The narcotic drug problem

by Ernest S. Bishop

It is practically impossible to argue successfully on the basis of theory with the man who has experienced facts. Narcotic addiction furnishes a class of patients who know more about their own disease than any other class of people. They can accurately estimate the extent of understanding and knowledge possessed by the man who is treating them, and they are desperately critical. Almost without exception, except for some of the true “underworld,” they desire above all else to escape from their condition. I know that this is not the popular conception and for the present may be by some regarded as heresy. Therefore, it is of essential importance that between the doctor who treats an addict of average intelligence and that addict must exist co-operation and understanding. As soon as this patient realizes two things—that the doctor does not believe his expressed wish to be cured, and that he interprets the patient’s desire for relief from suffering as simply a desire for more opiate and the expression of habit, vice or degraded appetite which should be controlled by the exercise of “will-power,”—there is an end to that patient’s confidence in that doctor, and to the help that that doctor can give to that patient. As I have written elsewhere, the opiate addict of average intelligence will co-operate with his medical adviser to the extent of his physical endurance, so long as he has any belief in that adviser’s understanding of his condition, and ability to help him.

In my own work, and as a result of my own experience I have found that as a rule the extent to which an intelligent addiction patient cooperates with me has been a measure of the understanding and technical ability with which I handled him, rather than a measure of his desire to be helped. It is held by many that a majority of addiction-patients are not possessed of average intelligence and are not honest in their statements. I will simply say that even in the Alcoholic and Prison Wards of Bellevue and in the narcotic wards of the New York Workhouse Hospital I came more and more to seek in faults of medical and nursing handling the explanation of apparent lack of cooperation. In the Annual Report of the New York Department of Correction for 1915, in commenting upon the work of the narcotic wards, is stated, “In ratio as there has been at any given time among our interne and nursing staff comprehension and understanding of the manifestations and underlying principles of narcotic drug addiction-disease and of its rational handling in the individual case, our results have been good or bad.”

Several years ago I wrote as follows: “As to the existing opinion that the morphinist does not want to be cured and that while under treatment he cannot be trusted and will not cooperate but will secretly secure and use his drug, I can only quote from personal experience with these cases. During my early attempts, my patients, beginning with the best intentions in the world, often tried to beg, steal or get in any possible way, the drug of their addiction. Like others I placed the blame upon their supposed weakness of will and lack of determination to get rid of their malady. Later I realized the fact that the blame rested entirely upon the shoulders of my medical inefficiency and my lack of understanding and ability to observe and interpret my patient’s condition. The morphinist as a rule will cooperate and will suffer to the limit of his endurance. Demanding cooperation of a case of morphinism during and following incompetent withdrawal of the drug is much like asking a man to cooperate for an indefinite period in his own torture. There is a limit to every one’s power of endurance of suffering.”

Of primary importance, then, if a physician, institutional or practitioner, is to have any success in handling a case of opiate addiction-disease, is his attitude towards his patient—divesting himself of all conception of habit, appetite or vice as explanation of characteristic physical manifestations and symptomatology, and approaching the patient as a man with a definite disease requiring and deserving intelligent clinical handling. The patient will be the very first to mark a physician’s shortcomings. If he has not confidence in the doctor’s ability and understanding of his illness the doctor can help him but little. This statement applies not to addiction-disease alone but to every medical condition.

There are three clinical demonstrable elements to be determined, measured and controlled in the actual therapeutic handling of cases of narcotic addiction-disease. The first of these is the actual amount of drug which the patient’s body demands to maintain functional and organic efficiency and to escape physical distress. The second of these is the extent of auto- and intestinal-intoxication, autotoxicosis and malnutrition. The third of these, which is both a result of and a causative element in the other two, is the extent of inhibition of function.

