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 coöperative 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.