THE NEED OF ADEQUATE SPECIFIC TREATMENT FOR THE DRUG-TAKER
The Internal Revenue Reports are the only index to the extent of the drug
consumption in the United States. They show for years past an annual
increase in the importation of opium and its derivatives and cocaine, and
for last year a very marked increase over that of any preceding year. This
is not due to the increase in population; our immigrants are not
drug-takers. Among the thousands of drug-users that I have treated or
known, I have never seen an Italian, a Hungarian, a Russian, or a Pole.
Moreover, I have met with only four cases of drug-taking by Hebrews. Few
Jews--except in the under-world--acquire the habit knowingly. It may
become fastened upon them through the use of a medicine the danger of
which they do not realize, but, once freed, they will not again come under
its power. The practical sagacity of their race is their surest
safeguard.
What is commonly spoken of as the "American type," highly nervous, living
under pressure, always going to the full limit, or beyond, is peculiarly
liable to disorders that lead to the habitual use of drugs. We are all
hypochondriacal by nature, prone to "take something" whenever we feel
badly. Lack of opportunity alone, of knowledge of what to take and how to
procure it, has saved many a person under severe physical or mental strain
from recklessly resorting to drugs. Since the passage of the Pure Food and
Drugs Act, which was intended to protect the public by requiring the
express statement of any dangerous ingredients in a compound, the sale of
preparations containing habit-forming drugs has preceptibly increased. It
seems a just inference that the information given, instead of serving as a
warning to the unwary, has been chiefly effective in pointing out a
dangerous path to many who otherwise would not have known where to find
it.
Women, it should be said, though constitutionally more liable than men to
feel the need of medicines, form the lesser portion of the drug-taking
class. In the beginning their addiction is due almost exclusively to a
physician's prescription, except in the under-world.
The habitual users of drugs in the United States come from every grade of
society. Professional men of the highest responsibility and repute,
laborers wearying of the dullness in a mining-camp, literary men,
clergymen, newspaper men, wire-tappers, shoplifters, vagrants, and
outcasts--all are among the number. Strangely assorted as they are, they
become yet more strangely alike under the influence of the common habit.
Shoplifting is not confined to the professional thief; it is noticeable in
many a drug-user who has had every moral and worldly advantage.
The major part of the habit-forming drugs used in the United States is
consumed by the under-world. It would be impossible to calculate the
extent of their influence. Many a record of heinous crime tells of the
stimulus of a drug. But when the school-children in some of our larger
cities are found to be using cocaine, and able to buy it at will, the
limit of tolerance has surely been reached.
THE DRUG-TAKING PHYSICIAN, NURSE, AND PHARMACIST
Among the widely varying classes of drug-users, three in particular are a
source of the gravest danger: the drug-taking physician, nurse, and
pharmacist. To realize this, one has merely to recall that the drug-taker
is a confirmed evader of responsibility; and the physician, of all men, is
in a responsible position. He must not forget or break his appointments;
he must realize the effects of the medicines he is prescribing; if a
surgeon, his work must never be below its best. But the proportion of
physicians that I have treated, or consulted with, suggests one specially
grave danger. It is a characteristic of the drug-taker, no matter who he
is or how he acquired the habit, on the smallest excuse to advise others
to take the drug whenever pain or fatigue gives the slightest occasion for
it. While he grows callous to everything else, he has an abnormal sympathy
with suffering. Thus it will readily be seen that there are few more
dangerous members of society than the physician who is addicted to a drug.
The fact that there are not more drug-taking doctors speaks volumes for
the high character of the profession. The physician has such drugs
constantly at hand. The more a man knows of their insidious action and the
more he handles them, the more cautious he feels himself to be, and the
more confident that he can discontinue the use of them whenever he
chooses. Any fear that the layman may have of them is due less to the
dread of being personally overcome than to the mystery which surrounds
them; but for the physician they have no such mystery. Furthermore, by the
nature of his calling he is peculiarly exposed to the need of such drugs.
He is often under excessive physical and nervous strain not only because
he is unable to arrange his work so as to prevent periods of too great
pressure upon his time and strength, but also because in a unique manner
he puts his heart into it.
