disease which has existed insufficiently appreciated in
this country for over half a century. When the conditions under which
wounded and sick must be handled in the emergencies of war, and the
higher percentage of urgent and severe cases are taken into account,
it will be found that the proportion of wounded and sick soldiers with
this addiction-disease is no greater and is very probably not so great
as the proportion of people in civil life and practice who have in the
past contracted this disease, and are even at present contracting it as
a result of opiate medication, unavoidably or otherwise continued to
the point of addiction.
As the facts of addiction-disease development as a result of
unavoidable military therapeutics become known it will be well to
remember that the conditions are no different in character and exist in
no greater relative proportion than the same conditions in civil life
and practice. The principal difference lies in the greater opportunity
for early recognition.
As to the illegitimate or non-therapeutic contraction of addiction
within the army, its dangers are no greater and possibly not as
great as in civil life. Some non-medical cases of addiction may have
developed within the ranks of the army. It may be said of them,
however, that army life and activity and training probably saved
many more or less idle and ignorant youths imbued with a spirit of
curiosity, and with lack of normal outlet for physical and nervous
surplus energies, from the associations and environments which have
been taken advantage of by those associated with illicit commerce
in the creation of the addict of non-medical origin, which has so
increased in the past four or five years.
It is my belief that the gathering together of young men presents an
opportunity for the education of the youth as to the physical and
disease facts of opiate addiction which should be of incalculable
benefit in the solution of the narcotic problem and in the suppression
and prevention of “underground” and underworld narcotic traffic.
The foregoing opens to discussion another legitimate use of narcotics.
This use is the intelligent administration of opiate in the control and
therapeutic handling of whatever cases of addiction are found to exist.
The situation within the army as regards addiction is in the general
indications for its handling, identical with the situation existing in
civil life. The man who has fully developed opiate addiction-disease
will have to have his opiate supplied to him intelligently and
with proper appreciation of the symptomatology and reactions of
addiction-disease until there is equipment and educated personnel
provided for his intelligent and competent handling. Under any other
immediate arrangements, the addicted soldier, just as the addicted
civilian, will in his desperation and physical torments of bodily need
for opiate drug, endeavor to smuggle, steal or otherwise obtain in any
way possible this medication.
In brief then, and to recapitulate, the legitimate use of narcotics
will be roughly divided under two broad heads. The first is the
necessary administration of opiate to those who are not addicted for
the control of emergency or other indication with which every competent
physician or surgeon is familiar. To use opiate as indicated in such
cases is not only legitimate, but failure to use it would be inhuman
and barbarous and result in the loss of many lives and in the making
of wrecks of many others. The second is the administration of opiates
to those unfortunates, who either through their own ignorance or
carelessness, or through unavoidably or otherwise prolonged legitimate
or necessary medication have developed in their body the condition of
opiate addiction-disease, until such time as their disease can be
arrested by competent medical care of their addiction-disease mechanism.
As to addiction created in war time, there is considerable amount of
information. This is not the time nor the place for detailed discussion
of that information. Calm consideration of it should, however, suffice
to still the voice of any objections and irrefutably answer arguments
criticizing existence of war-time addiction. The greatly lacking and
needed element in its consideration and handling is appreciation of it
as physical, controllable and arrestable disease. The laity and the
mothers and other relatives and the friends of those in the Army and
Navy will not exhibit panic and fear once the intangible horror and
vague and morbid and erroneous picture of the “dope fiend” is in its
application to opiate addiction erased from popular conception and
replaced by comprehension of a definite physical disease clinically
controllable and in most cases therapeutically remediable.
To what extent narcotic drug addiction-disease will prove to be a
medical sequela of war and of necessary war-time medication may
never be made a matter of accurate statistics. The popular and
prevailing attitudes towards and conception of the condition and
of its possessor tend to influence towards desperate concealment
rather than to encourage self-revelation. As has been stated before
addiction-disease followed the Civil War, occasional cases recently
existing and possibly still existing among the few remaining veterans
of that struggle, addiction dating back to Civil War medication. The
Spanish War and necessary medication added to the list of war-time
contracted addiction-disease. Of addiction among those participating in
the last war, it is at present wise to simply recognize the condition,
and to hope that as the addiction-disease sufferer, developed through
necessary war-time medication becomes known, he will not have to
carry the addiction stigma of past attitudes and conceptions, and
that we shall be in a position to accord him intelligent and humane
consideration and handling as a deserving sick man, whose disease was
contracted in our defense.