CONTENTS
THE NARCOTIC DRUG PROBLEM
CHAPTER I
INTRODUCTION
It is a fact becoming more and more obvious that too little study and effort to interpret their physical condition have been given to those unfortunates suffering from narcotic drug addiction.
We have neglected their disease in its origin and subsequent progress and formed our conception of its character from fully developed conditions and spectacular end-results. We have seen some of them during or after our fruitless efforts at treatment, their tortures and poor physical condition overcoming their resolutions, until they plead for and attempted to obtain more of their drug. We have seen others exhausted, starved, with locked-up elimination, toxic from self-made poisons of faulty metabolism, worn with the struggle of concealment and hopeless resistance, and for the time being more or less irresponsible beings, made so, not because of their addiction-disease itself, but because they were hopeless and discouraged and did not know which way to turn for relief.
What literature has appeared on the subject has usually pictured them as weak-minded, deteriorated wretches, mental and moral derelicts, pandering to morbid sensuality; taking a drug to soothe them into supposed dream states and give them languorous delight; held by most of us in dislike and disgust, and regarded as so depraved that their rescue was impossible and they unworthy of its attempt.
We have overlooked, ignored or misinterpreted intense physical agony and symptomatology, and regarded failure to abstain from narcotics as evidence of weak will-power or lack of desire to forego supposed morbid pleasure. We have prayed over our addicts, cajoled them, exhorted them, imprisoned them, treated them as insane and made them social outcasts; either refused them admission to our hospitals or turned them out after ineffective treatment with their addiction still fastened to them. To a great extent the above has been their experience and history.
In great numbers they have realized our failure to appreciate their condition and to remedy it, and have after desperate trials of quacks, charlatans and exploited “cures,” finally accepted their slavery and by regulation of their drug and life, their addiction unsuspected, maintained a socially and economically normal existence. Some failing in this, perhaps broken and impoverished, their addiction recognized, have become social and economic derelicts and often public charges.
From these last, together with the addicted individuals from the class of the fundamentally unfit, we have painted our addiction picture. Confined and observed by the custodial official and the doctor of the institution of correction and restraint, or concealed as family skeletons in many homes, descriptions of them have given to the narcotic addicts as a whole their popular status—cases of mental and moral disorder due to supposed drug action or habit deterioration, and based upon inherent lack of mental and moral stamina.
It was with the above conception of these addiction conditions that I began my work in the Alcoholic, Narcotic and Prison Service of Bellevue Hospital, attracted to the service not by hope of helping nor by interest in “jags” and “dope fiends” as I then considered them, but by the mass of clinical material available for surgical and medical diagnosis and study which was daily admitted to those wards. When I left the service after sixteen months of day and night observation, with personal oversight and attempt to care for in the neighborhood of a thousand admissions a month, my early and faulty conception of narcotic addicts was replaced by a settled conviction that these cases were primarily medical problems. I realized that these patients were people sick of a definite disease condition, and that until we recognized, understood and treated this condition, and removed the stigma of mental and moral taint from those cases in which it did not exist, we should make little headway towards solution of the problem of addiction.
It is a fact that the narcotic drugs may afford pleasurable sensations to some of those not yet fully addicted to them, and that this effect has been sought by the mentally and morally inferior purely for its enjoyment for the same reasons and in the same spirit that individuals of this type tend to yield themselves to morbid impulses, curiosities, excesses and indulgences. Experience does not teach them intelligence in the management of opiate addiction and they tend to complicate it with cocaine and other indulgence, increasing their irresponsibility and conducing to their earlier self-elimination.
Wide and varied experience, however, hospital and private, with careful analysis of history of development, and consideration of the individual case, demonstrates the fact that a majority of narcotic addicts do not belong to this last described type of individuals. It will be found upon careful examination that they are average individuals in their mental and moral fundamentals. Among them are many men and women of high ideals and worthy accomplishments, whose knowledge of narcotic administration was first gained by “withdrawal” agonies following cessation of medication, who have never experienced pleasure from narcotic drug, are normal mentally and morally, and unquestionably victims of a purely physical affliction.
The neurologist, the alienist, the psychologist, the law-maker, the moralist, the sociologist and the penologist have worked in the field of narcotic addiction in the lines of their special interests, and interpreted in the lights of their special experiences. Each has reported conditions and results as he saw them, and advised remedies in accordance with his understanding. With very few exceptions little has been heard from the domain of clinical medicine and from the internist. It is only here and there that the practitioner of internal medicine has been sufficiently inspired by scientific interest to seriously consider narcotic drug addiction and to make a clinical study of its actual physical manifestations and phenomena.
The idea that narcotic drug addiction should be accorded a basis of weakness of will—neurotic or otherwise, inherent or acquired—and should be classed as a morbid appetite, a vice, a depraved indulgence, a habit, has been generally unquestioned and the prevailing dogma for many years. It is very unfortunate that we have paid so little attention to material facts and have made so little effort to explain constant physical symptomatology on a basis of physical cause, and that there has not been a wider recognition and more general acceptation of scientific work that has been done.
Despite the years of effort that have been devoted to handling the narcotic addict on the basis of inferiority and neurotic tendencies, and of weakness of will and perverted appetite—in spite of exhortation, investigation, law-making and criminal prosecution—in spite of the various specific and special cures and treatments—narcotic addiction has increased and spread in our country until it has become a recognized menace calling forth stringent legislation and desperate attempts at administrative and police control. And though a large amount of money has been spent in custodial care and sociological investigation on the prevailing theories, and in various legislation, much of it necessary and much of it wisely planned, we have made but little progress in the real remedy of conditions.
It is becoming apparent that in spite of all the work which has been done—in spite of all the efforts which have been made—there has been practically no change in the general situation, and there has been no solution of the drug problem.
In analyzing results of efforts and arriving at causes for failure, it seems to me that it is always wise to begin at the beginning, and to ask ourselves whether we have not started out with an entirely erroneous conception of our basic problem. Is it not possible that instead of punishing a supposedly vicious man, instead of restraining and mentally training a supposedly inherent neuropath and psychopath, we should have been treating an actually sick man? Is it not possible that the addict did not want his drug because he enjoyed it but that he wanted it because his body required it? This is not only possible—it is fact—and the whole secret of our failure has been the misconception of our problem based on our lack of understanding of the average narcotic drug addict and his physical conditions.
