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+Project Gutenberg (https://www.gutenberg.org) public repository for
+eBook #69186 (https://www.gutenberg.org/ebooks/69186)
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-The Project Gutenberg eBook of The narcotic drug problem, by Ernest
-S. Bishop
-
-This eBook is for the use of anyone anywhere in the United States and
-most other parts of the world at no cost and with almost no restrictions
-whatsoever. You may copy it, give it away or re-use it under the terms
-of the Project Gutenberg License included with this eBook or online at
-www.gutenberg.org. If you are not located in the United States, you
-will have to check the laws of the country where you are located before
-using this eBook.
-
-Title: The narcotic drug problem
-
-Author: Ernest S. Bishop
-
-Release Date: October 20, 2022 [eBook #69186]
-
-Language: English
-
-Produced by: Charlene Taylor and the Online Distributed Proofreading
-             Team at https://www.pgdp.net (This file was produced from
-             images generously made available by The Internet
-             Archive/American Libraries.)
-
-*** START OF THE PROJECT GUTENBERG EBOOK THE NARCOTIC DRUG
-PROBLEM ***
-
-
-
-
-
-  THE NARCOTIC DRUG
-  PROBLEM
-
-
-
-
-  [Illustration]
-
-  THE MACMILLAN COMPANY
-  NEW YORK · BOSTON · CHICAGO · DALLAS
-  ATLANTA · SAN FRANCISCO
-
-  MACMILLAN & CO., LIMITED
-  LONDON · BOMBAY · CALCUTTA
-  MELBOURNE
-
-  THE MACMILLAN CO. OF CANADA, LTD.
-  TORONTO
-
-
-
-
-  THE NARCOTIC DRUG
-  PROBLEM
-
-  BY
-  ERNEST S. BISHOP, M.D., F.A.C.P.
-
-  Clinical Professor of Medicine, New York Polyclinic Medical School;
-  Member Narcotic Committee, Conference of Judges and Justices
-  of New York State; Committee on Habit Forming Drugs,
-  Section on Food and Drugs, American Public
-  Health Association.
-
-  Formerly Resident Physician, Alcoholic, Narcotic and Prison Service,
-  Bellevue Hospital; Formerly Visiting Physician and President of
-  the Medical Board, Workhouse Hospital. New York Department
-  of Corrections; Fellow Academy of Medicine, Visiting
-  Physician St. Joseph Tuberculosis Hospital, Consulting
-  Physician to St. Mark’s Hospital,
-  etc., etc.
-
-
-  New York
-  THE MACMILLAN COMPANY
-  1920
-
-  _All rights reserved_
-
-
-
-
-  COPYRIGHT, 1920
-  BY THE MACMILLAN COMPANY
-
-  Set up and electrotyped. Published January, 1920.
-
-
-
-
-  TO
-  MY WIFE,
-
-  WHO HAS SHARED MY BURDENS AND HELPED IN
-  MY WORK, AND WHOSE INTEREST IN AND SYMPATHY
-  WITH MY WORK HAS MADE MUCH OF IT
-  POSSIBLE,
-  THIS BOOK IS INSCRIBED.
-
-
-
-
-PREFACE
-
-
-This book has been prepared in response to a growing demand that the
-author group together under one cover some of the material collected
-out of a varied experience with many aspects and phases of narcotic
-drug addiction, and with activities in the attempted solution of its
-problems.
-
-Some of this experience has been previously presented in many addresses
-before scientific and other societies and in articles in the medical
-press.
-
-The author is not associated with nor interested in any hospital or
-institution active in the care of these cases for financial return or
-pecuniary benefit. He is not the exponent or mouthpiece or proponent of
-any special or specific “remedy” or “treatment” or method of so-called
-“cure.” He has no axe to grind.
-
-He is not a “specialist” in the treatment of narcotic drug addiction.
-He is a practitioner of diagnostic and clinical medicine, in whose
-professional work the care of the narcotic addict has constituted much
-the smaller part of his activities and studies, and that part has been
-largely carried on without recompense and often at his personal expense.
-
-Some years ago, through hospital affiliations and duties, the writer
-was brought to face this problem of opiate addiction and after a while
-saw in it very important and very interesting clinical problems of
-physical disease and physical reactions upon which he made observations
-and studies.
-
-Hospital connections and the publishing of various articles have
-since that time brought him into association with practically all
-phases and aspects of activity in the consideration and handling
-of the narcotic drug problem. He has listened to discussions of the
-subject by promoters; by reformers of various sorts; by those engaged
-in legislative, judiciary, administrative, custodial, penological,
-sociological, psychological or psychiatrical, medical and other lines
-of work, and by narcotic addicts from all classes and types of people
-and their friends and relatives, etc., in groups, or as individuals.
-
-Two vital elements seem to the author to have received insufficient
-consideration in the efforts to solve the narcotic drug problem. One
-of these elements is the sufferings and struggles and problems of the
-narcotic addict, and the other is the nature of the physical disease
-with which he is afflicted.
-
-This book is an effort to accomplish two things, first to present
-the two elements above stated, and second to outline, discuss and
-correlate various elements and conflicting activities so that each
-of us can appreciate the relation of his own endeavor to the whole
-narcotic drug problem, can realize the comparative importance of
-his own observations, and can cooperate with the others for the
-benefit of humanity, for the welfare of society and posterity and for
-the increased health and happiness and economic usefulness of the
-individual.
-
-
-
-
-CONTENTS
-
-
-  CHAPTER                                                    PAGE
-
-  PREFACE                                                     vii
-
-  I. INTRODUCTION                                               1
-
-  II. FUNDAMENTAL CONSIDERATIONS                               11
-
-  III. THE NATURE OF NARCOTIC DRUG ADDICTION-DISEASE           23
-
-  IV. THE MECHANISM OF NARCOTIC DRUG ADDICTION-DISEASE         35
-
-  V. REMARKS ON METHODS OF TREATING NARCOTIC
-  DRUG ADDICTION                                               50
-
-  VI. THE RATIONAL HANDLING OF NARCOTIC DRUG
-  ADDICTION-DISEASE                                            61
-
-  VII. RELATION OF NARCOTIC DRUG ADDICTION TO SURGICAL
-  CASES AND INTERCURRENT DISEASES                              85
-
-  VIII. LAWS, AND THEIR RELATIONS TO NARCOTIC DRUGS            95
-
-  IX. SOME COMMENTS UPON THE LEGITIMATE USE OF
-  NARCOTICS IN PEACE AND WAR                                  114
-
-  X. GENERAL SURVEY OF THE SITUATION AND THE
-  NEED OF THE HOUR                                            122
-
-  APPENDIX: HUMAN DOCUMENTS,--STATEMENTS OF SUFFERERS
-  FROM NARCOTIC DRUG ADDICTION-DISEASE                        137
-
-
-
-
-THE NARCOTIC DRUG PROBLEM
-
-
-
-
-CHAPTER I
-
-INTRODUCTION
-
-
-It is a fact becoming more and more obvious that too little study and
-effort to interpret their physical condition have been given to those
-unfortunates suffering from narcotic drug addiction.
-
-We have neglected their disease in its origin and subsequent progress
-and formed our conception of its character from fully developed
-conditions and spectacular end-results. We have seen some of them
-during or after our fruitless efforts at treatment, their tortures and
-poor physical condition overcoming their resolutions, until they plead
-for and attempted to obtain more of their drug. We have seen others
-exhausted, starved, with locked-up elimination, toxic from self-made
-poisons of faulty metabolism, worn with the struggle of concealment and
-hopeless resistance, and for the time being more or less irresponsible
-beings, made so, not because of their addiction-disease itself, but
-because they were hopeless and discouraged and did not know which way
-to turn for relief.
-
-What literature has appeared on the subject has usually pictured them
-as weak-minded, deteriorated wretches, mental and moral derelicts,
-pandering to morbid sensuality; taking a drug to soothe them into
-supposed dream states and give them languorous delight; held by most
-of us in dislike and disgust, and regarded as so depraved that their
-rescue was impossible and they unworthy of its attempt.
-
-We have overlooked, ignored or misinterpreted intense physical agony
-and symptomatology, and regarded failure to abstain from narcotics as
-evidence of weak will-power or lack of desire to forego supposed morbid
-pleasure. We have prayed over our addicts, cajoled them, exhorted them,
-imprisoned them, treated them as insane and made them social outcasts;
-either refused them admission to our hospitals or turned them out after
-ineffective treatment with their addiction still fastened to them. To a
-great extent the above has been their experience and history.
-
-In great numbers they have realized our failure to appreciate their
-condition and to remedy it, and have after desperate trials of quacks,
-charlatans and exploited “cures,” finally accepted their slavery and
-by regulation of their drug and life, their addiction unsuspected,
-maintained a socially and economically normal existence. Some failing
-in this, perhaps broken and impoverished, their addiction recognized,
-have become social and economic derelicts and often public charges.
-
-From these last, together with the addicted individuals from the class
-of the fundamentally unfit, we have painted our addiction picture.
-Confined and observed by the custodial official and the doctor of
-the institution of correction and restraint, or concealed as family
-skeletons in many homes, descriptions of them have given to the
-narcotic addicts as a whole their popular status--cases of mental and
-moral disorder due to supposed drug action or habit deterioration, and
-based upon inherent lack of mental and moral stamina.
-
-It was with the above conception of these addiction conditions that
-I began my work in the Alcoholic, Narcotic and Prison Service of
-Bellevue Hospital, attracted to the service not by hope of helping nor
-by interest in “jags” and “dope fiends” as I then considered them, but
-by the mass of clinical material available for surgical and medical
-diagnosis and study which was daily admitted to those wards. When I
-left the service after sixteen months of day and night observation,
-with personal oversight and attempt to care for in the neighborhood
-of a thousand admissions a month, my early and faulty conception of
-narcotic addicts was replaced by a settled conviction that these
-cases were primarily medical problems. I realized that these patients
-were people sick of a definite disease condition, and that until we
-recognized, understood and treated this condition, and removed the
-stigma of mental and moral taint from those cases in which it did not
-exist, we should make little headway towards solution of the problem of
-addiction.
-
-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.
-
-Abundant evidence of what I have written is easily found among the many
-sufferers from the disease of opiate addiction who have maintained for
-years a personal, social and economic efficiency--their affliction
-unknown and unsuspected. These cases are not widely known but there
-are a surprising number of them. When one of them becomes known his
-success in handling his condition and its problems is generally
-attributed to his being on a rather higher moral and mental plane than
-his fellow sufferers and possessed of will-power sufficient to resist
-temptation to over-indulge his so-called appetite. We have not as a
-rule considered any other explanation nor sought more at length for the
-cause of his apparent immunity to the hypothetical opiate stigmata. It
-would have been wiser and more profitable for us to have respectfully
-listened to his experiences and learned something about his disease.
-
-The facts in such cases are that instead of being men of unusual
-stamina and determination, they are simply men who have used their
-reasoning ability. They have tried various methods of cure without
-success. They have realized the shortcomings and inadequacy of the
-usual understanding and treatment of their condition. Being average
-practical men, and making the best of the inevitable, they have made
-careful and competent study of their own cases and have achieved
-sufficient familiarity with the actions of their opiate upon them and
-their reactions to the opiate to keep themselves in functional balance
-and competency and control. The success of these people is not due to
-determined moderation in the indulgence of a morbid appetite. It is due
-to their ability to discover facts; to their wisdom in the application
-of common-sense to what they discover; and to rational procedure in
-the carrying out of conclusions reached through their experiences.
-They have simply learned to manage their disease so as to avoid
-complications. When I tried to account for some of the things I saw by
-questioning these men who had studied and learned upon themselves, I
-soon obtained a clearer conception of what opiate addiction was.
-
-When we eliminate the distracting and misleading complications, mental
-and physical, and study the residue of physical symptomatology left, we
-make some very surprising and striking observations.
-
-We find that we are dealing fundamentally with a definite condition
-whose disease manifestations are not in any way dependent in their
-origin upon mental processes, but are absolutely and entirely physical
-in their production, and character. These symptoms and physical signs
-are clearly defined, constant, capable of surprisingly accurate
-estimation, yielding with a sureness almost mathematical in their
-response to intelligent medication and the recognition and appreciation
-of causative factors; forming a clean-cut symptom-complex peculiar to
-opiate addiction. Any one--whether of lowered nervous, mental and moral
-stamina, or a giant of mental and physical resistance--will, if opiates
-are administered in continuing doses over a sufficient length of time,
-develop some form of this symptom-complex. It represents causative
-factors, and definite conditions which are absolutely and entirely due
-to changed physical processes which fundamentally underlie all cases
-of opiate addiction, and which proceed to full development through
-well-marked stages.
-
-During the past years I have had under my care a number of excellent
-and competent physicians of unusual mental and nervous balance and
-control in whom there could be no hint of lack of courage, nor of
-deficient will-power, nor of lack of desire to be free from their
-affliction. Possessing, some of them, unusual medical training and
-scientific ability, having added to this the actual experiences of
-opiate addiction, they with others have co-operated and aided in
-experiment, study and analysis, and the result has been in their minds
-as in mine, complete confirmation of the facts above stated.
-
-Primarily, there are two phrases I should like to see eliminated from
-the literature of opiate drug addiction. I believe they have worked
-great injustice to the opiate addict and have played no small part in
-the making of present conditions. It seems to me that to speak and
-write as we still often do of “drug habit” and “drug fiends” is placing
-upon the opiate addict a burden of responsibility which he does not
-deserve. If long ago we had discarded the word “habit” and substituted
-the word “disease” I believe we would have saved many people from the
-hell of narcotic drug addiction. I believe if it had not been for
-the use of the word “habit” that the medical profession would long
-ago have recognized and investigated this condition as a disease. A
-man, physician or layman, believes that he can control a habit when
-he would fear the development of a disease. Until now, however, the
-description has been “drug habit.” And the man who acquires one of the
-most terrible diseases to be encountered in the practice of medicine
-is unconscious of his being threatened with a physical disease process
-until this process has become so developed and so rooted that it is
-beyond average human power to resist its physical demands.
-
-In the near future, I earnestly hope the true story and the real
-facts concerning the opiate drug addict will become universally
-known. Without familiarity with them and understanding of them, and
-comprehension and appreciation of their disease, we shall never make
-real progress in the solution of the narcotic drug problem. From the
-present day trend of articles and stories in the newspapers and lay
-and medical magazines it cannot be doubted that the time is not far
-distant when in the lay press will appear, in plain, sober, unvarnished
-truth, the true story of the experiences and struggles of the opiate
-drug addict. I have marked a rapidly growing appreciation of fact and
-a steadily increasing activity in the investigation of conditions.
-This is sooner or later bound to be followed by intelligent public
-and scientific demand for competent and common-sense explanation and
-solution.
-
-
-
-
-CHAPTER II
-
-FUNDAMENTAL CONSIDERATIONS
-
-
-My earliest efforts in the handling of narcotic addicts were
-institutional. They were along the lines of forcible control, based
-upon the theory that I could expect no help nor co-operation from my
-patients.
-
-While this theory is undoubtedly true as applied to many of those who
-have developed opiate addiction, it is true of them as individuals
-whose personal characteristics are such that they require forcible
-control for the accomplishment of desirable ends in general. It is not
-true of them simply because of narcotic addiction. It is equally true
-of these same people afflicted with other diseases. Their successful
-handling for tuberculosis, venereal disease, cardiac conditions, or
-anything else requires for its successful issue constant oversight
-and what practically amounts to custodial care. I shall refer to them
-later. They are fundamentally custodial or correctional cases and
-success in their handling will never be accomplished in any other way,
-whether they are being treated for narcotic addiction or for anything
-else, mental, moral or physical.
-
-What appears in this chapter does not solve the problem of the handling
-of the narcotic addict of this type. There are many factors and
-elements in their mental and physical make-up other than drug addiction
-which should be considered, and these factors and elements lie at the
-bottom of their irresponsibility and the real difficulty of their
-handling.
-
-Experience and the analysis of unsuccessful effort and results showed
-that, however necessary forcible control might be in the handling
-of some narcotic addicts, it was not successful nor sufficient nor
-even the most important factor in the treatment of most cases of
-addiction-disease.
-
-I soon came to see that I had an erroneous conception of my medical
-and clinical problems and an unjust attitude towards many if not most
-of my addiction patients. Studying them--not as drug addicts, but as
-individual human beings--I found them in their personal, mental, moral
-and other characteristics, as various as people suffering from any
-other disease condition. There were no narcotic laws at that time and
-opiates were easily and cheaply obtainable. Very many, perhaps most of
-those who came to my wards were not forced in either by fear of the
-law or by scarcity of opiate supply. They did not have to come for
-treatment, but voluntarily presented themselves in the hope of cure.
-Something was wrong with my theories.
-
-In seeking for solution I began to realize that the narcotic addict
-of average individual characteristics obtained no enjoyment from the
-use of his opiate, and that he co-operated as a rule to the extent of
-his ability and endurance in efforts to relieve him of his condition,
-so long as he had any hope of possible ultimate success. I learned,
-trained and experienced physician though I was, that I was far more
-ignorant of the clinical manifestations and physical reactions of
-narcotic drug addiction than many of the patients I was trying to
-treat. It was soon evident to me, moreover, that the man who recognized
-my ignorance above all others was my patient. I came to see that what I
-had interpreted as lack of co-operation was largely due; first to his
-memory of previous experience, second to recognition of my ignorance,
-and third to his anticipation of useless and harmful suffering which he
-expected from my care and treatment of his case.
-
-Looking back over that period, I am free to confess that my efforts,
-though honestly made, amply realized his expectations.
-
-I began to see that I knew nothing of this disease or how to treat
-it as a problem of clinical disease. I saw that addict after addict
-sneezed and trembled, jerked and sweated, vomited and purged,
-became pallid and collapsed, that his heart and circulation were
-profoundly and alarmingly disturbed, that he had the unquestionable
-facies or expression of intense physical suffering, and the many
-constant and obvious signs which attend physical need for opiate
-drug. I could not escape the conclusion that here were tangible,
-material, incontrovertible physical facts for which I had no physical
-explanation. It seemed unreasonable to be satisfied with any
-explanation of them that did not have a physical basis; and it seemed
-a logical conclusion that the establishment of a basis of physical
-disease mechanism could offer the only hope of remedy. I therefore
-ignored for the time being my past teachings and ideas of the drug
-addict, and I looked to the patient himself, questioning him as to his
-experiences and studying the symptomatology and physical phenomena
-he presented. In short, I adopted the attitude which must be widely
-adopted before the medical problem of the clinical handling of drug
-addiction will be solved--in my attitude towards these cases I became
-the clinical student and practitioner of internal medicine, treating my
-patient to the best of my ability as I would a sufferer from any other
-disease, and studying his case.
-
-Struck by clinical facts which did not accord with past teaching,
-I tried to seek out from my personal study and observation of the
-individual case data upon which to form theories which would accord
-with clinical facts and with verified histories and, if possible, give
-a basis of help to these unfortunates.
-
-Gradually since then I have gotten together, from my own work and that
-of others, and with some success attempted to interpret and explain
-and apply, what seemed to me facts about opiate addiction. To my mind
-and in my experience these facts offer a beacon-light of hope and
-assure ultimate rescue to a very large proportion if not most of those
-suffering from narcotic drug addiction-disease.
-
-It is well to state here that of late some of these facts have
-secured recognition in medical and lay authoritative announcement and
-literature. The Preliminary Report of a special investigating committee
-of the New York State Legislature is quoted from elsewhere in this
-book, and the report in June, 1919, of a special committee appointed
-by the Secretary of the Treasury speaks of, “the more or less general
-acceptance of the old theory that drug addiction is a vice or depraved
-taste, and not a disease, as held by modern investigators.”
-
-It is on account of “the more or less general acceptance of the old
-theory” that it is necessary in this place to discuss some of the
-tenets of that theory for the benefit of those whose interests or
-emergencies have not led them to investigation of and familiarity with
-the scientific and other writings on this subject of recent years.
-
-It has been demonstrated to be a fact that description of narcotic
-drug addiction as “habit,” “vice,” “morbid appetite,” etc., absolutely
-fails to give any competent conception of its true characteristics, and
-clinical and physical phenomena. A large majority of opiate users are
-gravely wronged in a wide-spread opinion still prevalent. This opinion,
-as previously outlined, is that chronic opiate addiction is a morbid
-habit; a perverted appetite; a vice; that only he who is mentally or
-morally defective will allow it to get a hold upon him; and that its
-main and characterizing manifestations are those of mental, physical
-and moral degeneration. Opiate addicts are supposed to have irrevocably
-lost their self-respect, their moral natures and their physical
-stamina. They are still painted by many, as inevitable liars, full of
-deceit, and absolutely untrustworthy--people who are supposed to use a
-dream and delight producing drug for the sensuous enjoyment it gives
-them, and who do not want to discontinue its use. They are thought
-of as physical, mental and moral cowards who, after realizing their
-deplorable condition, refuse to exert “will-power” enough to stop the
-administration of opiates.
-
-With these views I did my early work on this condition. On these
-hypotheses, trying to follow current available literature and teaching,
-I treated my patients for a considerable time with results which
-superficially interpreted seemed to corroborate both literature and
-teaching. Many of them managed to get their drugs even while in the
-institution, and practically all of them left uncured with but an
-exceedingly small number of possible exceptions.
-
-From my patients themselves, and from watching and studying them,
-I later learned the truth, which has since been continually
-strengthened--that the so-called “discomforts” we think of them as
-suffering upon withdrawal of their drug, are actually unbearable
-suffering, accompanied by physical manifestations sufficient to prove
-this to be so. I also learned that the supposed delightful sensations
-which have formed the background of most pictures painted of them, had
-in many, if not in most of the cases with which I came in contact,
-never been experienced. If they had ever existed they had long ago been
-lost and all that remained in opiate effect was support and balance to
-organic processes necessary to the continuance of life and economic
-activity. As I have written, these sensations seem to be, “part of the
-minor toxic action of the opiate against which the addict is nearly or
-completely immune and to the securing of which very many and probably
-a majority of the innocent or accidental addicts have never carried
-their dosage.” In plain English the sufferer from opiate addiction has,
-in many if not a majority of cases, never experienced any enjoyment
-as a result of the drug and has endured indescribable agony in its
-non-supply.
-
-I do not want to be understood as claiming that opiates will not
-produce pleasant sensations, nor that they are never used to the end
-of experiencing these sensations. There is a class of the inherently
-or otherwise defective or degenerate, who first indulge in opium or
-its products from a morbid desire for sensuous pleasures, just as they
-would and do indulge in any form of perversion or gratify any idle
-curiosity. They are mentally incapable of self-restraint, indulging
-jaded appetite with new stimuli. They yield themselves to any and all
-forms of self-indulgence and gratification of appetite. There comes a
-time when for them opiates, from increasing tolerance and dependence
-lose power to give pleasurable sensations and become simply a part of
-their daily sustenance, exacting physical agony as a result of their
-non-administration. When this occurs they make no effort to control
-amount or method or use; and overdosage together with conditions
-incidental to and attendant upon their mode of life soon relieves
-society of the menace of their membership. As a class they have
-been regarded as incurable and hopeless--socially, economically and
-personally unworthy of salvage. To whatever extent this may be true,
-however, it is not true simply because they happen to have acquired
-opiate addiction, but because they are fundamentally what they are,
-diseased, degenerate and defective.
-
-The opiate element is as incidental to their fundamental condition as
-are the venereal and other diseases from which many if not most of
-them suffer. Observations and conclusions upon addicts from this type
-of humanity have been given great prominence in the public press and
-elsewhere and have had an unwarranted influence in the status of opiate
-addiction and the conception of and attitude towards the addiction
-sufferer. Because addicts of this class began to use opium or its
-derivatives and products to secure sensuous gratification is no reason
-for stigmatizing the mass of those afflicted with addiction-disease as
-people of perverted appetites. No one should study addiction in them
-unless he is possessed of sufficient ability in clinical observation to
-separate physical signs of opiate addiction from the manifestations of
-defective mentality--and unless he has enough insight and breadth of
-vision to see behind end-results, primary causative factors; and unless
-he has enough common-sense to refrain from applying to the worthy many
-the observations he has made upon the unworthy few.
-
-It is only fair to state in passing, however, that from my experiences
-as Visiting Physician in the wards of the Workhouse Hospital, New York
-Department of Correction, I am convinced that we all too often casually
-include in the above generally considered derelict class of society,
-many who under intelligent and humane handling could be restored to or
-converted into useful citizens.
-
-There are some above this class, of the type of spoiled and idle youth,
-who indulge first in opiates in a spirit of bravado or curiosity. The
-tremendous increase in addiction since its spectacular incidental and
-morbid aspects became so widely published is largely contributed to
-from this class.
-
-There are some who first used opiates to temporarily boost them over an
-emergency, post-alcoholic excesses, severe mental strain, etc.
-
-The majority of narcotic addicts, however, and especially those
-developing previous to the activities of the past few years, present
-a very different history. Mentally and morally they are of the same
-average equipment as other people. They form a class which might
-be called “accidental or innocent” addiction-disease sufferers.
-They had no voice nor conscious part in the early administration of
-opiate, realizing no desire or need for it by name, but only wishing
-for the unknown medicine which relieved their sufferings. Very many
-addiction patients have received their first knowledge of opiate
-administration in the withdrawal symptoms which followed the attempted
-discontinuance of its use. There is in these sufferers no element
-of lack of will-power; no trace of desire to indulge appetite or to
-pander to sensuous gratification. In some, before their condition was
-recognized, their tolerance for or dependence upon opiate had proceeded
-to a point where their bodies’ demand for morphine was imperative and
-their withdrawal suffering unendurable. In others, before body need
-was completely established--with their stamina and nervous resistance
-below par from sickness and suffering--they have been unable to forego
-opiate’s supportive and sedative and pain-relieving action, or to
-endure the nervous and other symptoms attendant upon its withdrawal
-after even a brief period of administration.
-
-As to what the addict is;--the tendency and effect of legislative,
-administrative, police and penological activities in general have
-been to place the sufferer from addiction-disease in the position
-of the criminal and vicious. The tendency of the psychologist and
-psychiatrist is to analyze him from the viewpoint of mental weakness,
-defect or degeneration, and to so classify and regard him. The average
-practitioner of internal medicine, and even the recognized leaders
-and authorities in this field of medical science will tell you that
-narcotic drug addiction is a condition to which they have given but
-little attention and have no clean-cut ideas of its physical disease
-problems. The addict himself, whose testimony has been all too little
-consulted or sought, will tell you that he is sick with some kind of
-a physical condition which causes suffering and incapacity whenever a
-sufficient amount of narcotic is not administered.
-
-In the above attitudes and statements the administrative, police and
-penological authorities are right in some cases;--the psychologists and
-psychiatrists have good basis for their opinions in some cases;--the
-addict has physical grounds for his statement in all cases--he is
-always sick, sick with addiction-disease.
-
-In my experience with and study of narcotic drug addiction and the
-narcotic drug addict, an experience touching practically every phase
-of the narcotic situation and giving me opportunity to observe the
-condition in practically every type of individual, the one constant
-and more and more strikingly emphasized observation has been constant
-physical symptomatology and the manifestations of pain and suffering
-and of fear. I have in my possession histories of addicts taken from
-all walks of life and from all classes and conditions of men. Some of
-my histories are of patients who were primarily defective, degenerate,
-weak or vicious. Some of my histories are of people of high mentality;
-of high ethical and moral standards; of high economic efficiency and
-social standing. These histories, stripped of names and possibilities
-of personal recognition, would form a very instructive collection of
-material for the man, physician, psychologist, sociologist, legislator
-or administrator who wishes to study the addict as he really is and to
-get some conception of the diversity of the problems which he presents.
