The narcotic drug problem

by Ernest S. Bishop

In caring for the narcotic addict, therefore, one of the most important therapeutic measures is the regulation of the interval of his narcotic drug administration. I have repeatedly experimented upon addicts who were not confined or under restraint in any way. I explained to them the inhibitory effects of too frequent dosage and instructed them to use the amount of drug they found necessary for twenty-four hours in larger doses at longer intervals. This procedure alone, in many cases transforms the pallid, starved, constipated and deteriorated addict within a surprisingly short time into a well-nourished, well-reactive and practically normally functioning individual. With the return of health, vitality, and normal nutrition and elimination, his body requires still less drug and he voluntarily and without mental struggle and nervous strain reduces the amount of drug used. I wish to emphasize that in these experimental cases there were no other therapeutic measures employed in the way of medication.

The practical therapeutic application of wide-interval administration of opiate drug is made possible by the fact that the narcotic addict can tolerate without harm large doses of the drug of addiction. It is made controllable by the fact, that, within certain limits, the length of time over which a dose of narcotic drug will maintain a patient in narcotic drug balance—or free from the symptomatology of drug need—is in mathematical ratio to the size of the dose administered. Each addict requires, under the conditions of his daily life at a given time, to satisfy the demands of his physical addiction-disease mechanism, and to maintain him in narcotic drug balance, an amount of drug which can be estimated in terms of twenty-four hours and which I have called the amount of minimum daily need. The most important consideration in the administration of narcotic drug to a narcotic addict is to supply the amount of minimum daily need and maintain narcotic drug balance with the least inhibition of function.

Failure to maintain narcotic drug balance and a degree below the amount of minimum daily need renders the addict functionally and physically incompetent. He is in a condition of physical and nerve incapacity and exhaustion. He has no physical tone; he has markedly impaired circulation; he cannot react, he has no recuperative powers; he has constantly in his body, according to modern theory, unneutralized autogenous poison which robs him of vitality, reaction and functional efficiency even though it may not be present in sufficient amounts to give rise to the violent spectacular and agonizing manifestations of complete narcotic deprivation. In other words, as I have written elsewhere, “the reduction of the drug of addiction below the amount of body-need robs the addict of his most valuable asset in securing and maintaining recuperative powers.” In no other disease would an intelligent physician persist in the application of measures which robbed his patient of recuperative powers and expect satisfactory issue of the case he was trying to treat. Until the physician and patient are ready and prepared for the institution of the stage of final withdrawal of drug, the patient should never be allowed to drop below the amount of minimum daily need in his opiate intake.

It is evident therefore, that upon the intelligent and competent estimation, measure and control of physical narcotic drug balance and inhibition of function depend the reaction, well being and therapeutic progress of the man who has narcotic drug addiction-disease. These factors also markedly influence the action of all medication, including the drug of addiction, upon the body of the opiate addict. They influence the reaction of the addict’s body to all medication. Medication cannot be intelligently administered to the opiate addict unless those who administer it have understanding and clinical appreciation of the widely varying reaction of the addict under different conditions of drug balance and inhibition of function. Failure to recognize and appreciate this fact explains a considerable portion of the past failures and the past mortality attending specific and special methods and treatments, and so-called “cures.” The dosage of medication administered and the time of its administration should therefore be determined upon with watchful eye to the reaction of the patient, and with intelligent comprehension of the possibilities in reactionary change.

The actions and the dosage of therapeutic agents have been largely determined by experimentation on individuals and animals of average normal reaction. The toxic, the inhibited and the narcotic addicted do not display the normal reaction to therapeutic agents. Under some conditions they over-react both physically and nervously, and under other conditions they under-react. Detailed consideration of this matter is not possible in this book. It offers for investigation a field well worthy of exploration both clinical and laboratory. It will only state that as the manifestations and influences of toxemia, functional exhaustion, inhibition, and, in the addicted, of varying physical drug balance, have become increasingly definite and tangible and capable of clinical measure and determination, my medication of the toxic and the exhausted and the inhibited individual, as well as of the narcotic addicted, has become progressively more effective. These observations apply to conditions other than opiate drug addiction, and are worthy of consideration in all toxic, and exhaustion and depression states.

