PSYCHOLOGY AND DRUGS
Drug habits may be classified in three groups: the first and largest is
created by the doctor, the second is created by the druggist and the
manufacturer of proprietary and patent medicines, and the third, and
smallest, is due to the tendency of certain persons toward dissipation.
The major importance of the first two groups is due to the fact that they
include by far the greater number of cases, and to the pitiful fact that
such victims are always innocent. Speaking generally, and happily omitting
New York State from our statement, it is safe to say that the
manufacturer, the druggist, and the physician are without legal restraint
despite their importance as promoters of drug habits, while the
comparatively unimportant drug-purveyor in the under-world is held more or
less strictly in control by the police, and is subject to severe
punishment by the courts in case of a conviction.
With few exceptions, the part which the doctor plays in the creation of
drug habits is due to lack of knowledge; but the druggist's part in the
spread of this national curse is purely commercial, and may justly be
designated as premeditated. He always has gone and always will go as far
as is permissible toward creating markets for any of the wares that he
sells.
Regulation of the upper-world in regard to the distribution of
habit-forming drugs will automatically regulate the under-world in its
similar activities. The amount which will be smuggled by those of criminal
tendencies always will be small as compared with the amount improperly
distributed through channels now recognized as legitimate until all the
States have passed restrictive legislation founded upon, modeled after,
and cooperative with New York State's legislation; and all this must be
backed and buttressed by Federal legislation of a special kind before real
and general good can be accomplished in the United States. Illicit drugs
rarely find their way into the possession of users who have acquired drug
habits through illness or pain. So it must be admitted that most of the
effort that in the past has been made toward restrictive legislation has
really been devoted to the interests of the unworthy rather than to those
of the worthy. Save in New York State, the man or woman with a
sheep-skin--the doctor, the druggist, or the nurse--remains virtually a
free-lance, permitted to create the drug habit in others or in himself or
herself at will.
THE DOCTOR A MEANS OF SPREADING THE DRUG HABIT
The man in severe pain is immediately exposed, by the very reason of his
misfortune, to the physician with a hypodermic or the druggist with a
headache powder; the man who cannot sleep may at any moment be made a
victim by the physician whom in confidence he consults, or by the druggist
to whom he may foolishly apply for "something" which will help him to
secure the necessary rest. Save in New York State, the druggist's shelves
are crowded with jars and bottles holding dangerous compounds which he may
dispense at will, his drawers are crowded with neat pasteboard boxes
containing powders which are potent of great peril. The public will have
made a long step toward real safety when it realizes that any drug which
brings immediate relief from pain or which will artificially produce sleep
is an exceedingly dangerous thing.
The sick man's confidence in his doctor is one of the doctor's greatest
assets; it has saved innumerable lives. It is of the same general nature
as the mysterious mental phenomena which frequently control physical
conditions, and which have been capitalized by various bodies, such as
Faith Cure and Christian Science; but if this is an asset to the
physician, the general public knowledge that he carries in his case or in
his pocket drugs which he can use without restraint of law for the relief
of pain may become a general peril. In the old days when the doctor's work
was a mysterious process, operating by methods of which he alone was
cognizant, this peril was less well defined; but now that the spread of
education has made everybody a reader and periodical literature of the
times has given even children a smattering of knowledge concerning medical
matters, the nature of the means by which the doctor works his miracles is
well known, and his unrestraint may become a public peril.
Of one thousand patients who may consult the average physician, nine
hundred and ninety-nine know perfectly well that he can stop their pain if
he desires to do so. Pain is unpleasant; naturally their demands that he
use his power are insistent. If he refuses, they are likely to call in
another and less scrupulous physician. The medical profession is
overcrowded, and perhaps the doctor needs the money. Even if he is swayed
by nothing but financial need, he is likely to be tempted into the
administration of pain-deadening substances when his patient urges him.
There is another powerful influence which works upon the most admirable of
men--the pity of the temperamental physician for the human sufferer. Most
men who choose the medical profession as the avenue for their life-work
have the qualities of mercy, pity, and sympathy notably developed in their
psychology. This is likely to induce them to stretch points in favor of
relieving suffering patients. Even when their previous experience has
proved to them the danger lying in narcotics, they are likely to forget
it, or to take a chance if a special emergency arises. This may be done
without great peril to the patient.