-
-Neglect of this study and absence of this conception is the chief
-cause of past failure. We have tended to regard and handle and treat
-and legislate concerning narcotic addicts simply as narcotic addicts,
-instead of appreciating that different individuals and different types
-and classes of people who may suffer from addiction-disease present
-entirely different problems, and require entirely different handling.
-
-If we are going to consider all narcotic addicts as in one class we can
-with justice only consider those characteristics which are common to
-all members of that class. There is just one fact and characteristic
-that stands out as of striking and paramount importance in every one
-of my histories--it is the fact of physical suffering upon complete
-withdrawal of opiate drug, or a supply of that drug which does not
-meet the requirements of the physical body-need. Whatever or whoever
-the narcotic addict was before his use of opiate drugs--whatever had
-been the character and circumstances of the initial administration of
-narcotic drug--after a time, as I have repeatedly written elsewhere,
-after addiction-disease has once developed, the history of every opiate
-addict is that of suffering and of struggle. After addiction-disease
-is once developed the addict loses whatever euphoric sensation he may
-possibly have experienced, and all that narcotic administration spells
-for him is relief from suffering. Without the drug of his addiction
-he endures intense physical suffering and misery. Without the drug
-of his addiction he cannot pursue a social, economic, or physically
-endurable existence. He may have been primarily defective, degenerate,
-depraved or vicious; his primary administration of the drug may have
-been deliberate indulgence, disreputable associations, idle curiosity,
-any combination of conditions which may be stated;--he may have been
-an upright, honest and intelligent, hard-working, self-supporting,
-worthy and normal citizen in whom the primary administration of opiate
-drug was a result of unwise, ignorant or unavoidable medication;--he
-may have been an ignorant purchaser of advertised patent medicines
-containing addiction-forming drugs. Whatever his original status,
-mental, moral, physical or ethical, and whatever the circumstances
-of his primary indulgence; once addiction-disease has developed in
-his body the vital fact of his history is the same--subsequent use of
-opiate drug means not pleasure, not vice, not appetite, not habit--it
-means relief of physical suffering and the control of physical symptoms.
-
-My present definition of narcotic drug addiction is as follows; a
-definite physical disease condition, presenting constant and definite
-physical symptoms and signs, progressing through clean-cut clinical
-stages of development, explainable by a mechanism of body protection
-against the action of narcotic toxins, accompanied if unskillfully
-managed by inhibition of function, autotoxicosis and autotoxemia, its
-victims displaying in some cases deterioration and psychoses which
-are not intrinsic to the disease, but are the result of toxemia, and
-toxicosis, malnutrition, anxiety, fear and suffering.
-
-To express this somewhat differently--a narcotic drug addict is an
-individual in whose body the continued administration of opiate drugs
-has established a physical reaction, or condition, or mechanism, or
-process which manifests itself in the production of definite and
-constant symptoms and signs and peculiar and characteristic phenomena,
-appearing inevitably upon the deprivation or material lessening in
-amount of the narcotic drug, and capable of immediate and complete
-control only by further administration of the drug of the patient’s
-addiction.
-
-In plain English, the sufferer from narcotic drug addiction-disease is
-one who experiences the symptoms and signs referred to above and which
-will be discussed later, as a result of lack of supply or physically
-insufficient supply of opiate drug. I know of no definition along
-any other lines which will include all who suffer from narcotic drug
-addiction. This symptomatology, and the mechanism or process which
-produces it, are the only common and characteristic attributes and
-possession of all opiate addicts.
-
-How these are developed and how they may be controlled and arrested is
-the demand which the sufferer from narcotic drug addiction, and society
-as a whole, are making. Until a competent and acceptable answer to
-this demand is in the general possession of those handling narcotic
-addiction, all other discussions will remain inconclusive, and all
-other considerations incidental, for purposes of definite and final
-solution. This is the medical problem of narcotic drug addiction, and
-until those who handle narcotic addicts, and those who control the
-handling of narcotic addicts, have recognized it, are familiar with it,
-and can to some working measure explain and control its sufferings,
-physical phenomena and symptoms and signs, they are unprepared to
-assist intelligently and competently in the solution of a problem which
-now as never before menaces the welfare of society.
-
-
-
-
-CHAPTER III
-
-THE NATURE OF NARCOTIC DRUG ADDICTION-DISEASE
-
-
-It is a pertinent question to ask, “What type or class of individuals
-become narcotic addicts?” The only correct answer unquestionably
-is, any type or class or individual to whom opiates are given for a
-sufficiently long time. It has yet to be demonstrated that there is
-any warm-blooded animal, which following sufficiently prolonged and
-constant administration of opiate drug, is immune to the development of
-the symptomatology and constant physical phenomena of addiction-disease.
-
-Color, nationality, social or economic position, age, mental and moral
-attributes of whatever sort are no bar to the development of the
-condition. These may influence, of course, the conduct and incidental
-manifestations of the individual addicted, just as they do in any
-other condition. The addicted judge, or the addicted physician, or the
-addicted clergyman, or the addicted man of business or other affairs,
-or the addicted clerk or industrial worker reacts differently to
-the sufferings and trials of narcotic drug addiction than does the
-addict of the underworld, or the heroin “sniffer” of idle and curious
-adolescence, or the addicted defective, degenerate, or criminal. Also
-he reacts differently to everything else. What is true of one man who
-has opiate addiction may be absolutely false of another. One narcotic
-addict is honest, competent, truthful and intelligent. Another is
-dishonest, incompetent, untruthful and incapable of appreciation or
-self-control. Neither the one set of attributes, nor the other, is
-peculiar to narcotic addicts. They are simply personal attributes
-possessed by different men and types of men who may or may not be
-narcotic addicts. If the addict of a higher type displays at times
-attributes not typical of his preaddicted days, and seems to show a
-lowering of his mental and ethical tone, it is well to estimate in
-his case the influences of past worry, fear, suffering, strain and
-struggle, the attitude of society, medical and lay, towards him, and
-the manner in which he has been handled, before blaming it all upon the
-mere presence and effects of narcotic drug addiction, or of narcotic
-drug. If such changes were inherent in the action of continued narcotic
-drug medication, they would be found in all addicts, whereas the fact
-is that they most decidedly are not.
-
-As to age in addicts there is no limit. I have seen an infant
-newly-born of an addicted mother, displaying the characteristic
-physical symptoms, signs and phenomena of body-need for opiate a
-few hours after birth. This case is discussed more in detail in the
-transcribed testimony of the New York State Legislative Investigation
-hearings, (Whitney Committee) pages 1524 to 1529, at which I reported
-it. The infant undoubtedly developed addiction-disease prenatally,
-reacting in its unborn body against the presence of opiates, supplied
-through its mother’s blood, exactly, as is now demonstrated through
-experimental laboratory animals and by clinical study upon adults, this
-disease is always developed--through physical and constant reaction
-of the body to the continued presence of opiates, however supplied.
-There have been many such cases, some of which are matters of medical
-record. This condition of prenatal development of addiction-disease
-exists beyond dispute and certainly cannot be explained upon grounds of
-conscious appetite or deliberate self-indulgence. I am told that there
-are or until very recently have been old soldiers, veterans of the
-Civil War, whose addiction dated from medication for wounds received
-during that struggle. The late Doctor T. D. Crothers told me once that
-opiate addiction in this country received its first wide dissemination
-in that way. This points to the serious consideration of what may be an
-urgent and important medical problem of modern warfare.
-
-This brings us up to the origin of addiction. There is only one actual
-origin of addiction, and that is the continued administration of an
-addiction-developing drug sufficiently long to develop the physical
-manifestations symptomatology, and phenomena and body need for that
-drug. This statement is the only one which can be made as generally
-inclusive. I have many records and histories, much correspondence, and
-other data, collected from addicts, relatives, friends and associates
-of addicts, physicians, official conferences and workers in the
-various fields of narcotic endeavor. My material covers an active
-interest of many years duration, and an experience which has dealt
-with various types and classes of patients under various conditions.
-I have held different beliefs at different times, influenced by the
-demands of my immediate position, and by my best interpretation of my
-own experience, by the conditions under which I happened to be working
-and by the class of people coming to my attention under the conditions
-of my work. At one time I believed that all addicts were defective,
-irresponsible, degenerated, unreliable and liars, made addicts by
-curiosity, environment and morbid appetite. At one time I believed
-that the narcotic addict did not physically need narcotic drug under
-any circumstances, and that he could get along without it if he only
-had the will and the desire to do so. I proceeded on that theory for a
-while in the handling of my cases, and have to thank the illicit supply
-which is present in all institutions that my mortality was no higher,
-for it is agreed and on record by many competent authorities that
-forcible deprivation of opiate drug may at times cause death.
-
-These are examples of a few of the various beliefs and ideas I have
-held at various times, and upon which I used to generalize, as is the
-habit and tendency of those who as yet lack experience or breadth
-of experience. I have in time found many of my beliefs wholly or
-partly erroneous, or to apply only to selected groups of cases or to
-incidental phases and aspects of the main problem. They all have their
-bearings on the general situation, and may be of primary importance in
-the immediate handling and control of certain phases of it. I have come
-now to keep my general statements to the solid rock of basic disease
-and draw on my past experience for the measure and estimation of
-associated problems and complications as they arise.
-
-The actual origin of addiction is the administration of opiate
-drugs continuously over a sufficient length of time. The incidental
-details in their early administration to those who become addicted
-vary widely. In the origin of some proportion of addicts, we of the
-medical profession must sooner or later come to recognize and assume
-our part, unconscious and innocent, but none the less beyond question.
-What this proportion is is variously estimated by various authorities
-and statisticians and investigators. It is now beyond dispute that
-many cases of addiction-disease had their origin in medication during
-illness, the condition developing unsuspected by either physician or
-by patient until its physical manifestations had passed the bounds of
-control.
-
-The old fallacy that an opiate might be administered safely to a
-sufferer so long as the patient did not know what was being given him
-is completely disproven by the evidence of addicted infants, and by the
-excellent and exhaustive laboratory experiments upon addicted animals
-by such men as Giofreddi, Hirschlaff and more recently Valenti of
-Italy whose work, published in 1914, should have widest recognition.
-This fallacy has been responsible for many a case of addiction. Very
-many opiate addicts have passed into the stage of fully established
-addiction-disease before they were aware that they had ever taken an
-opiate.
-
-Clinical familiarity with the symptoms and signs of beginning and
-developing addiction should be the possession of every physician
-and surgeon. It would save from the physical sufferings, and mental
-tortures and fears of narcotic addiction many human beings. It has
-been my experience when called in as a medical consultant upon medical
-and surgical cases whose progress towards recovery seems unaccountably
-tedious and unsatisfactory, to detect as the basis for the lack
-of function and recuperative power, unsuspected developing opiate
-addiction in time to prevent its further progress. Unwisely prolonged
-opiate medication makes more opiate addicts than we have realized.
-
-The addict in whom it is most profitable to study addiction origin
-and development and handling, if we are to get a clean-cut picture of
-addiction-disease, is the individual who is primarily normal, mentally,
-morally and physically, whose addiction condition is a result of
-ignorant, misguided or unavoidable medication, either professionally or
-self-administered. Their number is far greater than is yet generally
-appreciated. Many if not most of them are unsuspected and unknown and
-they include eminent people in all walks of life. They are social, and
-economic assets whose interests and welfare we cannot ignore when we
-are considering the disposition and handling of the narcotic addict.
-
-Many of them have gone from one institution to another, and have
-attempted, in desperate effort to be cured, each newly-discovered and
-announced specific or theory of treatment. They have never derived any
-pleasure from narcotic use. For them the narcotic drug has been only
-necessary medication to relieve physical suffering and to maintain
-economic existence and the support of themselves and their families.
-They should be classed as innocent or accidental addicts--normal and
-worthy sick people. They earnestly desire treatment and help, and once
-their addiction process is completely arrested do not tend to return
-to narcotic drug use. Whatever associations they may have had with
-the unworthy or unfit of the so-called “underworld” and with illicit
-and illegitimate traffic has been the result of desperate necessity,
-in their best judgment, in the obtaining of opiate supply when it has
-seemed to them to be otherwise denied them, and which was necessary to
-them for the relief and avoidance of suffering and for the maintaining
-of a condition making possible self-support and the avoidance of
-revelation and disgrace.
-
-The narcotic addict of this type presents primarily and fundamentally a
-purely medical problem. Competent and complete arrest of the physical
-mechanism of narcotic drug need permanently removes him from the
-ranks of the narcotic drug user. The problem of his handling is one
-falling within the province of medical practice. His care is purely and
-simply a matter of the treatment of disease with medical intelligence
-and judgment on the established lines of medical practice in disease
-conditions generally. His after-care is simply such management of
-convalescence as is needed in ordinary medical cases. The length of his
-convalescence will depend entirely, just as in other diseases, upon
-the competency and intelligence of his medical handling and upon his
-physical condition, reaction, and recuperative ability.
-
-For such a man custodial care and institutional handling under
-conditions of enforced restraint are undesirable and harmful. His
-withdrawal from self-supporting citizenship should be for the
-shortest time commensurate with adequate therapeutic results.
-He should be restored to normal personal, social, and economic
-environment and activity at as early a time as possible following
-his clinical treatment and the arrest of his physical mechanism of
-addiction-disease. Given intelligent clinical handling, with rational
-therapeutic treatment, and a comprehensive meeting of the indications
-of disease in his case, he is no more a subject for unusual restraint
-and custodial care than is a case of malaria or pneumonia or other
-medical condition. He is in most cases a clinically curable medical
-case. He presents the true picture of addiction-disease uncomplicated
-by the distracting and confusing incidentals often met with in the
-types of cases more commonly discussed. The development of addiction in
-a case of this type is a purely physical matter, and is the addiction
-which should be considered in the fundamental comprehension of basic
-facts.
-
-
-_Stages of Addiction Development_
-
-Every case of well-developed addiction has followed in its development
-a course through several stages, definitely marked by clinical signs
-and reaction phenomena. I shall not exhaustively discuss all of these
-stages and their phenomena. The ones I shall mention will be recognized
-by most of those who have gone through them or have watched them
-develop.
-
- 1. _Stage of Normal Reaction to Therapeutic and Toxic Doses._
-
-The manifestations of this state in morphine administration for example
-are more fully described in our text-books of materia medica than I
-can take space for in this book, and are familiar to all physicians.
-The narcotic and analgesic effect with therapeutic doses; the euphoric
-and inhibitory action of doses in excess of the therapeutic; the
-toxic action manifested by the slowed pulse, slowed respiration, and
-generally arrested metabolism and function are too familiar to need
-elaboration.
-
- 2. _Stage of Increased Tolerance._
-
-Following continuous and consecutive administration of morphine (and
-the same is true of other opiates) comes failure to secure the effect
-which followed the early administration. Larger doses are needed for
-the relief of pain or other symptoms, or the original doses give relief
-for a shorter time. Toxic manifestations do not follow what would
-formerly have been a toxic dose. The patient requires what was formerly
-a toxic dose to secure the former therapeutic effect. The phenomena of
-this stage are familiar to every observing clinician who has used or
-seen morphine used for continued therapeutic action. The patient has
-acquired an increased tolerance of the drug and a beginning immunity
-to its toxic action. He does not, however, suffer appreciable hardship
-from drug deprivation. Discontinuance of the drug causes little or none
-of the symptoms to be described as “withdrawal signs.”
-
- 3. _Stage of Beginning Addiction._
-
-Following the stage of increased tolerance comes a stage where
-discontinuance or lack of administration of the narcotic drug gives
-definite signs and symptoms, beginning “withdrawal signs,” due to some
-beginning physical body demand for the drug and completely relievable
-only by its administration. These signs are identical with the first
-appearing withdrawal signs in a case of established addiction but as
-yet do not go beyond the beginning manifestations of “withdrawal”
-in a completely developed addiction. They are limited to a peculiar
-nervousness, restlessness, weakness, depression, etc. They persist for
-a few days only if the drug is denied and are endurable.
-
-As to length of time required for the passage through each of these
-previous stages or through both of them--dogmatic statement is
-impossible. The time is apparently influenced by a number of factors.
-Of course the varying inherent resistance or susceptibility of
-different individuals to any given disease condition must be considered
-in this disease. It varies also with different forms of opiates used
-and their modes of administration. The probable physical factors I am
-not yet ready to discuss. The recent Report of the Special Committee
-of the Treasury Department says, “Any one repeatedly taking a narcotic
-drug over a period of 30 days, in the case of a very susceptible
-individual for 10 days, is in grave danger of becoming an addict.”
-Certainly a physician should look for the signs and symptoms of
-tolerance and beginning addiction throughout his opiate administration.
-It is also well to exhaustively inquire into possible past history of
-unrecognized addiction in any of its three general stages. Some of
-those patients who have demonstrated an apparent unusual susceptibility
-and very rapid development will be found on careful analysis to have
-experienced an unrecognized or forgotten addiction in some stage of
-development. I have interesting data on this point.
-
- 4. _Stage of Established Addiction._
-
-In this stage the “withdrawal” symptoms and signs become more evident
-as results of opiate deprivation. They proceed through the mild
-discomfort and nervousness of the previous stage to the definite
-manifestations and constant unmistakable withdrawal phenomena to be
-described. The patient endures physical suffering and displays all
-the clinical evidence of it. There can be no question of will-power
-in this stage, nor of desire for narcotic drug for any other purpose
-than to escape physical suffering. Whether the patient was primarily an
-innocent and unconscious recipient of the drug, or of the class of the
-vicious and weak, he is now fundamentally a sick man, afflicted with
-a physical disease. Whether or not he ever experienced any euphoria
-or sensuous enjoyment, he now gets nothing of pleasure from narcotic
-administration. He gets, _simply_, relief from suffering. The opiate
-drug has become his _only_ immediate means of securing and maintaining
-a physical efficiency, a semblance of normality. No other drug will
-take its place. He can take tremendous doses without toxic effect.
-In this stage, if the drug is denied or withdrawn without competent
-handling, his suffering and incompetency is not, as in the previous
-stage, a matter of days but may persist for weeks or months after no
-narcotic has been administered.
-
-The general stages of addiction-disease development as above rather
-superficially outlined are not of course sharply marked in their
-transitions. They slowly merge one into the next and taken together
-constitute a gradual development from normal reaction to opiate to
-established addiction-disease.
-
-Most patients are in or nearing the stage of developed addiction when
-they are recognized or come for treatment. Developed addiction for
-narcotic drug means physical, bodily need for that drug; functional
-incompetency and suffering without that drug; comparative normality
-and efficiency only to be immediately secured and maintained by the
-continued use of that drug.
-
-This is the situation of the sufferer from addiction-disease until such
-time as the activity of his addiction-disease mechanism is arrested.
-
-       *       *       *       *       *
-
-Before I attempt exposition of the mechanism which seems to me best to
-explain addiction-disease and offer a basis for its rational handling,
-I shall offer several observations bearing upon physical or body
-reaction in the state of addiction.
-
-1. Experience of addicts and observations upon them show that the
-length of time over which an addiction sufferer is free from his
-“withdrawal” manifestations is in proportion to the amount he has
-recently taken. Under conditions eliminating various factors, outside
-of the addiction mechanism, which may influence this general rule,
-the ratio between the amount of recent dosage and the interval of
-freedom is almost mathematical. For example, if under given conditions
-one grain of morphine will keep an addict free from withdrawal
-manifestations for four hours, two grains will do this for nearly eight
-hours and three will have the same effect for about eleven hours. It
-would almost seem as if there were some substance produced in definite
-amount in each individual case at a given time, and neutralized or
-opposed by or in some way negatived in its action by a definite amount
-of opiate drug.
-
-2. Each addict shows a definite and approximately measurable daily
-minimum need for the drug of his addiction. If he is suffering from the
-deprivation of his drug, he will require a certain dose, measurable
-by its effect upon his symptomatology, before he is made physically
-comfortable and physically efficient again.
-
-3. The narcotic drug administered to an addict suffering withdrawal
-phenomena and symptomatology will relieve those manifestations exactly
-in proportion to the amounts of drug administered. Each addict has a
-constant sequence of symptoms attending the so-called “dying-out” of
-the drug. These symptoms are relieved in constant reverse sequence by
-the administration of the drug, and in exact proportion to the amount
-of drug administered, various incidental influences being eliminated.
-A small amount of the opiate will relieve the symptoms last appearing;
-another insufficient amount will relieve another proportion of the
-withdrawal signs, and so on, until the opiate drug administered
-balances in amount the extent of the addict’s deprivation, or physical
-need.
-
-This is almost mathematical in its working, and the average intelligent
-addict, after a few trials, can tell within a very close margin just
-how much opiate, in his accustomed form, has been administered by the
-extent to which it relieves his withdrawal signs. It almost seems as
-if the narcotic drug acted as some sort of an antidote for some poison
-present in definite amounts in the addict’s body.
-
-
-
-
-CHAPTER IV
-
-THE MECHANISM OF NARCOTIC DRUG ADDICTION-DISEASE
-
-
-I have in previous chapters referred to what are known as “withdrawal
-signs.” By this term has come to be known the manifestations displayed
-by a sufferer from addiction-disease at such times as his opiate is
-taken away or “withdrawn,” either totally or in part to such an extent
-that its amount does not meet the requirements of his physical needs.
-
-In observing opiate addicts over a length of time no one can escape the
-recognition of a chain of constantly present physical manifestations
-inevitably following the non-administration of the drug of addiction.
-These may vary in priority of onset, in sequence, and in relative
-violence of manifestation in different cases, but they are the
-inevitable result of non-administration of opiate to an opiate addict.
-I described them as follows in a paper on “Narcotic Addiction--A
-Systemic Disease Condition,” which was published in the _Journal of
-the American Medical Association_, February 8, 1913. “In a general way
-they may be said to begin with a vague uneasiness and restlessness
-and sense of depression; followed by yawning, sneezing, excessive
-mucous secretion, sweating, nausea, uncontrolled vomiting and purging,
-twitching and jerking, intense cramps and pains, abdominal distress,
-marked circulatory and cardiac insufficiency and irregularity, pulse
-going from extremes of slowness to extremes of rapidity with loss
-of tone, facies drawn and haggard, pallor deepening to greyness,
-exhaustion, collapse, and in some cases death.”
-
-These manifestations have been noted in various ways and to various
-extents and have been casually commented upon by most writers of the
-past. The conception of drug addiction as a “habit” has, however, in
-the past so overwhelmingly dominated the attitude of writers both
-medical and lay, that consideration of withdrawal signs as physical
-phenomena, and the analysis of their origin and mechanism on the basis
-of physical disease and constant body reaction has received all too
-little attention. The tendency has been to casually regard or belittle
-them as a part of the essential picture of narcotic addiction, and to
-place overwhelming emphasis upon mental desire as an explanation of the
-drug addict’s inability to discontinue the administration of opiate
-drugs. That these physical manifestations have had such incidental
-place and consideration in the general handling of the narcotic
-addict and in the consideration of the drug problem is to my mind the
-basic cause for past failure. Non-appreciation of them unquestionably
-explains in part the almost uniform lack of success which attended my
-own earliest efforts.
-
-One of the obstacles to an appreciation of narcotic drug
-addiction-disease has been the casual assumption on the part of the
-average person, both lay and scientific, that opiate drugs act upon
-the addict, and that he reacts to them similarly to the actions and
-reactions in the non-addicted individual. Morphine action, however,
-as commonly observed following therapeutic administration or in
-experimentation upon un-addicted animals gives no conception of its
-manifestations in the man or woman grown tolerant to its use. Many
-of the actions and reactions of opiate upon the un-addicted are
-practically lost in the addicted, and absolutely new reactions, unfound
-in the un-addicted individual, become the dominating factors in the
-opiate medication of the addict.
-
-To some extent the fallacies connected with the general conception
-of narcotic addiction have arisen from the mistaken application
-to addicts of opiate experience, experimental or otherwise, of the
-non-addicted. In the matter of sensations, for example, supposed
-to follow opiate administration, and to the enjoyment of which is
-widely attributed the addict’s indulgence--in practically none of the
-opiate addicts, once tolerance and organic dependence are completely
-established, do these sensations occur. The immediate effect of opiate
-to the addict, depending upon the extent of tolerance, and the reaction
-of the patient, in dosage not too much in excess of physical body need,
-is apparently support to function, the restoration or maintaining of
-normal circulation and nerve and glandular balance, prevention or
-relief of the agonizing withdrawal pains and manifestations and of
-impending collapse.
-
-Opiate is used by the large majority of opiate addicts simply and
-solely for its supportive action, and a certain amount for each addict
-becomes as much of a definite need and a necessary and integral part
-of his daily sustenance as food or air. The dream states and other
-sensuous results, occasionally observed, are when they occur as part of
-the minor toxic action of the drug, against which the developed addict
-is nearly or completely immune, and to the experiencing of which very
-few of the honest, innocent or accidental addicts have ever carried
-their dosage. They are commonly found only in the opium pipe smokers,
-an entirely different problem from that of the average narcotic addict.
-
-As has been stated, it is a fact that for each addict, a definite
-amount, varying with his condition of health, elimination, physical and
-mental activity, etc., meets a definite body-need. On this amount he
-can be put and kept in good physical and mental condition under normal
-circumstances of environment, exertion, and general hygiene. Years
-of efficient activity and upright responsible lives, accomplished by
-well-known men and women, unsuspected addicts, bear witness to this
-fact. An addict neither underdosed nor overdosed practically defies
-detection. Less than the definite amount required for nervous and
-glandular and circulatory support and organic balance deprives the
-patient of reaction, places his vitality and energy far below par and
-for a long time hinders his betterment. More than this amount displays
-the inhibitory effects of opiates, locks up or slows secretions and
-body functions, and causes malnutrition, autotoxemia, autotoxicosis,
-and the consequent mental and physical deterioration commonly and
-erroneously attributed to the direct action of opiate drug.
-
-In 1912 I wrote that so far as I knew the symptomatology attending
-insufficient supply of morphine (or other opiate) to an opiate
-addict had never received the amount of detailed study and analysis
-that it deserved and was not adequately interpreted. W. Marme had
-attributed the symptoms of morphine addiction to the toxic action
-of oxydimorphine. Rudolph Kobert, however, stated that Ludwig Toth
-subjected Marme’s claims to subsequent testing and was unable to
-confirm them, and that his own findings agreed with those of Toth. They
-found that oxydimorphine was inert by subcutaneous injection and that
-when thrown into the blood-stream it formed an insoluble substance
-causing emboli, and so producing the symptoms observed by Marme.
-Kobert seems to be in accord with the early findings of Magendie, that
-oxydimorphine is non-toxic. The experiments of Faust on dogs concerning
-increased power of the body to destroy morphine are well-known. It is
-still a matter of scientific dispute as to what extent the body of the
-opiate addict has developed the power to limit or destroy the poisonous
-properties of opiates by the conversion of these poisons through
-oxidation or other chemical action.
