The history of the Opium Commission appointed by Mr. Taft is sufficient to show how any less comprehensive regulation would act. When Mr. Taft was Governor-General of the Philippines, he found that an enormous quantity of opium was being smoked by the natives and the large Chinese settlement, of whom it was estimated that fifty-five thousand were smokers. He appointed a commission headed by Bishop Brent, now stationed at Manila, who has since headed two international opium conferences, at Shanghai in 1909 and at The Hague in 1911. Mr. Taft sent the commission into the most important opium-producing countries to find out how they were dealing with the problem and what progress was being made toward decreasing the use of the drug. The nearest approach they found to a reform was the method of the Japanese in their newly acquired island of Formosa. Japan, with the most stringent regulation of the sale of opium in the world, had made it a government monopoly in Formosa, had compelled the registration of all smokers, and was gradually lessening the amount which each smoker could buy. After the exhaustive report of the commission, our Government adopted the same tactics in the Philippines. To the surprise of the officials, they found that out of the fifty-five thousand opium-smokers they could obtain a registration of only from ten to twelve thousand, which meant that the great majority were getting smuggled opium. By special act of Congress the authorities at Manila were allowed to stop the importation of opium entirely. But this, while it meant a great loss of revenue to the local government, apparently did not lessen the amount smoked. After the sale was stopped, there were virtually no voluntary applications for opium treatment, as there must have been if anybody’s supply had been cut off, which conclusively showed that nobody had discontinued the habit merely because importation had been discontinued. Stopping importation, then, is a farce, unless at the same time there is rigid governmental control in those countries that produce or import the drug. And, therefore, unless there should be a coöperation of all governments, it is futile to try to regulate the traffic. As long as people can get opium, they will smuggle it.
It has been demonstrated to be quite practicable for all the opium-producing countries to make the drug a government monopoly; it would be equally practicable for them to sell directly to those governments that use it for governmental distribution. The only obstacle to an international understanding is that the producing countries know very well that government regulation would materially lessen the sale of the drug. Within the borders of our own country such a system would simplify rather than complicate present conditions. We have to-day along our frontier and in our ports inspectors trying to stop the illicit traffic in opium, and the money thus spent by our Government would be more than sufficient to handle and distribute all of the drug that is needed for legitimate purposes. Any druggist could of course continue to buy all that he wished, but he would have to account for what he bought. The drug would serve only its legitimate purpose, because the druggist could sell it only on prescription. This would at once eliminate the gravest feature of the case, the indiscriminate sale of proprietary and patent medicines containing small quantities of opium. The physician would thus have to shoulder the entire responsibility for the use of any habit-forming drug. With the Government as the first distributor and the physician as the last, the whole condition of affairs would assume a brighter aspect, for it would be a simple matter to get from the physician a proper accounting for what he had dispensed. Thus the new crop of users would be small, and less than ten per cent. of the opium at present brought into this country would be sufficient to meet every legitimate need.
THE HABIT-FORMING DRUGS
The important habit-forming drugs are opium, cocaine, and the small, but dangerous, group of hypnotics. These last—trional, veronal, sulphonal, medinal, etc.—are chiefly coal-tar products, and are not always classified as habit-forming drugs, but they are such, and there are many reasons why the sale of them should be scrupulously regulated. The opium derivatives go under the general head of narcotics. Morphine is the chief active principle, and codeine and heroin are the chief derivatives of morphine. Codeine is one eighth the strength of morphine; heroin is three times as strong as morphine.
