The narcotic drug problem

by Ernest S. Bishop

Very many, if not most, internists and practitioners view with gravest concern the presence of addiction in a serious illness coming under their care.

That the addict has borne this undeserved reputation as a poor surgical and medical risk, and that this reputation has been seemingly merited by previous medical and surgical experience, is not to be laid at the door of the existence of addiction in the patient. It is to be laid at the door of insufficient medical comprehension of addiction-disease and its mechanism in its material manifestations, and in its functional and organic influences, and at the door of inadequate clinical study into the analysis, estimation and control of these. Like much else that has been for generations generally accepted as true about narcotic drug addiction, the belief is erroneous that the addict is a poor surgical and medical risk because he is an addict.

As a surgeon once stated “These addicts have no resistance, and they go right out.” Swayed by the old conception of addiction, this more than ordinarily humane and generous-hearted man had not the slightest suspicion as to why the addicts that he had operated upon had displayed no resistance and had tended to “go right out.” He had in his mind simply the then prevailing and practically unquestioned conception of the narcotic addict, and he had not the slightest suspicion that a definite physical disease, whose mechanism should have received intelligent clinical handling and control was complicating the surgical cases of the addicts who went right out. He had based, as all of us once did, his opiate medication on his materia medica conception of therapeutic dosage instead of on the demands of an addiction-disease mechanism. It is rumored that more than one illustrious life, full of past accomplishment and potential future benefit to humanity and society, has ended in this way.

The above statements do not apply to surgery alone. They are equally true of medical conditions. Dominated by their teachings as to opiate dosage in ordinary therapeutics, and by the older “habit” conception of addiction, with little or no instruction as to the dosage indications of addiction-disease, most practitioners, institutional and private, do not adequately conceive and have no basis for determination of opiate dosage in this disease. They do not believe that the addict physically needs nor do many of them realize that the addict can physically tolerate what seems to them such dangerous and lethal amounts, and they tend to ascribe his statements of usual dosage to mental “cravings” to which they refuse to pander. Many appreciate that such patients have often to be very carefully watched to prevent their suicide and that many of them die, but fail to comprehend that these events may be ascribed to inability to longer endure the suffering and physical incompetency of body-need for opiate medication.

The recent epidemic of influenza and pneumonia furnishes examples of the importance of recognizing addiction-disease mechanism in intercurrent diseases. A number of instances have come to my attention. One of them is of particular interest because of the graphic picture presented by a series of sphygmographic tracings showing the physical organic dependence upon opiate in the circulation of an addict. It may be said in passing that these tracings and others made upon addicts in partial or complete opiate withdrawal parallel similar tracings by other clinical observers, and also those made by experimental laboratory workers upon addicted dogs.

The subject of these tracings was a man well-known and prominent in his community, 63 years of age, suffering from pneumonia with marked and persisting cardiac and circulatory deficiency which did not respond to the administration of the usual circulatory stimulants even in very large doses. I was called in consultation. Found the patient very weak and exhausted, with facial expression of protracted suffering and anxiety and despondency. Morphine in usual therapeutic doses had been daily administered for relief of pain, restlessness and sleeplessness, being insufficient however to control those manifestations. Pulse was, as shown in tracing number 1, very weak and intermittent. It was impossible to account for the whole clinical picture and history on the grounds of a typical pneumonia, present or resolving. Opiate addiction was suspected and the patient questioned. He had been suffering from opiate addiction-disease for many years, his addiction developing unsuspected by him as a result of medication for a painful and protracted condition many years previous. He begged to be allowed to die without his wife and son being told of his affliction. The following tracings made upon him are very instructive and significant, and cannot be interpreted upon any grounds of psychical explanation of addiction phenomena.

The last dose of morphine prior to these tracings was one-eighth of a grain given at 3:30 P. M.

(Chart of Sphygmographic Tracings)

First tracing (number 1) was made about 6:00 P. M.