-
-The explanation of tolerance and withdrawal phenomena on the basis of
-something akin to an antitoxin or antitoxic substance circulating in
-the blood of the addict, has also, like the oxidation explanation,
-been a subject of controversy. Hirschlaff claimed to have produced
-an antitoxic serum against morphine. Morgenroth failed to confirm
-Hirschlaff’s findings, and argued against the existence of an
-antitoxin. The animal experimental and laboratory work and findings,
-however, of such men as Hirschlaff, Giofreddi and Valenti have helped
-to influence the trend of modern thought towards what may be regarded
-as the present strong tendency in scientific conception of the physical
-mechanism of narcotic drug addiction-disease--an autogenous antidotal
-or antitoxic substance.
-
-A recent paper by DuMez of the United States Public Health Service
-gives a comprehensive review of the work which has been done in
-connection with the study of increased tolerance and withdrawal
-phenomena, and shows conclusively the gradual inclination of modern
-opinion.
-
-There is considerable literature discussing various theories and
-experiments and observations, which has, however, not had widespread
-recognition.
-
-
-REFERENCES
-
- Bishop, E. S., “Narcotic Addiction--A Systemic Disease Condition,”
- _Journal A. M. A._, Feb. 8, 1913.
-
- Marme, W., “Untersuchungen zur acuten und chronischen
- Morphinvergiftung,” _Deutsch. med. Wchnschr._ 9: 197-198.
-
- Kobert, R., “Lehrbuch der Intoxikationen,” Stuttgart, 2; 995, 1906.
-
- Toth, L., “Bemerkungen zur Erklärung der chronischen Morphium
- Intoxikation,” Schmidt’s Jahrb. 229: 135, 1891.
-
- Faust, E. S., “Über die Uraschen der Gewöhnung an Morphin” Arch. f.
- exper. Path. u. Pharmakol. 44: 217-238, 1900.
-
- Hirschlaff, L., “Ein Heilserum zur Bekämpfung der Morphinsucht und
- Ähnlicher Intoxikationen,” _Berl. klin. Wchnschr._ 39: 1149-1152 and
- 1174-1177, 1902.
-
- Gioffredi, C, “L’immunite artificielle par les alcaloides,” 28,
- 402-407, and 31, fasc. 3, 1897.
-
- Valenti, A., “Experimentalle Untersuchungen über den chronischen
- Morphinismus; Kreislaufstörungen hervorgerufen durch das Serum
- morphinistscher Tiere in der Abstinenzperiode,” Arch. f. exper. Path
- u. Pharmakol., 75: 437-462, 1914.
-
- DuMez, A. G., “Increased Tolerance and Withdrawal Phenomena in Chronic
- Morphinism, A Review of the Literature,” _Jour. A. M. A._, 72:
- 1069-1072, 1919.
-
-My own present opinion and conception remains as expressed in a
-paper, “Narcotic Addiction--A Systemic Disease Condition,” written
-in 1912 and published in the _Journal of the American Medical
-Association_, Feb. 8, 1913, as follows, “It is my opinion that,
-however much increased oxidation aids in the handling of morphine, it
-is to the formation of an antitoxic substance that we must look for
-explanation of our clinical manifestations and for the classification
-of morphine-addiction as a definite medical entity. This opinion is
-based on certain clinical manifestations of morphine effect and the
-symptomatology attending insufficient supply of morphine to those
-addicted, on certain phenomena observed during and following treatment,
-on the persistence of tolerance and on the susceptibility of the cured
-patient to the re-formation of addiction.”
-
-Before elaborating this conception of addiction-disease, I think it
-desirable to repeat the enumeration of the principal manifestations of
-“withdrawal” or body-need for opiate drug. In a general way, they may
-be said to begin with a vague uneasiness and restlessness and sense
-of depression and weakness; followed by yawning, sneezing, sweating,
-excessive mucous secretion, nausea, uncontrollable vomiting and purging
-or diarrhea, twitching and jerking, sometimes violent jactitation,
-intense muscular cramps and pains (described as if the flesh were
-being torn from the bones), abdominal pain and distress, marked
-cardiac and circulatory insufficiency, and irregularity (often with
-marked dyspnea), pulse going from extremes of slowness to extremes of
-rapidity, with lowered blood-pressure and loss of tone, facies drawn
-and haggard, pallor deepening to greyness, exhaustion, collapse and in
-some cases, death.
-
-
-_Essential Mechanism of Narcotic Drug Addiction-Disease_
-
-If such clean-cut, strikingly apparent, constant, and undeniably
-physical phenomena and symptomatology as I have described are to be
-adequately explained, there must be some physical mechanism, some
-definite body process working upon fundamental principles of disease
-reaction. They certainly are not psychiatric manifestations nor the
-expressions of habit, appetite, vice, nor morbid indulgence. Enjoyment
-of morphine for itself, even in such patients as have ever experienced
-such enjoyment, is lost long before the stage of rooted or completely
-developed addiction is reached. Physical results must be explained by
-physical cause.
-
-Tolerance of and immunity to the toxic effects of narcotic drugs are
-primary and striking characteristics in the development of addiction.
-An antitoxin or antidotal substance is the recognized mechanism
-of their production in most diseases admittedly developing these
-characteristics. I have adopted the hypothesis, therefore, that an
-antidotal substance is manufactured by the body as a protection against
-the poisonous effects of narcotic drugs constantly administered. Such
-a substance, manufactured in the body, being antidotal to morphine,
-might well possess toxic properties of its own, exactly opposite in
-manifestation to those possessed by morphine and other opiates. Toxic
-substances exactly opposite to opiate in their action might readily
-account for the severe withdrawal signs, parallel in their extent
-to the extent of opiate insufficiency, and resembling in their
-characteristics the manifestations of acute poisoning.
-
-A hypothetical antidotal toxic substance, manufactured by the body as
-a protection against the toxic effects of continued administration of
-an opiate drug, will therefore explain the well-known development of
-tolerance and immunity in these cases, and will account for the violent
-physical withdrawal signs. In a word, it will explain the disease
-fundamentals on a definite physical basis.
-
-Such an hypothesis will explain the stages of development of
-addiction before outlined. In the stage of tolerance the antidotal
-toxic substance has begun to make its appearance in the body and
-to protect it against slight narcotic excess, but its manufacture
-is not sufficiently established to continue longer than necessary
-to neutralize the narcotic administered. In the stage of beginning
-addiction, or beginning narcotic-need, its manufacture has become
-more developed and more constant and proceeds for a longer time
-after the discontinuance of the narcotic drug. In the stage of fully
-developed addiction, or absolute narcotic need, the manufacture of
-the antidotal toxic substance has become practically an established
-pseudo-physiological body-process, and will continue long after the
-administration of the narcotic drug for reasons into which I have gone
-elsewhere. In other words, in narcotic drug addiction some antidotal
-toxic substance has become the constantly present poison, and the
-narcotic drug itself has become simply the antidote demanded for its
-control. In brief, fundamentally and basically, narcotic drug addiction
-is a condition presenting definite physical phenomena, symptoms, and
-signs, due to the presence within the body of some autogenous poison
-requiring narcotic drug for neutralization of it or of its effects.
-
-This explains the phenomena of the mathematical exactness with which
-the minimum daily need can be estimated under experimental conditions,
-and with which doses less than the amount of actual body need relieve
-existing withdrawal signs in definite proportion to the amount of
-opiate administered. In exact proportion as the drug of addiction is
-present in the body to neutralize or oppose some antidotal poison, is
-the patient free from withdrawal symptoms and from physical craving for
-the narcotic drug.
-
-The development and existence of such mechanism in the body of the
-opiate addict is suggested also by the apparent continuance of
-tolerance to opiate existing after long periods without drug in
-individuals who had previously suffered from addiction-disease, and in
-the susceptibility of the former sufferer subsequent to the arrest of
-his physical need for opiate, to the re-establishment of that need by
-the subsequent administration of the drug.
-
-Illustrative of this phenomenon is a case who, after about two years
-of relief from addiction-disease, developed pneumonia and to whom in
-delirium and threatened death, opiates were administered as unavoidable
-medication. After cessation of his delirium, he was dismayed to
-discover addiction-manifestations and body-need for opiate drug had
-been re-established. This history is one of a number in my possession,
-and has been verified.
-
-The case demonstrating the longest persistence of susceptibility among
-my records, is that of a man in the early fifties who underwent an
-emergency operation for infected gall-bladder. A day or two following
-operation he developed excruciating pain in his right side just under
-the ribs. It had been necessary to administer opiates since a day or
-two before the operation. I was called in consultation for the purpose
-of determining the character and origin of the pain, and diagnosed a
-pleurisy, the pain of which subsided on the following day. Opiates were
-discontinued with a result of precipitating unmistakable withdrawal
-phenomena. To his great anger and surprise, I accused the patient of
-being an opiate addict. He indignantly declared that he had never
-used opiates in his life. Subsequent investigation with the aid of
-older members of his family disclosed a distinct and typical history
-of addiction manifestations following opiate administration in the
-course of treatment of a complicated fracture of his thigh in early
-boyhood. The drug had been withdrawn at that time and the addiction
-manifestations finally disappeared, he never having been aware of the
-facts. His reawakened addiction-manifestations were easily and quickly
-checked.
-
-It is evident from many histories that large dosage robbed of or
-modified in its toxic effect, and even in the opiate manifestations
-usual in subjects who have never been made tolerant, and small dosage
-being sufficient to re-awaken physical need for opiates are conditions
-which do exist and persist for indefinite periods. The resemblance
-between this continued tolerance and the conditions existing in
-diseases which confer immunity and having a generally accepted
-antitoxin mechanism is too close to be ignored.
-
-Evidence of a toxic substance in the body of a narcotic-addict is
-further presented by the similarity of the clinical pictures presented
-by these cases of acute opiate need and extremely severe cases of
-acute poisoning from materials such as the ptomains and some other
-poisons. Acute opiate need is clinically typical of intense suffering
-and prostration from the action of some powerful poison. Its symptoms
-cannot be due to opiate, for the reason that the administration of
-opiate relieves them, and relieves them exactly in ratio to the
-amount of opiate administered. They can be held at any given stage by
-gradation of the opiate dosage. Their manifestations, moreover, are
-exactly opposite to opiate effect. They are to my mind best explained
-as due to the action of some toxic substance, antidotal to opiate,
-prepared by the body for its protection in response to continued opiate
-presence in the body, as antitoxins are prepared for the neutralization
-of or opposition to the organic poisons of invading bacteria. The
-chemical or physical character or nature of such substance has not been
-yet determined.
-
-The presence of such a substance would explain the establishing of
-tolerance, the manifestations following opiate administration and the
-apparent definiteness of the amount of opiate needed. It would explain
-the results of under-dosage and the results of over-dosage, and the
-practical non-interference with function or general health when a
-dosage is maintained exactly sufficient in amount to neutralize the
-effect of some exactly antidotal body or substance.
-
-An antidotal substance would also explain the after effects of and
-the so-called “relapses” which occur after most of the cases treated
-by whatever method or procedure, without due appreciation and proper
-estimation of the clinical manifestations and indications of addiction
-symptoms and physical body need, and without due consideration of the
-patient’s reactive abilities and physical condition. These patients are
-in a condition of restlessness, discomfort, vague pains, mental and
-physical depression, lowered physical vitality and weakness. They have
-a sense of a physical lack of support. They cannot endure nor react to
-over-exertion, worry, strain, etc. This condition may persist for weeks
-and months after no opiate has been administered. The above seem to be
-mild withdrawal symptoms of an incompletely arrested addiction-disease
-mechanism and might be explained by a continued manufacture of small
-amounts-of antidotal toxic substance, causing a low grade chronic
-poisoning. They can be duplicated in active opiate addiction before
-withdrawal by administering an amount of opiate slightly below the
-amount of need and so leaving unneutralized a small amount of the
-antidotal toxic substance.
-
-If continued production of a toxic antidotal substance, after
-discontinuance of the drug which called it into being is to explain
-the existence of the condition I have just described, the causation
-of this continued production must be accounted for. It is conceivable
-that in the development of addiction-disease mechanism a tolerance
-of and slowness to eliminate opiate or some product of opiate is
-acquired by all the cells of the body, perhaps especially by the
-liver, and that these tolerant and atonic cells are extremely slow of
-opiate elimination. Under this condition, a residue of opiate or some
-product of opiate capable of antidotal substance stimulation might
-remain unresponsive, or very slow of response, to ordinary cellular
-and other elimination. If this should prove to be the fact, it would
-account for a continued production of antidotal toxic substance, and
-might, moreover, in any given case, either before or after cessation of
-opiate medication, be one of the determining factors in the amount of
-antidotal substance produced, or, in other words, in the measure of the
-extent of body-need for opiate drug.
-
-
-_Inhibition of Function_
-
-What characteristic action exists in opiate or narcotic drugs which
-gives them this power to establish the above described mechanism?
-It seems to me that it is, above all, their power to inhibit body
-function. They tend markedly to arrest metabolic processes. They
-inhibit glandular activity. They inhibit unstriped muscle activity and
-hence peristalsis. They, therefore, cause a slowing up of glandular
-function and intestinal activity, and of elimination. This results in
-an accumulation of opiate in the body. It is this constant accumulation
-to which the body must become tolerant by the development of some
-mechanism for its protection.
-
-
-_Autointoxication and Autotoxicosis_
-
-It is to the element of inhibition of function also that we must look
-for explanation of what is by far the most important element in the
-immediate picture presented by most individual cases. I refer to
-autotoxicosis and to auto- and intestinal toxemia. The same power that
-locks up within the body the opiate drug, locks up the toxic products
-of tissue activity and tissue waste, of intestinal poisons and of
-insufficient metabolism. Autotoxemia itself is markedly inhibitory in
-its action, and contributes no little to its own increase and to the
-further development of narcotic disease.
-
-It is not at all impossible that any inhibiting poison constantly
-present in the body will some day be found to establish a mechanism of
-protection, similar to that of opiate addiction, and that some of the
-states now popularly and loosely classified under the general head of
-“autointoxications” will be recognized as really addiction-states, in
-which the body has become progressively tolerant of its own poisons.
-I believe that it can be demonstrated that some of the phenomena and
-manifestations at times observed in chronically inhibited and autotoxic
-individuals in whom there can be no suspicion of any opiate or narcotic
-element are analogous to the phenomena of narcotic addiction mechanism.
-It is not inconceivable that any inhibiting poison or toxin is capable
-of producing its own addiction-mechanism, and it has seemed to me that
-my own clinical familiarity with the action and reaction of narcotic,
-inhibiting, or addiction-forming drugs and of addiction-mechanism upon
-circulation, glandular and intestinal and other function has been of no
-little assistance in the interpretation, control and remedy of other
-chronic intoxications.
-
-Upon the extent of inhibition of function and autointoxication,
-therefore, depend some of the immediately predominating manifestations
-in individual cases. They must be reckoned with and eliminated in
-the measure of addiction-disease in the individual sufferer. In many
-cases they contribute the immediate and compelling indications for
-rational therapeutic endeavor. To a considerable extent they determine
-circulatory efficiency and metabolic and glandular activity and
-balance. They largely control physical tone and physical reaction.
-Inhibition and intestinal and autotoxemia cause most of the physical
-and mental deterioration, and much of the incidental symptomatology
-so widely ascribed directly to narcotic drug effect. Upon the extent
-of their presence, therefore, depends greatly the clinical picture in
-the individual case. This doubtless accounts for the acidosis, noted
-by Jennings and others, inasmuch as it has been definitely proved that
-acidosis is commonly present in all conditions of functional depression
-and exhaustion.
-
-With inhibition and auto and other toxemia eliminated or reduced to
-a minimum, the patient can go through many years, an apparent normal
-man, well-nourished, reactive, in good physical tone, mentally sane
-and physically competent. Under these conditions he shows practically
-nothing abnormal as long as he gets properly administered, his
-accustomed narcotic drug, in the amount of its minimum physical
-requirement or body-need. His condition is often unsuspected by those
-nearest and dearest to him, and the popularly held opinion that
-narcotic addiction shortens life does not seem to be upheld by the
-facts in his case. Such cases as his are far more numerous than has as
-yet been realized.
-
-In the types of narcotic addicts most widely recognized inhibition
-of function and autointoxication is marked, and the opiate drug is
-used in excess of body-need. The addict of this description becomes a
-deteriorated wreck, requiring high doses of opiate for the satisfaction
-of abnormal body-need, mentally and physically incompetent--the
-generally accepted picture of the so-called “dope-fiend,” a
-deteriorated, degenerated, malnourished wretch, degraded, avoided and
-condemned.
-
-Inhibition of function and autointoxication should not be vague
-terms. They cause and are measurable by definite clinical evidence.
-They display manifest phenomena and symptoms, and become increasingly
-defined material entities as the clinician looks for them as such.
-Much of inhibition of function and autointoxication and of their
-manifestations, has been recognized and taught under their own
-heading and in connection with conditions other than narcotic drug
-addiction-disease. That the influence and importance of inhibition of
-function and autointoxication in the development, and manifestations
-of the narcotic drug addict has escaped general and widespread
-recognition, is evidence of the small amount of unbiased clinical
-study, and of analytical clinical interpretation of material physical
-phenomena, hitherto accorded to narcotic drug cases.
-
-I would not have it concluded that all symptoms and manifestations
-arising in the handling of a drug addict are due to the factors and
-elements I have discussed in this chapter. It must be always in the
-mind of the intelligent and conscientious physician, that he has in his
-care a human being with the same medical and psychical possibilities
-that must be taken into careful and complete account, as in the
-handling of any other sick person. There is an unfortunate tendency to
-overlook concurrent, or complicating or pre-existing conditions in the
-handling of the narcotic drug addict. These cases are often extremely
-complex and difficult to analyze, and for adequate comprehension and
-handling of them, the symptoms and manifestations they show should be
-appreciated in their true origin and character as they occur in each
-individual case.
-
-
-
-
-CHAPTER V
-
-REMARKS ON METHODS OF TREATING NARCOTIC DRUG ADDICTION
-
-
-Most physicians have at some time or other in the course of their
-practice encountered cases of narcotic addiction. Most addicts have
-appealed to the physician for advice and help. A very large proportion
-of them have at different times made effort to obtain relief from
-their affliction through the avenues of various forms of treatment,
-advertised and otherwise. Most physicians have at some time or other
-made effort to rescue some victim from drug addiction, and as a rule
-have given over the effort as hopeless, because even when they had
-succeeded in taking his narcotic away from the patient, usually after
-an experience trying and exhausting to both, the patient has resumed
-narcotic administration--according to the patient, because he had
-to--according to the average observer, because he wanted to. Frequently
-the patient has refused to persevere to the end of treatment and has
-abandoned his attempts before the treatment has reached the point of
-cessation of opiate medication--the patient stating that he could
-not--the observer believing that he would not, continue, and did not
-have the courage or stamina or will to endure the necessary suffering.
-The medical profession as a whole has adopted a cynical attitude
-towards the possibility of permanent “cure,” and towards the efficacy
-of medical treatment, which has tended to send the addict to quacks and
-charlatans and various advertised remedies.
-
-It is not my purpose to discuss in this book in detail the various
-methods, and treatments and cures advocated and employed in the
-handling of the drug addict. This alone would require a volume in
-itself.
-
-Three broad lines of procedure have been employed; so-called
-“slow-reduction,” “sudden withdrawal,” and withdrawal accompanied by
-the administration of various drugs, such as those in the belladonna
-group and its alkaloids.
-
-Slow reduction or “gradual reduction” as a “method” is employed by
-slowly or gradually, reducing the patient’s accustomed dosage to the
-point of discontinuance of opiate medication. Interpreted by a great
-many to mean that the fact of reduction is the principal indication in
-clinical procedure, successful in the hands of a few who have acquired
-unusual technical skill and clinical ability in the interpretation
-of addiction manifestations, I believe it to have failed as a method
-of cure in the hands of the average. Practically every addict has
-attempted it one or more times. As a method of procedure in some
-stages and under some conditions of addiction treatment, slow or
-gradual reduction of dosage has its value. In my opinion, however,
-all other considerations aside, there are very few who are possessed
-of sufficient understanding of narcotic addiction and ability in the
-interpretation of clinical indications, and have the technical skill
-required to carry it through to a clinically successful culmination.
-As a method of routine or forcible application it has many serious
-objections as well as potentialities for damage to the patient. In
-cases whose opiate intake is in excess of actual physical-need, gradual
-reduction as often practiced is perfectly easy and unnecessarily
-slow down to the amount demanded as a minimum by the patient’s
-addiction-disease requirements. Then must come withdrawal, nagging,
-exhausting and protracted, if unskillful reduction is persisted in,
-and the wrench of actual final withdrawal is nearly as severe from a
-very small dosage as from a moderate one, other conditions in the
-case, physical and mental, being equal. Prolonged “withdrawal” without
-rare technical skill and without unusual and not commonly available
-environment and conditions of life, means subjecting the patient to
-the continued strain of persistent self-denial and self-control in the
-face of continued suffering, discomfort, and physical need and constant
-desire for their relief. It is my opinion that this experience has
-in many cases tended to deeply impress upon the mind of the patient
-so-called “craving” for the drug, and has converted many a case of
-simple physical addiction-disease into a more or less mental state
-which may be described as “morphinomania” or “narcomania.”
-
-This last observation does not apply to the method of gradual reduction
-only, but is equally true of protracted suffering under any other
-procedure in which the individual is cognizant of the existence of
-means of immediate if only temporary relief.
-
-In the comprehension of this a physician has only to glance back over
-his professional experience and recall cases of various conditions
-other than addiction which have come to him, and whose histories
-present the effect of long protracted suffering and discomfort in the
-conversion of an average normal, self-supporting human being into a
-dependent neurasthenic.
-
-The histories given by most narcotic addicts of their efforts to get
-relieved of addiction, show that following the withdrawal of opiate
-drug in many if not most instances has come weeks and months of
-weakness, and discomfort, nervousness, sleeplessness, and pain which
-have persisted for weeks and months, establishing the basis for the
-much emphasized “after care,” of some investigators.
-
-While so-called “after care” is unquestionably as important as
-convalescence from any other disease, it is my belief that as
-understanding of addiction as a clinical disease becomes more general,
-and more attention is paid to the study and scientific management of
-the disease itself, the stage of “after care” will come to assume less
-importance. Addiction is not the only disease which furnishes examples
-of cases in which incomplete and unsatisfactory results have been
-merely a low-grade continuation of the fundamental disease and have
-been interpreted as a protracted convalescence.
-
-“After care,” or convalescence, following satisfactory results of
-clinical treatment and complete arrest of addiction-mechanism activity
-has no terrors for either physician or patient. It is very short and
-does not require any more restraint than any other convalescence,
-unless conditions exist following active treatment which should have
-been recognized and handled and eliminated earlier from the picture. I
-shall discuss this again later.
-
-“Sudden” or “forcible” withdrawal, or immediate deprivation of opiate
-drug is still advocated by some investigators, fewer and fewer of
-them, however, among medical men. There are cases of, and stages in
-addiction-disease and its development where this means of procedure may
-be pursued without all of the serious objections with which it must be
-regarded as a routine method of general enforcement.
-
-That forcible deprivation of opiate drug may end in death is a matter
-of too easily found and authoritative medical record to be ignored. It
-has been discussed as one of the possibilities by medical writers over
-many years. Even the newspaper reports of deaths and suicides following
-sudden deprivation of opiate should be sufficient to give pause to
-those who would still advocate this measure as a desirable procedure.
-
-Reference to the previous enumerations of the physical manifestations
-of body-need for opiate, or “withdrawal signs,” should be sufficient
-for the comprehension of its tortures and easily explains the suicides
-which have attended sudden deprivation. Any one who has watched a
-well-developed case of addiction-disease in the agonies of opiate
-deprivation should hesitate to prolong them if possibly avoidable.
-While under some conditions, and in some cases, it may be argued that
-“the ends will justify any means,” as a routine procedure of wide
-application, it must be stated that both in its immediate torment and
-in its end results, mere forcible sudden withdrawal is not a procedure
-of election. Some of its supporters still cling to and quote the old
-fallacy that after seventy-two hours without opiate a narcotic addict
-no longer physically requires it. This fallacy is probably based upon
-the estimated maximum time of opiate elimination in normal human
-beings and experimental animals. It is most decidedly false doctrine
-as applied to the well-developed case of addiction-disease in whom the
-mechanism of disease, and not the mere administration or elimination of
-opiate has become what should be the dominating consideration.
-
-As stated before, the mere withdrawal of opiate drug does not arrest
-the activity of addiction-disease, nor prevent the endurance of the
-exhausting and incapacitating and protracted low-grade manifestations
-before referred to. Its potentialities of permanent damage, moreover,
-are attested by and displayed by many who show for years shattered
-nerves, premature old age, etc.
-
-It is perhaps wise to state again in this place that in this book
-the consideration of narcotic or opiate addiction, its mechanism
-symptomatology and handling, is not to be applied to cocaine and
-alcohol use nor to the various other drugs often loosely grouped
-with opiates as “habit-forming.” Until a distinct physical disease
-mechanism, attended by analogous characteristic and constant physical
-phenomena, can be demonstrated as resulting from the action of one of
-these drugs or substances, its continued use should not be classed with
-opiate addiction-disease.
-
-The third general method of procedure is that in which effort is
-made to utilize other drugs than opiates, or other measures than mere
-reduction or withdrawal or deprivation to secure cessation of opiate
-medication. The efforts have been, in a general plan, either to oppose
-or replace the action of opiate by substance or substances seemingly
-to have physiologically antagonistic or substitution properties--or to
-combat, offset or benumb the sufferings of what is described as the
-“withdrawal period.” Such agents have been employed in this disease
-for very many years, and in their variety include most of the known
-analgesic, sedative, antispasmodic, hypnotic or anesthetic agents and
-measures.
-
-Prominent among the drugs mentioned have been the preparations and
-alkaloids of belladonna, of hyoscyamus, pilocarpine, and some others.
-These drugs have by reason of more or less supposed specific action,
-alone, or in various combinations or in conjunction with purgatives,
-etc., formed the basis for many if not most of the various special
-treatments and “cures.” For example, what is described as the “specific
-mixture” of one of the most widely-known treatments contains as its
-active agents belladonna and hyoscyamus. These drugs are not mentioned
-here in condemnation of their employment as therapeutic measures
-in the hands of those skilled in the estimation of their values,
-indications and actions--and dangers if unskillfully employed. They
-have unquestioned therapeutic value in their proper places, as and when
-properly indicated, in individual cases. Routinely used, as specific
-curative agents, they seem to me to be demonstrating their failure. In
-the conception of addiction-disease herein outlined it is difficult to
-attribute to them specific properties.
-
-In a paper, “The Rational Handling of the Narcotic Addict” read before
-the Section on Pharmacology and Therapeutics, Annual Session of the
-American Medical Association, 1916, I stated, “It is not my purpose
-to enter into discussion of the various therapeutic methods and
-therapeutic measures which have been advocated and employed in the
-treatment of narcotic addiction. Their number is legion, and they
-include most of the therapies known to lay as well as to medical
-literature.
-
-“Their multitude is conclusive proof of lack of conception and of
-understanding of addiction-disease in the past. They have been directed
-towards incidental and complicating manifestations. They have no more
-place in the treatment of the addict than they have in the treatment
-of any other disease condition. I know of no medication that can be
-called ‘specific’ in the arrest of the mechanism of narcotic drug
-addiction-disease. There is no more of a specific remedy for narcotic
-drug addiction than there is for typhoid or pneumonia. The wide
-advertisement of treatments based on supposed ‘specific’ action of
-the products of the belladonna and hyoscyamus and similar groups is
-unfortunate. They have in my opinion, no action as curative agents in
-narcotic drug addiction-disease which can entitle them to consideration
-as specific or special curative remedies. The drugs of this group
-are useful in many cases, intelligently applied to meet therapeutic
-indications. They exhibit wide variation of action and reaction in
-narcotic drug addicts at different clinical stages and under different
-clinical conditions, and their dosage presents an extremely wide range
-of individual measure. They are dangerous drugs in the hands of the
-inexpert or careless, or used in a routine manner or dosage. The status
-which they have acquired as specific medication in narcotic addiction
-disease I hold to be a medical fallacy which should be strongly opposed
-and early remedied.”
