The narcotic drug problem

by Ernest S. Bishop

Most physicians have at some time or other in the course of their practice encountered cases of narcotic addiction. Most addicts have appealed to the physician for advice and help. A very large proportion of them have at different times made effort to obtain relief from their affliction through the avenues of various forms of treatment, advertised and otherwise. Most physicians have at some time or other made effort to rescue some victim from drug addiction, and as a rule have given over the effort as hopeless, because even when they had succeeded in taking his narcotic away from the patient, usually after an experience trying and exhausting to both, the patient has resumed narcotic administration—according to the patient, because he had to—according to the average observer, because he wanted to. Frequently the patient has refused to persevere to the end of treatment and has abandoned his attempts before the treatment has reached the point of cessation of opiate medication—the patient stating that he could not—the observer believing that he would not, continue, and did not have the courage or stamina or will to endure the necessary suffering. The medical profession as a whole has adopted a cynical attitude towards the possibility of permanent “cure,” and towards the efficacy of medical treatment, which has tended to send the addict to quacks and charlatans and various advertised remedies.

It is not my purpose to discuss in this book in detail the various methods, and treatments and cures advocated and employed in the handling of the drug addict. This alone would require a volume in itself.

Three broad lines of procedure have been employed; so-called “slow-reduction,” “sudden withdrawal,” and withdrawal accompanied by the administration of various drugs, such as those in the belladonna group and its alkaloids.

Slow reduction or “gradual reduction” as a “method” is employed by slowly or gradually, reducing the patient’s accustomed dosage to the point of discontinuance of opiate medication. Interpreted by a great many to mean that the fact of reduction is the principal indication in clinical procedure, successful in the hands of a few who have acquired unusual technical skill and clinical ability in the interpretation of addiction manifestations, I believe it to have failed as a method of cure in the hands of the average. Practically every addict has attempted it one or more times. As a method of procedure in some stages and under some conditions of addiction treatment, slow or gradual reduction of dosage has its value. In my opinion, however, all other considerations aside, there are very few who are possessed of sufficient understanding of narcotic addiction and ability in the interpretation of clinical indications, and have the technical skill required to carry it through to a clinically successful culmination. As a method of routine or forcible application it has many serious objections as well as potentialities for damage to the patient. In cases whose opiate intake is in excess of actual physical-need, gradual reduction as often practiced is perfectly easy and unnecessarily slow down to the amount demanded as a minimum by the patient’s addiction-disease requirements. Then must come withdrawal, nagging, exhausting and protracted, if unskillful reduction is persisted in, and the wrench of actual final withdrawal is nearly as severe from a very small dosage as from a moderate one, other conditions in the case, physical and mental, being equal. Prolonged “withdrawal” without rare technical skill and without unusual and not commonly available environment and conditions of life, means subjecting the patient to the continued strain of persistent self-denial and self-control in the face of continued suffering, discomfort, and physical need and constant desire for their relief. It is my opinion that this experience has in many cases tended to deeply impress upon the mind of the patient so-called “craving” for the drug, and has converted many a case of simple physical addiction-disease into a more or less mental state which may be described as “morphinomania” or “narcomania.”

This last observation does not apply to the method of gradual reduction only, but is equally true of protracted suffering under any other procedure in which the individual is cognizant of the existence of means of immediate if only temporary relief.

In the comprehension of this a physician has only to glance back over his professional experience and recall cases of various conditions other than addiction which have come to him, and whose histories present the effect of long protracted suffering and discomfort in the conversion of an average normal, self-supporting human being into a dependent neurasthenic.

The histories given by most narcotic addicts of their efforts to get relieved of addiction, show that following the withdrawal of opiate drug in many if not most instances has come weeks and months of weakness, and discomfort, nervousness, sleeplessness, and pain which have persisted for weeks and months, establishing the basis for the much emphasized “after care,” of some investigators.

While so-called “after care” is unquestionably as important as convalescence from any other disease, it is my belief that as understanding of addiction as a clinical disease becomes more general, and more attention is paid to the study and scientific management of the disease itself, the stage of “after care” will come to assume less importance. Addiction is not the only disease which furnishes examples of cases in which incomplete and unsatisfactory results have been merely a low-grade continuation of the fundamental disease and have been interpreted as a protracted convalescence.

“After care,” or convalescence, following satisfactory results of clinical treatment and complete arrest of addiction-mechanism activity has no terrors for either physician or patient. It is very short and does not require any more restraint than any other convalescence, unless conditions exist following active treatment which should have been recognized and handled and eliminated earlier from the picture. I shall discuss this again later.

“Sudden” or “forcible” withdrawal, or immediate deprivation of opiate drug is still advocated by some investigators, fewer and fewer of them, however, among medical men. There are cases of, and stages in addiction-disease and its development where this means of procedure may be pursued without all of the serious objections with which it must be regarded as a routine method of general enforcement.