The narcotic drug problem

by Ernest S. Bishop

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known the manifestations displayed by a sufferer from addiction-disease at such times as his opiate is taken away or “withdrawn,” either totally or in part to such an extent that its amount does not meet the requirements of his physical needs.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.