-
-The search for panaceas, specifics and routine treatments has
-constituted a stage in the therapeutic history of most disease
-conditions. It marks the effort to make wide and general application
-of a partial comprehension of facts and imperfect recognition
-of fundamentals and is successful only as an individual case is
-occasionally capable of responding, perhaps by clinical accident, to
-the specific routine employed.
-
-Undue insistence and publicity secured for or given to a procedure of
-this description, is a real obstacle to the development of clinical
-and scientific understanding of the condition treated. It distracts
-attention from broad clinical consideration of disease itself, from
-scientific investigation into pathology and disease mechanism, from
-determination and observation of fundamental facts, whose comprehension
-and analysis form the essential factor in the widespread successful
-handling of any condition, and from proper conception and appreciation
-of the addiction patient and the addiction problem as a whole with its
-many and varied aspects.
-
-Various procedures in themselves, however, are not to be utterly
-discredited and condemned. They have performed a function in a
-transitional stage of education and progress. They can all bring
-evidence in support of some “cures.” In their origin and inception
-they represent honest effort, study and original thought. In analysis
-of them can be seen, in the minds of those who first evolved them,
-recognition and application of one or another of the basic elements,
-reactions or facts of addiction-disease. Each generation builds upon
-and adds to the work of the previous one, discards or adopts according
-to its more complete knowledge. We are building upon the various
-procedures of the past just as our successors will build upon our work
-of the present and will discard or adopt our various instruments and
-theories.
-
-We are nearing the end of consideration of routinely applied
-procedures, in all diseases. In addiction we are entering upon a
-stage of attitude and handling in which there shall be in each case
-comprehension of intrinsic elements and appreciation of their relative
-importance, and in which there shall be competent interpretation of
-symptomatology and competent selection and application of therapeutic
-measures, placing our efforts on a rational basis and adapting handling
-and treatment to the needs of the individual.
-
-Our stumbling-block in the past has been that our minds have been too
-much focused upon the mere use of narcotic drug and upon the stopping
-of drug use and too little upon the individual we were treating and the
-mechanism of his disease. We have tended to apply our remedial efforts
-to narcotic use instead of to narcotic drug addiction-disease.
-
-This may explain the paucity of clinical and scientific information
-as to addiction-disease coming from the institutions in which these
-cases are gathered. It seems to be the fact that the narcotic wards of
-our great charity hospitals and institutions of custody and correction
-still in great measure proceed with their handling of narcotic addicts
-on the basis of mental or moral degeneracy or deficiency or weakness of
-will, or morbid appetite, etc., or apply one or another of the various
-remedies or combinations of remedies. Their internes and nurses do not
-seem to graduate with a conception of addiction as a definite physical
-disease, with clinically significant symptomatology and constant
-physical reactions and phenomena. That these institutions have after
-many years given us so little information as to the definite physical
-symptoms and phenomena which their patients constantly manifest is
-in large measure the result of attention directed to control of drug
-use instead of to alleviation of physical addiction-disease. There
-has been much discussion over various methods of treatment and over
-measures for the control of patient and of narcotic drug, and there
-has been insufficient study and analysis of the clinical details
-of addiction-disease manifestations and their possible therapeutic
-significance.
-
-There has been of late, however, signs of change in this situation,
-and in this change lies one of the greatest hopes of solution of the
-narcotic drug problem. The attitude towards addiction is beginning to
-follow the trend of modern medicine in getting away from special or
-routine treatments, and the search for specifics and panaceas, and in
-aiming at and devoting great effort to the searching out, consideration
-of, and treatment of fundamental cause and underlying condition. When
-this method of approach is applied widely to addiction-disease, and
-the facilities of our great hospitals and institutions of research
-properly directed to its furtherance, there will come a re-arrangement
-of conception of opiate addiction. Restraint and custodial care,
-and psychologic and psychiatric classification will be applied more
-sparingly. Many worthy sick people will--instead of being refused
-treatment, or turned back upon their own resources after inadequate
-treatment--thus adding to the public and private burden of the care of
-the unfit--be rationally treated as sick people and returned to health
-and self-supporting competency.
-
-The one great point to be kept in mind is that narcotic addicts are
-sick; sick of a definite and now demonstrable disease. This disease is
-variously complicated and widely variable as it occurs in individual
-patients. Although some individuals, afflicted with this disease, may
-require custodial or correctional handling--the fundamental physical
-disease cannot be properly arrested nor handled successfully by
-mental, moral, sociological or penological methods only. Any toxic,
-worried, fear-ridden or suffering sick man may show psychological or
-even psychiatrical manifestations or complications, but observing and
-attempting to control complications only will not cure basic disease.
-
-Even if it should some day develop that a serum can be produced
-against the underlying toxins of addiction-disease; and this is not
-beyond the bounds of possibility; its usefulness and application must
-remain for the present matters of academic speculation. Other than
-this possibility, there seems practically no hope of a properly called
-“specific medication” in narcotic drug addiction-disease. Even with its
-discovery, it is highly improbable that a routine treatment applicable
-to all cases could ever be successfully adopted. In the very few
-disease conditions in which we can properly be said to have “specific”
-medication, routine handling and treatment of all cases is inadvisable
-and unsatisfactory.
-
-There is not and probably never will be any specific routine treatment
-successfully applicable to all cases of any complex and variable
-disease condition. We shall save much public money, and personal
-effort and time, and shall save the narcotic addict much suffering and
-discouragement, and shall add much to human health, competency and
-happiness when we realize these facts as applied to addiction-disease,
-and proceed upon them in a spirit of broad humanity and of rational
-clinical study and remedy of obvious disease symptomatology. Narcotic
-drug addiction-disease is a definite, and in most cases arrestable
-disease. It should be widely so regarded and studied and treated.
-
-
-
-
-CHAPTER VI
-
-THE RATIONAL HANDLING OF NARCOTIC DRUG ADDICTION-DISEASE
-
-
-If anything has been demonstrated conclusively concerning narcotics it
-is that the methods of the past, legal, administrative, and medical,
-have not solved the narcotic drug problem, nor controlled the narcotic
-drug situation, nor been successful in the handling of the narcotic
-drug addict.
-
-Some factor or element of great and fundamental importance has
-obviously been neglected. This lacking element is general recognition
-of the presence of disease processes which cause the symptomatology
-and phenomena of body-need for opiate drug. One of the essentials for
-the practical solution and management of the narcotic drug problem is
-the realization by the medical profession, legislators, administrators
-and laity that opiate drug addiction is a definite disease entity, to
-be treated as such, and calling for extensive clinical and laboratory
-investigation and study such as have been accorded other diseases over
-which we have gained the mastery. One of the most needed achievements
-in the line of practical remedy is the admission of narcotic drug
-addiction-disease to its legitimate place as an accepted part of
-the practice of internal medicine and the stimulating of education
-concerning it among medical practitioners, medical students and nurses.
-
-As was stated in the last chapter, too much emphasis has been placed
-on drug use and drug withdrawal, as if the drug itself were the most
-important element in the clinical picture of addiction. In the handling
-and treatment of addiction-disease it should be constantly borne in
-mind that the ultimate withdrawal of opiate from the addict is simply
-one stage, and not by any means the most important consideration
-in his rational handling. Its management in most cases is a matter
-of scientific clinical certainty and satisfactory accomplishment
-by the physician who understands the disease he is treating and
-who is clinically proficient in the control of its elements by
-indicated therapeutic procedure. The ease of handling the stage of
-final withdrawal, the extent to which suffering, nervous strain and
-exhaustion can be avoided in it, and its final issue depend greatly
-upon the physical and reactive condition of the man from whom drug
-is withdrawn. Like the stage of crisis in pneumonia, its course
-and conduct and results are largely influenced by the condition in
-which the patient approaches the withdrawal. It is of vastly more
-importance to measure and control reactions and treat a patient so as
-to get him into the fittest possible condition for final withdrawal
-and rapid convalescence, than it is to focus attention on the mere
-reduction or withdrawal of drug, or on the mere amount of drug used.
-Final withdrawal of drug, like an operation of election, is to be
-done when the patient is in the fittest condition and ready for it.
-With the addict who is well nourished, non-inhibited, and physically
-and glandularly reactive, it can be accomplished with little or no
-discomfort, in a very short time, leaving practically nothing to demand
-a protracted and difficult stage of convalescence or of so-called
-“after care.”
-
-It becomes evident, therefore, that the handling of an opiate addict,
-preliminary to withdrawal of the drug to which he is addicted is
-of greatest importance. The ease of withdrawal and rapidity and
-completeness of subsequent recuperation, is largely commensurate
-with the extent of organic dependence upon the drug and the physical
-condition of the patient. One man using the same amount as another is
-dependent upon its effects for the support of his organic processes
-to a much greater extent. The evident solution lies in a preliminary
-stage, removing inhibition, reducing in so far as possible organic
-and functional dependence upon drug, and putting the patient into the
-best possible reactive condition. I believe that in many cases it is
-imperative for successful issue to train the patient for the shock and
-strain of opiate withdrawal and in practically all other cases, though
-less imperative, most desirable.
-
-It has been objected that this will prolong treatment. My experience
-has been that it very much facilitates withdrawal treatment, and not
-only renders it easier and more uniformly successful and complete, but
-that it tends to shorten and make less troublesome, and in some cases
-practically eliminates, convalescence.
-
-I have therefore instituted as an important part of my procedure, a
-Preliminary Stage of study and handling and treatment of my patient
-before attempting withdrawal of the drug. During this time I study my
-patient, regarding him not simply as a narcotic addict but as a sick
-man to be investigated as carefully as a cardiac or any other patient,
-and all his organic and functional conditions appreciated, and all of
-his functional and glandular actions estimated in their competency
-and balance and their reactions both to the drug of addiction and to
-the influences of addiction disease mechanism. Conditions long masked
-by opiates, and forgotten, even by the patient himself, may seriously
-affect treatment, convalescence and prognosis if undetected before
-withdrawal is instituted. Their relations to and possible influence
-upon addiction and its treatment, and fully as important--the possible
-effect of treatment and withdrawal of drug upon them, should be very
-carefully estimated. If advisable or possible they should be remedied
-before withdrawal of the drug of addiction.
-
-Also such mental or psychical disturbances as may exist in a given
-case should be traced to their origin, estimated and reckoned with.
-Very often they will be found to be not inherent but a result of past
-suffering and present worry and fear. The patient’s confidence in
-his physician’s ability to treat the disease from which he suffers
-should be strengthened, and his doubts and fears allayed. Addiction
-patients are well informed concerning opiates and are acquainted with
-the manifestations of addiction-disease, and have had experience with
-or full information concerning the various methods of cure. They are,
-like any other chronic sick person, suspiciously and keenly analytic of
-themselves and of the physician, and unless handled with appreciation
-of their condition are naturally the prey of constant worry and fear.
-Co-operation and confidence between patient and physician vastly
-influence the amount of nervous energy expended by both, and in this,
-as in other diseases are big factors in treatment and in convalescence.
-
-Another advantage of a preliminary stage is one which has been too
-little considered, but which will before long come to demand the same
-intelligent attention and measure as is given to the contemplation
-of operations in and treatment for chronic other conditions. It
-is this--in what condition will withdrawal of opiate even though
-skillfully conducted and successfully accomplished, leave the
-individual in his value to himself, and to his family and to the
-community, in view of co-existing physical conditions? Withdrawal of
-opiate drug has been in not a few cases the cause of transforming of
-a capable and useful citizen into an invalid incompetent, for whose
-ultimate salvation and competent physical and mental function and
-organic and glandular control resumption of opiate medication was
-determined to be a therapeutic necessity.
-
-Such considerations as this should be all taken, analyzed and
-estimated in a preliminary stage and if treatment is only going to
-injure a patient he should be instructed how to handle his addiction,
-and advised to continue his opiate medication, and not be subjected to
-useless expense and trials.
-
-
-_Basic Principles of Addiction-disease Handling_
-
-Intelligent addicts well know that, other factors being equal, the less
-number of times in a day they take their drug, the less inhibited, the
-less constipated and more normal they are, and the smaller amount of
-narcotic drug they require to maintain them physically and mentally
-competent. It is unfortunate that this therapeutic principle so widely
-recognized among intelligent addicts has not received full recognition
-and therapeutic employment by all of those who handle and treat
-addiction-disease. Its probable explanation is very simple--apparently
-a period of inhibition follows the administration of narcotic or opiate
-drugs; and the length of this period is not in ratio to the size of the
-dose administered. Consequently, the fewer number of times in a day a
-dose of narcotic drug is administered, the greater amount of competent
-metabolism is present--the more adequate is the patient’s elimination
-and nutrition--the smaller amount of opiate or its product lies stored
-in inhibited and atonic cells, and the smaller amount of antidotal
-substance is manufactured for the protection of the body, and to some
-extent, the smaller amount of opiate is required.
-
-In caring for the narcotic addict, therefore, one of the most important
-therapeutic measures is the regulation of the interval of his narcotic
-drug administration. I have repeatedly experimented upon addicts who
-were not confined or under restraint in any way. I explained to them
-the inhibitory effects of too frequent dosage and instructed them to
-use the amount of drug they found necessary for twenty-four hours in
-larger doses at longer intervals. This procedure alone, in many cases
-transforms the pallid, starved, constipated and deteriorated addict
-within a surprisingly short time into a well-nourished, well-reactive
-and practically normally functioning individual. With the return of
-health, vitality, and normal nutrition and elimination, his body
-requires still less drug and he voluntarily and without mental struggle
-and nervous strain reduces the amount of drug used. I wish to emphasize
-that in these experimental cases there were no other therapeutic
-measures employed in the way of medication.
-
-The practical therapeutic application of wide-interval administration
-of opiate drug is made possible by the fact that the narcotic addict
-can tolerate without harm large doses of the drug of addiction. It is
-made controllable by the fact, that, within certain limits, the length
-of time over which a dose of narcotic drug will maintain a patient in
-narcotic drug balance--or free from the symptomatology of drug need--is
-in mathematical ratio to the size of the dose administered. Each addict
-requires, under the conditions of his daily life at a given time, to
-satisfy the demands of his physical addiction-disease mechanism, and
-to maintain him in narcotic drug balance, an amount of drug which can
-be estimated in terms of twenty-four hours and which I have called the
-amount of minimum daily need. The most important consideration in the
-administration of narcotic drug to a narcotic addict is to supply the
-amount of minimum daily need and maintain narcotic drug balance with
-the least inhibition of function.
-
-Failure to maintain narcotic drug balance and a degree below the amount
-of minimum daily need renders the addict functionally and physically
-incompetent. He is in a condition of physical and nerve incapacity
-and exhaustion. He has no physical tone; he has markedly impaired
-circulation; he cannot react, he has no recuperative powers; he has
-constantly in his body, according to modern theory, unneutralized
-autogenous poison which robs him of vitality, reaction and functional
-efficiency even though it may not be present in sufficient amounts
-to give rise to the violent spectacular and agonizing manifestations
-of complete narcotic deprivation. In other words, as I have written
-elsewhere, “the reduction of the drug of addiction below the amount
-of body-need robs the addict of his most valuable asset in securing
-and maintaining recuperative powers.” In no other disease would an
-intelligent physician persist in the application of measures which
-robbed his patient of recuperative powers and expect satisfactory issue
-of the case he was trying to treat. Until the physician and patient are
-ready and prepared for the institution of the stage of final withdrawal
-of drug, the patient should never be allowed to drop below the amount
-of minimum daily need in his opiate intake.
-
-It is evident therefore, that upon the intelligent and competent
-estimation, measure and control of physical narcotic drug balance and
-inhibition of function depend the reaction, well being and therapeutic
-progress of the man who has narcotic drug addiction-disease. These
-factors also markedly influence the action of all medication,
-including the drug of addiction, upon the body of the opiate addict.
-They influence the reaction of the addict’s body to all medication.
-Medication cannot be intelligently administered to the opiate addict
-unless those who administer it have understanding and clinical
-appreciation of the widely varying reaction of the addict under
-different conditions of drug balance and inhibition of function.
-Failure to recognize and appreciate this fact explains a considerable
-portion of the past failures and the past mortality attending specific
-and special methods and treatments, and so-called “cures.” The dosage
-of medication administered and the time of its administration should
-therefore be determined upon with watchful eye to the reaction of the
-patient, and with intelligent comprehension of the possibilities in
-reactionary change.
-
-The actions and the dosage of therapeutic agents have been largely
-determined by experimentation on individuals and animals of average
-normal reaction. The toxic, the inhibited and the narcotic addicted
-do not display the normal reaction to therapeutic agents. Under some
-conditions they over-react both physically and nervously, and under
-other conditions they under-react. Detailed consideration of this
-matter is not possible in this book. It offers for investigation a
-field well worthy of exploration both clinical and laboratory. It
-will only state that as the manifestations and influences of toxemia,
-functional exhaustion, inhibition, and, in the addicted, of varying
-physical drug balance, have become increasingly definite and tangible
-and capable of clinical measure and determination, my medication of the
-toxic and the exhausted and the inhibited individual, as well as of
-the narcotic addicted, has become progressively more effective. These
-observations apply to conditions other than opiate drug addiction, and
-are worthy of consideration in all toxic, and exhaustion and depression
-states.
-
-I have already spoken of the imperative physical need for the drug of
-addiction. I have also referred to the amount of minimum daily need for
-the drug of addiction. The recognition of factors which influence these
-is of great importance. Many of these factors are so commonplace and
-so obvious in their relation to the extent of body need that they are
-appreciated by most intelligent addicts. Anything which increases the
-expenditure of physical and nervous energy increases the addict’s need
-for opiate drug. Among the most potent influences are worry, fear and
-physical suffering. They consume physical fuel; and an important part
-of the addict’s physical fuel is the drug of his addiction. In addition
-to this, worry and fear and suffering are also markedly inhibitory
-of glandular and peristaltic function. The expenditure of energy in
-mental and muscular work also calls for increased supply of the drug of
-addiction. I need not enlarge upon this important fact. Its application
-to the handling and treatment of the addict is evident. Narcotic drug
-should be supplied to meet the physical needs of the individual case,
-and only be decreased as intelligent handling of the factors which
-determine that need have lessened it.
-
-The method of gradual reduction of dose to the point of ultimate
-discontinuance is practical and feasible under conditions and at an
-expense of time and money which are possible to but very few addicts.
-The forcible reduction of dose without regard to the environmental,
-mental, economic, physical or other conditions of the average and
-individual addict, and absolutely ignoring the considerations of the
-mechanism and symptomatology of his addiction-disease is barbarous,
-harmful and futile. Enforced reduction of dose below the point of
-body need is not worth what it costs in nerve-strain, suffering, and
-physical inadequacy. The extent of addiction-disease and the degree of
-progress in its remedy cannot be measured in terms of amount of drug
-administered. It must be measured in terms of clinical symptomatology,
-just as progress is measured in any other disease. Reduction of dose
-below the amount of body need, prior to the stage of final withdrawal,
-constitutes a serious therapeutic handicap and is most decidedly
-contra-indicated. Withdrawal of opiate from an addict whose physical
-reaction and strength and nerve force have been reduced and depleted by
-continued reduction of amount of drug without commensurate reduction
-in the extent of body need is harder than withdrawal from a reactive
-individual with reserve nerve and physical force who may be taking a
-much larger dose.
-
-The average addict must support himself and his family. His physical
-well-being and economic efficiency should be considerations in
-the welfare of the community in which he lives. Legislative and
-other investigation has shown that we are entirely unequipped both
-institutionally and professionally for the successful immediate
-withdrawal of opiate from even a small proportion of our present
-census of the opiate addicted. In view therefore, of the practical
-impossibility of immediate successful withdrawal treatment, and in
-view of what is known and can be demonstrated and taught in the
-accomplishment of final withdrawal, I do not hesitate to state that,
-until we are prepared and in a position to skillfully and competently
-handle the stage of final withdrawal to assured successful issue, it
-is much wiser to supply to the addict who is not a public menace the
-drug of his addiction to the extent of his physical needs, and to teach
-him how to use the drug of addiction in such a way as will maintain
-his physical and economic efficiency, than it is by enforced reduction
-of dose to deprive him for a long time of working ability and his
-family of his support. Furthermore, the addict who is insufficiently
-supplied with the opiate of his addiction, turns in desperation to the
-use of things far more harmful to him than the drug of his addiction.
-This he does in the vain hope of obtaining mental and nervous and
-physical stimulus and support and some surcease of his misery. The
-many wrecks of addicts to be seen trying through insufficient supply
-of narcotic drug, self-poisoned with other drugs which they have
-purchased, alcohol, bromides, coal tar products, cocaine, and of late
-hyoscine--their addiction disease unrelieved and undiminished--are
-sufficient argument against mere reduction of dose, below physical body
-need.
-
-The personal attitude of the physician towards opiate addicted patients
-is of great importance. The medical man who is to treat a case
-suffering from addiction-disease successfully to the end of relieving
-this condition, or who is treating addiction-disease as an intercurrent
-condition complicating another disease, must first of all make his
-patient realize that the physician himself knows something about
-addiction as a disease. He must never give his patient any hint or
-reason to suspect that he regards opiate addiction as a habit, a vice,
-a degrading indulgence which can be to any curative or even therapeutic
-extent, combatted by the exercise of will-power.
-
-In their desperation and ignorance, the vast majority of addicts
-have repeatedly exercised will-power in self-denial of their drug to
-the limits of their physical endurance, and they know the futility
-and suffering of attempts based simply and solely upon the exercise
-of will-power. Experience has taught them actual facts concerning
-the physical action of narcotic drugs and concerning the results of
-insufficient supply of narcotic drug in a man who is addicted. The
-addict knows that he does not take a drug because he enjoys it. He
-knows that he experiences no sensuous gratification or other pleasure
-from its administration. He knows that he uses a narcotic drug simply
-and solely because he has to use it to escape physical incompetence and
-physical agony. As I said before, almost without exception the narcotic
-addict has proceeded of his own accord, or under the direction and
-advice of others, on the theory of exercising will power, and resisting
-temptation. With the few exceptions of those made in a very early stage
-and before addiction mechanism had become strongly developed and rooted
-in his physical processes, such efforts on the basis of this theory
-have been useless.
-
-It is practically impossible to argue successfully on the basis of
-theory with the man who has experienced facts. Narcotic addiction
-furnishes a class of patients who know more about their own disease
-than any other class of people. They can accurately estimate the extent
-of understanding and knowledge possessed by the man who is treating
-them, and they are desperately critical. Almost without exception,
-except for some of the true “underworld,” they desire above all else
-to escape from their condition. I know that this is not the popular
-conception and for the present may be by some regarded as heresy.
-Therefore, it is of essential importance that between the doctor who
-treats an addict of average intelligence and that addict must exist
-co-operation and understanding. As soon as this patient realizes two
-things--that the doctor does not believe his expressed wish to be
-cured, and that he interprets the patient’s desire for relief from
-suffering as simply a desire for more opiate and the expression of
-habit, vice or degraded appetite which should be controlled by the
-exercise of “will-power,”--there is an end to that patient’s confidence
-in that doctor, and to the help that that doctor can give to that
-patient. As I have written elsewhere, the opiate addict of average
-intelligence will co-operate with his medical adviser to the extent of
-his physical endurance, so long as he has any belief in that adviser’s
-understanding of his condition, and ability to help him.
-
-In my own work, and as a result of my own experience I have found
-that as a rule the extent to which an intelligent addiction patient
-cooperates with me has been a measure of the understanding and
-technical ability with which I handled him, rather than a measure
-of his desire to be helped. It is held by many that a majority of
-addiction-patients are not possessed of average intelligence and are
-not honest in their statements. I will simply say that even in the
-Alcoholic and Prison Wards of Bellevue and in the narcotic wards
-of the New York Workhouse Hospital I came more and more to seek in
-faults of medical and nursing handling the explanation of apparent
-lack of cooperation. In the Annual Report of the New York Department
-of Correction for 1915, in commenting upon the work of the narcotic
-wards, is stated, “In ratio as there has been at any given time
-among our interne and nursing staff comprehension and understanding
-of the manifestations and underlying principles of narcotic drug
-addiction-disease and of its rational handling in the individual case,
-our results have been good or bad.”
-
-Several years ago I wrote as follows: “As to the existing opinion that
-the morphinist does not want to be cured and that while under treatment
-he cannot be trusted and will not cooperate but will secretly secure
-and use his drug, I can only quote from personal experience with these
-cases. During my early attempts, 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 upon their supposed weakness of will and lack of determination
-to get rid of their malady. Later I realized the fact that the blame
-rested entirely upon the shoulders of my medical inefficiency and my
-lack of understanding and ability to observe and interpret my patient’s
-condition. The morphinist as a rule will cooperate and will suffer
-to the limit of his endurance. Demanding cooperation of a case of
-morphinism during and following incompetent withdrawal of the drug is
-much like asking a man to cooperate for an indefinite period in his
-own torture. There is a limit to every one’s power of endurance of
-suffering.”
-
-Of primary importance, then, if a physician, institutional or
-practitioner, is to have any success in handling a case of opiate
-addiction-disease, is his attitude towards his patient--divesting
-himself of all conception of habit, appetite or vice as explanation
-of characteristic physical manifestations and symptomatology, and
-approaching the patient as a man with a definite disease requiring and
-deserving intelligent clinical handling. The patient will be the very
-first to mark a physician’s shortcomings. If he has not confidence in
-the doctor’s ability and understanding of his illness the doctor can
-help him but little. This statement applies not to addiction-disease
-alone but to every medical condition.
-
-There are three clinical demonstrable elements to be determined,
-measured and controlled in the actual therapeutic handling of cases of
-narcotic addiction-disease. The first of these is the actual amount
-of drug which the patient’s body demands to maintain functional and
-organic efficiency and to escape physical distress. The second of these
-is the extent of auto- and intestinal-intoxication, autotoxicosis
-and malnutrition. The third of these, which is both a result of and
-a causative element in the other two, is the extent of inhibition of
-function.
-
-In the successful handling of a case of addiction-disease, therefore,
-the first effort should be to determine approximately the amount of the
-patient’s minimum daily physical need for the drug of his addiction.
-This need is clinically recognizable and definitely measurable. It
-should be met to whatever extent it is present so long as it exists,
-and dosage diminished only as competent treatment diminishes the extent
-of need. This physical need can be demonstrated and accurately measured
-by clean-cut symptomatology. It can be expressed in mathematical
-terms of amounts of drug required in twenty-four hours. Work, worry,
-strain--anything which consumes physical or nervous energy increases
-this need. If this physical need is not met the patient is robbed of
-physical tone and physical reaction. He is robbed of metabolic balance
-and functional competency. He is, in short, robbed of the basic ability
-which his body has to regain health.
-
-In the estimation of this amount of physical need the procedure is
-very simple. Have administered to the patient who is manifesting the
-symptomatology of drug-need, sufficient drug to remove the symptoms
-and restore him to complete physical, functional and nerve balance.
