The narcotic drug problem

by Ernest S. Bishop

It is therefore much wiser to direct immediate efforts to the securing and maintaining of health, reaction and tone—irrespective of the amount of drug required—until there is time and opportunity for the undertaking of competent withdrawal—a stage of handling and treatment concerning whose physical and clinical phenomena and manifestations and dangers too few are educated to and familiar with.

In regulating the administration of drug as to size and intervals of dosage—amounts should be sufficient to allow the patient long intervals between doses. In the determination of this, it is necessary to study and experiment with the reactions in the individual case. The effort, however, should be to have the drug administered the smallest possible number of times in the twenty-four hours compatible with the patient’s well-being. For example—if a given patient’s daily need is three grains a day, it is much wiser to administer this amount of drug in doses of one grain three times a day or a grain and a half twice a day as soon as practicable, than it is to have it administered in larger numbers of smaller doses at more frequent intervals. The reason is, that, apparently after a dose of narcotic drug is administered function is inhibited for a length of time which is not in proportion to the size of the dose administered. On the other hand, as has been stated, within limits, the length of time over which a dose of narcotic drug will hold a patient in drug balance and free from the physical manifestations of drug need is in proportion to the size of the dose. Therefore large doses at wide intervals permit greatest freedom from functional inhibition and as well, if not better, supply the demands of physical drug need.

I have briefly referred to the elements of intestinal and autointoxication and autotoxicosis. Intestinal and autointoxication, combined with worry, fear, and anxiety, constitute very important causative and controlling factors in whatever mental and physical deterioration has taken place in a case of narcotic-drug-addiction-disease. Physical, mental and moral deterioration are to a very small extent direct results of narcotic drug action per se. As long as a narcotic drug addict is maintained non-toxic, uninhibited and unworried, he is practically at his individual normal, plus an added physical need. It should not be necessary to recall to memory many cases of upright, honorable and competent and apparently healthy men and women who have been narcotic addicts over very many years, unknown to but very few or none of their relatives or friends or even physicians. As has been stated before, their apparent immunity to the supposed stigmata of narcotic drug action was not due to the fact that they were on a higher mental or moral plane than their less fortunate fellows, or that they were possessed of sufficient will-power to resist temptation in the over-indulgence of their so-called appetite. The facts are that by experience they found out that if they used narcotic drug in amounts indicated by the manifestations of their disease, and did not take it too often and kept their bowels open and did not worry, they were as normal as anybody else except for the fact that they had to take a dose of a certain medicine two or three times a day. In other words they simply learned to manage their disease in a way to avoid complications. They met their issue squarely; they discounted theory and recognized facts, and they used common sense in the interpretation and application of what they learned.

The control of auto and intestinal intoxication in narcotic addiction is as a rule of easy accomplishment if the patient is uninhibited and in functional balance and is not over-supplied or under-supplied with the drug of his addiction. The narcotic addict who is non-toxic and in drug balance and is not harassed by worry or fear needs practically no more drastic methods of elimination than his non-addicted brother. If he is over-dosed his elimination is inhibited; if he is under-dosed his eliminative powers are not capable of response. The element in the securing of evacuation of the bowel in a drug case, as well as in a toxic case of whatever description, is sluggish peristalsis; in other words, it is inhibition of nervous impulse. It is therefore not necessary to load a bowel up with large amounts of drastic and irritating cathartics. Indeed this procedure is very harmful and abortive of ultimate results. An over-irritated intestinal tract is not a good eliminative organ. To my mind the so-called “typical stool,” of the so-called “Towns Treatment” with its content of jelly mucus has no clinical significance other than its evidence of a production of an exhaustive and irritative mucous colitis and means that however much purging may be accomplished competent elimination from the colon is at an end. Its appearance in a case under my care I should regard as evidence of injudicious treatment. For the bowel elimination of a case of narcotic-addiction there is needed practically nothing beyond the ordinary mild and non-irritating catharsis. All that is needed is to remember that if inhibition of peristalsis has not as yet been overcome, you may be wise to administer, about the time you should get an evacuation, strychnine or other peristaltic stimulators in sufficient amounts to overcome existing inhibition and stimulate peristalsis.

Inhibition of function, as I have already shown, is a basic factor in the development and maintaining of the narcotic addiction-disease state. It is of great importance to recognize, estimate and control its presence and influence. Inhibition of function is due to nervous exhaustion from overwork, fear, anxiety and suffering; it follows for a few hours the administration of opiate drugs; it is a constant result of chronic constipation and of intestinal and auto-toxemia. The rationale of its control is evident from the enumeration of its causes. Until its causative factors have been removed or controlled, its manifestations must be treated symptomatically—remembering always that for therapeutic action in an inhibited individual dosage of medicinal agents varies, and must be estimated from clinical observation and experiment and not from memory of the text-books. To the man experienced in their use some of the internal secretory glandular products are at times helpful. As has been stated above, strychnine or other peristaltic stimulator is useful.

Finally I repeat again my disbelief in and opposition to the use of any drug or combination of drugs under the impression that they have or may have specific curative action against addiction-disease. Although I at times employ various of the drugs commonly mentioned in connection with the treatment of addiction, I do so with no belief that they have “specific” properties in this disease. I use them in the treatment of addiction as I do in other disease conditions, simply and solely as they meet individual clinical and therapeutic indications. Petty took this stand years ago. I do not regard these drugs as curative of addiction-disease, and I do not constantly use any of them.

I do not use or endorse, a “belladonna” treatment, a “hyoscine” treatment, nor any other description of specific or routine treatment in addiction-disease. I regard the drugs of the belladonna and hyoscyamus groups, pilocarpine, etc., as extremely dangerous drugs to be routinely or carelessly used in the treatment of addiction-disease. They are rendered safe only after personal experience and study into their action and appreciation of the factors and influences which control their action in the functional, toxic, and narcotic drug conditions. The routine and unintelligent use of the products of these groups of drugs in the treatment of narcotic addiction—under the mistaken impression that they somehow or other have direct curative action upon the disease condition—has been the cause of a considerable mortality and an easily understood opposition among intelligent addicts. Hyoscine or scopolamine and the other members of this group, ezerine, pilocarpine, the coal tar products, etc., are at times useful drugs to meet indications in the treatment of a case of addiction. Increasing intelligence in the handling of the addiction mechanism itself, however, renders the necessity of their use less and less frequent and the dosage of them required for therapeutic action smaller and smaller. They should simply be classed as of use among other things, peristaltic and circulatory stimulation and support, indicated eliminants, kindness and consideration, understanding and intelligence or any of the other therapeutic weapons in our possession.

Elimination and the securing of it in the narcotic addicted has been referred to in this chapter. The chapter should not be closed however, without a word of warning against the excessive purgation with drastic and over irritating agents employed by some in this condition. Drastic purgation is not at all synonymous with competent elimination. Competent elimination is not to be measured in terms of bowel-movements; but in terms of clinical symptomatology of toxemia, circulation and measure of functional efficiency. Excessive purgation means over-irritation and over-stimulation of eliminative mechanism, results in the interference with and exhaustion of function and defeats true elimination.

Presence of good circulatory tone and absence of congestion in the eliminative organs is to me one of the most important factors in true elimination. The addict who is in good functional tone, has competent circulation, is in narcotic drug balance, and is noninhibited, needs no more drastic eliminative measures than belong to ordinary rational therapeutics in the nonaddicted.

As to final withdrawal of the drug, and ultimate arrest of the disease, I shall say but little in this book.