The narcotic drug problem

by Ernest S. Bishop

That forcible deprivation of opiate drug may end in death is a matter of too easily found and authoritative medical record to be ignored. It has been discussed as one of the possibilities by medical writers over many years. Even the newspaper reports of deaths and suicides following sudden deprivation of opiate should be sufficient to give pause to those who would still advocate this measure as a desirable procedure.

Reference to the previous enumerations of the physical manifestations of body-need for opiate, or “withdrawal signs,” should be sufficient for the comprehension of its tortures and easily explains the suicides which have attended sudden deprivation. Any one who has watched a well-developed case of addiction-disease in the agonies of opiate deprivation should hesitate to prolong them if possibly avoidable. While under some conditions, and in some cases, it may be argued that “the ends will justify any means,” as a routine procedure of wide application, it must be stated that both in its immediate torment and in its end results, mere forcible sudden withdrawal is not a procedure of election. Some of its supporters still cling to and quote the old fallacy that after seventy-two hours without opiate a narcotic addict no longer physically requires it. This fallacy is probably based upon the estimated maximum time of opiate elimination in normal human beings and experimental animals. It is most decidedly false doctrine as applied to the well-developed case of addiction-disease in whom the mechanism of disease, and not the mere administration or elimination of opiate has become what should be the dominating consideration.

As stated before, the mere withdrawal of opiate drug does not arrest the activity of addiction-disease, nor prevent the endurance of the exhausting and incapacitating and protracted low-grade manifestations before referred to. Its potentialities of permanent damage, moreover, are attested by and displayed by many who show for years shattered nerves, premature old age, etc.

It is perhaps wise to state again in this place that in this book the consideration of narcotic or opiate addiction, its mechanism symptomatology and handling, is not to be applied to cocaine and alcohol use nor to the various other drugs often loosely grouped with opiates as “habit-forming.” Until a distinct physical disease mechanism, attended by analogous characteristic and constant physical phenomena, can be demonstrated as resulting from the action of one of these drugs or substances, its continued use should not be classed with opiate addiction-disease.

The third general method of procedure is that in which effort is made to utilize other drugs than opiates, or other measures than mere reduction or withdrawal or deprivation to secure cessation of opiate medication. The efforts have been, in a general plan, either to oppose or replace the action of opiate by substance or substances seemingly to have physiologically antagonistic or substitution properties—or to combat, offset or benumb the sufferings of what is described as the “withdrawal period.” Such agents have been employed in this disease for very many years, and in their variety include most of the known analgesic, sedative, antispasmodic, hypnotic or anesthetic agents and measures.

Prominent among the drugs mentioned have been the preparations and alkaloids of belladonna, of hyoscyamus, pilocarpine, and some others. These drugs have by reason of more or less supposed specific action, alone, or in various combinations or in conjunction with purgatives, etc., formed the basis for many if not most of the various special treatments and “cures.” For example, what is described as the “specific mixture” of one of the most widely-known treatments contains as its active agents belladonna and hyoscyamus. These drugs are not mentioned here in condemnation of their employment as therapeutic measures in the hands of those skilled in the estimation of their values, indications and actions—and dangers if unskillfully employed. They have unquestioned therapeutic value in their proper places, as and when properly indicated, in individual cases. Routinely used, as specific curative agents, they seem to me to be demonstrating their failure. In the conception of addiction-disease herein outlined it is difficult to attribute to them specific properties.

In a paper, “The Rational Handling of the Narcotic Addict” read before the Section on Pharmacology and Therapeutics, Annual Session of the American Medical Association, 1916, I stated, “It is not my purpose to enter into discussion of the various therapeutic methods and therapeutic measures which have been advocated and employed in the treatment of narcotic addiction. Their number is legion, and they include most of the therapies known to lay as well as to medical literature.

“Their multitude is conclusive proof of lack of conception and of understanding of addiction-disease in the past. They have been directed towards incidental and complicating manifestations. They have no more place in the treatment of the addict than they have in the treatment of any other disease condition. I know of no medication that can be called ‘specific’ in the arrest of the mechanism of narcotic drug addiction-disease. There is no more of a specific remedy for narcotic drug addiction than there is for typhoid or pneumonia. The wide advertisement of treatments based on supposed ‘specific’ action of the products of the belladonna and hyoscyamus and similar groups is unfortunate. They have in my opinion, no action as curative agents in narcotic drug addiction-disease which can entitle them to consideration as specific or special curative remedies. The drugs of this group are useful in many cases, intelligently applied to meet therapeutic indications. They exhibit wide variation of action and reaction in narcotic drug addicts at different clinical stages and under different clinical conditions, and their dosage presents an extremely wide range of individual measure. They are dangerous drugs in the hands of the inexpert or careless, or used in a routine manner or dosage. The status which they have acquired as specific medication in narcotic addiction disease I hold to be a medical fallacy which should be strongly opposed and early remedied.”

The search for panaceas, specifics and routine treatments has constituted a stage in the therapeutic history of most disease conditions. It marks the effort to make wide and general application of a partial comprehension of facts and imperfect recognition of fundamentals and is successful only as an individual case is occasionally capable of responding, perhaps by clinical accident, to the specific routine employed.

Undue insistence and publicity secured for or given to a procedure of this description, is a real obstacle to the development of clinical and scientific understanding of the condition treated. It distracts attention from broad clinical consideration of disease itself, from scientific investigation into pathology and disease mechanism, from determination and observation of fundamental facts, whose comprehension and analysis form the essential factor in the widespread successful handling of any condition, and from proper conception and appreciation of the addiction patient and the addiction problem as a whole with its many and varied aspects.