In my own experience as a medical practitioner I know that non-appreciation of this fact was the cause of my early failures; and I further know that from the beginning of appreciation of this fact dates whatever progress I have made and whatever success I have attained. In my early efforts as Resident Physician to the Alcoholic and Prison Wards of Bellevue Hospital, devoid of previous experience in the treatment of narcotic addiction, directed by my available literature and by the teachings of those in my immediate reach, I followed the accepted methods. I tried the methods of the alienist; I tried the exhortations of the moralist; I tried sudden deprivation of the drug; I tried rapid withdrawal of the drug; I tried slow reduction of the drug; I tried well-known special “treatment.” In other words I exhausted the methods of handling narcotic drug addiction of which I knew. My results were, in these early efforts, one or two possible “cures,” but as a whole suffering and distress without relief; in a word failure.
The blame I placed not where it belonged—on the shoulders of my medical inefficiency and lack of appreciation and knowledge of the disease I was treating—but upon what I supposed was my patient’s lack of co-operation and unwillingness to forego what I supposed to be the joys of his indulgence. In discouragement and despair I held the addict to be a degenerate, a deteriorated wretch, unworthy of help, incurable and hopeless. Strange as it seems to me now, possessing as I did good training in clinical observation and being especially interested in clinical medicine, in calm reliance upon the correctness of the theories I followed, I ignored the presence of obvious disease.
As to the existing opinion that the addict does not want to be cured, and that while under treatment he cannot be trusted and will not co-operate, but will secretly secure and use his drug—I can only quote from my personal experience with these cases. During my early attempts with the commonly known and too frequently routinely followed procedures of sudden deprivation, gradual reduction and special or specific treatment, etc., my patients beginning with the best intentions in the world, often tried to beg, steal or get in any possible way the drug of their addiction. Like others, I placed the blame on their supposed weakness of will and lack of determination to get rid of their malady. Later I realized the fact that the blame rested almost entirely upon the shoulders of my medical inefficiency and my lack of understanding and ability to observe and interpret. The narcotic addict as a rule will co-operate and will suffer if necessary to the limit of his endurance. Demanding co-operation of a completely developed case of opiate addiction during and following incompetent withdrawal of the drug is asking a man to co-operate for an indefinite period in his own torture. There is a well-defined limit to every one’s power of endurance of suffering.
Abundant evidence of what I have written is easily found among the many sufferers from the disease of opiate addiction who have maintained for years a personal, social and economic efficiency—their affliction unknown and unsuspected. These cases are not widely known but there are a surprising number of them. When one of them becomes known his success in handling his condition and its problems is generally attributed to his being on a rather higher moral and mental plane than his fellow sufferers and possessed of will-power sufficient to resist temptation to over-indulge his so-called appetite. We have not as a rule considered any other explanation nor sought more at length for the cause of his apparent immunity to the hypothetical opiate stigmata. It would have been wiser and more profitable for us to have respectfully listened to his experiences and learned something about his disease.
The facts in such cases are that instead of being men of unusual stamina and determination, they are simply men who have used their reasoning ability. They have tried various methods of cure without success. They have realized the shortcomings and inadequacy of the usual understanding and treatment of their condition. Being average practical men, and making the best of the inevitable, they have made careful and competent study of their own cases and have achieved sufficient familiarity with the actions of their opiate upon them and their reactions to the opiate to keep themselves in functional balance and competency and control. The success of these people is not due to determined moderation in the indulgence of a morbid appetite. It is due to their ability to discover facts; to their wisdom in the application of common-sense to what they discover; and to rational procedure in the carrying out of conclusions reached through their experiences. They have simply learned to manage their disease so as to avoid complications. When I tried to account for some of the things I saw by questioning these men who had studied and learned upon themselves, I soon obtained a clearer conception of what opiate addiction was.
When we eliminate the distracting and misleading complications, mental and physical, and study the residue of physical symptomatology left, we make some very surprising and striking observations.
We find that we are dealing fundamentally with a definite condition whose disease manifestations are not in any way dependent in their origin upon mental processes, but are absolutely and entirely physical in their production, and character. These symptoms and physical signs are clearly defined, constant, capable of surprisingly accurate estimation, yielding with a sureness almost mathematical in their response to intelligent medication and the recognition and appreciation of causative factors; forming a clean-cut symptom-complex peculiar to opiate addiction. Any one—whether of lowered nervous, mental and moral stamina, or a giant of mental and physical resistance—will, if opiates are administered in continuing doses over a sufficient length of time, develop some form of this symptom-complex. It represents causative factors, and definite conditions which are absolutely and entirely due to changed physical processes which fundamentally underlie all cases of opiate addiction, and which proceed to full development through well-marked stages.
During the past years I have had under my care a number of excellent and competent physicians of unusual mental and nervous balance and control in whom there could be no hint of lack of courage, nor of deficient will-power, nor of lack of desire to be free from their affliction. Possessing, some of them, unusual medical training and scientific ability, having added to this the actual experiences of opiate addiction, they with others have co-operated and aided in experiment, study and analysis, and the result has been in their minds as in mine, complete confirmation of the facts above stated.
Primarily, there are two phrases I should like to see eliminated from the literature of opiate drug addiction. I believe they have worked great injustice to the opiate addict and have played no small part in the making of present conditions. It seems to me that to speak and write as we still often do of “drug habit” and “drug fiends” is placing upon the opiate addict a burden of responsibility which he does not deserve. If long ago we had discarded the word “habit” and substituted the word “disease” I believe we would have saved many people from the hell of narcotic drug addiction. I believe if it had not been for the use of the word “habit” that the medical profession would long ago have recognized and investigated this condition as a disease. A man, physician or layman, believes that he can control a habit when he would fear the development of a disease. Until now, however, the description has been “drug habit.” And the man who acquires one of the most terrible diseases to be encountered in the practice of medicine is unconscious of his being threatened with a physical disease process until this process has become so developed and so rooted that it is beyond average human power to resist its physical demands.
In the near future, I earnestly hope the true story and the real facts concerning the opiate drug addict will become universally known. Without familiarity with them and understanding of them, and comprehension and appreciation of their disease, we shall never make real progress in the solution of the narcotic drug problem. From the present day trend of articles and stories in the newspapers and lay and medical magazines it cannot be doubted that the time is not far distant when in the lay press will appear, in plain, sober, unvarnished truth, the true story of the experiences and struggles of the opiate drug addict. I have marked a rapidly growing appreciation of fact and a steadily increasing activity in the investigation of conditions. This is sooner or later bound to be followed by intelligent public and scientific demand for competent and common-sense explanation and solution.
