The narcotic drug problem

by Ernest S. Bishop

It is a fact that the narcotic drugs may afford pleasurable sensations to some of those not yet fully addicted to them, and that this effect has been sought by the mentally and morally inferior purely for its enjoyment for the same reasons and in the same spirit that individuals of this type tend to yield themselves to morbid impulses, curiosities, excesses and indulgences. Experience does not teach them intelligence in the management of opiate addiction and they tend to complicate it with cocaine and other indulgence, increasing their irresponsibility and conducing to their earlier self-elimination.

Wide and varied experience, however, hospital and private, with careful analysis of history of development, and consideration of the individual case, demonstrates the fact that a majority of narcotic addicts do not belong to this last described type of individuals. It will be found upon careful examination that they are average individuals in their mental and moral fundamentals. Among them are many men and women of high ideals and worthy accomplishments, whose knowledge of narcotic administration was first gained by “withdrawal” agonies following cessation of medication, who have never experienced pleasure from narcotic drug, are normal mentally and morally, and unquestionably victims of a purely physical affliction.

The neurologist, the alienist, the psychologist, the law-maker, the moralist, the sociologist and the penologist have worked in the field of narcotic addiction in the lines of their special interests, and interpreted in the lights of their special experiences. Each has reported conditions and results as he saw them, and advised remedies in accordance with his understanding. With very few exceptions little has been heard from the domain of clinical medicine and from the internist. It is only here and there that the practitioner of internal medicine has been sufficiently inspired by scientific interest to seriously consider narcotic drug addiction and to make a clinical study of its actual physical manifestations and phenomena.

The idea that narcotic drug addiction should be accorded a basis of weakness of will—neurotic or otherwise, inherent or acquired—and should be classed as a morbid appetite, a vice, a depraved indulgence, a habit, has been generally unquestioned and the prevailing dogma for many years. It is very unfortunate that we have paid so little attention to material facts and have made so little effort to explain constant physical symptomatology on a basis of physical cause, and that there has not been a wider recognition and more general acceptation of scientific work that has been done.

Despite the years of effort that have been devoted to handling the narcotic addict on the basis of inferiority and neurotic tendencies, and of weakness of will and perverted appetite—in spite of exhortation, investigation, law-making and criminal prosecution—in spite of the various specific and special cures and treatments—narcotic addiction has increased and spread in our country until it has become a recognized menace calling forth stringent legislation and desperate attempts at administrative and police control. And though a large amount of money has been spent in custodial care and sociological investigation on the prevailing theories, and in various legislation, much of it necessary and much of it wisely planned, we have made but little progress in the real remedy of conditions.

It is becoming apparent that in spite of all the work which has been done—in spite of all the efforts which have been made—there has been practically no change in the general situation, and there has been no solution of the drug problem.

In analyzing results of efforts and arriving at causes for failure, it seems to me that it is always wise to begin at the beginning, and to ask ourselves whether we have not started out with an entirely erroneous conception of our basic problem. Is it not possible that instead of punishing a supposedly vicious man, instead of restraining and mentally training a supposedly inherent neuropath and psychopath, we should have been treating an actually sick man? Is it not possible that the addict did not want his drug because he enjoyed it but that he wanted it because his body required it? This is not only possible—it is fact—and the whole secret of our failure has been the misconception of our problem based on our lack of understanding of the average narcotic drug addict and his physical conditions.

In my own experience as a medical practitioner I know that non-appreciation of this fact was the cause of my early failures; and I further know that from the beginning of appreciation of this fact dates whatever progress I have made and whatever success I have attained. In my early efforts as Resident Physician to the Alcoholic and Prison Wards of Bellevue Hospital, devoid of previous experience in the treatment of narcotic addiction, directed by my available literature and by the teachings of those in my immediate reach, I followed the accepted methods. I tried the methods of the alienist; I tried the exhortations of the moralist; I tried sudden deprivation of the drug; I tried rapid withdrawal of the drug; I tried slow reduction of the drug; I tried well-known special “treatment.” In other words I exhausted the methods of handling narcotic drug addiction of which I knew. My results were, in these early efforts, one or two possible “cures,” but as a whole suffering and distress without relief; in a word failure.

The blame I placed not where it belonged—on the shoulders of my medical inefficiency and lack of appreciation and knowledge of the disease I was treating—but upon what I supposed was my patient’s lack of co-operation and unwillingness to forego what I supposed to be the joys of his indulgence. In discouragement and despair I held the addict to be a degenerate, a deteriorated wretch, unworthy of help, incurable and hopeless. Strange as it seems to me now, possessing as I did good training in clinical observation and being especially interested in clinical medicine, in calm reliance upon the correctness of the theories I followed, I ignored the presence of obvious disease.

As to the existing opinion that the addict does not want to be cured, and that while under treatment he cannot be trusted and will not co-operate, but will secretly secure and use his drug—I can only quote from my personal experience with these cases. During my early attempts with the commonly known and too frequently routinely followed procedures of sudden deprivation, gradual reduction and special or specific treatment, etc., 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 on their supposed weakness of will and lack of determination to get rid of their malady. Later I realized the fact that the blame rested almost entirely upon the shoulders of my medical inefficiency and my lack of understanding and ability to observe and interpret. The narcotic addict as a rule will co-operate and will suffer if necessary to the limit of his endurance. Demanding co-operation of a completely developed case of opiate addiction during and following incompetent withdrawal of the drug is asking a man to co-operate for an indefinite period in his own torture. There is a well-defined limit to every one’s power of endurance of suffering.