The narcotic drug problem

by Ernest S. Bishop

Some factor or element of great and fundamental importance has obviously been neglected. This lacking element is general recognition of the presence of disease processes which cause the symptomatology and phenomena of body-need for opiate drug. One of the essentials for the practical solution and management of the narcotic drug problem is the realization by the medical profession, legislators, administrators and laity that opiate drug addiction is a definite disease entity, to be treated as such, and calling for extensive clinical and laboratory investigation and study such as have been accorded other diseases over which we have gained the mastery. One of the most needed achievements in the line of practical remedy is the admission of narcotic drug addiction-disease to its legitimate place as an accepted part of the practice of internal medicine and the stimulating of education concerning it among medical practitioners, medical students and nurses.

As was stated in the last chapter, too much emphasis has been placed on drug use and drug withdrawal, as if the drug itself were the most important element in the clinical picture of addiction. In the handling and treatment of addiction-disease it should be constantly borne in mind that the ultimate withdrawal of opiate from the addict is simply one stage, and not by any means the most important consideration in his rational handling. Its management in most cases is a matter of scientific clinical certainty and satisfactory accomplishment by the physician who understands the disease he is treating and who is clinically proficient in the control of its elements by indicated therapeutic procedure. The ease of handling the stage of final withdrawal, the extent to which suffering, nervous strain and exhaustion can be avoided in it, and its final issue depend greatly upon the physical and reactive condition of the man from whom drug is withdrawn. Like the stage of crisis in pneumonia, its course and conduct and results are largely influenced by the condition in which the patient approaches the withdrawal. It is of vastly more importance to measure and control reactions and treat a patient so as to get him into the fittest possible condition for final withdrawal and rapid convalescence, than it is to focus attention on the mere reduction or withdrawal of drug, or on the mere amount of drug used. Final withdrawal of drug, like an operation of election, is to be done when the patient is in the fittest condition and ready for it. With the addict who is well nourished, non-inhibited, and physically and glandularly reactive, it can be accomplished with little or no discomfort, in a very short time, leaving practically nothing to demand a protracted and difficult stage of convalescence or of so-called “after care.”

It becomes evident, therefore, that the handling of an opiate addict, preliminary to withdrawal of the drug to which he is addicted is of greatest importance. The ease of withdrawal and rapidity and completeness of subsequent recuperation, is largely commensurate with the extent of organic dependence upon the drug and the physical condition of the patient. One man using the same amount as another is dependent upon its effects for the support of his organic processes to a much greater extent. The evident solution lies in a preliminary stage, removing inhibition, reducing in so far as possible organic and functional dependence upon drug, and putting the patient into the best possible reactive condition. I believe that in many cases it is imperative for successful issue to train the patient for the shock and strain of opiate withdrawal and in practically all other cases, though less imperative, most desirable.

It has been objected that this will prolong treatment. My experience has been that it very much facilitates withdrawal treatment, and not only renders it easier and more uniformly successful and complete, but that it tends to shorten and make less troublesome, and in some cases practically eliminates, convalescence.

I have therefore instituted as an important part of my procedure, a Preliminary Stage of study and handling and treatment of my patient before attempting withdrawal of the drug. During this time I study my patient, regarding him not simply as a narcotic addict but as a sick man to be investigated as carefully as a cardiac or any other patient, and all his organic and functional conditions appreciated, and all of his functional and glandular actions estimated in their competency and balance and their reactions both to the drug of addiction and to the influences of addiction disease mechanism. Conditions long masked by opiates, and forgotten, even by the patient himself, may seriously affect treatment, convalescence and prognosis if undetected before withdrawal is instituted. Their relations to and possible influence upon addiction and its treatment, and fully as important—the possible effect of treatment and withdrawal of drug upon them, should be very carefully estimated. If advisable or possible they should be remedied before withdrawal of the drug of addiction.

Also such mental or psychical disturbances as may exist in a given case should be traced to their origin, estimated and reckoned with. Very often they will be found to be not inherent but a result of past suffering and present worry and fear. The patient’s confidence in his physician’s ability to treat the disease from which he suffers should be strengthened, and his doubts and fears allayed. Addiction patients are well informed concerning opiates and are acquainted with the manifestations of addiction-disease, and have had experience with or full information concerning the various methods of cure. They are, like any other chronic sick person, suspiciously and keenly analytic of themselves and of the physician, and unless handled with appreciation of their condition are naturally the prey of constant worry and fear. Co-operation and confidence between patient and physician vastly influence the amount of nervous energy expended by both, and in this, as in other diseases are big factors in treatment and in convalescence.

Another advantage of a preliminary stage is one which has been too little considered, but which will before long come to demand the same intelligent attention and measure as is given to the contemplation of operations in and treatment for chronic other conditions. It is this—in what condition will withdrawal of opiate even though skillfully conducted and successfully accomplished, leave the individual in his value to himself, and to his family and to the community, in view of co-existing physical conditions? Withdrawal of opiate drug has been in not a few cases the cause of transforming of a capable and useful citizen into an invalid incompetent, for whose ultimate salvation and competent physical and mental function and organic and glandular control resumption of opiate medication was determined to be a therapeutic necessity.

Such considerations as this should be all taken, analyzed and estimated in a preliminary stage and if treatment is only going to injure a patient he should be instructed how to handle his addiction, and advised to continue his opiate medication, and not be subjected to useless expense and trials.

Basic Principles of Addiction-disease Handling

Intelligent addicts well know that, other factors being equal, the less number of times in a day they take their drug, the less inhibited, the less constipated and more normal they are, and the smaller amount of narcotic drug they require to maintain them physically and mentally competent. It is unfortunate that this therapeutic principle so widely recognized among intelligent addicts has not received full recognition and therapeutic employment by all of those who handle and treat addiction-disease. Its probable explanation is very simple—apparently a period of inhibition follows the administration of narcotic or opiate drugs; and the length of this period is not in ratio to the size of the dose administered. Consequently, the fewer number of times in a day a dose of narcotic drug is administered, the greater amount of competent metabolism is present—the more adequate is the patient’s elimination and nutrition—the smaller amount of opiate or its product lies stored in inhibited and atonic cells, and the smaller amount of antidotal substance is manufactured for the protection of the body, and to some extent, the smaller amount of opiate is required.