-Have the length of time observed which elapses before the symptoms of
-drug need reappear. Have this repeated several times and information
-is secured as to what quantity of opiate under the existing conditions
-will hold that patient in drug-balance for a known length of time.
-In this way can be mathematically estimated the extent of physical
-drug-need. The average need for twenty-four hours can be easily
-computed from the data obtained. It is merely a matter of arithmetic.
-
-The regulation of dosage can also be estimated with approximate
-accuracy. As has been stated before, the interval of freedom from
-withdrawal manifestations is found to be, in a general way and within
-certain limits, in ratio to the size of the dosage. For example, if
-in a given case, under given conditions of fear, worry, physical or
-nervous strain, pain, etc., as discussed elsewhere--one grain of
-morphine will last a given patient at a given time for four hours;
-under the same conditions two grains will last for approximately eight
-hours. There are limits to the application of this rule. It is stated
-as the general operating of an addiction-disease phenomenon which is
-useful as a therapeutic guide.
-
-The amount of actual physical body need as capable of approximate
-estimation in the above manner should be administered to the patient,
-any reduction being guided by the fact that his clinical symptomatology
-and physical manifestations demonstrate that the amount required by his
-addiction-disease has been reduced. It is much wiser for the progress
-of the average addiction case to have the drug administered in the
-amount of estimated physical need than it is to attempt to reduce
-the amount of drug before his reactions show reduction in physical
-drug-need. The success of outcome and the measure of progress in
-such a case is not to be estimated by the amount of drug the patient
-is receiving, but is to be measured by the patient’s condition and
-clinical manifestations. The mere fact that a physician has reduced a
-narcotic addict’s opiate intake from a large dosage to a very small
-dosage, or indeed has denied him any opiate at all for a considerable
-length of time, is no evidence that he is curing or has cured his
-patient of addiction-disease. Unless the physical mechanism of
-body-need for an opiate has been completely and actually quieted, the
-patient may have in his body for perhaps weeks and months after the
-last administration of the drug, a physical demand for it. _The taking
-of opiate does not constitute opiate addiction-disease_. Also the mere
-fact that an addict is no longer taking opiate does not constitute
-proof that he is “cured” of opiate addiction. The non-recognition
-of this fact lies at the root of much past failure. The general
-axiomatic statement might be that an addict should be supplied with
-the drug of his addiction to the complete extent of his physical need
-at any given time until conditions are right for the undertaking of
-assuredly competent opiate withdrawal and complete arrest of his
-addiction-disease mechanism.
-
-The mere amount of drug used by a patient in twenty-four hours is
-a matter of minor importance compared with the general health,
-physical tone, nervous glandular and functional balance, reaction
-and resistance of that patient. Also the amount of drug taken by a
-patient in twenty-four hours is absolutely no adequate measure of the
-strength or stage of development of his addiction-disease. If he does
-not get enough opiate he cannot competently functionate; he cannot be
-adequately nourished; he cannot sufficiently eliminate. He is subjected
-to the influences of constant discomfort and nerve strain in the
-endurance of low-grade withdrawal manifestations. He is worried and
-becoming exhausted. It becomes apparent that by continued maintenance
-of narcotic administration below the amount of physical body-drug-need
-the very factors are created which have been described as increasing
-body-drug-need. It is difficult to see any therapeutic advantage in
-such a situation. Moreover, as has been stated before, it is far easier
-to eradicate completely and successfully narcotic drug need in a short
-time and without marked discomfort, from a functionally competent and
-organically healthy man who is taking a physically sufficient amount,
-than it is from a nerve-racked, worried and physically, nervously, and
-functionally exhausted wreck who is under-dosed.
-
-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.
-
-I follow no “routine” and have no set procedure. I am guided, as in my
-handling of the other stages of addiction-disease, by the condition of
-my patient and his clinical requirements. There is no one procedure
-applicable to all cases of any condition in medicine and surgery. In
-narcotic addiction-disease, as in all other conditions of medicine
-and surgery, the man who will have the best results is the man who
-is possessed of the widest and most varied experience combined with
-intelligent observation, technical skill and clinical judgment in the
-selection of procedure best adapted to the needs of the individual
-case. Familiarity and experience with different methods and procedures
-reveals in each and nearly all of them some advantages and some
-defects. The wise man and the man whose results will most approach
-uniform success is he who can make intelligent selection and use of
-whatever is most applicable to the needs of the case he treats, either
-out of his own experience and discoveries, or out of his familiarity
-with the work of others.
-
-An element in successful withdrawal of narcotic must also remain, as
-in everything else, the inherent personal gifts and qualifications of
-the individual operator. A man works best with the tools most adapted
-to his hand, and operators of different temperaments and of different
-experience and training will always disagree on points of procedure and
-technique. My own procedure in final withdrawal is determined largely
-by my study and measure of my patient and my patient’s reactions,
-addiction and otherwise, during my preliminary or preparatory work,
-selecting the time for final withdrawal of drug by consideration of
-similar factors as would be taken into account in an operation of
-election.
-
-After a preliminary stage, or stage of preparation, in which I have
-gotten rid of all possible abnormalities, physical and psychical, with
-my patient robust and reactive, confident and expectantly happy, with
-autointoxication, and inhibition removed and the possible residues of
-opiate or opiate product no longer stored in atonic body cells--the
-addiction-mechanism, therefore, only kept in activity by the current
-intake of opiate, which if properly handled and the patient not
-subjected to exhausting strain and struggle and suffering, can be
-eliminated in a very short time. With these conditions consummated,
-I hasten elimination, keeping well away from exhausting purgation,
-maintaining my patient’s circulatory and other functions, and
-conducting as rapid a withdrawal as is compatible with my patient’s
-reactive condition and the reactions of his disease.
-
-In other words, I endeavor by my conduct of the case to reverse the
-process of development of the physical addiction-disease with its
-concomitants and complications, as I find it in the individual case,
-arresting the addiction-disease mechanism only after I have cleared the
-clinical picture in so far as possible of all other considerations.
-
-In a majority of cases by experienced choice of clinical procedure,
-combined with judgment and technical skill, the arrest of
-addiction-mechanism and the restoration of the narcotic addict to
-health and freedom from both opiate need and thought of opiate drug is
-a matter of assured accomplishment attended by little if any nervous
-strain and physical suffering.
-
-Ability to accomplish this is not beyond the power or any competent
-practitioner, whether he reside in a hospital or is in private
-practice. All that is required is instruction or information as to
-the mechanism of addiction-disease, clinical demonstration of its
-manifestations and reactions and the same amount of experience in their
-handling as is expected of a man who treats any other disease.
-
-I have purposely refrained in this book from discussion of technical
-details of therapeutic procedures, and of various medications, and of
-their various indications, contraindications, applications, dosage,
-etc. Such discussion, to be adequate and competent, would require much
-space and would distract from the general presentation of the problem,
-which is the purpose of this volume.
-
-I have learned from experience in teaching and in treatment of cases
-that before there has been established appreciation of the whole
-personal and clinical problem and picture, and conception of its
-disease mechanism, and ability clinically to recognize and interpret
-symptomatology, discussion of technical details is premature and
-misleading.
-
-
-
-
-CHAPTER VII
-
-RELATION OF NARCOTIC DRUG ADDICTION TO SURGICAL CASES AND INTERCURRENT
-DISEASES
-
-
-It is a common idea in the minds of both surgeons and physicians that
-an addict to narcotic drug is a difficult case for surgical handling
-and is a poor surgical risk. Numerous instances of surgeons refusing to
-operate upon a narcotic addict until the addict should have “stopped”
-the use of the drug, voice the almost prevailing attitude.
-
-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.
-
-[Illustration: (Chart of Sphygmographic Tracings)]
-
-First tracing (number 1) was made about 6:00 P. M.
-
-Tracings 2, 3 and 4 were made at about fifteen minute intervals. They
-were made following experimental hypodermic injections of morphine
-sulphate to determine the extent of opiate need and organic dependence
-upon opiate medication, and the amount of opiate required to restore
-organic function and tone.
-
-Tracing number 4, taking into consideration the asthenic and exhaustion
-condition of the patient, shows full support to circulation with some
-overaction.
-
-Tracing number 5 was taken an hour or two after tracing number 4 to
-determine the holding power of the dosage administered, after the
-circulation had reacted from the immediate stimulation of the opiate
-medication. This tracing, interpreted and considered together with the
-clinical manifestations at the time, was decided to be about normal for
-that patient at that time.
-
-This patient would have died, not from pneumonia with cardiac
-complications, but from insufficient control of the mechanism of opiate
-addiction-disease.
-
-On balanced and indicated daily morphine dosage, patient made very
-rapid recovery and has continued well and active.
-
-Such cases as this, where addiction-disease co-exists or is
-intercurrent with other medical or with surgical conditions, are not
-as uncommon as may be supposed. That they are frequently unrecognized
-the histories of many narcotic addicts demonstrates, and is discussed
-later. Board of Health and Insurance mortality statistics are
-undoubtedly very incomplete upon this situation. Addiction, regarded
-as a habit or indulgence, may easily be overlooked or disregarded as
-a cause of death, direct or contributing. It may easily be omitted
-from returns made out, however actually important a part in the final
-issue may have been played by the influences, upon body function and
-upon physical resistance and recuperation, of an unappreciated and
-inadequately controlled addiction-disease.
-
-It is earlier stated that the common idea of the addict to narcotic
-drugs as a poor risk is an undeserved reputation, and is not to be
-laid at the door of addiction existence itself. In very many cases
-of opiate addiction, the opposite of the popular belief is true. The
-opiate addict, if his addiction mechanism is competently appreciated,
-its reactions accurately estimated, and its influences wisely
-controlled, is quite other than a bad risk. Indeed the mechanism of
-addiction and the opiate which caused it can often be handled in such
-a way in the control of glandular, circulatory, nervous and other
-function and reaction as to aid in the carrying over of emergencies,
-medical and surgical. A case in point is an emergency operation on the
-pancreas, performed upon a man in extremis, whose unexpected recovery
-and convalescence astonished all observers by being remarkedly rapid
-and uncomplicated, due unquestionably in large part to the early
-recognition and clinical handling of his addiction-disease, and the
-possibilities it created for unusual opiate medication.
-
-It has been my experience at times, when called in medical consultation
-upon post-operative cases whose lack of repair and slowness of recovery
-could not be accounted for, to discover an unsuspected addiction, and
-to find that the lack of repair and slowness of recovery was due simply
-and slowly to the want of comprehension of, or to inadequate control of
-addiction mechanism existing in the patient.
-
-Many opiate addicts when about to undergo operation, have provided
-for possible contingencies by the concealment of, or by outside
-provision for, a supply of opiate sufficient in amount to meet their
-physical needs. There are very many addicts who have, out of their
-past experience and study upon themselves, competently controlled
-their own narcotic-drug-disease during treatment for other conditions,
-operative or medical. The number of narcotic addicts is not few
-who have been cared for medically with nursing attention, or have
-undergone operations for the remedy of various surgical conditions,
-have recovered, convalesced and been discharged without the physician
-or surgeon becoming aware that his patient was addicted. This is
-not a comment in criticism upon my professional brethren. In my
-own experience such a case is a matter of quite recent occurrence.
-A patient treated by me in a hospital, for conditions other than
-addiction, one day unexpectedly revealed to me the fact of long
-standing addiction. The patient had been afraid to tell me about this
-condition until thoroughly convinced of my attitude towards it, and had
-secured opiate medication elsewhere.
-
-It seems strange that a condition of as powerful influence over body
-function and metabolism as is exerted by the addiction mechanism of
-narcotic drug-disease should not long ago have received exhaustive
-and complete clinical and laboratory study along the lines of its
-manifestations and influences, as well as along the line of reduction
-and deprivation of the drug of addiction. In view of the above it would
-seem to be of vastly more importance at the present time that the mass
-of practitioners of surgery as well as of medicine should understand
-and be able to control action and reaction in a narcotic addict as a
-result of his addiction-disease mechanism, than it is that they should
-attempt the mere reduction or denial of the drug of addiction.
-
-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.
-
-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.
-
-The honest physician has no desire to dodge responsibility for his
-handling of narcotic addicts to the best of his ability, nor should he
-have any objection to a reasonable responsibility and accounting for
-narcotic drugs used in that handling; especially since the taking of
-narcotic drugs has in certain of its phases, developed as a serious
-situation entirely outside of the medical profession, in which
-situation these drugs are non-professionally supplied and used to such
-an extent as to constitute a public menace. The non-medical supplying
-and administering of such drugs should not, however, be controlled
-in such a way as to unduly hamper their honest and legitimate use by
-medical men, and to deprive the honest, worthy and innocent sufferer
-from addiction-disease of their legitimate therapeutic administration.
-
-One of the chief and most serious phases of the narcotic drug problem,
-which for obvious reasons has especially called for legislation, is
-the illicit and illegitimate commerce in narcotic drugs. The class
-of addicts which constitutes a public menace is largely so supplied.
-This fact is recognized in the recent report of the Special Committee
-of Investigation Appointed by the Secretary of the Treasury, in which
-is stated, “This illegitimate traffic has developed to enormous
-proportions in recent years, and is a serious menace at the present
-time. It is through these channels that the addict of the underworld
-now secures the bulk of his supplies.”
-
-This Report further states that “there is the so-called ‘underground’
-traffic which is estimated to be equal in magnitude to that carried
-on through legitimate channels. This trade is in the hands of the
-so-called ‘Dope peddlers,’ who appear to have a national organization
-for procuring and disposing of their supplies. For the most part it is
-thought that they obtain their supplies by smuggling them from Mexico
-or Canada, although smaller quantities of these drugs are obtained from
-unscrupulous dealers in this country or by theft,” etc. There should
-be some way to dissociate entirely, conclusively and finally in the
-minds of the public the illegitimate and underworld traffic in narcotic
-drugs from the efforts of the honest physician to practice rational and
-scientific medicine in the help of the worthy and deserving addict.
-The regulation of the narcotic drug traffic of the underworld or
-“underground” is not the business of the medical profession, and the
-burden of responsibility for it should not be placed upon the shoulders
-of the medical profession or the consequences of it made to react upon
-the head of the honest physician and innocent addiction sufferer. There
-is a tremendous number of excellent and worthy and even illustrious
-people in whom addiction is in no way associated with vice, or other
-morbidity of mental or environmental origin, who are merely, solely
-and simply sick people suffering from addiction-disease, whose problem
-is the control of that disease until it can be arrested by competent
-therapeutic procedure, for which they constantly seek. Misconception
-of them and neglect of sufficient consideration of them is the tragic
-aspect of the narcotic drug situation, and causes tremendous individual
-and economic wastage. They do not in any way associate with underground
-traffic unless or until driven to it by failure of legitimate sources
-of opiate medication, or by the surrounding of legitimate sources with
-such restrictions as make the man of standing and reputation, afflicted
-with addiction-disease, fear possible publicity and economic detriment.
-
-It is the duty of the medical organizations to see to it that these
-deserving purely medical problems and worthy sick people and their
-honest medical advisers shall no longer than avoidable be permitted
-to remain confused in the minds of the laity and of the medical
-profession itself with the problems of regulation of “underground”
-traffic and the control of the “underworld” addict. It is the duty of
-the medical organizations also to see to it that in the public press
-and elsewhere, and especially in their own scientific journals, the
-acts of the occasional individual with medical degree who prostitutes
-his medical standing and the aims and ideals of his profession in the
-commercial exploitation of the drug addict are not presented in such
-a way as to cause by inference or otherwise, their confusion with the
-honest efforts of honest medical men who are engaged to the best of
-their ability in the humane and ethical help of the deserving sufferer
-from addiction-disease.
-
-It is, furthermore, the duty of the medical organizations to see to it
-that whatever laws and regulations are promulgated in the control of
-criminal and unworthy shall not be framed or administered in such a
-way as to unnecessarily jeopardize the reputation and liberties of the
-honest practitioner and to interfere with his conscientious efforts to
-care for his honest and innocent addiction-disease patients to such an
-extent as makes that care impossible.
-
-Legislation or administrative regulation which limits to responsible
-and authorized persons possession and distribution of narcotic drugs
-and which compels from such persons reasonable accounting for such
-possession and distribution, is under conditions which have long
-existed but only recently been sufficiently recognized necessary and
-desirable. The Harrison Law was a definite response to an obvious
-need, in its obvious intent and draughting a wise and unobjectionable
-legislation. It provided for responsible possession and distribution
-and it enforced an accounting for the same, but did not unwisely
-restrict, in its text, nor hamper the legitimate possession and
-honest therapeutic employment of narcotic drugs. From the medical
-organizations and educational and scientific institutions should
-be available scientific study and understanding of narcotic drug
-addiction-disease available for the information of conscientious
-executives and administrators, who must exercise their best judgment
-in the light of available and prevailing teaching. It is the duty of
-the medical organizations to see to it that available and prevailing
-addiction-disease information and teaching is honest, unbiased and
-competent.
-
-Those who are responsible for our laws should remember that the
-possible interpretation and administration of the laws they draught are
-very important considerations, and determine the real effect of the
-laws often more than does the intent of the makers. Legislation which
-is unduly stringent or is capable of unduly stringent administration
-may have unfortunate reaction and influence upon honest effort in
-the care of the deserving sick. Restricting beyond reasonable limits
-the care of the honest narcotic drug addict simply tends to make
-it impracticable and dangerous for the average medical man to have
-anything to do with narcotic addicts, and to drive the honest and
-deserving patient into the underworld, into the insane asylum or to
-suicide. Until we have provided scientific and clinical study, and
-have thoroughly investigated present and possible medical treatment
-and handling of narcotic-drug addiction-disease, and have established
-humane and effective therapeutic measures and procedures in the control
-and remedy of this disease, we should not deprive the majority of
-honest addicts of the only medication and means by which they can at
-present remain self-supporting citizens. The handling of the problem
-of the underworld and of underground supply is not going to be solved
-by too restrictive regulation of the honest physician. Legislation
-or regulation which makes it practically impossible for the honest
-physician to care for the honest case of addiction-disease is a boon
-to charlatans, and medical shysters, and the illicit underworld traffic.
-
-It is the opinion of some that the handling and treatment of narcotic
-addiction should be taken out of the hands of the practitioner of
-medicine. The statement is made that the practitioner of medicine is
-not competent to handle a case of this disease. It has been advised
-that the treatment of narcotic addicts should be restricted to a small
-number of specially designated and licensed men and institutions. How
-and by whom are those special men and institutions to be selected?
-In the present state of chaotic and widely diversified medical and
-lay opinion as to narcotic addiction and the narcotic addict it would
-be a very difficult matter to select the men or the institutions for
-such absolute control. The comprehension, study and investigation
-of narcotic drug addiction has entered a stage of evolution and
-development in which new facts and new truths--both as to the addict
-and as to the condition from which he suffers--are being recognized
-and must be threshed out, correlated and coordinated with hitherto
-existing opinion before too restrictive measures will be anything but
-narrow-visioned, premature and harmful.
-
-There are undoubtedly institutions, many of them not widely known,
-in which is available skillful, humane, intelligent and successful
-handling of this disease. From personal observation and experience
-in institutional work, and from analysis and investigation of many
-histories, it is my opinion that the results of institutional treatment
-depend more upon the quality of its medical and nursing staff than upon
-any other consideration. That the mere fact that addiction-disease is
-handled in an institution is a very minor consideration in comparison
-with the intelligence of that handling, is amply attested to in the
-testimony of the Whitney Hearings and by the experience of many
-addicts. Unquestionably, unknown and large numbers of narcotic addicts
-have been relieved of their addiction in reputable sanitaria conducted
-by skillful and competent medical men. Also unquestionably, large
-numbers of addicts have been relieved of their addiction through the
-honest efforts of practitioners of medicine, in private practice.
-Unfortunately these efforts and their results have received entirely
-too little recognition.
-
-The average physician may be inexpert and not as completely educated
-in the appreciation, understanding and clinical handling of narcotic
-drug addiction-disease as he is in other diseases. The common-sense
-remedy for this situation, however, is not to drive the addict out of
-his hands, but to make him as competent in that addict’s handling as
-he is in any other clinical condition. It is only a matter of time
-and education before the competent practitioner of internal medicine
-can be brought to a comprehension of and ability to intelligently
-handle addiction-disease. It is largely a matter of securing general
-appreciation of and ability to clinically recognize, and interpret
-physical symptomatology, and to meet the indications of individual
-disease manifestations.
-
-The ultimate solution of the problem of handling the narcotic addict
-lies largely in the education of medical men, both in institutions and
-in private practice, and through them securing lay appreciation of
-disease facts. Any legal or administrative restrictions which drive the
-care of the honest addict out of the hands of the honest medical man
-simply postpone the day when this ideal may be consummated.
-
-Some addicts, as individuals and types, will of course always require
-institutional and custodial handling. The handling of the addict who
-is criminal or vicious belongs within the province of the penological
-authorities, just as does the handling of any other man who is criminal
-or vicious. The handling of the addict who is fundamentally degenerate,
-defective or mentally weak may require the attention of the alienist
-and institutional restraint, just as may the handling of any other man
-who is degenerate or defective. Narcotic drug addiction-disease in the
-man who is vicious or criminal or defective or degenerate should be
-treated as narcotic drug addiction-disease, as any other disease is
-treated in the same individual.
-
-To our legislators and administrators and forces of penology, custody
-and correction rightfully belongs the problem of looking after the
-criminal and vicious addict as well as providing for the eradication of
-illicit, irresponsible, and “underground” traffic in narcotic drugs.
-If the illicit trafficker happens to be a physician he should have no
-more consideration at the hands of the law than any other criminal and
-in its action the law should have complete co-operation of the medical
-profession, which should see to it also that conscientious endeavor
-of its honest members is not confused in its consideration with
-illicit traffic and that the acts of the doctor shall be determined
-and estimated upon broad principles of medical practice and not upon
-violation of incidental technicalities. Great care should be taken that
-the sins of a guilty few are not visited upon the heads of a deserving
-many.
-
-Until there is available competent and adequate medical care for the
-honest narcotic addict sufficient in extent to meet the needs of the
-thousands of sufferers, and encouragement and protection as well as
-restriction is afforded to the honest physician, the illicit traffic
-will continue and grow, including in its toils many who would not
-otherwise seek it. Before we have further medical restrictions, we
-should have both medical and lay and official education. Over-emphasis
-on any aspect resulting in premature, narrow, ill-considered and
-ill-advised action only increases the complexity of the situation and
-defers final remedy. For as great and complicated a problem as narcotic
-drug addiction there will be found no special or specific panacea.
-
-In conclusion I feel that a great deal more thought and attention
-should be paid to the testimony of the public hearings of the New York
-Legislative Investigating Committee, under the leadership of Senator
-George H. Whitney, Chairman of the Committee. A vast amount of valuable
-data was produced. It showed for the first time to my knowledge an
-official effort to secure the true story of the narcotic addict in
-all of its applications and circumstances. It is significant that the
-Preliminary Report of the Whitney Committee gave official recognition
-of the fact that narcotic drug addiction is a physical disease. So
-important and enlightening was the above mentioned report, that it is
-deemed desirable to quote from it in part as follows:
-
-“Lack of understanding and appreciation of the disease of narcotic
-drug addiction and its treatment by a large majority of the medical
-profession has fostered conditions which make it impossible to
-determine a rational procedure for treating and curing the addicted by
-the State at this time.
-
-“Such absence of uniformity of opinion has worked great hardship upon
-the public and has laid the narcotic drug addict open to misconception,
-misunderstanding and medical treatment which, in many instances, has
-resulted in harm rather than good.
-
-“Evidence offered by physicians shows that many addicts have died under
-the methods of treatment existing to-day and that a large percentage of
-those discharged from institutions as ‘cured’ are driven back to use
-of narcotics through unbearable physical torture induced by improper
-withdrawal of their drug.
-
-“Evidence from physicians was adduced which denied that any cure
-for narcotic drug addiction existed in any of the private or public
-institutions of this State. Evidence from other eminent physicians was
-adduced which bore testimony to the fact that the disease of narcotic
-drug addiction was curable.
-
-“The difference of medical opinion existing in medical circles
-regarding this vitally important question should be made the subject
-of a thorough and searching investigation as a matter of the greatest
-importance to the welfare of a large number of people in the State of
-New York.
-
-“Your Committee has found that narcotic drug addiction bears no
-relation in point of character and seriousness to any other known habit
-induced by the use of stimulants. Narcotic drug addicts, according
-to evidence adduced, should not be classed with the alcoholic or the
-tobacco addict or the cocaine habitue.
-
-“The constant use of narcotics produces a condition in the human body
-that many physicians of medical authority now recognize as a definite
-disease, which diseased condition absolutely requires a continued
-administration of narcotics to keep the body in normal function unless
-proper treatment and cure is provided.
-
-“Withdrawal of the drug of addiction induces such fundamental physical
-disorganization and unbearable pain that addicts are driven to
-any extreme to obtain narcotic drugs and allay their suffering by
-self-administration.
-
-“Testimony of physicians coming in contact with the addicts and
-statements of addicts themselves show that those afflicted with this
-disease express every desire to secure humane and competent treatment
-and cure and that most narcotic drug users are willing to undergo
-physical torture and often do voluntarily undergo such torture, in an
-effort to be rid of their so-called habit.
-
-“In the present chaotic condition of medical opinion on this subject,
-it is impossible for the addict to-day to either secure authentic
-information on the subject of his disease and its treatment, or to
-procure at the hands of the average physician competent treatment for
-his malady.
-
-“It has further been stated by competent authorities before your
-Committee that drug addiction is not confined to the criminal or
-defective class of humanity.
-
-“This disease, however contracted, is prevalent among members of every
-social class. Some physicians estimate that addicts of the so-called
-underworld are far out-numbered by unfortunate drug users drafted from
-social circles of refinement and intelligence in the State of New York,
-who have become addicted to the constant use of narcotic drugs, but who
-are able to hide their affliction from the public.
-
-“The attitude of the public toward the narcotic drug addict, fostered
-by the increasing prevalence of the disease in the criminal classes and
-by the apparent lack of medical help, has forced such drug users to
-keep their affliction a secret.
-
-“This necessity in turn, your Committee finds, has apparently
-contributed to the existence of many unsound nostrums for the cure
-of narcotic drug addiction and many private institutions where this
-disease is purported to be cured which exist solely for the purpose of
-preying upon the addict.
-
-“State investigation and regulation of such cures and institutions is
-recommended by your Committee.
-
-“Your Committee is inclined to criticize the medical profession for its
-lack of study of the increasingly important subject of narcotic drug
-addiction. The only excuse which can be offered for this unfortunate
-condition lies in the fact that there has not been medical appreciation
-of conditions and that legislation, both State and Federal, has forced
-upon the physician a situation for which he was wholly unprepared.
-
-“The testimony taken by your Committee shows that those charged with
-the sale and distribution of narcotic drugs are in the main observing
-the law, and that the legal distribution of these drugs is less than
-before the enactment of existing narcotic laws, Federal and State.
-
-“On the other hand it is apparent from this testimony that public
-consumption of narcotic drugs has increased to an alarming extent. The
-inevitable conclusion is that the unfortunate addict has been forced to
-and does obtain his supply illegally.
-
-“This condition arises very largely from the fact that many physicians
-and pharmacists, either through misunderstanding of the law or the true
-nature of the addict’s disease, have refused to prescribe or dispense
-narcotic drugs to the sufferer.