In the successful handling of a case of addiction-disease, therefore, the first effort should be to determine approximately the amount of the patient’s minimum daily physical need for the drug of his addiction. This need is clinically recognizable and definitely measurable. It should be met to whatever extent it is present so long as it exists, and dosage diminished only as competent treatment diminishes the extent of need. This physical need can be demonstrated and accurately measured by clean-cut symptomatology. It can be expressed in mathematical terms of amounts of drug required in twenty-four hours. Work, worry, strain—anything which consumes physical or nervous energy increases this need. If this physical need is not met the patient is robbed of physical tone and physical reaction. He is robbed of metabolic balance and functional competency. He is, in short, robbed of the basic ability which his body has to regain health.

In the estimation of this amount of physical need the procedure is very simple. Have administered to the patient who is manifesting the symptomatology of drug-need, sufficient drug to remove the symptoms and restore him to complete physical, functional and nerve balance. Have the length of time observed which elapses before the symptoms of drug need reappear. Have this repeated several times and information is secured as to what quantity of opiate under the existing conditions will hold that patient in drug-balance for a known length of time. In this way can be mathematically estimated the extent of physical drug-need. The average need for twenty-four hours can be easily computed from the data obtained. It is merely a matter of arithmetic.

The regulation of dosage can also be estimated with approximate accuracy. As has been stated before, the interval of freedom from withdrawal manifestations is found to be, in a general way and within certain limits, in ratio to the size of the dosage. For example, if in a given case, under given conditions of fear, worry, physical or nervous strain, pain, etc., as discussed elsewhere—one grain of morphine will last a given patient at a given time for four hours; under the same conditions two grains will last for approximately eight hours. There are limits to the application of this rule. It is stated as the general operating of an addiction-disease phenomenon which is useful as a therapeutic guide.

The amount of actual physical body need as capable of approximate estimation in the above manner should be administered to the patient, any reduction being guided by the fact that his clinical symptomatology and physical manifestations demonstrate that the amount required by his addiction-disease has been reduced. It is much wiser for the progress of the average addiction case to have the drug administered in the amount of estimated physical need than it is to attempt to reduce the amount of drug before his reactions show reduction in physical drug-need. The success of outcome and the measure of progress in such a case is not to be estimated by the amount of drug the patient is receiving, but is to be measured by the patient’s condition and clinical manifestations. The mere fact that a physician has reduced a narcotic addict’s opiate intake from a large dosage to a very small dosage, or indeed has denied him any opiate at all for a considerable length of time, is no evidence that he is curing or has cured his patient of addiction-disease. Unless the physical mechanism of body-need for an opiate has been completely and actually quieted, the patient may have in his body for perhaps weeks and months after the last administration of the drug, a physical demand for it. The taking of opiate does not constitute opiate addiction-disease. Also the mere fact that an addict is no longer taking opiate does not constitute proof that he is “cured” of opiate addiction. The non-recognition of this fact lies at the root of much past failure. The general axiomatic statement might be that an addict should be supplied with the drug of his addiction to the complete extent of his physical need at any given time until conditions are right for the undertaking of assuredly competent opiate withdrawal and complete arrest of his addiction-disease mechanism.

The mere amount of drug used by a patient in twenty-four hours is a matter of minor importance compared with the general health, physical tone, nervous glandular and functional balance, reaction and resistance of that patient. Also the amount of drug taken by a patient in twenty-four hours is absolutely no adequate measure of the strength or stage of development of his addiction-disease. If he does not get enough opiate he cannot competently functionate; he cannot be adequately nourished; he cannot sufficiently eliminate. He is subjected to the influences of constant discomfort and nerve strain in the endurance of low-grade withdrawal manifestations. He is worried and becoming exhausted. It becomes apparent that by continued maintenance of narcotic administration below the amount of physical body-drug-need the very factors are created which have been described as increasing body-drug-need. It is difficult to see any therapeutic advantage in such a situation. Moreover, as has been stated before, it is far easier to eradicate completely and successfully narcotic drug need in a short time and without marked discomfort, from a functionally competent and organically healthy man who is taking a physically sufficient amount, than it is from a nerve-racked, worried and physically, nervously, and functionally exhausted wreck who is under-dosed.