An even greater danger, in some respects, is the drug-taking professional
nurse. Whatever has been said of physicians both in the way of extenuation
and of warning may be repeated of nurses. They have the same exposure to
the habit, and, once addicted, are likely to exhibit signs of
irresponsibility. They are more dangerous in that their opportunity for
mischief is greater, since they are closer to the patient and able to
thwart the doctor's orders with perfect freedom. "I have had several
nurses on this drug case," a doctor once said to me, "and I find that they
have all smuggled morphine to my patient." This was, no doubt, an
exceptional case, but the fact remains that nurses, because of their close
alliance with druggists and doctors, find it comparatively easy to
purchase drugs and hypodermics at any drug store without causing the
slightest suspicion or reproof. Nor should one censure them too severely
for clandestine compliance with the demands of a patient. It should not be
overlooked that the nurse, in being paid by the patient and not by the
doctor, is ordinarily subjected to great pressure when the patient clamors
for morphine. In such circumstances the protection of a physician's
monopoly of the drug would be most welcome. But how much worse is the
pressure when the well-intentioned nurse also is a drug-taker! The
morphinist has an abnormal sympathy with those who have undergone or are
undergoing experiences similar to his own, and there is no stronger bond
than that which unites two morphine victims. As a matter of the most
elementary precaution for all concerned, no nurse should under any
conditions be allowed to buy habit-forming drugs.
Another kind of drug-taker against whom physicians' distribution would be
a safeguard, and the only safeguard that can be devised, is the
pharmacist. The contingency of a drug-taking pharmacist, perhaps more than
anything else, will bring sharply home to the average man the menace of
morphine when used by a professional person. By reason of closer and more
personal observation one may feel rashly confident of his ability to
detect when a doctor or a nurse is "queer," but generally the patron of a
drug store has no such opportunity for observation. Addiction to a drug
incapacitates the pharmacist for filling prescriptions. Often the
slightest deviation from a precise formula in either quantity or
ingredient is of the gravest consequence, and hence the utmost care should
be used to insure the scrupulousness of one on whom such responsibility
rests. As long as he is accountable to no one, or even accountable to the
Government only on a business basis, there can be no safety for the
public. If he may sell to any purchaser other than a physician, he may
always supply his own wants. But if he has to account to a physician for
the entire amount of habit-forming drugs that he distributes, any leakage
may quickly be detected by the man who more than any one else can be
relied upon to stop such a leakage promptly and sternly. A pharmacist
should be allowed to dispense habit-forming drugs only on a physician's
prescription.
The physician should be limited as to his authority not only for
prescribing such drugs, but, as the Boylan Act provided, there must be a
careful accounting on his part for all such drugs administered or given
away. In other words, he must account for all such drugs which he buys for
office use, and he cannot prescribe such drugs except under certain
definite limitations.
METHODS OF TREATMENT: "THE HOME CURE"
For many years only two methods of dealing with the drug habit were known.
They continue to be the only ones in general use to-day. They are the
"home cure" and the sanatorium method. Neither is in any proper sense a
treatment or anything more than a process of substitution and deprivation.
In many of the periodicals and daily papers are carefully worded
advertisements setting forth that a man may be cured of a drug habit
quickly, secretly, painlessly, and inexpensively. These are written by
people who thoroughly understand the mental and physical condition of the
drug-taker. In almost all cases he wishes to be freed from the habit, but
at the same time to avoid the disgrace of being classed with
"drug-fiends"; he is unwilling that even his family or his intimates
should know of his condition. He has an exaggerated sensitiveness to pain,
upon which also the advertisement relies. Furthermore, attention is
directed to the fact that the patient may take the alleged remedy without
spending much more money than he has been spending for the drug itself,
naturally a powerful appeal to a man of limited means. Moreover, the
people who take these "cures" are generally those who are unable to
consider the expense of leaving home. That the advertisement is very
alluring to the average drug-taker is shown by the fact that in my entire
practice I have encountered few patients who have not at some time or
other taken a home cure.
A minister wrote to me the other day begging me to cure a fellow-minister
of the cure habit. His friend had had occasional attacks of renal colic,
and a physician had eased their acuteness with a hypodermic. The patient
of course knew what he was taking, and since he was forced to consider the
cost of the physician's visits for the mere administration of the
hypodermic, he naturally procured his own outfit, and in a short time was
using it regularly upon himself. When he found that he could not leave off
the practice he entered into correspondence with a succession of
"home-cure" advertisers, whose clever use of the word "privacy" offered a
hope that his condition might be concealed from his congregation. For ten
years he had been undergoing the cures, and during all this time had been
forced to take a regular dosage of the so-called remedies.