-
-“Your Committee contends that any member of the medical or
-pharmaceutical professions who refuses either to prescribe or to
-dispense narcotic drugs to the honest addict to alleviate the suffering
-and pain occasioned by lack of narcotics is not living up to the high
-standards of humanity and intelligence established by these great
-professions.”
-
-
-
-
-CHAPTER IX
-
-SOME COMMENTS UPON THE LEGITIMATE USE OF NARCOTICS IN PEACE AND WAR
-
-
-Before commenting upon the legitimate use of narcotics, it is desirable
-to emphasize again that the term “narcotics” as used in this volume
-refers particularly to the preparations and derivatives of opium,
-because as the term “narcotics” has come to be used it is synonymous
-in the minds of many with “habit-forming drugs,” a phrase often
-loosely used and grouping under its title a number of drugs of widely
-dissimilar action and properties.
-
-Although many of these drugs have narcotic properties, their action
-upon the human body is in many respects totally unlike the action
-of the opiates themselves. Also the condition resulting from their
-prolonged and continuous administration is an entirely different
-condition clinically and physiologically from that manifested in the
-case of opiate addiction-disease. The problems associated with the use
-of alcohol, cocaine, chloral, cannabis, the various coal tars, etc.,
-differ from each other and all of them are, in their basic medical
-principles, of an entirely different character from the problems
-associated with the use of opiates. As has been previously stated,
-it has not yet been demonstrated that any of them form the basis for
-an addiction-disease mechanism such as clinical study and laboratory
-experiment seem to demonstrate in opiate addiction-disease.
-
-In considering legitimate as well as illegitimate use of opiates,
-therefore, it is important not to confuse them with the drugs above
-mentioned and to be sure that in the mind of the reader there shall
-not exist any lingering impression that attributes popularly supposed
-to be associated with so-called “habit-forming drugs” are of necessity
-displayed in the opiate group.
-
-The habitual use of cocaine for example, may be regarded as an
-indulgence of appetite and the obtaining of sensation and artificial
-stimulation and not as based upon the demands of a specific physical
-addiction-disease mechanism. The therapeutics of its discontinuance
-are entirely different. Habitual indulgence in cocaine tends to
-result in mental and moral deterioration. In the addict of the
-so-called “underworld” it is the coincident use of cocaine with its
-manifestations of mental, moral and physical deterioration that has
-led to the wide and erroneous attributing of characteristics of this
-class of cocaine habituates to the average opiate addict. The habitual
-use of cocaine is an entirely different matter from the continued
-administration of opiate in the case of an opiate addict, and its
-manifestations should be completely dissociated from the clinical
-picture and problem of opiate addiction-disease.
-
-Some writers, especially those associated with municipal or state
-institutions of penology and correction, lay emphasis upon the case
-of the so-called “mixed addict.” The crimes of violence with which
-addiction has become associated in the popular mind are practically
-never connected with the action of opiate drug. They are, however,
-characteristic of the cocaine crazed individual. When they are
-performed by a so-called “mixed addict” they are the result of cocaine
-habituation rather than of opiate addiction. Such crimes of violence as
-are committed by the opium or morphine addict are well explained in the
-Report of the Treasury Investigation Committee in the following words,
-“There are many instances of cases where victims of this disease were
-among people of the highest qualities morally and intellectually, and
-of the greatest value to their communities, who, when driven by sudden
-deprivation of their drug, have been led to commit felony or violence
-to relieve their misery.”
-
-This erroneous grouping of so-called “habit forming drugs” is to some
-extent responsible for a misconception of opiates and of opiate use and
-opiate result to such an extent that, there is unfortunately manifested
-at times a lack of appreciation of the very important legitimate uses
-of these drugs.
-
-The paramount issue of legitimate narcotic medication is that of the
-opiates. Opiates form and must continue to form the most indispensable
-medication, emergency and otherwise, for shock, wounds and allied
-conditions. It may be safely stated that of all emergency medication,
-the opiates would be the last to be surrendered by the intelligent
-physician or surgeon. This is true of every day civil practice and its
-importance is increased tremendously under conditions of active warfare.
-
-The opiates possess combined actions and powers not found in any
-other group of drugs. In therapeutic doses they support the heart and
-circulation, they relieve pain, they hold in check excessive activity
-of the glands of internal secretion with all their associated phenomena
-of exhaustion and collapse; they control spasm and they give sleep.
-In no other drugs or group of drugs are these properties combined
-as they are in the opiate group. In emergency medication, opium and
-its alkaloids, especially morphine, are the medications often most
-responsible for the saving of life and reason. It is not necessary to
-argue this point with any intelligent physician or surgeon. For the
-benefit of the laity, however, and for the benefit of the occasional
-fanatic and hysterical reformer it is well to state that without the
-use of morphine and other opiates the mortality among the sick and
-wounded would be vastly greater, and many of those who might survive
-in spite of its non-administration to them would bear for the rest
-of their lives physical and mental and nerve consequences of gravest
-character. The lives and minds that have been saved by the timely
-administration of an opiate drug are incalculable. One has only to talk
-with those who have worked under the stern necessities and emergency
-conditions of warfare to appreciate this fact. There is no known drug
-which will replace clinically and therapeutically the opiate group. At
-present it is as indispensable in meeting emergency indications as is
-the scalpel of the surgeon.
-
-It would be entirely unnecessary to discuss or to apparently defend
-the use of narcotics in peace as well as in war-time medication if it
-were not for the fact of recent recognition of the wide existence of
-opiate addiction in the civilized world. Combined with this is the
-belief, often met, that as a result of prolonged opiate administration,
-a certain proportion of soldiers have developed this condition. If
-the facts of addiction-disease were widely known and applied to its
-proper handling and remedy, there should be no hysteria concerning
-and no criticism against legitimate opiate medication; even if
-unavoidably continued to the point of creating this condition. That
-opiate-addiction is one of the medical problems of war is recognized
-and must be openly met. In many cases, just as in private civil
-practice, the physician is confronted by a choice of evils. To save
-life or reason he must continue opiate medication even into and
-past the danger zone of beginning opiate addiction. Lack of popular
-recognition, appreciation and comprehension of this fact, in the
-present status of narcotic addiction, contains grave dangers of
-hysteria and of undeserved and irresponsible criticism. That this
-criticism is based on ignorance makes it none the less unpleasant and
-hampering to efficient service.
-
-It should be at once and widely taught that the cases of opiate
-addiction that follow war time administration of opiate do not
-constitute a new medical problem, but simply constitute additional
-cases of a disease which has existed insufficiently appreciated in
-this country for over half a century. When the conditions under which
-wounded and sick must be handled in the emergencies of war, and the
-higher percentage of urgent and severe cases are taken into account,
-it will be found that the proportion of wounded and sick soldiers with
-this addiction-disease is no greater and is very probably not so great
-as the proportion of people in civil life and practice who have in the
-past contracted this disease, and are even at present contracting it as
-a result of opiate medication, unavoidably or otherwise continued to
-the point of addiction.
-
-As the facts of addiction-disease development as a result of
-unavoidable military therapeutics become known it will be well to
-remember that the conditions are no different in character and exist in
-no greater relative proportion than the same conditions in civil life
-and practice. The principal difference lies in the greater opportunity
-for early recognition.
-
-As to the illegitimate or non-therapeutic contraction of addiction
-within the army, its dangers are no greater and possibly not as
-great as in civil life. Some non-medical cases of addiction may have
-developed within the ranks of the army. It may be said of them,
-however, that army life and activity and training probably saved
-many more or less idle and ignorant youths imbued with a spirit of
-curiosity, and with lack of normal outlet for physical and nervous
-surplus energies, from the associations and environments which have
-been taken advantage of by those associated with illicit commerce
-in the creation of the addict of non-medical origin, which has so
-increased in the past four or five years.
-
-It is my belief that the gathering together of young men presents an
-opportunity for the education of the youth as to the physical and
-disease facts of opiate addiction which should be of incalculable
-benefit in the solution of the narcotic problem and in the suppression
-and prevention of “underground” and underworld narcotic traffic.
-
-The foregoing opens to discussion another legitimate use of narcotics.
-This use is the intelligent administration of opiate in the control and
-therapeutic handling of whatever cases of addiction are found to exist.
-The situation within the army as regards addiction is in the general
-indications for its handling, identical with the situation existing in
-civil life. The man who has fully developed opiate addiction-disease
-will have to have his opiate supplied to him intelligently and
-with proper appreciation of the symptomatology and reactions of
-addiction-disease until there is equipment and educated personnel
-provided for his intelligent and competent handling. Under any other
-immediate arrangements, the addicted soldier, just as the addicted
-civilian, will in his desperation and physical torments of bodily need
-for opiate drug, endeavor to smuggle, steal or otherwise obtain in any
-way possible this medication.
-
-In brief then, and to recapitulate, the legitimate use of narcotics
-will be roughly divided under two broad heads. The first is the
-necessary administration of opiate to those who are not addicted for
-the control of emergency or other indication with which every competent
-physician or surgeon is familiar. To use opiate as indicated in such
-cases is not only legitimate, but failure to use it would be inhuman
-and barbarous and result in the loss of many lives and in the making
-of wrecks of many others. The second is the administration of opiates
-to those unfortunates, who either through their own ignorance or
-carelessness, or through unavoidably or otherwise prolonged legitimate
-or necessary medication have developed in their body the condition of
-opiate addiction-disease, until such time as their disease can be
-arrested by competent medical care of their addiction-disease mechanism.
-
-As to addiction created in war time, there is considerable amount of
-information. This is not the time nor the place for detailed discussion
-of that information. Calm consideration of it should, however, suffice
-to still the voice of any objections and irrefutably answer arguments
-criticizing existence of war-time addiction. The greatly lacking and
-needed element in its consideration and handling is appreciation of it
-as physical, controllable and arrestable disease. The laity and the
-mothers and other relatives and the friends of those in the Army and
-Navy will not exhibit panic and fear once the intangible horror and
-vague and morbid and erroneous picture of the “dope fiend” is in its
-application to opiate addiction erased from popular conception and
-replaced by comprehension of a definite physical disease clinically
-controllable and in most cases therapeutically remediable.
-
-To what extent narcotic drug addiction-disease will prove to be a
-medical sequela of war and of necessary war-time medication may
-never be made a matter of accurate statistics. The popular and
-prevailing attitudes towards and conception of the condition and
-of its possessor tend to influence towards desperate concealment
-rather than to encourage self-revelation. As has been stated before
-addiction-disease followed the Civil War, occasional cases recently
-existing and possibly still existing among the few remaining veterans
-of that struggle, addiction dating back to Civil War medication. The
-Spanish War and necessary medication added to the list of war-time
-contracted addiction-disease. Of addiction among those participating in
-the last war, it is at present wise to simply recognize the condition,
-and to hope that as the addiction-disease sufferer, developed through
-necessary war-time medication becomes known, he will not have to
-carry the addiction stigma of past attitudes and conceptions, and
-that we shall be in a position to accord him intelligent and humane
-consideration and handling as a deserving sick man, whose disease was
-contracted in our defense.
-
-
-
-
-CHAPTER X
-
-GENERAL SURVEY OF THE SITUATION AND THE NEED OF THE HOUR
-
-
-From the foregoing it is easy to see that the sooner the
-established facts of the fundamental physical basis and reactions
-of the addiction-states become matters of medical, sociological,
-administrative, and lay knowledge, the earlier there will be a rational
-and practical consideration of the use as well as of the abuse of
-narcotic drugs, and a beginning of solution of the narcotic drug
-problem.
-
-Lack of knowledge of the fundamental and constant physical reactions
-and phenomena, and of the characteristic clinical manifestations of
-this disease, and of the physical suffering of drug deprivation is in a
-very large measure responsible for failure in its therapeutic handling
-in the past, and indirectly responsible for whatever is unjust and
-misdirected in the framing of the various laws, and also for a great
-part of whatever incompetency and lack of wisdom has appeared in their
-administration.
-
-Lack of knowledge of the disease facts of narcotic addiction is also
-responsible for the practical absence of widespread provision for
-humane and intelligent handling, for much of the jeopardy and fear on
-the part of the medical practitioner towards these cases, and for the
-existence of conditions resulting in the rapid growth and increase of
-the worst evils of the present situation.
-
-The worst evils of the narcotic drug situation are not, as is widely
-taught, rooted in the inherent depravity and moral weakness of those
-addicted. They find their origin in opportunity, created by ignorance,
-neglect and fear, for commercial and other exploitation of the
-physical suffering resulting from denial of narcotic drug to one
-addicted. The many widely advertised drug cures derive their prosperity
-from the desperate desire of the narcotic addict to be cured of the
-condition which may at any time cause him intense physical suffering.
-The worst evil of the narcotic situation in the past few years, and
-especially since the enforcement of restrictive legislation, without
-provision for complete investigation of the whole situation, for
-education, and adequate treatment of disease aspects, is the rapid
-growth and spread of criminal and underworld and illicit traffic in
-narcotic drugs. This exists to its present extent because conditions
-have been created which make smuggling and street peddling and criminal
-and illicit traffic tremendously profitable, and it would not exist to
-its present extent otherwise. It is simply and plainly the exploitation
-of human suffering by the supplying to desperate and diseased
-individuals, at any price which may be demanded, one of the necessities
-of their immediate existence.
-
-Such exploitation would become unprofitable on any large scale if the
-disease created by continued administration of opiates were recognized
-as it exists and its physical demands comprehended and provided for in
-more legitimate and less objectionable ways.
-
-One of the most important and immediately available of these
-ways is the honest practitioner of medicine. If the average
-practitioner of medicine were made familiar with the physical facts
-of addiction-disease, and its phenomena and reactions, and were
-encouraged by both legal and medical authoritative support to admit
-addiction-disease patients to his practice, to be cared for just as
-other patients to the best of his honest therapeutic ability and
-judgment--if he were taught to regard them as sick people whom he could
-help--if he were relieved of uncertainty as to the meaning and possible
-interpretation of laws and regulations, and as to the possible action
-or lack of action and attitude of his medical brethren and medical
-organizations towards him--the best available, honest, humane and
-intelligent machinery would be set in motion for the immediate care
-of the average honest sufferer from addiction-disease, and for the
-discouragement of underworld or underground exploitation. This has been
-demonstrated. It would react furthermore as a stimulus to the education
-of the physician, to familiarize himself with the scientific and
-medical facts of this disease.
-
-Another immediate provision is the establishing under proper
-supervision and management, especially as to competent medical
-management, and without possibilities of humiliation and interference
-with self-support, of stations or clinics at which those who for
-financial or other reasons are unable to secure reputable and honest
-medical help, may obtain their necessary opiate at minimum expense and
-in physically necessary amounts to enable them to work and support
-themselves and families, without resorting to underworld associations
-and illicit commerce. Such clinics might be established in connection
-with the various hospitals on the same basis as their other medical and
-surgical clinics or dispensaries, and in connection with various health
-departments. In them the narcotic addict could not only be supplied
-with opiate medication, but taught the nature of his disease and the
-elements and principles of its control and be given such medication
-other than opiate for the relief of such associated or intercurrent
-conditions as might exist. Such clinics would have great educational
-value, as well as fulfilling a therapeutic need.
-
-Pending further study and investigation and education into narcotic
-drug addiction-disease and the conditions surrounding it, and pending
-the widespread acceptance and recognition of practical and desirable
-procedures in the handling of the disease, and pending the provision
-of sufficient and scientifically adequate accommodations for the army
-of those who seek relief--legitimate supply of the drug of addiction
-under medically competent and intelligent direction fulfills a great
-economic and sociologic and medical need.
-
-The financial possibilities of commercial exploitation of the
-sufferings of addiction-disease, combined with general ignorance of
-the true nature of the addiction condition, are responsible for the
-tremendous increase of late of narcotic addiction, of non-medical
-or non-therapeutic origin, among the youth. In ignorance of actual
-physical results, not knowing nor ever having been told that they
-are contracting a disease of torturing manifestations, actuated by
-curiosity and search for adventure, in some cases stimulated by
-unfortunate spectacular publicity, the youths fell easy prey to the
-agents, male and female, of the drug trafficker. The trafficker’s
-intended consummation is reached when these youths finally become,
-to their surprise and consternation, through the development of
-addiction-disease and physical dependence upon narcotic drug, enforced
-and continued customers and in some cases, virtual slaves.
-
-Those who are interested in prostitution and in so-called
-“white-slavery” would do well to turn their attention to the chains
-forged by the suffering, and the fear of suffering, experienced by
-those who have developed narcotic drug addiction-disease.
-
-It is this class of youthful addicts that has so alarmingly increased
-since the enforcement of the various narcotic laws. I have previously
-called attention to this situation, and also to the fact that for
-this increase the laws themselves are not so much to be blamed as
-is the totally inadequate meeting of the clinical and therapeutic
-and educational needs of the narcotic drug situation. There has been
-practically no organized scientific, medical or public health activity,
-so far as I know, directed towards the clinical and laboratory
-investigation of this disease--towards a dispassionate review, analysis
-and testing out of the truths and errors of its literature--towards an
-investigation of the scientific and other qualifications and experience
-of those whose utterances or writings influence medical and lay opinion
-and action, towards the establishing of pathological and physical
-facts and reactions and of clinical symptomatology and phenomena as
-fundamental bases for its rational handling and therapeutics, and for
-practical education of the public as to its sufferings and dangers.
-
-The neglect of this education is largely indirectly responsible for
-illicit traffic in narcotic drugs. Illicit and underground traffic
-exists because it is profitable. This is the direct and immediate
-reason for its existence. Every new addict made of an adventurous youth
-means a new customer for the smugglers and vendors. If that adventurous
-youth had been taught the facts of the physical hell of the “withdrawal
-signs” of opiate addiction-disease--if he knew the sufferings attendant
-upon body-need for opiate drug--if he knew that any red-blooded animal
-will develop this physical body need if opiate drug is administered
-for a sufficiently prolonged period--that no living being is immune
-to the development of this disease--if he thought of addiction as
-he thinks of tuberculosis, and as he is now being taught to regard
-venereal-disease, instead of it as being something vague and surrounded
-by a halo of adventure and experience, he would not fall an easy
-victim to the agents of the trafficker. In other words, the most
-potent activity in the arrest of development of even the vicious and
-criminal aspects of the narcotic addiction situation lies in education.
-Laws and their enforcement in the control of the incorrigible and
-vicious will always be a necessity, but laws and their administration
-alone are not sufficient for the control of the many-sided addiction
-situation. Even in the control of smuggling and illicit traffic we
-need the application of every available influence capable of exertion,
-not only upon its end results but upon the machinery of its origin
-and development. As so much of it originates and develops through
-ignorance, the method of its remedy lies in education, education as to
-the facts of narcotic drug addiction-disease.
-
-It is ignorance also that has stamped the honest and innocent,
-worthy and intelligent, and often illustrious sufferer from narcotic
-addiction-disease with the attributes and characteristics of the
-inherently irresponsible or otherwise incapable of self-guidance and
-self-restraint. The ignorance of the facts of addiction-disease has
-taken from these people even their ordinary legal and public rights in
-any issue which involved the possible revelation of their addiction. It
-has placed them in a position where any procedure which might reveal
-their narcotic medication would expose them to public gaze as members
-of a popularly despised and unworthy class of individuals. Until very
-recently the testimony of a known narcotic addict has been almost as
-a rule of no value in a court of law. Irrespective of a life-time of
-honesty and accomplishment, the revelation of a minute might destroy
-the reputation and standing of many years. Whatever the injustices
-or grievances suffered by an addict, he could not hope to evoke the
-protection or rights accorded an ordinary individual under statute law
-without the practical certainty, if his addiction became revealed, of
-personal, social and economic detriment far in excess of the legal
-rights to which he was entitled. The continuation of whatever is
-spurious or unworthy in methods of handling, advertised or otherwise,
-lies partly in the fact that the former patient cannot afford, however
-great his physical or other damage, to make public the existence of
-addiction-disease by the instituting of a suit for malpractice or other
-civil or criminal procedure. This alone has been one of the factors
-in lack of progress and in the persistence of narrow vision or false
-conception. He is in effect, however high his personal, moral and other
-status, deprived of some of his constitutional rights, simply because
-he has developed addiction-disease.
-
-The great numbers of innocent and worthy unsuspected sufferers from
-this disease, who could not by any stretch of wildest imagination, be
-regarded as mentally or morally abnormal or subnormal have therefore
-been placed in a position where they could not afford to demand their
-rights or state their case. Their problems are only recently beginning
-to receive general consideration. Their cases have compelled us to
-revise our conception of the narcotic addict, and to question ourselves
-as to the necessity for their continued addiction over the years of
-their addiction. For their own good and that of society, what shall
-we do with them, and what can we do for them? In the present state of
-public opinion and public attitude towards narcotic addicts in general
-would it benefit either them or society to class them merely as “drug
-addicts” along with the drug-users of other types of individuals and
-other personal characteristics for administrative handling by detailed
-administrative supervision and control? Can the same administrative and
-other methods which admittedly must be employed to protect society from
-the manifestly unfit accomplish anything of good in the cases of these
-responsible and valuable citizens?
-
-Until there is a truer understanding of addiction-disease, and a wider
-appreciation of the facts that the personal attributes of its victims
-differ as widely as those of cardiac or any other disease condition,
-and that merely because a man has contracted this disease is no reason
-for regarding him as in any way unworthy or unfit--will stringent
-and drastic forcible regulative measures directed against mere use
-of narcotics work out to the advancement or hindrance of ultimate
-solution and to the ultimate benefit or harm of society? These are the
-questions to be applied to all restrictive administrative activities.
-The problem of the care of the worthy and innocent addict in such a way
-as not to unnecessarily harm him nor deprive his family and society
-of his competent activity is just as important as the handling of the
-addict of the type of individual from whom society must be protected.
-The large numbers of worthy and valued citizens who are individually
-and personally social and economic assets and who are sufferers from
-addiction-disease constitute a very important consideration in the
-narcotic problem.
-
-They certainly are not fit subjects for enforced custodial and
-correctional handling, and if such were forced upon them they would be
-seriously harmed, personally, socially, economically and physically.
-Very many of them our equals or betters, we have no right to subject
-them to associations and experiences which we ourselves would rebel
-against and be humiliated by simply because they have developed a
-disease condition from which no one of us is immune.
-
-Where is the blame for their continued addiction? Certainly not because
-of lack of effort on their part. Addicted for years, they have tried
-one after another of the various and diverse treatments and so-called
-cures without success or benefit. Is the blame theirs for lack of
-success and cure, or has there been something wrong in our treatment
-and handling of them? Did we know enough about addiction-disease to
-treat them intelligently and to exercise upon their cases the same
-professional skill and technical ability that we have been educated
-and trained to apply to other diseases? In the light of present
-available clinical information and study, and in the light of recent
-and competent laboratory research, we are forced to admit that we have
-not treated our addiction sufferers with sympathetic understanding
-and clinical competency, and that the blame for past failure to
-control the narcotic drug problem rests largely upon the educational
-inadequacy of the past.
-
-We are in a stage of transition in our concepts of, attitude towards,
-and handling of the narcotic addict. Serious consideration of drug
-addiction as a problem of clinical and internal medicine, and of
-experimental laboratory research is a comparatively new thing to a
-majority of the medical profession, and of course also to legislators
-and administrators. We should all remember that no matter how strong
-we are in our beliefs and theories, there are many others whose
-experiences and results have caused them to hold just as strongly
-to opposite theories and beliefs, and that we are all on trial for
-the validity and extent of practical application of our beliefs and
-theories.
-
-Each new theory or belief that is brought forward should be taken
-simply for record and investigation. Much that we believe to-day we
-know to-morrow to be based upon misinterpretation and lack of complete
-information. Much that we believed in the past to apply to and solve
-conditions, we found later to have been merely based upon observations
-of distracting incidentals or non-basic aspects and phases. What we
-need is competent, disinterested, and honest effort to get together
-and evaluate all available material of whatever sort and from whatever
-source. If it were possible of accomplishment, it would be of advantage
-to get together in open and frequent discussion the various workers
-in the field. We are all partly wrong and partly right. There is no
-one of us who cannot learn from any one of the others. The real end
-of effort should be, not to prove one or another of us right, but to
-take each from the other whatever is of value and all to contribute in
-true scientific spirit of broad tolerance towards the ideas of others
-and of willingness to correct or modify ideas and theories of our
-own, searching for no panaceas or specifics, medical, legislative or
-administrative, simply hunting for truth wherever we may find it and
-applying it intelligently to meet the needs of the individual.
-
-There is too much work to be done, and the situation is too urgent for
-remedy, to permit of longer delay in scientific approach. Under present
-conditions, no man’s announcement of theory or of remedy is to be taken
-as ultimate authority, but simply as his opinion based on his personal
-deductions, and his personal experience, to be evaluated in accordance
-with the extent and variety of his personal experience in the light of
-his individual ability and training.
-
-Education and training are the best hopes we have as a foundation for
-the alleviation of present conditions and the prevention of their
-further spread. Lack of appreciation of and of ability to recognize and
-meet varied and various clinical and other indications for treatment
-and handling under widely different circumstances and in widely
-differing individuals means failure in a majority of cases, and throws
-a burden upon society and a complexity of problems upon municipal,
-state and federal authorities which they are unable to meet. Each class
-of workers should be working in its own field in co-operation with
-those working in other fields, none trying to dominate the rest, but
-each giving to the others credit for honest effort and appreciation of
-difficulties to be made easier if possible.
-
-All possible forces should be encouraged to the work of study
-and investigation and education. A campaign of medical and lay
-investigation and education will require a much shorter time than a
-continuous trying out of various panaceas, medical, legislative or
-administrative. Also, it will bring far more satisfactory and earlier
-results. The narcotic wards of our great charity hospitals should be
-made use of for honest unbiased and trained clinical and laboratory
-study. The narcotic addict himself should be given a much wider hearing
-than he has in the past received. The mass of honest and intelligent
-narcotic addicts should be encouraged to tell their stories and their
-experiences, and should receive a fair and unbiased hearing as to
-the reactions upon them of various measures proposed. We, doctors,
-legislators, administrators are in truth as much on trial with the
-narcotic addict and with society for our understanding and handling of
-the narcotic addict and his problems as the addict is for his condition.
-
-The remedy is plain, and the necessity for immediate activity is
-obvious. Education--scientific medical and lay, administrative and
-public health education is the lacking element or factor in the
-solution of the many sided narcotic drug problem. Appreciation of
-addiction-disease and what it may mean in the individual should be
-as widespread and as comprehensive as possible and at the earliest
-possible moment.
-
-       *       *       *       *       *
-
-Without a basis of generally recognized and widely appreciated
-fundamental facts, there can be no competent treatment, legislation,
-administration or judicial decision. There can be no competent
-evaluation of the merits and defects of various measures promulgated,
-medical, legislative or administrative. There can be no competent
-selection of those in whose hands shall lie the handling of a
-tremendous problem, a problem of disease, of sociology, of economics,
-of public health and welfare. There can be no competent evaluation of
-the remedies advanced, nor of the qualifications and true authority of
-those who recommend them. Under such conditions various measures or
-procedures in their adoption or discarding or application must depend
-more upon the publicity and other influence of their proponents than
-upon their intrinsic values.
-
-There are always some things about any condition which either are or
-are not, some things which are physically determinable. The basic facts
-of addiction-disease are now physically determinable. There are many
-material and obvious and easily demonstrable physical facts of greatest
-value to the medical profession and to the laity, facts which are still
-but little appreciated, and not widely known.