CHAPTER II
FUNDAMENTAL CONSIDERATIONS
My earliest efforts in the handling of narcotic addicts were institutional. They were along the lines of forcible control, based upon the theory that I could expect no help nor co-operation from my patients.
While this theory is undoubtedly true as applied to many of those who have developed opiate addiction, it is true of them as individuals whose personal characteristics are such that they require forcible control for the accomplishment of desirable ends in general. It is not true of them simply because of narcotic addiction. It is equally true of these same people afflicted with other diseases. Their successful handling for tuberculosis, venereal disease, cardiac conditions, or anything else requires for its successful issue constant oversight and what practically amounts to custodial care. I shall refer to them later. They are fundamentally custodial or correctional cases and success in their handling will never be accomplished in any other way, whether they are being treated for narcotic addiction or for anything else, mental, moral or physical.
What appears in this chapter does not solve the problem of the handling of the narcotic addict of this type. There are many factors and elements in their mental and physical make-up other than drug addiction which should be considered, and these factors and elements lie at the bottom of their irresponsibility and the real difficulty of their handling.
Experience and the analysis of unsuccessful effort and results showed that, however necessary forcible control might be in the handling of some narcotic addicts, it was not successful nor sufficient nor even the most important factor in the treatment of most cases of addiction-disease.
I soon came to see that I had an erroneous conception of my medical and clinical problems and an unjust attitude towards many if not most of my addiction patients. Studying them—not as drug addicts, but as individual human beings—I found them in their personal, mental, moral and other characteristics, as various as people suffering from any other disease condition. There were no narcotic laws at that time and opiates were easily and cheaply obtainable. Very many, perhaps most of those who came to my wards were not forced in either by fear of the law or by scarcity of opiate supply. They did not have to come for treatment, but voluntarily presented themselves in the hope of cure. Something was wrong with my theories.
In seeking for solution I began to realize that the narcotic addict of average individual characteristics obtained no enjoyment from the use of his opiate, and that he co-operated as a rule to the extent of his ability and endurance in efforts to relieve him of his condition, so long as he had any hope of possible ultimate success. I learned, trained and experienced physician though I was, that I was far more ignorant of the clinical manifestations and physical reactions of narcotic drug addiction than many of the patients I was trying to treat. It was soon evident to me, moreover, that the man who recognized my ignorance above all others was my patient. I came to see that what I had interpreted as lack of co-operation was largely due; first to his memory of previous experience, second to recognition of my ignorance, and third to his anticipation of useless and harmful suffering which he expected from my care and treatment of his case.
Looking back over that period, I am free to confess that my efforts, though honestly made, amply realized his expectations.
I began to see that I knew nothing of this disease or how to treat it as a problem of clinical disease. I saw that addict after addict sneezed and trembled, jerked and sweated, vomited and purged, became pallid and collapsed, that his heart and circulation were profoundly and alarmingly disturbed, that he had the unquestionable facies or expression of intense physical suffering, and the many constant and obvious signs which attend physical need for opiate drug. I could not escape the conclusion that here were tangible, material, incontrovertible physical facts for which I had no physical explanation. It seemed unreasonable to be satisfied with any explanation of them that did not have a physical basis; and it seemed a logical conclusion that the establishment of a basis of physical disease mechanism could offer the only hope of remedy. I therefore ignored for the time being my past teachings and ideas of the drug addict, and I looked to the patient himself, questioning him as to his experiences and studying the symptomatology and physical phenomena he presented. In short, I adopted the attitude which must be widely adopted before the medical problem of the clinical handling of drug addiction will be solved—in my attitude towards these cases I became the clinical student and practitioner of internal medicine, treating my patient to the best of my ability as I would a sufferer from any other disease, and studying his case.
Struck by clinical facts which did not accord with past teaching, I tried to seek out from my personal study and observation of the individual case data upon which to form theories which would accord with clinical facts and with verified histories and, if possible, give a basis of help to these unfortunates.
Gradually since then I have gotten together, from my own work and that of others, and with some success attempted to interpret and explain and apply, what seemed to me facts about opiate addiction. To my mind and in my experience these facts offer a beacon-light of hope and assure ultimate rescue to a very large proportion if not most of those suffering from narcotic drug addiction-disease.
It is well to state here that of late some of these facts have secured recognition in medical and lay authoritative announcement and literature. The Preliminary Report of a special investigating committee of the New York State Legislature is quoted from elsewhere in this book, and the report in June, 1919, of a special committee appointed by the Secretary of the Treasury speaks of, “the more or less general acceptance of the old theory that drug addiction is a vice or depraved taste, and not a disease, as held by modern investigators.”
It is on account of “the more or less general acceptance of the old theory” that it is necessary in this place to discuss some of the tenets of that theory for the benefit of those whose interests or emergencies have not led them to investigation of and familiarity with the scientific and other writings on this subject of recent years.
It has been demonstrated to be a fact that description of narcotic drug addiction as “habit,” “vice,” “morbid appetite,” etc., absolutely fails to give any competent conception of its true characteristics, and clinical and physical phenomena. A large majority of opiate users are gravely wronged in a wide-spread opinion still prevalent. This opinion, as previously outlined, is that chronic opiate addiction is a morbid habit; a perverted appetite; a vice; that only he who is mentally or morally defective will allow it to get a hold upon him; and that its main and characterizing manifestations are those of mental, physical and moral degeneration. Opiate addicts are supposed to have irrevocably lost their self-respect, their moral natures and their physical stamina. They are still painted by many, as inevitable liars, full of deceit, and absolutely untrustworthy—people who are supposed to use a dream and delight producing drug for the sensuous enjoyment it gives them, and who do not want to discontinue its use. They are thought of as physical, mental and moral cowards who, after realizing their deplorable condition, refuse to exert “will-power” enough to stop the administration of opiates.
With these views I did my early work on this condition. On these hypotheses, trying to follow current available literature and teaching, I treated my patients for a considerable time with results which superficially interpreted seemed to corroborate both literature and teaching. Many of them managed to get their drugs even while in the institution, and practically all of them left uncured with but an exceedingly small number of possible exceptions.