Before the passage of the Pure Food and Drugs Act the ingredients of such
remedies were not stated. The patient seems never to have suspected the
truth--that the bottle contained the very drug he had been taking, its
presence disguised by added medicines. In certain instances the makers
boldly advertised that a trial bottle would be sufficient to prove clearly
that the taker could not get along without using his drug. Now that the
law compels a list of dangerous drugs on the label, the cures proceed
admittedly by a reductive principle. The patient graduates from a number
one bottle to a number two, containing less opium, and so on, until
finally he is supposed to be cured. The proprietors of these cures make a
great deal of capital out of the fact that the reduction is so gradual
that the taker experiences no discomfort. This consideration is highly
effective, for while it irresistibly appeals to the morbidly sensitive
morphinist, it also makes him comprehend, as time goes on, why the process
of cure is so slow. It is hardly necessary to state that the final stage
is almost never reached.
Almost without exception, the basis of restoration to health is the
perfect elimination of the effects of the drug. It should go without
saying that it is impossible to eliminate the effects of opium with opium
or to find any substitute for opium that is not itself opium. At the
International Opium Conference in China I exhibited seventy-six
opium-cures which I had had analyzed and found to contain opium; and as a
consequence of the Pure Food and Drugs Act all the American "cures"
announced on their labels that they also contained it. Thus it is easy to
see why the sale of these cures had always greatly increased wherever the
rigid enforcement of anti-opium enactments had closed up the customary
sources of habit-forming drugs.
Up to the passage of the act, however, the presence of opium in the
American cures was concealed, and their formulas were kept secret; and
hence all of them, by the very nature of the case, were put forth either
by irresponsible persons or by persons outside the pale of the profession;
for one of the pledges given by a physician is that he will not patronize
or employ any secret treatment, and that he will give to the profession
whatever he finds to be of benefit to his fellow-men.
In very rare cases these home cures have been able to relieve a man of
strong will power, with the added assistance of a regimen for building up
his bodily tone. But these cases have been so infrequent as to be
virtually negligible, for to administer the treatment successfully demands
from the patient the exercise of precisely that power of self-control the
loss of which drove him to the cure in the first place. If there ever was
any curative property in one of these so-called cures, a man could not be
benefited unless he were under constant supervision. A treatment of this
sort must, except in case of a miracle, be administered by another and
under continuous medical surveillance. A man addicted to a drug, be he
physician or longshoreman, in a short time becomes utterly unable to deal
justly with himself, for it is the nature of the drug to destroy his sense
of responsibility.
THE SANATORIUM TREATMENT
Besides the home cure there was, and is, the sanatorium treatment. Unlike
the former, this was first established and carried on by trustworthy
medical men, who depended for their support upon the patients of reputable
doctors. A physician who had a morphine patient was obliged to send him to
a sanatorium because there was nothing else to be done with him; elsewhere
no course of treatment under constant surveillance could be given. It
afforded the only opportunity of carrying the patient through the long
period of gradual reduction which was then the only known treatment. Thus
there was nothing optional about the matter; the physician could not
recommend a home cure, and the only means of approximating systematic
treatment was the sanatorium. Furthermore, those relatives and friends who
knew of the patient's condition were anxious that he should go to one,
since they realized the increasing awkwardness of keeping him at home. In
many cases, indeed, they even went so far as to resort to means of
commitment, if they failed to get his voluntary cooperation. It is due to
the ease with which this type of patient can be committed that the State
of Connecticut, for instance, abounds in sanatoriums. In that State, when
a patient has entered one of them, he can often be detained there
virtually at the pleasure of his relatives and friends.
The method of treatment at most of the sanatoriums is like the home cure,
except that it is under surveillance; that is, it is merely one of gradual
reduction accompanied by an upbuilding of bodily tone. The morphine-taker
with means and time at his disposal will stay in a sanatorium as long as
he can be made comfortable. This shows that whatever reduction he has
undergone is extremely slight; for gradual reduction, when it is carried
to any extent, sets up a highly nervous state, together with insomnia and
physical disturbance. The patient, as is often said, has an exaggerated
dread of discomfort, and will not, if he can help it, endure it at all.