-
-These facts in addiction-disease could be easily investigated. The
-various conflicting statements of different schools of thought or
-of observers working from different angles should be investigated,
-evaluated and correlated--taking from each whatever is useful,
-determining its true sphere of application and making it available
-to all. Every possible interest or worker should be encouraged, and
-every source of information sought out, not least among them the
-honest and intelligent sufferer from addiction-disease of many years
-duration whose knowledge of the facts of his condition, and efforts
-to control it, and search for and trial of remedy and remedies for
-it, and the experiences and problems, social, economic and personal,
-which its possession has forced upon him would constitute a touchstone
-of greatest value for the determination of validity of promulgated
-measures and procedures.
-
-The wards of the great charity hospitals, the institutions of science
-and medical experiment and research, the Departments of Health, and
-the Public Health Services are in existence and are equipped for the
-early determination of clinical, and laboratory facts, and for their
-dissemination. These are the things towards which their activities are
-directed in other diseases and conditions affecting public welfare
-and public health. It would take a very short time to determine
-the physical facts of addiction-disease--to establish finally and
-conclusively its clinical symptomatology and constant reactions and
-phenomena for authoritative and educational dissemination. Every one
-of us who has written in description or exposition of his study and
-observations, together with what we have written and taught, should
-be made the subject of critical and unbiased investigation, and
-whatever of truth we have stated should be made the possession of
-all. The experimental development of addiction-disease in dogs and
-other experimental laboratory animals, the symptoms and phenomena
-observed in them recorded by instruments such as the sphygmomanometer
-and the sphygmograph and paralleling similar records and observations
-upon the addicted human, the reactions of the serum of these animals
-injected into the non-addicted of their species are not to be lightly
-ignored, and should be matters of common scientific knowledge. The
-manifestations of addiction-disease in the new-born developed in the
-infant’s body prenatally long before vice or habit or appetite can
-be possibly considered as causative factors, demand more than casual
-consideration and have a significance much deeper than as occasional
-curiosities.
-
-An educational campaign as to the facts of addiction would save many
-an innocent person from the contraction of the disease, and many a
-present sufferer from unintelligent handling. Authoritative bodies
-with sufficient power and independence might easily institute unbiased
-review of what is written, and trial and proving out of what is stated
-by various writers, and give out their findings for the guidance of
-future work and action. Hospitals and public institutions for the
-handling of narcotic addicts may be erected. Without comprehension
-of addiction-disease and full and complete familiarity with its
-manifestations, the possession of those who work in them, will they
-accomplish anything of good?
-
-The deduction from the testimony of the Whitney Investigation and from
-other sources leads to the conclusion that one of the reasons why
-the narcotic addict does not go to many of our present institutions
-is that he is more afraid of them, and anticipates more suffering
-in them than he cares to face in view of the fact that neither from
-previous personal experience or from repute he has little hope of
-being discharged from them in a condition of physical competency with
-his addiction mechanism arrested. He sees no use in going through
-them only to come out in a condition where he will have to revert
-to his opiate to enable him to endure and work. This is not an
-all-inclusive statement. It expresses, however, the frequent response
-of the addict seeking advice when asked why he does not go to the
-municipal institutions for treatment. Again then the work of those in
-the institutions will be the determinating factor in their success
-or failure, and their education is the dominant element required for
-success. Some interesting observations upon this point will be found in
-the Yearly Report for the Department of Correction of New York City,
-1915.
-
-Of public clinics the same thing may be said. Whether they react to
-the benefit of the addict and of the community, or to the harm of the
-addict and community will depend upon their intelligent understanding
-and competent management.
-
-Hospitals and clinics might be made into sorely needed educational
-centers for the training of doctors and nurses to go out and take up
-the work of the care of the addict--either private or institutional.
-
-Education is the great need of the hour. Until it is accomplished all
-else will fail. Until we all know what we are dealing with, how can we
-hope to successfully handle it? It is to be hoped that the time is not
-far distant when in every medical school and hospital will be taught
-in principle and practice, in class-room and clinic all that is known
-or will be known of the pathology, symptomatology, physical phenomena
-and rational therapeutics of narcotic addiction-disease. It is to be
-hoped that in school and college, in pulpit and press, the facts of
-addiction will be presented in their practical existence, stripped of
-spectacularity; a calm, cold presentation of basic facts. There is no
-subject upon which philanthropy can better expend its forces than to
-this end of education as to addiction-disease and humane help to its
-sufferer.
-
-In the past the problem of control of addiction has been “What shall be
-done _with_ or what shall be done _to_ the narcotic addict to make him
-stop using drugs?” It is now gradually coming to be realized that the
-true problem is “What can be done _for_ the narcotic addict to relieve
-him of the physical necessity of using drugs?” and “What can be done
-to so educate the public as to the facts of addiction, so that this
-disease will claim as few victims as possible?”
-
-In this change of attitude lies the hope for the future. Some of the
-narcotic addicts will have to be done _with_ or done _to_. They are
-the inherently irresponsible, vicious or defective. They demand care
-and restraint irrespective of their addiction. The mass of addicts,
-however, need something done _for_ them. They are clinical problems of
-internal medicine, victims of a definite disease, characteristic in its
-symptomatology, reactions and phenomena, a disease which will before
-long come to be known as clinically and therapeutically controllable
-and arrestable.
-
-
-
-
-APPENDIX
-
-HUMAN DOCUMENTS--PERSONAL STATEMENTS
-
-
-The great importance of the real story of the sufferer from narcotic
-drug addiction-disease has been referred to several times in this
-book. It had been my first intention to include in the course of the
-various discussions, stories and statements of narcotic drug addicts
-illustrative of the various matters discussed, and to take them from my
-own collection of addiction histories.
-
-That I might avoid any personal controversy, however, as to their
-personality or reliability, and also to make such statements free from
-any possible hint of influence or bias, I have taken them from medical
-literature and am using them as an appendix.
-
-In December, 1917, _American Medicine_ published a special addiction
-number, containing statements written for it by addicts of evident
-and vouched for intelligence and standing, stating their personal
-experiences and personal views.
-
-Through the courtesy of _American Medicine_ and its editors, I am
-reproducing these, believing that they are of great value and that they
-illustrate many of the discussions which appear in this book.
-
-       *       *       *       *       *
-
-HUMAN DOCUMENTS[1]
-
-[1] For obvious reasons the names of the authors of these contributions
-are not given. The editor, however, has every one of them, and has
-taken especial care to establish the authenticity and good faith of
-each article. Each contribution appears as received.
-
-THE PERSONAL SIDE OF DRUG ADDICTION
-
-SOME VIEWS ON DRUG ADDICTION--PERSONAL AND LEGAL
-
-BY A PROMINENT MEMBER OF THE NEW YORK BAR
-
-A half dozen years ago I had a long, severe attack of gallstones and
-inflammation of the gall-bladder. I suffered so much pain that the
-physicians gave me morphine for nearly a year. When I got better I
-tried my very best to get along without the drug, but could not. I
-came to a physician in New York for treatment who had made a special
-study of drug addiction and is a recognized authority on that subject.
-However, he could not help me at that time on account of a recurrence
-of my gall-bladder inflammation with severe jaundice and fever.
-
-Since that time I have tried repeatedly to stop and reduce the quantity
-of the drug, but have found it impossible because of the physical pain
-and exhaustion due to the lack of the drug. This is unbearable. I have
-since then kept my daily amount of morphine medication at a minimum
-which permitted me to work and to maintain good health and bodily
-function. The idea which I have heard so often expressed, that addicts
-tend to increase their daily intake of narcotic, is certainly untrue
-in my case, and there seems to me no reason nor temptation to do so. I
-have simply found the smallest amount which would keep me from physical
-suffering, and have experienced no difficulty in maintaining that
-dosage, except in occasional emergencies of gall-bladder attacks or
-other crises, after which I found it a simple matter to discontinue the
-excess dosage. As I have never experienced the slightest pleasurable
-or sensually enjoyable sensations from the administration of morphine,
-there seems to me no foundation for this prevalent idea of tendency to
-increase. It may be true of the degenerate who has become addicted, but
-it certainly is untrue in my case, and must be untrue of the thousands
-like me whose misfortune it has been to become afflicted with this
-condition.
-
-Recently I have again consulted specialists, and it seems that with
-my condition I must continue the administration of morphine for the
-present, and perhaps for the rest of my life. Physical conditions
-render present attempts to discontinue its use impractical, undesirable
-and dangerous.
-
-Now what am I to do under the present “Drug Habit” laws of this State?
-I am a lawyer long past middle age--have held important state and
-judicial positions, and many positions of responsibility and trust. It
-would be ruinous to me if my addiction condition became public.
-
-This law was enacted to control the drug traffic and to stop the evils
-which are connected with it. In many respects it is an excellent law,
-but the provisions which require the record of the name, age and
-residence of the addict to be filed in the Board of Health Office is
-outrageous. It does not affect the underworld, for they don’t care and
-avoid registration by not going to those who have to register them. But
-see the position of a man who has a good reputation and standing in the
-community--forever recorded in the records of the State Board of Health
-as a “dope fiend,” even though his condition is not the result of his
-own acts or desires and absolutely beyond his control.
-
-This part of the law which requires the recording of the name, age
-and residence of the addict should be repealed. The only effect of
-these provisions is to record the addict as what everybody considers a
-“dope fiend” or force him to go to the smugglers for his drug. He must
-either place his good name and social and economic position in constant
-jeopardy or in some way or other evade the law with its attendant
-penalty, and constant fear of detection. I should not be surprised if
-it finally develops to be the fact that a majority of decent sufferers
-from this condition have chosen the latter course as the lesser of
-evils.
-
-I am informed that the Health Department has recently issued monthly
-registration blanks to physicians, demanding, in addition to the
-name, age and residence of the addict, the date and amounts of each
-prescription together with other information as to the individual cases
-treated. This makes conditions still more obnoxious and unbearable.
-Furthermore, this action of the authorities of the Board of Health
-is unwarranted and illegal. There is nothing in the powers of the
-Board of Health which permits them such action, and such action is
-without any justification in the letter of the law or in any possible
-interpretation of the spirit and intent of the law.
-
-The data demanded were submitted to the Legislature as provisions in
-the law when the bill was being considered, and were rejected. The
-Health Department is usurping the powers of the Legislature, which
-it has no authority to do. The law plainly states what the physician
-shall report and the Board of Health has no power to require additional
-matters. Such action constitutes illegal interference with the
-rights of physician and patient as to matters of treatment and as to
-violation of professional confidence. It is my opinion that a narcotic
-addict might have grounds for legal procedure against a physician who
-furnished such information as the Health Department demands.
-
-Conditions in New York today, affecting the honest addict, constitute
-in effect persecution of the sick. It is bad enough to be afflicted
-with this disease. Agonizing as gall-stone attacks have been, the
-physical suffering from lack of morphine in an addict is worse. Added
-to this is the knowledge that your name is on file at Albany, and
-perhaps elsewhere, as an addict. You know that disclosure of your
-condition will ruin you and disgrace your family. You are potentially
-subject to leakage from those records and the attendant possibilities
-of blackmail and other persecution. Such conditions tend to force and
-undoubtedly have forced many innocent and honest addicts of good social
-and economic standing to become criminals by obtaining their necessary
-opiate medicine through illegal channels.
-
-Something certainly should be done to remedy existing conditions
-and existing laws. The great State of New York should not place its
-unfortunate sick in their present position.
-
-       *       *       *       *       *
-
-THE PERSONAL HISTORY OF A MEDICAL ADDICT
-
-BY A WELL-KNOWN AMERICAN PHYSICIAN
-
-When the suggestion was first made by a medical friend that I should
-write a short account of my personal experience as a drug addict,
-particularly in reference to my status as a practitioner of medicine,
-the idea, for obvious reasons, was repellent, notwithstanding the
-fact that my identity should not be disclosed. But after mature
-deliberation, I realized that it is largely due to this natural
-reticence on the part of those in position to speak, that the
-unfortunate addict is regarded as a social pariah by the general
-public, and that until the medical profession shall acquire more
-accurate and less distorted knowledge of this serious question, we
-cannot hope for any improvement along these lines. Until this is done,
-cruel and unjust laws will be enforced, wretched victims will be
-imprisoned as felons, and what is more distressing, these unfortunates
-will, in many instances, be subjected to torture to which death is
-preferable--and not infrequently results. All this is based upon the
-accepted theory that drug addiction is a vicious habit requiring only
-a little fortitude and strength of will on the part of the wretched
-victim to rid himself of it, while the saddest feature of it all is
-that this canker, eating at the very heart of the nation itself,
-blighting and destroying the lives of many useful men and women, is not
-being reached.
-
-That the average medical men can remain so hopelessly, I might say
-criminally, negligent of the true conditions of drug addiction is
-a cause for wonder as well as condemnation. If the perusal of my
-paper induces even one conscientious physician to seek more definite
-information upon this tremendously vital subject, my efforts shall not
-have been in vain. And now for my story.
-
-At the age of 24 I had finished my medical and hospital courses and was
-ready to begin my career. My plans had long been formed with reference
-to entering the army as a surgeon; the decision having been made for
-two reasons, first as a matter of predilection; secondly, for lack of
-means to sustain me during the time usually required to establish a
-private practice.
-
-Then a tragedy occurred that blasted my hopes for the army and altered
-my entire future.
-
-The examinations were scheduled for the late spring; in January I
-had come down from my home in New England to New York to complete
-some clinical work. Generally, I was in bad shape, and about that
-time I began having attacks very suspicious of angina pectoris.
-Finally I consulted a great specialist, who after thorough and
-repeated examinations, frankly told me that from overwork and long
-hours of study my heart had become enlarged and badly disordered
-functionally--that I need never hope to pass the physical examination
-required for entrance to the army. He prescribed rest and freedom from
-care--two remedies entirely beyond my reach.
-
-It was then that I went to a far distant city in the West to begin my
-career on a small amount of borrowed capital. It would be useless to
-dwell upon my struggles, hampered as I was by lack of funds and ill
-health, but in due time I became established. During the first few
-years my heart attacks were infrequent, but as work increased they
-returned, especially after an attack of typhoid fever which left my
-heart in a most disturbed state. Naturally, all remedies were tried
-with an occasional rest, but to no avail. One night after a very trying
-day I was called to an obstetrical case; while hurriedly dressing I
-felt the premonitory symptoms of a heart attack; it was then in a state
-of desperation T took my first hypodermic. The attack was aborted, but
-the next day I was desperately sick. I may here add that at no time did
-I ever experience any of the ecstatic sensations described by some from
-a dose of morphine--it steadied my heart, but for some time after it
-was followed by a general malaise.
-
-My obstetrical work increased rapidly and I frequently found it
-necessary to resort to the one remedy that proved efficacious. As was
-natural the time came when I found that the daily necessity had become
-fixed.
-
-Having been taught that it was only a habit that required self will and
-force of character to abandon--both of which I knew I possessed--I was
-not particularly worried, as I had planned a long vacation when summer
-came, which I would devote to the accomplishment of my purpose. But for
-certain unavoidable reasons the vacation became impossible, and the
-next winter found me with added responsibilities.
-
-During all this time I had constantly struggled against the increase of
-the drug. If under great pressure I was obliged to take an additional
-amount, as soon as it was over I began to reduce. There were occasions
-when I succeeded in taking only a fraction of my accustomed dose, but
-if a call came, I was either obliged to refuse it, or resort to the
-needle.
-
-While naturally I had taken no one into my confidence, the habit
-had been so insidious and gradual that I had failed to realize how
-necessary it was that it should not be suspected. I did not consider
-myself an addict and only awaited a propitious occasion to relieve
-myself of it, but that winter I awoke to the realization that some
-radical step must be taken or my professional reputation would be
-damaged.
-
-In the midst of this perplexity I developed an attack of la grippe and
-judging from past experience I felt that I would be confined to the
-house for some time, so resolved to take advantage of the enforced rest
-and abandon the use of the drug.
-
-It was a hazardous and probably unwise decision, but I reasoned it
-was for the best. At the end of three weeks, after days and nights of
-physical and mental torture, I was able to leave my bed, freed from
-the specter that had haunted me, but for the time a wretched type of
-humanity. Four weeks of rest in the country enabled me to return to
-my practice, and although the heart attacks mercifully remained in
-abeyance, it was only by sheer force of will that I could accomplish my
-routine work, resting every spare moment that was afforded me, often
-refusing calls.
-
-At the end of six months my work had so increased that the heart
-symptoms began to trouble me. The situation was desperate. Besides a
-wife and two children depending upon me I had other obligations, and
-was still in debt from my illness. I was unfitted for any other form of
-business.
-
-I shall not enter into a discussion of the ethics of my act, but after
-sleepless nights of deliberation I reached the decision to return to
-the remedy that alone would enable me to attend to my duties, knowing
-all that it involved, but hoping that by constant vigilance to lessen
-the baneful effects of the drug until some day when I should be free to
-leave off work and again be cured.
-
-During the years that followed, this object was ever before me,
-always fighting against an increase, devoting my vacations always
-to the same cause. In a measure I succeeded. I never progressed to
-extremely large doses, and I watched for and combatted any possible
-symptoms of peculiarity or degeneration that are supposed to obtain
-with the addict. I felt no sense of moral inferiority or degradation,
-nor did I deplete my strength with useless anticipation of dreaded
-possibilities. I would do all that lay in my power to preserve myself
-and the future lay in the hands of fate.
-
-During these years success came to me. My clientele grew both in size
-and character. Positions of trust were conferred upon me, such as
-the examinership for some of the most important insurance companies,
-presidency of the County Medical Society, etc. I was elected visiting
-physician to two of our largest hospitals, and for some years did
-special work for the federal government, the nature of which for
-obvious reasons I do not care to mention.
-
-In mentioning these facts, I do so with no vainglorious idea
-of boasting, but simply to record the history of my career. At
-the same time I used sometimes to ponder over the anomaly of my
-position--realizing with what horrified promptness the public would
-strip me of my honors, and transform its patronage and good will
-to contempt and pity, if it suspected the truth, although from its
-continued patronage my work was evidently entirely satisfactory. Even
-my intimate friends would shrink from me if the truth were known. Yet
-my philosophy and natural optimism sustained me.
-
-It was at the end of about fifteen years that my circumstances were
-such that I felt in position to leave off work and take the long
-anticipated “cure.” The institution selected was one whose methods
-seemed most reasonable. I stated to the specialist that I was anxious
-to be cured as rapidly as possible, and was willing to undergo whatever
-was necessary, to the limit of my endurance.
-
-The three weeks that followed I remember as a horrid nightmare of
-mental and physical agony. The method was not intended to be harsh, and
-the physician was well-intentioned, though far from scientific.
-
-In my desire for rapid recovery I overestimated my powers of endurance
-and my nervous system sustained a shock from which it has never
-recovered, but I persisted, with the assistance of my wife who remained
-with me and without whose assistance I should have lost my reason.
-
-When I left the sanitarium I was no longer an “addict,” but a wretched
-neurasthenic. Naturally the possibility of returning to my practice
-in this condition was not to be thought of so I began making plans
-to spend the winter in southern California. Here again the fates
-interposed. It was the autumn when the sudden financial panic swept the
-country, wrecking the fortunes of so many and tying up the resources
-of so many others. I was among the latter. There was nothing for me to
-do but to return to practice which I did after a further rest of six
-weeks--I need not add that in a short time I was again depending upon
-the drug to sustain me in the work that I was obliged to resume.
-
-During the next five years I directed every energy towards shaping my
-affairs with the one end in view--that of retiring from practice and
-getting permanently well. By this time my two sons had finished their
-education and were established. My income was sufficient to provide
-us with the comforts, if not the luxuries of life. So with a heavy
-heart, but with a feeling of gratification, I abandoned the practice
-that I had acquired and sustained through so many years of bitter and
-sometimes heart-rending struggles.
-
-My hopes for speedy restoration were doomed to disappointment. I should
-have realized that when release suddenly came from the long years of
-daily combat with so powerful an antagonist, a decided reaction must
-be the natural sequence. It came in the form of an almost complete
-prostration, that only by force of will prevented from permanently
-overcoming me; but more than two years elapsed before I felt equal to
-the effort of again submitting myself to treatment.
-
-This time I selected a well-known specialist in the Middle West. I
-bared my entire life to his scrutiny, placing myself absolutely in his
-hands. Forty-eight hours as an inmate of the institution convinced me
-that I had made an unfortunate selection; but from a sense of false
-pride at being a “quitter” and a belief in my own powers I remained.
-The methods were absolutely crude and unscientific, the food poor and
-unsuitable, and the entire environment unfitted to the well being of
-such patients as I was.
-
-At the end of seven weeks I was visited by the one most interested in
-me, who took me from my bed, from which I could not have arisen without
-assistance, and brought me East. It is true that the amount of the
-drug that I had been taking had been reduced to a very small amount,
-but at the expense of a badly shattered nervous system which required
-many months to regain even its partial normal status.
-
-This fall I am in New York and have placed myself under the care of a
-physician who, while not claiming to be a specialist has, in my opinion
-and the opinion of many others, the clearest conception of the meaning
-of drug addiction and its pathology. His opportunities for the study
-of these cases have been most unusual. His methods are both humane and
-scientific. Through him I have the hope that should time be allowed
-me I shall when I am summoned to the great unknown, be freed from the
-chains that so long oppressed but failed in the end to overwhelm me and
-compass my ruin.
-
-       *       *       *       *       *
-
-DRUG ADDICTION FROM THE VIEWPOINT OF AN AFFLICTED PHYSICIAN
-
-BY A PROMINENT MEDICAL MAN, FORMERLY A HEALTH OFFICIAL OF AN AMERICAN
-CITY
-
-Maximum efficiency of every individual member of this nation is
-necessary today as never before in its history. Hence any condition
-responsible for lessened efficiency on the part of thousands of
-citizens is a thing to be seriously considered, especially when among
-these are to be found a large proportion of men and women who would
-otherwise be useful workers in every important field of activity.
-
-Addiction to narcotic drugs is today depriving the country, either
-wholly or partially, of the services of thousands of individuals who
-but for this handicap would be entirely fit (many of them preeminently
-so) for work of the utmost importance. This is a problem of the first
-magnitude and one which will have to be solved largely by the medical
-profession.
-
-But the medical profession as a whole is utterly lacking at the present
-time in such knowledge of addiction as is needed to enable them to
-attack the problem. For these reasons I feel it to be my duty to do my
-“bit” as a medical man, to put on record some of the lessons which,
-from years of personal experience, I have learned as to addiction
-itself, and the methods of treatment with which I have had experience
-in my efforts to be cured.
-
-The subject is too important to excuse anything but the utmost
-frankness in speaking of the serious misconception which medical men
-only too generally share with the masses in regard to the subject of
-addiction. Unless the profession realizes its own ignorance, all point
-will be taken from the appeal which I wish to make to the physicians of
-this country to lose no time in equipping themselves to deal adequately
-with this great problem.
-
-It may well be imagined that the task which I have thus set myself is
-no easy one, viewed from any one of half a dozen angles. Yet, if I am
-correct, in believing that I can thereby make a small contribution to
-the cause which now means so much to all of us, I must do so regardless
-of every difficulty.
-
-Addiction with me goes back a number of years, covering in fact, almost
-my entire career as a physician. During this entire time, as will be
-more fully referred to, I have tried cure after cure, besides having,
-time and again, sought by own efforts to rid myself of this burden. I
-have naturally during these years studied and thought much about the
-problem which has meant so much to me. All this by way of showing why I
-believe that my experiences and opinions should have some value.
-
-First of all, let it be clearly understood that the addiction which
-I shall discuss is limited strictly to opium and its derivatives;
-first, because my own experience is limited to this group and, second,
-because much that I shall have to say does not apply to all so-called
-habit-forming drugs to an equal extent, and to some of them not at all.
-Addiction as thus limited is as true a disease as any with which the
-human body is afflicted.
-
-To look on the opium addict as a man with a vicious habit which
-he could quit if only he truly cared to do so displays a profound
-misunderstanding of plain facts. As well claim that a man with typical
-malarial infection has simply become so accustomed to having chills and
-fever at a given hour on certain days that when this hour arrives he
-quakes through mere habit as to claim that the equally characteristic
-and even more pronounced and distressing symptoms which manifest
-themselves when the addict is deprived of his drug are due to habit,
-that is, to “a condition which by repetition has become spontaneous.”
-
-We would, as a matter of fact, be less absurd in the former instance
-than in the latter; for we could argue the case out with our malarial
-friend, telling him he could conquer his “habit” by the exercise of
-will power, and--provided we argued long enough--we might convince
-ourselves that we were right because he would cease to shake, his fever
-would subside and until the next crop of parasites was turned loose
-in his blood stream, he would to all intents and purposes feel a well
-man, while in the latter case the more we talked of habit--that is, the
-longer the addict was deprived of his dose--the plainer would become
-the picture of a disease-racked body and a tormented mind.
-
-I do not, of course, mean to offer the above comparison as either
-perfect in itself, or as sufficient to establish the claim that
-addiction is a true disease. The fact that it is a disease has
-impressed itself on all competent observers of a sufficient number of
-cases, and must be accepted. Yet it is astonishing to find that many
-educated physicians do not know this, while an even larger number,
-though readily admitting that addiction is a disease, nevertheless
-show, both by their manner of discussing the subject and by their
-attitude towards addicts seeking their advice, that this is little more
-than a verbal concession on their part.
-
-If, however, it be argued that the contention as to addiction being a
-disease is vitiated by the fact that an occasional addict stops taking
-his drug by “will power,” that is, without taking treatment, we can
-point to an even larger proportion of mild cases of malarial fever in
-which spontaneous cure has come about. But this does not prove that the
-one, any more than the other, is not a disease.
-
-Indeed, there could be no stronger argument in favor of the fact that
-addiction is an actual disease than the very phenomena presented by the
-occasional addict who stops taking the drug by “will power.” Neither
-medical writers nor literary geniuses, whether themselves addicts or
-mere observers, have yet succeeded in presenting a true picture of
-the tortures which this involves. There could be no greater error than
-to regard cure as dating from the time the last dose was taken. When,
-in these cases, cure comes at all, it is only after weeks, or months,
-of horrible existence, during which kind nature brings about a more or
-less complete restoration of body and mind not alone from the disease
-of addiction, but also from the profound shock of unskilled or unwise
-withdrawal. Will power has enabled the addict to abstain from taking
-the drug, while nature cured the disease.
-
-There has been no time during all the years of my addiction that I have
-not earnestly longed to be free from its clutches. This is sufficiently
-proved by the many efforts which I have made to find a cure, each time
-at great personal sacrifice and expense, each time only to have my
-hopes shattered, after untold suffering and fresh disillusionment.
-
-But a real cure I have thus far been unable to find. I have tried
-everything that seemed to offer a chance: gradual reduction,
-self-conducted and at institutions, the Keeley cure several times,
-and since then all of the vaunted cures, as each appeared in turn,
-advocated by men of high standing in the medical profession. Concerning
-this last class, I have each time hoped that such men could not
-be totally in error as to the practical results of their methods,
-notwithstanding what has seemed to me the most bizarre pathology on
-which they have claimed these methods to be based.
-
-I might, perhaps, have been warned by certain palpable danger signs,
-but I have been too anxious to find the cure. I cared not at all how
-mistaken their pathology; for I could not believe that men of such
-standing could be equally mistaken as to the success or failure of what
-went on under their very eyes.