From my patients themselves, and from watching and studying them, I later learned the truth, which has since been continually strengthened—that the so-called “discomforts” we think of them as suffering upon withdrawal of their drug, are actually unbearable suffering, accompanied by physical manifestations sufficient to prove this to be so. I also learned that the supposed delightful sensations which have formed the background of most pictures painted of them, had in many, if not in most of the cases with which I came in contact, never been experienced. If they had ever existed they had long ago been lost and all that remained in opiate effect was support and balance to organic processes necessary to the continuance of life and economic activity. As I have written, these sensations seem to be, “part of the minor toxic action of the opiate against which the addict is nearly or completely immune and to the securing of which very many and probably a majority of the innocent or accidental addicts have never carried their dosage.” In plain English the sufferer from opiate addiction has, in many if not a majority of cases, never experienced any enjoyment as a result of the drug and has endured indescribable agony in its non-supply.
I do not want to be understood as claiming that opiates will not produce pleasant sensations, nor that they are never used to the end of experiencing these sensations. There is a class of the inherently or otherwise defective or degenerate, who first indulge in opium or its products from a morbid desire for sensuous pleasures, just as they would and do indulge in any form of perversion or gratify any idle curiosity. They are mentally incapable of self-restraint, indulging jaded appetite with new stimuli. They yield themselves to any and all forms of self-indulgence and gratification of appetite. There comes a time when for them opiates, from increasing tolerance and dependence lose power to give pleasurable sensations and become simply a part of their daily sustenance, exacting physical agony as a result of their non-administration. When this occurs they make no effort to control amount or method or use; and overdosage together with conditions incidental to and attendant upon their mode of life soon relieves society of the menace of their membership. As a class they have been regarded as incurable and hopeless—socially, economically and personally unworthy of salvage. To whatever extent this may be true, however, it is not true simply because they happen to have acquired opiate addiction, but because they are fundamentally what they are, diseased, degenerate and defective.
The opiate element is as incidental to their fundamental condition as are the venereal and other diseases from which many if not most of them suffer. Observations and conclusions upon addicts from this type of humanity have been given great prominence in the public press and elsewhere and have had an unwarranted influence in the status of opiate addiction and the conception of and attitude towards the addiction sufferer. Because addicts of this class began to use opium or its derivatives and products to secure sensuous gratification is no reason for stigmatizing the mass of those afflicted with addiction-disease as people of perverted appetites. No one should study addiction in them unless he is possessed of sufficient ability in clinical observation to separate physical signs of opiate addiction from the manifestations of defective mentality—and unless he has enough insight and breadth of vision to see behind end-results, primary causative factors; and unless he has enough common-sense to refrain from applying to the worthy many the observations he has made upon the unworthy few.
It is only fair to state in passing, however, that from my experiences as Visiting Physician in the wards of the Workhouse Hospital, New York Department of Correction, I am convinced that we all too often casually include in the above generally considered derelict class of society, many who under intelligent and humane handling could be restored to or converted into useful citizens.
There are some above this class, of the type of spoiled and idle youth, who indulge first in opiates in a spirit of bravado or curiosity. The tremendous increase in addiction since its spectacular incidental and morbid aspects became so widely published is largely contributed to from this class.
There are some who first used opiates to temporarily boost them over an emergency, post-alcoholic excesses, severe mental strain, etc.
The majority of narcotic addicts, however, and especially those developing previous to the activities of the past few years, present a very different history. Mentally and morally they are of the same average equipment as other people. They form a class which might be called “accidental or innocent” addiction-disease sufferers. They had no voice nor conscious part in the early administration of opiate, realizing no desire or need for it by name, but only wishing for the unknown medicine which relieved their sufferings. Very many addiction patients have received their first knowledge of opiate administration in the withdrawal symptoms which followed the attempted discontinuance of its use. There is in these sufferers no element of lack of will-power; no trace of desire to indulge appetite or to pander to sensuous gratification. In some, before their condition was recognized, their tolerance for or dependence upon opiate had proceeded to a point where their bodies’ demand for morphine was imperative and their withdrawal suffering unendurable. In others, before body need was completely established—with their stamina and nervous resistance below par from sickness and suffering—they have been unable to forego opiate’s supportive and sedative and pain-relieving action, or to endure the nervous and other symptoms attendant upon its withdrawal after even a brief period of administration.
As to what the addict is;—the tendency and effect of legislative, administrative, police and penological activities in general have been to place the sufferer from addiction-disease in the position of the criminal and vicious. The tendency of the psychologist and psychiatrist is to analyze him from the viewpoint of mental weakness, defect or degeneration, and to so classify and regard him. The average practitioner of internal medicine, and even the recognized leaders and authorities in this field of medical science will tell you that narcotic drug addiction is a condition to which they have given but little attention and have no clean-cut ideas of its physical disease problems. The addict himself, whose testimony has been all too little consulted or sought, will tell you that he is sick with some kind of a physical condition which causes suffering and incapacity whenever a sufficient amount of narcotic is not administered.
In the above attitudes and statements the administrative, police and penological authorities are right in some cases;—the psychologists and psychiatrists have good basis for their opinions in some cases;—the addict has physical grounds for his statement in all cases—he is always sick, sick with addiction-disease.
In my experience with and study of narcotic drug addiction and the narcotic drug addict, an experience touching practically every phase of the narcotic situation and giving me opportunity to observe the condition in practically every type of individual, the one constant and more and more strikingly emphasized observation has been constant physical symptomatology and the manifestations of pain and suffering and of fear. I have in my possession histories of addicts taken from all walks of life and from all classes and conditions of men. Some of my histories are of patients who were primarily defective, degenerate, weak or vicious. Some of my histories are of people of high mentality; of high ethical and moral standards; of high economic efficiency and social standing. These histories, stripped of names and possibilities of personal recognition, would form a very instructive collection of material for the man, physician, psychologist, sociologist, legislator or administrator who wishes to study the addict as he really is and to get some conception of the diversity of the problems which he presents.
Neglect of this study and absence of this conception is the chief cause of past failure. We have tended to regard and handle and treat and legislate concerning narcotic addicts simply as narcotic addicts, instead of appreciating that different individuals and different types and classes of people who may suffer from addiction-disease present entirely different problems, and require entirely different handling.