I have already spoken of the imperative physical need for the drug of addiction. I have also referred to the amount of minimum daily need for the drug of addiction. The recognition of factors which influence these is of great importance. Many of these factors are so commonplace and so obvious in their relation to the extent of body need that they are appreciated by most intelligent addicts. Anything which increases the expenditure of physical and nervous energy increases the addict’s need for opiate drug. Among the most potent influences are worry, fear and physical suffering. They consume physical fuel; and an important part of the addict’s physical fuel is the drug of his addiction. In addition to this, worry and fear and suffering are also markedly inhibitory of glandular and peristaltic function. The expenditure of energy in mental and muscular work also calls for increased supply of the drug of addiction. I need not enlarge upon this important fact. Its application to the handling and treatment of the addict is evident. Narcotic drug should be supplied to meet the physical needs of the individual case, and only be decreased as intelligent handling of the factors which determine that need have lessened it.

The method of gradual reduction of dose to the point of ultimate discontinuance is practical and feasible under conditions and at an expense of time and money which are possible to but very few addicts. The forcible reduction of dose without regard to the environmental, mental, economic, physical or other conditions of the average and individual addict, and absolutely ignoring the considerations of the mechanism and symptomatology of his addiction-disease is barbarous, harmful and futile. Enforced reduction of dose below the point of body need is not worth what it costs in nerve-strain, suffering, and physical inadequacy. The extent of addiction-disease and the degree of progress in its remedy cannot be measured in terms of amount of drug administered. It must be measured in terms of clinical symptomatology, just as progress is measured in any other disease. Reduction of dose below the amount of body need, prior to the stage of final withdrawal, constitutes a serious therapeutic handicap and is most decidedly contra-indicated. Withdrawal of opiate from an addict whose physical reaction and strength and nerve force have been reduced and depleted by continued reduction of amount of drug without commensurate reduction in the extent of body need is harder than withdrawal from a reactive individual with reserve nerve and physical force who may be taking a much larger dose.

The average addict must support himself and his family. His physical well-being and economic efficiency should be considerations in the welfare of the community in which he lives. Legislative and other investigation has shown that we are entirely unequipped both institutionally and professionally for the successful immediate withdrawal of opiate from even a small proportion of our present census of the opiate addicted. In view therefore, of the practical impossibility of immediate successful withdrawal treatment, and in view of what is known and can be demonstrated and taught in the accomplishment of final withdrawal, I do not hesitate to state that, until we are prepared and in a position to skillfully and competently handle the stage of final withdrawal to assured successful issue, it is much wiser to supply to the addict who is not a public menace the drug of his addiction to the extent of his physical needs, and to teach him how to use the drug of addiction in such a way as will maintain his physical and economic efficiency, than it is by enforced reduction of dose to deprive him for a long time of working ability and his family of his support. Furthermore, the addict who is insufficiently supplied with the opiate of his addiction, turns in desperation to the use of things far more harmful to him than the drug of his addiction. This he does in the vain hope of obtaining mental and nervous and physical stimulus and support and some surcease of his misery. The many wrecks of addicts to be seen trying through insufficient supply of narcotic drug, self-poisoned with other drugs which they have purchased, alcohol, bromides, coal tar products, cocaine, and of late hyoscine—their addiction disease unrelieved and undiminished—are sufficient argument against mere reduction of dose, below physical body need.

The personal attitude of the physician towards opiate addicted patients is of great importance. The medical man who is to treat a case suffering from addiction-disease successfully to the end of relieving this condition, or who is treating addiction-disease as an intercurrent condition complicating another disease, must first of all make his patient realize that the physician himself knows something about addiction as a disease. He must never give his patient any hint or reason to suspect that he regards opiate addiction as a habit, a vice, a degrading indulgence which can be to any curative or even therapeutic extent, combatted by the exercise of will-power.

In their desperation and ignorance, the vast majority of addicts have repeatedly exercised will-power in self-denial of their drug to the limits of their physical endurance, and they know the futility and suffering of attempts based simply and solely upon the exercise of will-power. Experience has taught them actual facts concerning the physical action of narcotic drugs and concerning the results of insufficient supply of narcotic drug in a man who is addicted. The addict knows that he does not take a drug because he enjoys it. He knows that he experiences no sensuous gratification or other pleasure from its administration. He knows that he uses a narcotic drug simply and solely because he has to use it to escape physical incompetence and physical agony. As I said before, almost without exception the narcotic addict has proceeded of his own accord, or under the direction and advice of others, on the theory of exercising will power, and resisting temptation. With the few exceptions of those made in a very early stage and before addiction mechanism had become strongly developed and rooted in his physical processes, such efforts on the basis of this theory have been useless.