DANGER OF THE KNOWLEDGE OF PAIN-RELIEVING DRUGS
The physician should exhaust every means known to medical science to
prevent his patient from knowing what it is that eases pain when his
practice makes it absolutely necessary that a substance of the sort should
be administered, and this is very much less frequent than the average
doctor realizes, as will be shown in another passage of this book. It is
in this necessity for concealment that the great danger of using the
hypodermic syringe as an administrating instrument principally lies. The
moment the hypodermic syringe is taken from the doctor's or the nurse's
kit, the sufferer is made aware of the means which will be used to give
him ease. He remembers it, forming a respect and admiration, almost an
affection, for the mere instrument, and with the most intense interest
gathers such information as he may find it possible to acquire about this
wonder-working little tool and the material which is its ammunition of
relief. He knows absolutely that the relief which he has found is not due
to medical skill, but to the potency of a special drug administered in a
special way. He stops guessing as to whether he has been soothed by an
opiate; he knows he has been.
It is not only those of weak psychology or mental characteristics who are
affected by this knowledge and who through it become drug-takers, though
it is the general impression that this is the case. No impression was ever
more inaccurate. The mentally strong and the morally lofty are as much
averse to suffering physical pain as the mentally weak and the morally
degenerate. All are in the same class when the drug has been administered
until that point of tolerance is reached where its administration cannot
be neglected without the indignant protest of the physical body. That this
fact should be impressed upon the medical profession as a whole is one of
the most needful things I know.
Another hazard which the doctor runs, if he passes the point of extreme
caution in the administration of drugs to patients, is the possibility,
even the probability, that through such an administration he will lose
control of his patients. From the moment the patient becomes cognizant of
the means which the doctor has successfully used to alleviate his pain, he
begins to dictate to the doctor rather than to accept dictation from him.
No doctor can control a case successfully unless his judgment is accepted
as the supreme law of treatment. A patient who is not susceptible to the
doctor's dictation cannot be expected to get the full advantage of the
doctor's skill or knowledge. If diagnosis shows that a patient requires
some operation, as in certain uterine troubles, or more especially in the
case of bladder affections or gall-stones,--cases in which frequently only
an operation can give relief,--and if that patient is aware that even if
the operation is not performed, the doctor can still ease all suffering,
that patient, loath to run the risk of the surgeon's knife, horrified by
the thought of hospitals and operating theaters, is likely to demand the
relief which opiates offer, and refuse to risk the cure which surgical
procedure alone would certainly afford.
The conscientious doctor who insists upon the proper course in such a case
is seriously handicapped by the presence in the medical profession of many
men who are less conscientious, and who may yield more readily to the
urgings of the patient. Thus the possibility of unrestricted use of
habit-forming drugs by the medical profession becomes a handicap to the
conscientious man and a commercial advantage to the unscrupulous
practitioner.
UNCONSCIOUS VICTIMS OF THE DRUG HABIT
Episodes occurring continually in the course of my work add to the
strength of my conviction of the physician's responsibility. For years not
a week has passed which has not brought me patients with stories of the
manner in which they have become victims of drug addiction through the
treatment of their physicians. Lying before me as I write is a
communication from a young man in Pennsylvania. He had been hurt, and
through improper surgical attention a healing fracture had been left
intensely painful. The attending doctor, unable to correct his imperfect
work, had left with him a box of tablets to be taken when the pain became
severe. Promptly and inevitably the youth achieved the drug habit. He felt
disgraced, he would not tell his father, his wife, or his sister. His
doctor could give him no relief. By some accident he saw an article of
mine which was published in the "Century Magazine," and made a pitiful
appeal to me. I have received many such communications.
A pathetic letter comes to me from a woman suffering with fistula. Having
achieved the morphine habit as the direct and inevitable result of taking
pain-killing drugs given to her by her family physician, she now feels
herself disgraced. Like many sensitive women who in this or some other way
become victims of the drug habit, she is obsessed, as her letter clearly
shows, with the conviction that her achievement of the habit has been a
personal sin, and that her continued yielding to it puts her beyond the
pale of righteousness. She writes that she finds herself incapable of
going to her church for Sunday services or to prayer meetings because she
feels ashamed when in the imminent presence of her Maker. Another woman,
evidently animated by a similar psychological phenomenon, writes that
having acquired the drug habit, although blamelessly, since it was through
the administration of narcotics by her doctor, she finds it a
psychological impossibility to kneel at her bedside and offer that prayer
to God which it had been her nightly practice to deliver.
I could multiply such instances indefinitely. It is impossible to conceive
any episodes more pitiful than the cases of this sort which have been
detailed to me by drug victims, doctor-made. That feeling of disgrace,
that unjustified conviction of sin on the part of absolutely innocent
women victims of the drug habit, is apparently among the most terrible of
humanity's psychological experiences. If I had the pen of a Zola and the
imagination of a Maupassant, I might properly impress the medical world
with a sense of its responsibility in this matter. Without it I fear that
I may fail to do so; but could I accomplish only this one thing, I should
feel that my life had been of use to that humanity which I desire above
all things to serve.