If we are going to consider all narcotic addicts as in one class we can with justice only consider those characteristics which are common to all members of that class. There is just one fact and characteristic that stands out as of striking and paramount importance in every one of my histories—it is the fact of physical suffering upon complete withdrawal of opiate drug, or a supply of that drug which does not meet the requirements of the physical body-need. Whatever or whoever the narcotic addict was before his use of opiate drugs—whatever had been the character and circumstances of the initial administration of narcotic drug—after a time, as I have repeatedly written elsewhere, after addiction-disease has once developed, the history of every opiate addict is that of suffering and of struggle. After addiction-disease is once developed the addict loses whatever euphoric sensation he may possibly have experienced, and all that narcotic administration spells for him is relief from suffering. Without the drug of his addiction he endures intense physical suffering and misery. Without the drug of his addiction he cannot pursue a social, economic, or physically endurable existence. He may have been primarily defective, degenerate, depraved or vicious; his primary administration of the drug may have been deliberate indulgence, disreputable associations, idle curiosity, any combination of conditions which may be stated;—he may have been an upright, honest and intelligent, hard-working, self-supporting, worthy and normal citizen in whom the primary administration of opiate drug was a result of unwise, ignorant or unavoidable medication;—he may have been an ignorant purchaser of advertised patent medicines containing addiction-forming drugs. Whatever his original status, mental, moral, physical or ethical, and whatever the circumstances of his primary indulgence; once addiction-disease has developed in his body the vital fact of his history is the same—subsequent use of opiate drug means not pleasure, not vice, not appetite, not habit—it means relief of physical suffering and the control of physical symptoms.
My present definition of narcotic drug addiction is as follows; a definite physical disease condition, presenting constant and definite physical symptoms and signs, progressing through clean-cut clinical stages of development, explainable by a mechanism of body protection against the action of narcotic toxins, accompanied if unskillfully managed by inhibition of function, autotoxicosis and autotoxemia, its victims displaying in some cases deterioration and psychoses which are not intrinsic to the disease, but are the result of toxemia, and toxicosis, malnutrition, anxiety, fear and suffering.
To express this somewhat differently—a narcotic drug addict is an individual in whose body the continued administration of opiate drugs has established a physical reaction, or condition, or mechanism, or process which manifests itself in the production of definite and constant symptoms and signs and peculiar and characteristic phenomena, appearing inevitably upon the deprivation or material lessening in amount of the narcotic drug, and capable of immediate and complete control only by further administration of the drug of the patient’s addiction.
In plain English, the sufferer from narcotic drug addiction-disease is one who experiences the symptoms and signs referred to above and which will be discussed later, as a result of lack of supply or physically insufficient supply of opiate drug. I know of no definition along any other lines which will include all who suffer from narcotic drug addiction. This symptomatology, and the mechanism or process which produces it, are the only common and characteristic attributes and possession of all opiate addicts.
How these are developed and how they may be controlled and arrested is the demand which the sufferer from narcotic drug addiction, and society as a whole, are making. Until a competent and acceptable answer to this demand is in the general possession of those handling narcotic addiction, all other discussions will remain inconclusive, and all other considerations incidental, for purposes of definite and final solution. This is the medical problem of narcotic drug addiction, and until those who handle narcotic addicts, and those who control the handling of narcotic addicts, have recognized it, are familiar with it, and can to some working measure explain and control its sufferings, physical phenomena and symptoms and signs, they are unprepared to assist intelligently and competently in the solution of a problem which now as never before menaces the welfare of society.
CHAPTER III
THE NATURE OF NARCOTIC DRUG ADDICTION-DISEASE
It is a pertinent question to ask, “What type or class of individuals become narcotic addicts?” The only correct answer unquestionably is, any type or class or individual to whom opiates are given for a sufficiently long time. It has yet to be demonstrated that there is any warm-blooded animal, which following sufficiently prolonged and constant administration of opiate drug, is immune to the development of the symptomatology and constant physical phenomena of addiction-disease.
Color, nationality, social or economic position, age, mental and moral attributes of whatever sort are no bar to the development of the condition. These may influence, of course, the conduct and incidental manifestations of the individual addicted, just as they do in any other condition. The addicted judge, or the addicted physician, or the addicted clergyman, or the addicted man of business or other affairs, or the addicted clerk or industrial worker reacts differently to the sufferings and trials of narcotic drug addiction than does the addict of the underworld, or the heroin “sniffer” of idle and curious adolescence, or the addicted defective, degenerate, or criminal. Also he reacts differently to everything else. What is true of one man who has opiate addiction may be absolutely false of another. One narcotic addict is honest, competent, truthful and intelligent. Another is dishonest, incompetent, untruthful and incapable of appreciation or self-control. Neither the one set of attributes, nor the other, is peculiar to narcotic addicts. They are simply personal attributes possessed by different men and types of men who may or may not be narcotic addicts. If the addict of a higher type displays at times attributes not typical of his preaddicted days, and seems to show a lowering of his mental and ethical tone, it is well to estimate in his case the influences of past worry, fear, suffering, strain and struggle, the attitude of society, medical and lay, towards him, and the manner in which he has been handled, before blaming it all upon the mere presence and effects of narcotic drug addiction, or of narcotic drug. If such changes were inherent in the action of continued narcotic drug medication, they would be found in all addicts, whereas the fact is that they most decidedly are not.
As to age in addicts there is no limit. I have seen an infant newly-born of an addicted mother, displaying the characteristic physical symptoms, signs and phenomena of body-need for opiate a few hours after birth. This case is discussed more in detail in the transcribed testimony of the New York State Legislative Investigation hearings, (Whitney Committee) pages 1524 to 1529, at which I reported it. The infant undoubtedly developed addiction-disease prenatally, reacting in its unborn body against the presence of opiates, supplied through its mother’s blood, exactly, as is now demonstrated through experimental laboratory animals and by clinical study upon adults, this disease is always developed—through physical and constant reaction of the body to the continued presence of opiates, however supplied. There have been many such cases, some of which are matters of medical record. This condition of prenatal development of addiction-disease exists beyond dispute and certainly cannot be explained upon grounds of conscious appetite or deliberate self-indulgence. I am told that there are or until very recently have been old soldiers, veterans of the Civil War, whose addiction dated from medication for wounds received during that struggle. The late Doctor T. D. Crothers told me once that opiate addiction in this country received its first wide dissemination in that way. This points to the serious consideration of what may be an urgent and important medical problem of modern warfare.
