The narcotic drug problem

by Ernest S. Bishop

Appreciation of the above would make available to narcotic addicts, suffering from other conditions, hospital and professional treatment and remedy of those conditions. Under present prevailing conceptions of addiction, many honest and worthy people addicted to opiates dare not avail themselves of needed treatment for medical conditions or operation for surgical conditions because of their uncertainty regarding the attitude towards and handling of addiction-disease existing in and carried out by the institution or practitioner to whom they would ordinarily appeal for help. The addict lives in constant fear of some injury or illness which may necessitate his coming into the hands of those whose conception of addiction is not in accord with the addict’s experience of addiction-disease facts.

As I have emphasized in previous chapters, the actual withdrawing of opiate from an addict is simply one stage, and by no means the most important stage in the rational consideration and handling of a case of narcotic drug addiction. The fact that a patient is using an opiate drug, and that he uses, within reasonable limits, a larger or smaller amount of that drug, is a matter of very minor importance as compared with his general functional, nutritional, and metabolic efficiency. This is true as a general proposition in the handling of any case of narcotic drug addiction, and is vastly more true in the handling of cases of other conditions or diseases, operative or otherwise, that are complicated by narcotic drug addiction-disease. The physician or surgeon should realize that the use of a narcotic drug by a patient under his care is of very little immediate importance compared with the satisfactory recovery of his patient from the condition for which he is treating him. The physician or the surgeon who has in his care a narcotic drug addict whom he is treating for another disease condition should remember that the patient’s recovery from the condition for which the doctor was consulted, depends to a great extent upon the amount of functional balance and organic and metabolic adequacy which exists in that patient, and he should realize that functional balance and organic and metabolic adequacy in a narcotic addict are largely under the control of, and vary with the extent to which that patient is kept in, adequate narcotic drug balance.

The establishing and maintaining of adequate drug balance, therefore, is one of the most important elements to be considered in the conduct of a case of narcotic addiction undergoing operation or treatment for a condition other than the cure of his addiction. In handling such a patient, the physician or surgeon should completely put out of his mind any idea of at the same time trying to “cure” the addiction with which his patient is afflicted. I have repeatedly heard of many, and have personally come into contact with cases where the physician or surgeon was trying to withdraw opiate drug from a patient with addiction-disease, as an incidental in the course of treatment of other disease conditions. There are cases of addiction-disease in which this may be successfully accomplished. In the majority of cases, however, this procedure is too harmful to be anything but condemned. Not only will the surgeon or physician ordinarily fail in his attempt to remedy the addiction condition, but he may very severely handicap his other work on that patient and very seriously jeopardize the success of his efforts in the remedy of the condition which he was originally called upon to treat.

It must be remembered that addiction-disease is a chronic condition, and that it is practically never indicated as a matter of clinical emergency, in a case of established addiction, that the opiate be immediately withdrawn. As has been previously stated, drug withdrawal is very much like an operation of election to be done when the patient is ready for it and by whatever procedure is indicated when the proper time arrives. The getting of the patient ready for it often determines, just as is the case in the operation of election, to a great measure, the success of the work and the freedom from complications and sequelae.

Since the final withdrawal of drug is to be regarded as comparable to an operation of election, and the best time for its execution is a matter of arrangement and of preceding preparation, it is obvious that it should not be undertaken with expectation of satisfactory issue in the course of treatment for an ailment or condition which demands and expends much physical resistance and recuperative powers. Recuperative forces should be maintained and directed towards whatever is the indication of paramount importance at any given time. In the conduct of a surgical case or a serious medical case, the indication of paramount importance is recovery from the condition for which the patient applies to the surgeon or physician. All other conditions present should be handled in such a way as to interfere as little as possible with the successful accomplishment of the main issue. The proper control of narcotic addiction-disease mechanism and of its influences upon the patient addicted is the important problem presented by narcotic addiction as met in the field complicating surgical and general medical conditions.

CHAPTER VIII
LAWS, AND THEIR RELATIONS TO NARCOTIC DRUGS

The first general appreciation of the widespread existence of narcotic drug use was brought about by the passage of anti-narcotic laws. The United States Federal legislation which went into effect in 1914, was what is known as the Harrison Law, still in effect and in its purpose and drafting a wise piece of legislation. It sought to limit and control the use of opiate drugs and cocaine by making their possession and distribution illegal by other than those of professional and other status designated in the law, as qualified for their intelligent application and responsible distribution. Its administration was placed in the Department of Internal Revenue under a provision which licensed responsible distributors and required a yearly tax.

Taken as a whole, in its original form, administered with understanding of addiction-disease facts, and with honest and intelligent scientific, educational and remedial activities coincidently pursued, it should be sufficient to control a rapidly growing menace. In its attitude towards the medical profession it wisely limited its restrictions to the broad statement that these drugs named must not be distributed other than in the “course of legitimate professional practice,” wisely making no attempt to define such “legitimate practice,” but apparently anticipating investigative activities of the scientific professions in the determination and dissemination of medical facts for the guidance of honest practitioners, and of those who should interpret and enforce the law.

Unfortunately addiction as a disease was, at that time, not a matter of wide recognition, the public in general and the medical profession itself still almost universally holding to the old conceptions of it on the basis of supposed morbid indulgence and “habit.” It seems to the author that the failure of the Harrison Law to check or limit the illegitimate use of the drugs it describes, is not due to a defect in the law itself, but is due to the failure of the scientific professions to clarify the situation with a clean cut understanding of the condition legislated against. The reaction within the medical profession as a result of this law was unfortunate. Instead of stimulating scientific interest and investigation into the character of this disease, the result was that medical men in general having little or no conception of its disease basis, regarded the narcotic addict as a mental or correctional problem and left his consideration and handling to the lay officials and the special institutions whose activities had been along other lines than scientific research into physical disease.

In the minds of most lay and of many medical workers the only consideration was the stopping of drug use per se, an attitude which to a less extent still persists. Uninformed as to the now established facts of addiction-disease, the administrators of the law, and to a large extent the medical profession, tended to regard supply of opiate to an addict as the prolongation of a habit, and not as medication indicated by the mechanism and symptomatology of a disease—and therefore as not being legitimate medical practice. This attitude had the effect of making the practitioner of medicine unwilling to receive the narcotic addict as a patient.