No work could be of more importance to the world of sufferers than one
which would put the use of these potentially beneficent, but, alas! often
injurious, drugs upon a respectable basis, so that the man who must be
given the relief which they alone can offer may no more hesitate to tell
his neighbor that he is taking morphine than he now will hesitate to tell
his neighbor that he is taking blue mass pills or citrate of magnesia.
RESPONSIBILITY OF THE TRAINED NURSE
That the medical world should ever have been so lax in its realization of
its proper responsibility as to allow trained nurses to carry hypodermic
syringes and to administer habit-forming drugs seems to me to be one of
the most amazing things in the world. No physician who has had an
extensive experience with drug addiction and who has any conscientious
scruples whatsoever will fail to make sure before he leaves a nurse in
charge of a patient that the attendant possesses no habit-forming drugs
and is without any instrument with which they may be hypodermically
administered. If such drugs are to be used, they should be kept in the
physician's possession until they are used, and should be administered by
means of an instrument which he carries with him. When such drugs are
left, the nurse should give an accounting for every fraction of a grain.
I have no desire to convey the impression that in my opinion all nurses
are untrustworthy or unscrupulous, but it must be remembered of them, as
it must be remembered of the doctor, that they are in the employ of the
patient, that their income depends upon giving satisfaction to their
employer, and that they are likely to make almost any kind of concession
and resort to almost any practice in order to make comfortable and
profitable assignments last as long as possible. It is impossible not to
admit the truth of this statement, and it must be recognized that if it
is true, a nurse is under too great a responsibility when she is in
possession of a hypodermic kit, particularly if the patient knows that it
is _her_ kit, _her_ hypodermic, _her_ drug, and that she will not be
called to account by the physician for such drugs as she may administer.
It must be rather disconcerting for a physician to reflect upon the fact
that a nurse whom he has left in charge of a critical case, through greed
or even through the general and admirable quality of mercy, is equipped
for, and ignorantly may yield to the temptation of, resorting to a
practice that may not only undo all the good his treatment has
accomplished, but, in addition, may afflict the patient with suffering
more terrible than any which disease could give. This element of mercy,
soft-heartedness, and readiness to pity must specially be remembered in
considering the relation of the trained nurse to the patient. If men are
often induced to enter the medical profession because of its presence in
their soul, even more frequently are women led by it to become trained
nurses. The sympathetic woman is even more likely to yield to the
pleadings of suffering patients than is the sympathetic male doctor.
It must also be remembered that, like the doctor, the nurse is human, and
neither iron-nerved nor iron-muscled. She is frequently under terrific
strain, which makes her tend toward the use of stimulants of any kind.
That which she can administer to herself by means of the hypodermic is
closest to her hand, is easiest to take, and is least likely to be
discovered. Again, too, it must be remembered that the nurse is as
susceptible to pain as are the rest of us. Suffering, with the means of
alleviation at her hand, and, like the doctor, ignorant of its true peril,
what is more natural than that she herself should use the hypodermic for
her own relief? Thus it comes about that probably a larger proportion of
trained nurses than of doctors are habitual drug-users. This is not a
statement which is critical of the profession, for if all mankind knew of
drugs, had hypodermics, and knew how to use them, a very large proportion
of the human race would resort to this quick and effective, if inevitably
perilous, means of finding comfort when agony assailed them.
The world does not, the world cannot, understand that while to the normal
human being the worst that can come is pain, the worst pain is vastly less
terrible than the horrors which at intervals inevitably afflict the
habitual drug-user. Not one human being who has become a victim of a drug
habit through its use for the alleviation of pain but will voluntarily cry
after he has come to realization of the new affliction which possesses
him, "save me from this drug habit, and I will cheerfully endure the pain
which will ensue." The horror of pain is not so great as the horror of the
drug habit.
Another very serious reason for extreme caution on the part of the medical
profession in regard to the use of habit-forming drugs is that the effect
of such drugs upon a patient must almost certainly make accurate diagnosis
of his case difficult or even impossible. A patient whose consciousness of
pain is dulled or eliminated by the use of drugs cannot accurately
describe to a physician the most important symptoms of his ailment.
Without the assistance of such a description the physician is so
handicapped that all the skill which he has acquired in practice and all
the knowledge he has gained from study are apt to be of no avail. Indeed,
in the case of habitual drug-users accurate diagnosis of any physical
ailment is impossible until the effect of the drug has been so completely
eliminated that not one vestige of it remains.