This brings us up to the origin of addiction. There is only one actual origin of addiction, and that is the continued administration of an addiction-developing drug sufficiently long to develop the physical manifestations symptomatology, and phenomena and body need for that drug. This statement is the only one which can be made as generally inclusive. I have many records and histories, much correspondence, and other data, collected from addicts, relatives, friends and associates of addicts, physicians, official conferences and workers in the various fields of narcotic endeavor. My material covers an active interest of many years duration, and an experience which has dealt with various types and classes of patients under various conditions. I have held different beliefs at different times, influenced by the demands of my immediate position, and by my best interpretation of my own experience, by the conditions under which I happened to be working and by the class of people coming to my attention under the conditions of my work. At one time I believed that all addicts were defective, irresponsible, degenerated, unreliable and liars, made addicts by curiosity, environment and morbid appetite. At one time I believed that the narcotic addict did not physically need narcotic drug under any circumstances, and that he could get along without it if he only had the will and the desire to do so. I proceeded on that theory for a while in the handling of my cases, and have to thank the illicit supply which is present in all institutions that my mortality was no higher, for it is agreed and on record by many competent authorities that forcible deprivation of opiate drug may at times cause death.
These are examples of a few of the various beliefs and ideas I have held at various times, and upon which I used to generalize, as is the habit and tendency of those who as yet lack experience or breadth of experience. I have in time found many of my beliefs wholly or partly erroneous, or to apply only to selected groups of cases or to incidental phases and aspects of the main problem. They all have their bearings on the general situation, and may be of primary importance in the immediate handling and control of certain phases of it. I have come now to keep my general statements to the solid rock of basic disease and draw on my past experience for the measure and estimation of associated problems and complications as they arise.
The actual origin of addiction is the administration of opiate drugs continuously over a sufficient length of time. The incidental details in their early administration to those who become addicted vary widely. In the origin of some proportion of addicts, we of the medical profession must sooner or later come to recognize and assume our part, unconscious and innocent, but none the less beyond question. What this proportion is is variously estimated by various authorities and statisticians and investigators. It is now beyond dispute that many cases of addiction-disease had their origin in medication during illness, the condition developing unsuspected by either physician or by patient until its physical manifestations had passed the bounds of control.
The old fallacy that an opiate might be administered safely to a sufferer so long as the patient did not know what was being given him is completely disproven by the evidence of addicted infants, and by the excellent and exhaustive laboratory experiments upon addicted animals by such men as Giofreddi, Hirschlaff and more recently Valenti of Italy whose work, published in 1914, should have widest recognition. This fallacy has been responsible for many a case of addiction. Very many opiate addicts have passed into the stage of fully established addiction-disease before they were aware that they had ever taken an opiate.
Clinical familiarity with the symptoms and signs of beginning and developing addiction should be the possession of every physician and surgeon. It would save from the physical sufferings, and mental tortures and fears of narcotic addiction many human beings. It has been my experience when called in as a medical consultant upon medical and surgical cases whose progress towards recovery seems unaccountably tedious and unsatisfactory, to detect as the basis for the lack of function and recuperative power, unsuspected developing opiate addiction in time to prevent its further progress. Unwisely prolonged opiate medication makes more opiate addicts than we have realized.
The addict in whom it is most profitable to study addiction origin and development and handling, if we are to get a clean-cut picture of addiction-disease, is the individual who is primarily normal, mentally, morally and physically, whose addiction condition is a result of ignorant, misguided or unavoidable medication, either professionally or self-administered. Their number is far greater than is yet generally appreciated. Many if not most of them are unsuspected and unknown and they include eminent people in all walks of life. They are social, and economic assets whose interests and welfare we cannot ignore when we are considering the disposition and handling of the narcotic addict.
Many of them have gone from one institution to another, and have attempted, in desperate effort to be cured, each newly-discovered and announced specific or theory of treatment. They have never derived any pleasure from narcotic use. For them the narcotic drug has been only necessary medication to relieve physical suffering and to maintain economic existence and the support of themselves and their families. They should be classed as innocent or accidental addicts—normal and worthy sick people. They earnestly desire treatment and help, and once their addiction process is completely arrested do not tend to return to narcotic drug use. Whatever associations they may have had with the unworthy or unfit of the so-called “underworld” and with illicit and illegitimate traffic has been the result of desperate necessity, in their best judgment, in the obtaining of opiate supply when it has seemed to them to be otherwise denied them, and which was necessary to them for the relief and avoidance of suffering and for the maintaining of a condition making possible self-support and the avoidance of revelation and disgrace.
The narcotic addict of this type presents primarily and fundamentally a purely medical problem. Competent and complete arrest of the physical mechanism of narcotic drug need permanently removes him from the ranks of the narcotic drug user. The problem of his handling is one falling within the province of medical practice. His care is purely and simply a matter of the treatment of disease with medical intelligence and judgment on the established lines of medical practice in disease conditions generally. His after-care is simply such management of convalescence as is needed in ordinary medical cases. The length of his convalescence will depend entirely, just as in other diseases, upon the competency and intelligence of his medical handling and upon his physical condition, reaction, and recuperative ability.
For such a man custodial care and institutional handling under conditions of enforced restraint are undesirable and harmful. His withdrawal from self-supporting citizenship should be for the shortest time commensurate with adequate therapeutic results. He should be restored to normal personal, social, and economic environment and activity at as early a time as possible following his clinical treatment and the arrest of his physical mechanism of addiction-disease. Given intelligent clinical handling, with rational therapeutic treatment, and a comprehensive meeting of the indications of disease in his case, he is no more a subject for unusual restraint and custodial care than is a case of malaria or pneumonia or other medical condition. He is in most cases a clinically curable medical case. He presents the true picture of addiction-disease uncomplicated by the distracting and confusing incidentals often met with in the types of cases more commonly discussed. The development of addiction in a case of this type is a purely physical matter, and is the addiction which should be considered in the fundamental comprehension of basic facts.
Stages of Addiction Development
Every case of well-developed addiction has followed in its development a course through several stages, definitely marked by clinical signs and reaction phenomena. I shall not exhaustively discuss all of these stages and their phenomena. The ones I shall mention will be recognized by most of those who have gone through them or have watched them develop.
