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 In this stage, if the drug is denied or withdrawn without competent handling, his suffering and incompetency is not, as in the previous stage, a matter of days but may persist for weeks or months after no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.