Unless he is committed, he transfers himself to another sanatorium the
moment he ceases to be made comfortable. I had one patient whose life had
been a continuous round of sanatoriums. He would stay in one place until
the point was reached where discomfort was in sight, and then remove to
another, remaining there for a similar period, and then to another, and so
on, until he had finished a long round of sanatoriums to his taste in
America and Europe. Then he would begin all over again.
A patient of mine who had visited eight different sanatoriums in the
vicinity of New York told me that in America the sanatorium treatment of
neurological patients was divided into three great schools: the
"forget-it" system, the "don't-worry" system, and the "brace-up" system.
Any nervous invalid who has stayed much at sanatoriums will appreciate the
humor of this classification.
The gravest aspect of these long stays at a sanatorium is the unavoidable
colonization. Picture to yourself a group of from half a dozen to fifty
morphine patients, eating together, walking together, sitting on the
veranda together, day in and day out. In this group are represented many
different temperaments and many different stations of life, from the
gambler to the clergyman. All the more on this account is there a general
and eager discussion of previous history and present situation. For where
the alcoholic is quite indifferent, the morphine victim has an insatiable
interest in symptoms. He has also an excessive sympathy with all who have
been through the same mill with himself. Thus, in a matter where
individual and isolated treatment is imperative, most sanatoriums deal
with patients collectively. Furthermore, these are peculiarly a class of
unfortunates who ought never to become acquainted. Whatever moral
restraint the habit has left in a man is completely relaxed when he hears
constant bragging of trickery and evasion and has learned to envy the
cleverness and resource so exhibited. The self-respect and pride which
must be the main factors in his restoration are sometimes fatally
weakened. Colonization should be restricted to the hopeless cases, and to
them only because it is unhappily necessary.
FAILURE OF THE REDUCTION METHOD
All this, moreover, is never, or almost never, to any purpose. As the
uncomfortable patient will move if possible, it is naturally the business
of the sanatorium to keep him from being uncomfortable. The method of
reduction, therefore, is rarely carried out to the point where it would
do any good, even if good were thus possible. But it is not possible. In
the first place, lessening the dose is of little avail; there is as much
suffering in the final deprivation of a customary quarter of a grain as of
twenty grains. In the second place, it cannot be ascertained by gradual
reduction whether there is any disability which makes morphine necessary,
since no intelligent diagnosis can be made so long as a patient is under
the influence of the smallest quantity of the drug. Obviously, the first
step in taking up a case should be to discover whether any such disability
is present, and, if so, whether it is one that can be corrected; otherwise
it may be a waste of time to try to correct it. The true physical
condition of the patient, which should be considered before a long course
of treatment is undertaken, can seldom be discovered by the reduction
method.
The best doctors have always felt that they could not afford to lend their
names to any institutions or sanatoriums except those which restricted
themselves to mental cases. Yet these home cures and sanatoriums,
unscientific and ineffective as they were, have offered to the victims of
the drug habit the only hope they could find. The investigations begun by
Mr. Taft in the Philippines extended over considerable time and cost two
hundred and fifty thousand dollars, but, although furthered in every way
by the whole world, they failed to discover a definite treatment for the
drug habit. It was generally believed by physicians that there was no hope
for the victims of it.
COST OF THE DRUG HABIT
It may be noted that I have not dwelt upon the expense of the habit. This
consideration may be omitted from the case. To the average victim, the
cost of his drugs, no matter what he may have to pay for them, seems
moderate. He is buying something which he deems a vital necessity, and
which, moreover, he places, if a choice be required, before food, drink,
family, sleep, pleasures, tobacco--every necessity or indulgence of the
ordinary man.
The real cost is not to the drug-taker, but to the world. If a human life
be considered merely as a thing of economic value, an estimate may perhaps
be made of the total loss due to the habit.
But the loss should not be reckoned in any such way. It should rather be
reckoned by the great amount of moral usefulness and good that might be
rendered to the world if these unfortunates could be freed from their
slavery, and by the actual harm being done by them, especially by those
that are now loosely classed as criminals and degenerates.
The retrieving of much of the waste of humanity may be accomplished by
adequate treatment of the drug habit.