1. Stage of Normal Reaction to Therapeutic and Toxic Doses.
The manifestations of this state in morphine administration for example are more fully described in our text-books of materia medica than I can take space for in this book, and are familiar to all physicians. The narcotic and analgesic effect with therapeutic doses; the euphoric and inhibitory action of doses in excess of the therapeutic; the toxic action manifested by the slowed pulse, slowed respiration, and generally arrested metabolism and function are too familiar to need elaboration.
2. Stage of Increased Tolerance.
Following continuous and consecutive administration of morphine (and the same is true of other opiates) comes failure to secure the effect which followed the early administration. Larger doses are needed for the relief of pain or other symptoms, or the original doses give relief for a shorter time. Toxic manifestations do not follow what would formerly have been a toxic dose. The patient requires what was formerly a toxic dose to secure the former therapeutic effect. The phenomena of this stage are familiar to every observing clinician who has used or seen morphine used for continued therapeutic action. The patient has acquired an increased tolerance of the drug and a beginning immunity to its toxic action. He does not, however, suffer appreciable hardship from drug deprivation. Discontinuance of the drug causes little or none of the symptoms to be described as “withdrawal signs.”
3. Stage of Beginning Addiction.
Following the stage of increased tolerance comes a stage where discontinuance or lack of administration of the narcotic drug gives definite signs and symptoms, beginning “withdrawal signs,” due to some beginning physical body demand for the drug and completely relievable only by its administration. These signs are identical with the first appearing withdrawal signs in a case of established addiction but as yet do not go beyond the beginning manifestations of “withdrawal” in a completely developed addiction. They are limited to a peculiar nervousness, restlessness, weakness, depression, etc. They persist for a few days only if the drug is denied and are endurable.
As to length of time required for the passage through each of these previous stages or through both of them—dogmatic statement is impossible. The time is apparently influenced by a number of factors. Of course the varying inherent resistance or susceptibility of different individuals to any given disease condition must be considered in this disease. It varies also with different forms of opiates used and their modes of administration. The probable physical factors I am not yet ready to discuss. The recent Report of the Special Committee of the Treasury Department says, “Any one repeatedly taking a narcotic drug over a period of 30 days, in the case of a very susceptible individual for 10 days, is in grave danger of becoming an addict.” Certainly a physician should look for the signs and symptoms of tolerance and beginning addiction throughout his opiate administration. It is also well to exhaustively inquire into possible past history of unrecognized addiction in any of its three general stages. Some of those patients who have demonstrated an apparent unusual susceptibility and very rapid development will be found on careful analysis to have experienced an unrecognized or forgotten addiction in some stage of development. I have interesting data on this point.
4. Stage of Established Addiction.
In this stage the “withdrawal” symptoms and signs become more evident as results of opiate deprivation. They proceed through the mild discomfort and nervousness of the previous stage to the definite manifestations and constant unmistakable withdrawal phenomena to be described. The patient endures physical suffering and displays all the clinical evidence of it. There can be no question of will-power in this stage, nor of desire for narcotic drug for any other purpose than to escape physical suffering. Whether the patient was primarily an innocent and unconscious recipient of the drug, or of the class of the vicious and weak, he is now fundamentally a sick man, afflicted with a physical disease. Whether or not he ever experienced any euphoria or sensuous enjoyment, he now gets nothing of pleasure from narcotic administration. He gets, simply, relief from suffering. The opiate drug has become his only immediate means of securing and maintaining a physical efficiency, a semblance of normality. No other drug will take its place. He can take tremendous doses without toxic effect. In this stage, if the drug is denied or withdrawn without competent handling, his suffering and incompetency is not, as in the previous stage, a matter of days but may persist for weeks or months after no narcotic has been administered.
The general stages of addiction-disease development as above rather superficially outlined are not of course sharply marked in their transitions. They slowly merge one into the next and taken together constitute a gradual development from normal reaction to opiate to established addiction-disease.
Most patients are in or nearing the stage of developed addiction when they are recognized or come for treatment. Developed addiction for narcotic drug means physical, bodily need for that drug; functional incompetency and suffering without that drug; comparative normality and efficiency only to be immediately secured and maintained by the continued use of that drug.
This is the situation of the sufferer from addiction-disease until such time as the activity of his addiction-disease mechanism is arrested.
Before I attempt exposition of the mechanism which seems to me best to explain addiction-disease and offer a basis for its rational handling, I shall offer several observations bearing upon physical or body reaction in the state of addiction.
1. Experience of addicts and observations upon them show that the length of time over which an addiction sufferer is free from his “withdrawal” manifestations is in proportion to the amount he has recently taken. Under conditions eliminating various factors, outside of the addiction mechanism, which may influence this general rule, the ratio between the amount of recent dosage and the interval of freedom is almost mathematical. For example, if under given conditions one grain of morphine will keep an addict free from withdrawal manifestations for four hours, two grains will do this for nearly eight hours and three will have the same effect for about eleven hours. It would almost seem as if there were some substance produced in definite amount in each individual case at a given time, and neutralized or opposed by or in some way negatived in its action by a definite amount of opiate drug.
2. Each addict shows a definite and approximately measurable daily minimum need for the drug of his addiction. If he is suffering from the deprivation of his drug, he will require a certain dose, measurable by its effect upon his symptomatology, before he is made physically comfortable and physically efficient again.
3. The narcotic drug administered to an addict suffering withdrawal phenomena and symptomatology will relieve those manifestations exactly in proportion to the amounts of drug administered. Each addict has a constant sequence of symptoms attending the so-called “dying-out” of the drug. These symptoms are relieved in constant reverse sequence by the administration of the drug, and in exact proportion to the amount of drug administered, various incidental influences being eliminated. A small amount of the opiate will relieve the symptoms last appearing; another insufficient amount will relieve another proportion of the withdrawal signs, and so on, until the opiate drug administered balances in amount the extent of the addict’s deprivation, or physical need.
This is almost mathematical in its working, and the average intelligent addict, after a few trials, can tell within a very close margin just how much opiate, in his accustomed form, has been administered by the extent to which it relieves his withdrawal signs. It almost seems as if the narcotic drug acted as some sort of an antidote for some poison present in definite amounts in the addict’s body.
CHAPTER IV
THE MECHANISM OF NARCOTIC DRUG ADDICTION-DISEASE
I have in previous chapters referred to what are known as “withdrawal signs.” By this term has come to be known the manifestations displayed by a sufferer from addiction-disease at such times as his opiate is taken away or “withdrawn,” either totally or in part to such an extent that its amount does not meet the requirements of his physical needs.
