What characteristic action exists in opiate or narcotic drugs which gives them this power to establish the above described mechanism? It seems to me that it is, above all, their power to inhibit body function. They tend markedly to arrest metabolic processes. They inhibit glandular activity. They inhibit unstriped muscle activity and hence peristalsis. They, therefore, cause a slowing up of glandular function and intestinal activity, and of elimination. This results in an accumulation of opiate in the body. It is this constant accumulation to which the body must become tolerant by the development of some mechanism for its protection.
Autointoxication and Autotoxicosis
It is to the element of inhibition of function also that we must look for explanation of what is by far the most important element in the immediate picture presented by most individual cases. I refer to autotoxicosis and to auto- and intestinal toxemia. The same power that locks up within the body the opiate drug, locks up the toxic products of tissue activity and tissue waste, of intestinal poisons and of insufficient metabolism. Autotoxemia itself is markedly inhibitory in its action, and contributes no little to its own increase and to the further development of narcotic disease.
It is not at all impossible that any inhibiting poison constantly present in the body will some day be found to establish a mechanism of protection, similar to that of opiate addiction, and that some of the states now popularly and loosely classified under the general head of “autointoxications” will be recognized as really addiction-states, in which the body has become progressively tolerant of its own poisons. I believe that it can be demonstrated that some of the phenomena and manifestations at times observed in chronically inhibited and autotoxic individuals in whom there can be no suspicion of any opiate or narcotic element are analogous to the phenomena of narcotic addiction mechanism. It is not inconceivable that any inhibiting poison or toxin is capable of producing its own addiction-mechanism, and it has seemed to me that my own clinical familiarity with the action and reaction of narcotic, inhibiting, or addiction-forming drugs and of addiction-mechanism upon circulation, glandular and intestinal and other function has been of no little assistance in the interpretation, control and remedy of other chronic intoxications.
Upon the extent of inhibition of function and autointoxication, therefore, depend some of the immediately predominating manifestations in individual cases. They must be reckoned with and eliminated in the measure of addiction-disease in the individual sufferer. In many cases they contribute the immediate and compelling indications for rational therapeutic endeavor. To a considerable extent they determine circulatory efficiency and metabolic and glandular activity and balance. They largely control physical tone and physical reaction. Inhibition and intestinal and autotoxemia cause most of the physical and mental deterioration, and much of the incidental symptomatology so widely ascribed directly to narcotic drug effect. Upon the extent of their presence, therefore, depends greatly the clinical picture in the individual case. This doubtless accounts for the acidosis, noted by Jennings and others, inasmuch as it has been definitely proved that acidosis is commonly present in all conditions of functional depression and exhaustion.
With inhibition and auto and other toxemia eliminated or reduced to a minimum, the patient can go through many years, an apparent normal man, well-nourished, reactive, in good physical tone, mentally sane and physically competent. Under these conditions he shows practically nothing abnormal as long as he gets properly administered, his accustomed narcotic drug, in the amount of its minimum physical requirement or body-need. His condition is often unsuspected by those nearest and dearest to him, and the popularly held opinion that narcotic addiction shortens life does not seem to be upheld by the facts in his case. Such cases as his are far more numerous than has as yet been realized.
In the types of narcotic addicts most widely recognized inhibition of function and autointoxication is marked, and the opiate drug is used in excess of body-need. The addict of this description becomes a deteriorated wreck, requiring high doses of opiate for the satisfaction of abnormal body-need, mentally and physically incompetent—the generally accepted picture of the so-called “dope-fiend,” a deteriorated, degenerated, malnourished wretch, degraded, avoided and condemned.
Inhibition of function and autointoxication should not be vague terms. They cause and are measurable by definite clinical evidence. They display manifest phenomena and symptoms, and become increasingly defined material entities as the clinician looks for them as such. Much of inhibition of function and autointoxication and of their manifestations, has been recognized and taught under their own heading and in connection with conditions other than narcotic drug addiction-disease. That the influence and importance of inhibition of function and autointoxication in the development, and manifestations of the narcotic drug addict has escaped general and widespread recognition, is evidence of the small amount of unbiased clinical study, and of analytical clinical interpretation of material physical phenomena, hitherto accorded to narcotic drug cases.
I would not have it concluded that all symptoms and manifestations arising in the handling of a drug addict are due to the factors and elements I have discussed in this chapter. It must be always in the mind of the intelligent and conscientious physician, that he has in his care a human being with the same medical and psychical possibilities that must be taken into careful and complete account, as in the handling of any other sick person. There is an unfortunate tendency to overlook concurrent, or complicating or pre-existing conditions in the handling of the narcotic drug addict. These cases are often extremely complex and difficult to analyze, and for adequate comprehension and handling of them, the symptoms and manifestations they show should be appreciated in their true origin and character as they occur in each individual case.