The narcotic drug problem

by Ernest S. Bishop

The immediate result was the sudden deprivation of opiate to such addiction-disease sufferers as had not had financial means or foresight to purchase large reserves before the laws went into effect. The history of the drastic early enforcement of the various laws, reduplicated with more or less completeness by periodical legislative and administrative activities, without adequate arrangement for the relief of the narcotic-deprived addiction-disease sufferer, shows suicides and deaths, and a rapid development of exploitation of the needs of the addict at the hands of illicit commerce. For this illicit commerce the laws themselves, however, are not so much to be blamed as the influence of long-prevailing and widely-taught attitudes and conceptions which caused scientific and other forces to fail to recognize and meet the need for clinical handling of the situation, and for study and investigation of the condition. Legislators and administrators simply reflect prevailing theories.

Early theories took scant if any account of the possibilities presented by the now rapidly-growing disease conception of addiction. The popular conception of an addict and even the description met in standard medical text-books was that of a “dope-fiend,” an irresponsible panderer to a morbid “habit,” bereft of will-power, honor and decency, a menace to himself and to society, and this conception has had unfortunate influence in the making, interpretation, and administration of laws. That it can be truthfully applied to some people who have developed addiction-disease is unquestioned, but that it fails to take into consideration a much larger number who are not irresponsible panderers to morbid habit, nor bereft of will-power, honor and decency, nor a menace to themselves or to society, but are honest and upright members of society and economic assets in the community, accounts in large part for the failure of laws and their administration to remedy the narcotic drug situation. Measures which might be very useful in the forcible control of those who can be justly characterized as “dope fiends” work great harm to those who are simply sick people.

That these sick people have been commonly regarded and classed as “dope-fiends” was due to the fact that the points of view and special experiences of the psychologist or psychiatrist, sociologist or penologist and the exponents of special methods of treatment dominated the literature and teaching in which appeared practically nothing of essential pathology, symptomatology and broad principles of addiction-disease therapeutics and handling. The occasional voice of the clinical student or experimental laboratory worker was almost unheard, and the opposition accorded unorthodox views and announcements made him a brave man who would state them, and tended to cause him to be regarded as an academic theorist, or possessed of ulterior motives.

In such a situation the dominant theme has been the stamping out of so-called “drug use.” The physician who under his best and honest therapeutic judgment strove to meet the immediate indications of the worthy and innocent addiction-disease sufferer by the administration of opiate drug, incurred a danger of severe criticism and at times of jeopardy to his liberties under the interpretation of his acts as perpetuating a “habit.”

It cannot be denied that in some cases unscrupulous holders of medical degrees have availed themselves of existing conditions in such a way that their supplying of opiates to narcotic addicts constitutes simply traffic in narcotic drugs and not the intelligent practice of medicine. It should be a matter of serious consideration for our lawmakers, administrators and judiciary, however, as to what extent the performance of the occasional medical vampire should be made a basis for the legal or administrative control of the honest practitioner, and to what extent he should be enveloped by legal and administrative restrictions, the innocent and unconscious violation of whose technicalities may at any time be made a basis for criminal procedure. It should be remembered that zealous administrators may not have proper conception of the scientific facts of disease nor of the practical problems of legitimate medical practice in addiction-disease. The quality of the act in the determination of legitimate medical practice is often if not as a rule more important than the mere act itself. There has been as yet, so far as I know, no satisfactory legal definition of legitimate medical practice. The author sees no reason why the same rules and criteria as have developed or are formulated for legitimate medical practice in other diseases might not be applied to the treatment of addiction-disease. In a general way the legitimate practice of medicine in the care of, handling of or treatment of a disease consists of such medical attention, advice, instruction and guidance, and clinical or therapeutic ministrations as may be indicated by the needs of the individual case. In addiction-disease if a physician proceeds upon the physical, clinical and other indications exhibited in the individual case, being held responsible for reasonable familiarity with such indications, and fulfilling to the best of his available equipment and professional ability the general and therapeutic requirements of each case, it is difficult for the author to see how he can be held to be engaged in illegitimate practice. He can of course be held responsible for reasonable familiarity with available teaching and information on the subject treated by him, and for average intelligence and honest application of medical principles and practice. It seems to the author that legitimate practice as determined in other diseases would go a long way towards the elimination of the charlatan and shyster physician and would not carry with it the menace and jeopardy which technical violation of often medically impractical administrative demands may involve. If the honest physician is left no leeway for the exercise of medical judgment in the handling of widely differing cases of addiction-disease, or if his exercise of honest clinical judgment is to be constantly influenced by a necessity of worrying about its possible interpretation, in the light of unduly stringent laws and regulations, a condition is created in which the intelligent practice of medicine upon the sufferer from addiction-disease becomes impossible.