In observing opiate addicts over a length of time no one can escape the recognition of a chain of constantly present physical manifestations inevitably following the non-administration of the drug of addiction. These may vary in priority of onset, in sequence, and in relative violence of manifestation in different cases, but they are the inevitable result of non-administration of opiate to an opiate addict. I described them as follows in a paper on “Narcotic Addiction—A Systemic Disease Condition,” which was published in the Journal of the American Medical Association, February 8, 1913. “In a general way they may be said to begin with a vague uneasiness and restlessness and sense of depression; followed by yawning, sneezing, excessive mucous secretion, sweating, nausea, uncontrolled vomiting and purging, twitching and jerking, intense cramps and pains, abdominal distress, marked circulatory and cardiac insufficiency and irregularity, pulse going from extremes of slowness to extremes of rapidity with loss of tone, facies drawn and haggard, pallor deepening to greyness, exhaustion, collapse, and in some cases death.”
These manifestations have been noted in various ways and to various extents and have been casually commented upon by most writers of the past. The conception of drug addiction as a “habit” has, however, in the past so overwhelmingly dominated the attitude of writers both medical and lay, that consideration of withdrawal signs as physical phenomena, and the analysis of their origin and mechanism on the basis of physical disease and constant body reaction has received all too little attention. The tendency has been to casually regard or belittle them as a part of the essential picture of narcotic addiction, and to place overwhelming emphasis upon mental desire as an explanation of the drug addict’s inability to discontinue the administration of opiate drugs. That these physical manifestations have had such incidental place and consideration in the general handling of the narcotic addict and in the consideration of the drug problem is to my mind the basic cause for past failure. Non-appreciation of them unquestionably explains in part the almost uniform lack of success which attended my own earliest efforts.
One of the obstacles to an appreciation of narcotic drug addiction-disease has been the casual assumption on the part of the average person, both lay and scientific, that opiate drugs act upon the addict, and that he reacts to them similarly to the actions and reactions in the non-addicted individual. Morphine action, however, as commonly observed following therapeutic administration or in experimentation upon un-addicted animals gives no conception of its manifestations in the man or woman grown tolerant to its use. Many of the actions and reactions of opiate upon the un-addicted are practically lost in the addicted, and absolutely new reactions, unfound in the un-addicted individual, become the dominating factors in the opiate medication of the addict.
To some extent the fallacies connected with the general conception of narcotic addiction have arisen from the mistaken application to addicts of opiate experience, experimental or otherwise, of the non-addicted. In the matter of sensations, for example, supposed to follow opiate administration, and to the enjoyment of which is widely attributed the addict’s indulgence—in practically none of the opiate addicts, once tolerance and organic dependence are completely established, do these sensations occur. The immediate effect of opiate to the addict, depending upon the extent of tolerance, and the reaction of the patient, in dosage not too much in excess of physical body need, is apparently support to function, the restoration or maintaining of normal circulation and nerve and glandular balance, prevention or relief of the agonizing withdrawal pains and manifestations and of impending collapse.
Opiate is used by the large majority of opiate addicts simply and solely for its supportive action, and a certain amount for each addict becomes as much of a definite need and a necessary and integral part of his daily sustenance as food or air. The dream states and other sensuous results, occasionally observed, are when they occur as part of the minor toxic action of the drug, against which the developed addict is nearly or completely immune, and to the experiencing of which very few of the honest, innocent or accidental addicts have ever carried their dosage. They are commonly found only in the opium pipe smokers, an entirely different problem from that of the average narcotic addict.
As has been stated, it is a fact that for each addict, a definite amount, varying with his condition of health, elimination, physical and mental activity, etc., meets a definite body-need. On this amount he can be put and kept in good physical and mental condition under normal circumstances of environment, exertion, and general hygiene. Years of efficient activity and upright responsible lives, accomplished by well-known men and women, unsuspected addicts, bear witness to this fact. An addict neither underdosed nor overdosed practically defies detection. Less than the definite amount required for nervous and glandular and circulatory support and organic balance deprives the patient of reaction, places his vitality and energy far below par and for a long time hinders his betterment. More than this amount displays the inhibitory effects of opiates, locks up or slows secretions and body functions, and causes malnutrition, autotoxemia, autotoxicosis, and the consequent mental and physical deterioration commonly and erroneously attributed to the direct action of opiate drug.
In 1912 I wrote that so far as I knew the symptomatology attending insufficient supply of morphine (or other opiate) to an opiate addict had never received the amount of detailed study and analysis that it deserved and was not adequately interpreted. W. Marme had attributed the symptoms of morphine addiction to the toxic action of oxydimorphine. Rudolph Kobert, however, stated that Ludwig Toth subjected Marme’s claims to subsequent testing and was unable to confirm them, and that his own findings agreed with those of Toth. They found that oxydimorphine was inert by subcutaneous injection and that when thrown into the blood-stream it formed an insoluble substance causing emboli, and so producing the symptoms observed by Marme. Kobert seems to be in accord with the early findings of Magendie, that oxydimorphine is non-toxic. The experiments of Faust on dogs concerning increased power of the body to destroy morphine are well-known. It is still a matter of scientific dispute as to what extent the body of the opiate addict has developed the power to limit or destroy the poisonous properties of opiates by the conversion of these poisons through oxidation or other chemical action.
The explanation of tolerance and withdrawal phenomena on the basis of something akin to an antitoxin or antitoxic substance circulating in the blood of the addict, has also, like the oxidation explanation, been a subject of controversy. Hirschlaff claimed to have produced an antitoxic serum against morphine. Morgenroth failed to confirm Hirschlaff’s findings, and argued against the existence of an antitoxin. The animal experimental and laboratory work and findings, however, of such men as Hirschlaff, Giofreddi and Valenti have helped to influence the trend of modern thought towards what may be regarded as the present strong tendency in scientific conception of the physical mechanism of narcotic drug addiction-disease—an autogenous antidotal or antitoxic substance.
A recent paper by DuMez of the United States Public Health Service gives a comprehensive review of the work which has been done in connection with the study of increased tolerance and withdrawal phenomena, and shows conclusively the gradual inclination of modern opinion.
There is considerable literature discussing various theories and experiments and observations, which has, however, not had widespread recognition.