Though the general impression is otherwise, the users of heroin acquire the habit as quickly and as easily as if they took morphine. Many cough and asthma preparations contain heroin, simply for temporary alleviation, since, like opium, it has no curative power whatever. From time to time I have had to treat cases of heroin-taking in which the victims had thought to satisfy their need for an opiate without forming a habit. In the cases where it was given by prescription, it was so given by the physician in the sincere belief that it would not create a habit. All this despite the fact that heroin is three times stronger than morphine, and despite the fact that physicians know that anything which will do the work of an opiate is an opiate. Codeine, notwithstanding the fact that it is weaker than morphine, is likewise habit-forming; yet doctors prescribe it on account of its relative mildness, even though they know that it is the cumulative effect of continued doses, and not the quantity of morphine in the dose, which results in habit. As with morphine, to use either of these drugs effectively means in the long run the necessary increase of the dose up to the limit of physical tolerance.
The most harmful of all habit-forming drugs is cocaine. Nothing so quickly undermines its victim or provides so short a cut to the insane asylum. It differs from opium in two important ways. A man does not acquire a habit from cocaine in the sense that it is virtually impossible for him to leave it off without medical treatment. He can do so, although he rarely does. On withdrawal, he experiences only an intense and horrible depression, together with a physical languor which results in a sleepiness that cannot be shaken off. Opium withdrawal, on the other hand, results in sleeplessness and extreme nervous and physical disorder. In action, too, cocaine is exactly the opposite of opium, for cocaine is an extreme stimulant. Its stimulus wears off quickly and leaves a corresponding depression, but it confers half an hour of capability of intense effort. That is why bicycle-riders, prize-fighters, and race-horses are often doctored, or “doped,” with cocaine. When cocaine gives out, its victim invariably resorts to alcohol for stimulus; alcoholics, however, when deprived of alcohol, generally drift into the use of morphine.
The widespread use of cocaine in the comparatively short period of time since its discovery has been brought about among laymen entirely by patent-medicine preparations containing small quantities of it. These have been chiefly the so-called catarrh cures, which of course cure nothing. With only a two or four per cent. solution, they have created a craving, and in the end those who could do so have procured either stronger solutions or the plain crystal. As with the other drugs, in order to maintain the desired result the dose must be increased in proportion as tolerance increases. Wherever the sale of patent medicines has been restricted to those presenting a physician’s prescription, the consumption of cocaine has at once been lessened. A man cannot afford to get a physician’s prescription for a patent medicine; and even if he could, the reputable physician refuses to prescribe one that contains cocaine. When an overseer in the South will deliberately put cocaine into the rations of his negro laborers in order to get more work out of them to meet a sudden emergency, it is time to have some policy of accounting for the sale of a drug like cocaine.
It is also extremely important to regulate the sale of the hypnotic coal-tar derivatives. All the group of hypnotics should be buyable only on a physician’s prescription. They all disturb heart action and impoverish the blood, thereby producing neurotics. No physician, without making a careful examination, will assume the responsibility of prescribing for a man who comes to him in pain, yet a druggist does so constantly. He knows nothing of the customer’s idiosyncrasy; that, for instance, an amount of veronal which would not ordinarily affect a child may create an intense nervous disorder in a particular type of adult. To the average druggist a headache is only a headache; he does not know that what will alleviate one kind of headache is exceedingly bad for another kind, and furthermore it is not his business to warn the customer that a particular means of headache alleviation may perhaps make him a nervous wreck. The patient usually has the same ignorance. In a case which was once brought to my attention, a girl swallowed nine headache powders within one hour. Had there been ten minutes’ delay in summoning a doctor, she would have died; as it was, she was seriously ill for a long time.
These, then, the narcotics, cocaine, and the hypnotics, are the chief habit-forming drugs. They form habits because it is necessary to increase the dose in order to continue to derive the apparent benefit obtained from them in the beginning, and because, when once the habit is set up, it cannot be terminated without such acute discomfort that virtually no one is ever cured without medical help. In drug addictions the condition of the patient is not mental, as is generally supposed, but physical. Definite medical treatment to remove the effects of the drug itself is imperative, whether the victim be suffering from the drug habit alone or from that habit in a body otherwise physically disordered. With regard to the cure of the habit, as in the case of the conditions which permit of its being acquired, it may justly be said that the victims have been unfairly treated.