A matter about which there has been a great deal of dispute is that of the prescribing or dispensing by the practitioner of medicine of opiate drugs to the narcotic addict in the handling of narcotic addiction, itself. The adherents of the older theory of addiction being merely habit or vicious indulgence, oppose as illegitimate practice the continued supply of the opiate to an addiction patient, unless in some cases the patient also suffers from some painful and incurable disease.

They take the attitude that, if the addict did not want to keep on using opiate he would go somewhere and be cured, and that as long as he can get opiate drug he will not get “cured.” The possibilities of immediate so-called “cure” are discussed elsewhere in this volume. Sufficient for present statement is the fact that, as demonstrated by the testimony of the Whitney Committee Legislative Investigation hearings, one of the most complete and valuable pieces of public investigation work into addiction ever done, there exists at present practically no adequate or competent machinery for the successful so-called “cure” of the great numbers of narcotic addicts. This is discussed elsewhere. Those who talk casually of the enforced immediate cure of the narcotic addict would do well to investigate and realize the lack of possibilities of its immediate attainment on any large scale. This is a basic fact which has been too little taken into account by those who still hold to the appetite and habit theories.

In the narcotic drug situation we are confronted by fact and not by theory. Intelligent comprehension and unbiased investigation are needed far more than we need premature conclusions drawn from insufficient experience or too narrow observation along special lines. The fundamental fact is this, as has been repeatedly stated, that the narcotic addict, until his disease mechanism can be competently and successfully arrested physically, needs the daily administration of sufficient quantities of the drug of his addiction to meet the indications of his disease. If the drug is not administered to him in sufficient amounts to meet these disease indications, he cannot be blamed if, in the agony of his suffering and the desperateness of his plight, he is forced into the underworld and the illicit channels of supply for the continuance of a physically endurable and economically possible existence. Until the medical profession and the medical institutions—hospital and otherwise—have in competent execution methods of handling and treatment of the narcotic addict which are more humane and more effective than those shown by ample testimony to be in common use, the supply of narcotic drug to the responsible narcotic addict to the extent of physical need, without unjustifiable exploitation, financial or otherwise, is the duty of the medical man. Any law which to this extent limits the supply of opiate drug to the addict should receive the support of the medical profession. Any law which renders it difficult or impossible for a physician to conscientiously and rationally meet, to this extent, the indications of narcotic drug disease, should meet from the medical profession with a united and honest attempt at its modification.

Above all there should be fostered and promoted by the medical profession an intelligent, unbiased investigation into the actual facts surrounding the problem of narcotic drug addiction as a definite disease. Such information concerning the physical and clinical facts of this disease, as we should be in a position to give, would be eagerly welcomed by the law-makers and the administrators and the judiciary; and we should be in a position to co-operate with them in the making and interpreting of narcotic drug laws. Lack of such information has played an important part in whatever mistakes our police, legislative and administrative bodies have made, and forced them to proceed as best they could to meet the demand of a public menace that could no longer be denied.

What has the law done for the addict? Like the physicians, the legislators have done the best they could in the light of their knowledge, experience and teaching. Some of them seem, however, to have had their attention directed unduly to a special class of those addicted, the addicts found among the type of person which begins or tends to end among the criminal or vicious of the so-called “underworld.” Legislators and administrators have realized that the taking of narcotic drugs was rapidly spreading, and that it constituted a public menace in the class to which their attention was directed; and they applied the means at their disposal in the remedy of what they saw. But again, like the physician, they tended to center their attention upon the mere taking of narcotic drug, and they attempted to control by legislation the possession and use of narcotic drugs with too little appreciation of fundamental disease facts and of general basic considerations of widespread application. They did not seem to have appreciated the extent to which their legislation or administration would affect the great numbers of upright, and innocent and worthy addiction-sufferers of whom they did not know, and who did not possess the fundamental characteristics of the class and type of person addicted against which they legislated. They rightly directed their attention towards the control of the sources of drug supply and they rightly limited the ultimate legal supplying of drug to duly licensed and responsible persons and institutions, specifically described. The slogan of most of the special legislation has been to place responsibility for the supply and use of narcotic drugs squarely upon the shoulders of the medical profession. Such effort is wise, and this is where the responsibility belongs. And this is where the medical profession would have it placed in so far as the medical profession supplies narcotic drugs.