-
-And right here let me set down what has impressed me as inexcusable
-neglect of these cases by most of these self same “big” men of the
-medical profession. One after another I have found physicians who
-receive and undertake to treat cases of addiction brought to them by
-the lure of high professional reputation and medical articles in which
-is painted a glowing picture of some new and wonderful cure. And, one
-after another, I have found these men of high professional standing
-giving to their cases not even enough time and attention to enable them
-to form an intelligent opinion as to their condition and progress, much
-less what would be needed for the proper study and treatment of one of
-the most difficult and distressing ailments which afflict mankind.
-
-Moreover, comparing notes with medical men who have been fellow
-patients under similar circumstances (many of them, I may remark, of
-the highest type, as men and as physicians), there has been among us a
-universal sense of shame and indignation that men with such reputation
-and standing should lay the medical profession open to the justly
-founded criticism of extortion and neglect of duty, frequently of
-seemingly rank commercialism, even including the splitting of fees with
-quacks and charlatans of the worst sort.
-
-In saying that I have found no cure, I do not mean that I have never
-succeeded in getting to the point where I could get along for shorter
-or longer periods without the drug. Many times I have succeeded by
-myself in gradually reducing the dose to a minimum and then making the
-final plunge and taking none at all for some time. What this has meant
-I will not undertake to describe. Several times I have managed to keep
-from using the drug for a while after taking treatment of one kind or
-another. But have I been cured?
-
-Let no one thoughtlessly reply that the very fact of my having on
-each of these occasions reached a point where, according to my own
-statement, I was able to live without the drug, constitutes proof
-that I was cured, or that when I started to use it again I was merely
-yielding weakly.
-
-What has actually happened has been this. Each time that I have
-succeeded, in one way or another, in reaching a point where I was no
-longer taking the drug, I have, even while the suffering was still
-acute, been filled with a sense of happiness and hope that enabled me
-to stand it thankfully. I have argued with myself that, being then
-able even to exist without the drug and, for a while finding this
-existence day by day a little less of torture, I might reasonably hope
-for continued improvement. I have not expected miracles, but I have
-felt that each week should be easier, until, after a period of some few
-months, I should again be normal.
-
-But this has not come about. Always I have reached a point where
-progress seemed to stop, and beyond this point my system refused to
-react. Occasionally this standstill has been quickly reached, that is,
-I could not react beyond a point where I was unable to sleep, where
-my legs ached atrociously, and where I was so completely unstrung
-that life was unendurable. At best, progress has continued for a few
-weeks, after which, though resting well, having a prodigious appetite
-and not undergoing marked physical suffering, I have actually been far
-from normal. This was shown, on these special occasions, chiefly by my
-inability to do satisfactory work, by my tiring altogether too easily
-and by a general feeling of unrest and disquietude.
-
-I realize the difficulty of so describing my condition during these
-most favorable occasions as to show at all convincingly that I was not
-actually cured and that, in consequence, my resuming the taking of the
-drug was anything but a relapse. This, however, I must not attempt to
-do, since the main contention which I wish to make is here directly led
-up to.
-
-And, hard as is the whole task I have set myself in writing this
-account, this special part of it is peculiarly difficult, involving
-the risk of appearing to set a false value on certain personal
-considerations.
-
-My life has been an active and useful one. I have done work which I
-know to be good and which has brought recognition. Successful work,
-even in a given line of endeavor, is not always due to the same
-qualities in different men. My own work has been characterized by
-the exercise of careful judgment and the power of accurate analysis,
-qualities which I have always been credited with possessing. Now, after
-the most favorable of the so-called treatments which I have taken,
-and after allowing considerable time for complete recovery, I have
-in no instance regained these most essential requisites for my work,
-and thus I have been placed in a position where I would either have
-had to discontinue my work, or else do the only thing which made the
-resuming of that work possible. And always there has been the absolute
-conviction that this state of affairs was due to my not having been
-actually cured. On this point there has not been one iota of doubt.
-
-Perhaps if I had been able at such times to take a complete rest of
-six months or even a year, I might have been fully restored, but this
-has not been possible. I have not been able to remain away from work
-for over five or six weeks after the “cure” proper, and even this has,
-as may well be understood, been a severe drain, when I have taken some
-cure or other at as short intervals as I could manage to get together
-sufficient funds and the opportunity to leave my practice.
-
-Of course it may be argued that, rather than return to the use of
-the drug and thus again be able to live a life as nearly approaching
-normal as is possible for an addict, it would be better to refrain
-from using the drug, even though this involved never again being able
-to do those things which, to the ambitious man, are essential to make
-life worth the living. I submit that it is a high motive and not a
-low one which makes a man willing to pay the price rather than live a
-vegetative existence when he knows himself capable of better things.
-To understand this point of view it must be remembered that the addict
-gets no rosy dreams, no wonderful journeys into a beautiful and unreal
-world, no artificially enhanced powers beyond those of the non-addict,
-but at best only such equanimity and energy as are the latter’s happy
-possessions.
-
-My point, therefore, is that my resorting to the drug after having
-stopped its use a number of times does not mean that I have many
-times been cured, and many times relapsed, but that I have not been
-truly cured. When the latest “cure” which I have taken has left me,
-even after weeks, still suffering acutely and continuously, and not
-improving in the slightest so far as I could see, I have taken the
-drug again for relief from torture no longer bearable. After “cures”
-which have left me in decidedly better plight but in the intolerable
-condition last described above, and with progress at a standstill, I
-have taken the drug only after calmly surveying the situation, and as
-the lesser of two evils.
-
-I must reiterate my strong desire to find a cure, a real cure, one
-deserving the name; that is, a cure which will leave me normal, without
-need of the drug, and able to do the work which I must do in the world
-unless I am willing to be a slacker. But until I can find such a cure
-(and, in spite of my unhappy experiences, I will keep up the quest) I
-would have only contempt for myself as a physician and as a rational
-being if I failed meanwhile to make the best compromise possible,
-namely, to take each day, just as I would take thyroid substance were
-I suffering from hypothyroidism, a sufficient amount of morphine to
-enable me to attend to life’s duties and to occupy in the world that
-useful place which my qualifications enable me to occupy.
-
-One of the great hardships under which every addict suffers is the
-constant dread lest his affliction become known and he be branded a
-“morphine fiend,” a term which should be prohibited, or at least never
-used by an intelligent physician. What this exposure would mean to a
-man of standing in his community I need not explain. This risk he must
-always run, but it would be robbed of some of its terror if the nature
-of addiction were better understood.
-
-Therefore the law now existing in some states requiring the
-registration of addicts is little short of barbarous. So little
-possible good can be accomplished by this law that one is tempted
-to believe that its passage was not instigated primarily by honest,
-though misguided zealots but by quite another class. The addict, in his
-efforts to find a cure, has learned something of a class of men, who,
-posing as public benefactors, are in reality a shrewd set of rascals,
-capitalizing the misfortunes of the addict most successfully. If such
-men were not the originators of the idea of registration, certainly
-they, and not the body politic, are its chief beneficiaries, since it
-affords them an authentic list of prospective victims.
-
-As for the effect of this law on the addict, it merely adds further to
-his dread of exposure. Think of the position of a man of prominence
-and respected in his community, having his own feelings as have other
-men, holding equally dear the sensibilities of those he loves, living
-under the constant dread that his necessities may any day force him to
-seek aid in a state in which his name will, as it were, be added to a
-rogues’ gallery!
-
-My plea is for realization of the great need for finding some means
-whereby the individual addict may get real relief and whereby addicts
-collectively may be restored to such condition as will render them
-capable of performing those services of which our country is now in
-need.
-
-I am confident that I am understating the case when I say that nine
-addicts out of ten earnestly desire to be cured. Why should they not?
-They get no pleasure out of taking the drug, but only relief from
-intolerable suffering which they must otherwise endure. Hence to be
-free both from this suffering and from the necessity of getting this
-relief by artificial, and at present exceedingly costly, means is bound
-to appeal to them. Most addicts, I am confident, are willing to go
-through whatever acute suffering may be involved in any really rational
-treatment which will, after a reasonable time, restore them to normal
-condition.
-
-Experiences such as I have described above are, I know, the rule and
-not the exception with those who have tried the various so-called
-cures. They can hardly be called satisfactory. Even admitting that they
-may prove successful in a small proportion of cases, relatively few
-addicts are able to find the means of taking them, such as I have been
-able to make for myself in the midst of a very active life.
-
-Surely a disease having so definite a symptomatology and, I believe,
-so plain a pathology, must be susceptible of rational cure. That such
-a cure has not yet been found by those who so loudly proclaim to
-have found one I honestly believe. Whether others have devised more
-promising lines of treatment I frankly do not know.
-
-But a cure must be found which does more than any I have succeeded in
-finding. In what other disease would a patient who, after reaching a
-certain point, beyond which he could not progress towards recovery, be
-told that from then on everything rested with him, although he himself
-knew that his need for help was really as great as it ever was? In what
-other disease would any physician worthy of the name calmly tell a
-patient that, having taken a “cure,” he was, _ipse facto_, cured, and
-become highly incensed when the patient pleaded that his condition was
-in many respects more desperate than before treatment?
-
-The medical profession must seriously study addiction. Of material
-there is, unfortunately, an abundance. Some high authority should see
-that every facility is afforded the proper persons for employing it.
-It is not unlikely that many of the “cures” which have been advocated
-have in them some elements of good, properly selected and properly
-applied in each individual case. Possibly competent investigation,
-furnished with every facility, might result in the discovery of a truly
-specific cure. I have long thought that there was such a possibility in
-more than one direction, but investigation of these would involve very
-careful and laborious work, as well as considerable cost. Here indeed,
-would seem to be a wonderful opportunity for philanthropy.
-
-But while such a specific cure would be an untold blessing, we need
-not find one in order to meet the situation--at least, much more
-successfully than it is being met at present. Coordination of the
-entire problem of addiction, in the hands of the few men whose work in
-this field is most promising (and the men I have in mind are not those
-with whose vaunted cures I have had such unhappy experiences) would
-almost certainly lead to valuable results.
-
-While every effort should be exerted to determine the best lines of
-treatment, meanwhile there is a great deal which should be done in
-other directions. Let the medical profession help in bringing about
-better understanding of addiction--first, of course, learning this
-themselves. Until the addict can be offered rational treatment, the
-profession should do what it can in making the lives of addicts
-less unbearable by removing from the public mind some of the gross
-misconceptions concerning addiction, seeing to it, especially, that
-these unfortunates are not stigmatized as “morphine fiends” and that
-they are given the means of obtaining, without risk and hardship and
-almost prohibitive cost, the supply of their drug which, until they are
-cured, is to them as necessary as the air they breathe.
-
-But the finding of a real cure or treatment--not necessarily specific,
-not a thing to be applied indiscriminately in every case, but a
-rational method of handling addiction as other well known diseases are
-handled--is the great aim, or, if it be that sufficient is already
-known by some men in the profession as to the rational handling of
-addicts, let these men be found and their services subsidized by the
-government and used to the fullest extent, in teaching others, and
-these still others, until there is built up a system extending over
-the entire country, capable and equipped for giving to every addict
-the opportunity for cure. This is a crying need in our country today.
-Surely there must be somewhere recognition of this fact and resources
-enough to make it possible for this need to be supplied.
-
-       *       *       *       *       *
-
-A PLEA FOR THE BROADER CONSIDERATION OF NARCOTIC DRUG ADDICTION BY THE
-MEDICAL PROFESSION
-
-BY A PRACTICING PHYSICIAN WHO HAS MET THE PROBLEM IN HIS OWN FAMILY
-
-In view of a recent experience of mine in seeking intelligent medical
-help for a near relative whom I learned was a narcotic drug addict, I
-take pleasure in recounting experiences of the past few months in the
-handling of such a case, and in calling attention to the conditions
-which my investigations have shown me to exist in our profession.
-
-My line of professional activity had not brought me knowingly into
-touch with narcotic drug addiction, and I entertained the prevailing
-medical opinions in regard to it.
-
-About five months ago I received a letter couched in apologetic
-language from a practitioner in another state informing me that a
-younger brother of mine had been under his care for a number of days
-suffering from withdrawal symptoms occasioned by inability to purchase
-morphine, and advising me to place him in some institution where he
-could be restrained.
-
-I immediately began asking my colleagues where I could send such a
-case, and was amazed at the general lack of knowledge in regard to and
-sympathy for these unfortunates. In truth no one could point out a
-single institution where such a patient could be sent with any hope
-that he might be handled in a humane and intelligent manner.
-
-My investigations of the institutions they suggested showed this to be
-the fact.
-
-Most every one seems to regard those suffering from this condition as
-being of a lower order of humanity, unwilling or too weak-minded to
-help themselves and fit subjects only for association with what is
-commonly known as the “underworld.” I wish to say that I myself have
-undergone a very complete revision of mind regarding these cases since
-the case of my brother has compelled me to investigate them. I have
-known my brother too well and for too many years to believe that he can
-possibly be placed in any such category.
-
-I have made careful inquiries into the circumstances and origin of his
-addiction, and the results are absolutely convincing that the first
-administrations of the narcotic were to meet therapeutic indications
-and were continued without his knowledge or appreciation of its actions
-or ultimate results. I know that he has never experienced any pleasure
-from the narcotic, and I know that when the condition of addiction
-manifested itself he did not know what was the matter with him. He only
-knew that narcotic relieved intense suffering. I had never seen a case
-of addiction to my knowledge before I went to see him in response to
-the letter I received. The clinical symptomatology of withdrawal of
-an opiate was truly a revelation to me. That the condition from which
-these patients suffer is a distinct disease cannot be questioned by any
-intelligent observer.
-
-I have found that the majority of patients who begin the use of
-opiates do so in search of relief from pain, and are not aware of the
-fact for a long time that the suffering they endure when the drug is
-discontinued is due to a disease they have contracted. Apparently the
-medical profession is also ignorant of this fact.
-
-A more pathetic sight I have never seen than one of these patients who
-has been suddenly deprived of his medicine. They will tell you that
-they will become insane or be driven to suicide if they cannot obtain
-relief from their suffering. Hence their willingness to obtain the drug
-at any cost. I have come to believe that any man is justifiable in
-lying or stealing to escape the agonies I have witnessed.
-
-It seems a crime that we of the profession have gone so long without
-any attempt to study or understand the disease which we in our daily
-rounds are constantly creating. Certainly our standard medical
-literature contains little if anything of value in regard to this
-condition, and investigation of the claims and procedure of the widely
-advertised so-called “treatments” and “cures” readily convinces one of
-their unworthiness.
-
-I know that much can be done for the cure of these patients by an
-intelligent effort on the part of the medical profession, and a
-willingness to open their minds to the clinical facts of this condition
-and to handle it like other diseases.
-
-In search of information I have gotten into touch with cases of
-addiction other than my brother’s, and I find that the majority of
-them are desperately anxious to be cured. They tell me, however, that
-institutions such as jails, workhouses, lunatic asylums, alcoholic
-wards of the charity hospitals, and those that they have tried of the
-advertised cures are places of insufferable torture from which they
-emerge in worse condition than that in which they entered.
-
-There are estimated to be as many as 500,000 or more addiction cases in
-the State of New York alone. I ask in all earnestness, is it not worth
-while to try to do something more than we are doing for these sufferers?
-
-
-PRINTED IN THE UNITED STATES OF AMERICA
-
-
-
-
-INDEX
-
-
-  Abnormalities, getting rid of, in preliminary stage, 83
-
-  Acidosis in opiate addiction, 48
-
-  Addict, criminal or vicious, handling of, 108
-    drug, as a surgical and medical risk, 85
-      coöperation of, 72
-      often unknown and unsuspected, 7
-    honest, and need of competent medical care, 109
-      and custodial care, 28
-    medical, personal history of, 140
-    mixed, 115
-    narcotic, failure to understand, 5
-      will coöperate and suffer, 6
-
-  Addicts, drug, accidental or innocent, 28
-      age of, 24
-      and influenza and pneumonia, 86
-      majority of, 17
-      often understand own cases, 7
-      what type or class become, 23
-    innocent and worthy, what shall we do with them? 129
-    narcotic, average individuals, 3
-      often men and women of high ideals, 3
-    worthy and innocent, problem of, 128
-    youthful, 125
-
-  Addiction, author’s definition of, 20
-    beginning stage of, 30
-    development of, 29
-    disease, author’s conclusions, 40
-      a chronic condition, 93
-      in newly born infant, 24
-      may afflict all classes, 19
-      mechanism of, 36, 41
-      rational handling of, 61
-      treatment of, and legitimate medical practice, 99
-    drug, a medical problem, 28
-      among soldiers, 117
-      and defectives, 16
-      a plea for broader consideration of, 156
-      and the average person, 17
-      as a sequelae of war, 120
-      contraction of, in the army, 118
-      in surgical cases, 85
-      medical problem of, 21
-      methods of treating, 50
-      origin of, 25
-      so-called specific, treatment of, 55
-      unsuspected, 26
-      viewpoint of physician afflicted with, 146
-      wrongly described, 14
-    established, stage of, 31
-    narcotic, a demonstrable disease, 59
-      a recognized menace, 4
-      classed as a vice or morbid appetite, 4
-    opiate, as a war problem, 117
-      complicated with cocaine, 3
-    picture wrongly painted, 2
-
-  Adequacy, metabolic and organic, relation to other disease
-   conditions, 92
-
-  Administration, narcotic drug, regulation of, 65
-
-  “After Care” or convalescence, 53
-
-  Age of addicts, 24
-
-  American Medicine, human documents from, 137
-
-  Antidotal substance, 42
-
-  Any one liable to drug addiction, 8
-
-  Attempts at administrative and police control, 4
-
-  Attitude of drug addict, 71
-    of lawmakers to drug addiction, 102
-    of medical profession, 50
-    personal, of physician to drug addict, 70
-    to drug addicts, author’s unjust, 12
-
-  Auto-intoxication and autotoxicosis, 46
-
-
-  Balance, drug adequate, importance of establishing and maintaining, 92
-    narcotic drug, and minimum daily need, 66
-      and operative procedure, 92
-      necessity of maintaining, 67
-
-  Basis of success, 132
-
-  Beacon-light of hope for drug addicts, 14
-
-  Belladonna, use of, 55
-
-  Bellevue Hospital, early work in alcoholic and narcotic wards, 2
-
-
-  Care, custodial, and the honest addict, 28
-
-  Cases demonstrating presence of antidotal substance, 43
-
-  Catharsis, non-irritating, 79
-
-  Cause of withdrawal symptoms, 38
-
-  Causes of failure in solving drug problem, 5
-
-  Clinics, drug, need for, under competent medical direction, 124
-    public, 135
-
-  Cocaine, habitual use of, 115
-
-  Committee appointed by Secretary of Treasury, report, 14
-
-  Complications, avoided by intelligent patients, 78
-
-  Conclusions of author, 40
-
-  Condition, another disease, relation of functional balance to, 92
-    drug patient’s, as index of successful treatment, 75
-
-  Considerations, fundamental, 11
-
-  Convalescence, and “after care,” 53
-
-  Coöperation of drug addict, factors which determine, 72
-
-  Cure of drug addiction, What constitutes? 76
-
-  “Cures,” basis of, 55
-
-  Custodial care and the honest addict, 28
-
-
-  Danger of restrictive legislation, 123
-
-  Dangers of belladonna, hyoscine, pilocarpine, etc., 80
-
-  Data, institutional, lack of, 58
-
-  Defectives and drug addiction, 16
-
-  Definition of term “narcotics,” 114
-
-  Deprivation, forcible, danger of, 53
-
-  Development of addiction stage, 29
-
-  Discontinuance of narcotic drug, difficulties of, 69
-
-  Disease, addiction, rational handling of, 61
-    drug addiction, nature of, 23
-
-  Documents, human, 137
-
-  Dosage, narcotic drug, in relation to withdrawal symptoms, 75
-
-  Doses, therapeutic, and toxic stage of normal reaction to, 29
-
-  Drug, narcotic, balance, 67
-    definite body need for, 37
-
-  Drugs, narcotic, and the physical condition established, 21
-    may afford pleasure, 3
-    legitimate use of, in peace and war, 114
-    prescribing and dispensing of, 100
-    relations of laws to, 95
-
-  Du Mez’s recent paper, 38
-
-
-  Education and training, 131
-    lay, medical and official, needed, 109
-    neglect of, and illicit traffic, 126
-
-  Efficiency, functional, nutritional and metabolic importance of, 92
-
-  Efforts, author’s early, 11
-
-  Elimination, competent, not measured in bowel movements, 81
-    of opiate, and cell tolerance, 46
-
-  Evils, chief, of present drug situation, 122
-
-  Exploitation, commercial, and its financial possibilities, 125
-    of physical suffering, 123
-
-
-  Facts concerning drug addiction, necessity for unbiased medical
-   investigation of, 101
-    significant, 13
-
-  Fear, constant, addict lives in, 92
-
-  Function, inhibition of, 46
-
-
-  Gioffredi, investigation of, 26, 38
-
-
-  Handling, institutional and custodial, and certain types of
-   addicts, 108
-    of criminal or vicious addict, 108
-    preliminary to withdrawal, 62
-    rational, of addiction disease, 61
-
-  Harrison Law, effect on medical profession, 96
-    reasons for failure of, 96
-    wise in purpose, 95
-
-  Hirschlaff’s experiments, 26, 38
-
-  History of medical addict, 140
-
-  Hyoscyamus, use of, 55
-
-
-  Ignorance, the harmful effects of, 127
-
-  Immunity to narcotic drugs, 4
-
-  Inefficiency, medical, 6
-
-  Infant, newly-born, and addiction disease, 24
-
-  Influenza and pneumonia in drug addicts, 86
-
-  Information, clinical, paucity of, 58
-
-  Intervals, long, between doses, desirable, 77
-
-  Introduction, 1
-
-
-  Jennings’ studies of acidosis, 48
-
-
-  Kobert’s and Toth’s studies, 38
-
-
-  Law, Harrison, failure of, 96
-    makers, attitude to drug addiction, 102
-    What has it done for the addict? 102
-
-  Laws and old conceptions of drug addiction, 96
-    and their relations to narcotic drugs, 95
-    drug, enforcement and increased suffering of addicts, 96
-
-
-  Magendie’s findings, 38
-
-  Marme and oxydimorphine, 38
-
-  Mechanism, essential, of addiction disease, 41
-    of narcotic drug addiction disease, 36
-    of protection, 47
-
-  Medication, ignorant or unavoidable, and drug addiction, 27
-    opiate, indispensable and legitimate, 116
-    “specific,” fallacy of, 56
-
-  Misunderstanding of addict, cause of early failures in treatment, 5
-
-
-  “Narcotics,” definition of term, 114
-
-  Need, drug, minimum daily, 66
-    of the hour in study of drug addiction, 130
-    narcotic drug, and mental and muscular work, 69
-
-
-  Observation in Bellevue, sixteen months, day and night, 3
-
-  Observations on physical or body reaction, 32
-
-  Opiate, withdrawing, simply one stage, 92
-
-  Opiates, and their unique properties, 116
-
-  Organizations, medical duty of, 104
-
-  Origin of addiction, 25
-
-  Oxydimorphine and Marme theory, 38
-
-
-  Panaceas, search for, 56
-
-  Patients, intelligent, and the avoidance of complications, 78
-
-  People, eminent, and drug addiction, 27
-
-  Philanthropy and its opportunity, 135
-
-  Physician, average, is inexpert in handling addiction disease, 108
-    suffering from drug addiction, viewpoint of, 146
-
-  Physicians, honest, and their responsibility, 103
-
-  Pilocarpine, use of, 50
-
-  Practice, legitimate medical, 95
-
-  Practitioner, honest, and control of illicit drug traffic, 123
-
-  Principles, basic, of addiction-disease handling, 65
-
-  Problem, drug, still unsolved, 5
-    of drug addiction, ultimate solution of, 108
-    of the care of the innocent and worthy addict, 129
-
-  Profession, medical, attitude of, 50
-
-  Prostitution and “white-slavery,” 125
-
-  Protection, bodily, against opiate, 42
-    mechanism of, 47
-
-  Pulpit and press, duty of, 135
-
-  Purgation, excessive, warning against, 81
-
-  Purpose, chief, of most lay and medical workers, 96
-
-
-  Questions that confront the American people, 136
-
-
-  Reaction, normal, stage of, 29
-      to therapeutic and toxic doses, 29
-    of drug addicts to therapeutic agents, 68
-
-  Reduction, enforced, below bodily need, dangers of, 69
-    slow, 51
-
-  References to recent literature, 39
-
-  Regulation, legislative and administrative, 105
-    of intervals of narcotic drug administration, 66
-
-  “Relapses” and production of antidotal substance, 45
-
-  Report, 1915, of New York Dept. of Correction, 72
-    Preliminary, of Whitney Committee, 110
-
-  Responsibility for drug addiction laid on medical profession, 102
-
-  Restoration of drug addict to health, 83
-
-
-  Side, personal, of drug addiction, 137
-
-  Solution of drug problem, ultimate, 108
-
-  Stage of study, preliminary to withdrawal, 63
-    preliminary, abnormalities in, 83
-
-  Stages of addiction development, 29
-
-  Stool, “typical,” of Towns treatment, 79
-
-  Study, clinical and laboratory, lack of, 91
-    of patient, essential as preliminary to withdrawal, 63
-
-  Substance, antidotal, to opiate, and bodily protection, 42
-
-  Suffering, physical, and drug addiction, 20
-
-  Survey of the situation, 122
-
-
-  Terms that should be eliminated, 9
-
-  Testimony of Whitney Committee, deductions from, 134
-
-  Theories, author’s wrong, 12
-
-  Tolerance, explanation of, 38
-    increased, stage of, 30
-
-  Traffic in narcotic drugs, illicit, 103
-
-  Treatment, importance of regulating intervals of narcotic drug
-   administration in, 65
-    rational, of addiction disease, 61
-    so-called specific, 55
-    specific, author’s disbelief in, 80
-
-
-  “Underworld” and desperate necessity of addict, 28
-
-  Use, legitimate, of narcotics in peace and war, 114
-
-
-  Valenti’s studies, 26, 38
-
-  Veterans, Civil War and drug addiction, 24
-
-  Views, personal and legal, of drug addiction, 137
-
-
-  Whitney Committee. Hearings, testimony of, 107
-
-  Withdrawal accompanied by use of various drugs, 51
-    forcible, and suicide, 53
-    stage of, 62
-    sudden, 53
-    symptoms, 35
-
-  Withdrawing of opiate simply one stage, 92
-
-
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-
-
-
-
-Transcriber’s Notes
-
-Errors and omissions in punctuation have been fixed.
-
-Page 27: “physicial sufferings” changed to “physical sufferings”
-
-Page 39: “Deutch. med” changed to “Deutsch. med”
-
-Page 66: “normally functionating individual” changed to “normally
-functioning individual”
-
-Page 76: “continued maintainance” changed to “continued maintenance”
-
-Page 100: “oppose as illegitimatc” changed to “oppose as illegitimate”
-
-Page 101: “he is forccd” changed to “he is forced” “physical nced”
-changed to “physical need” “should mcet” changed to “should meet”
-“would be eagcrly” changed to “would be eagerly”
-
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-<p style='text-align:center; font-size:1.2em; font-weight:bold'>The Project Gutenberg eBook of The narcotic drug problem, by Ernest S. Bishop</p>
-<div style='display:block; margin:1em 0'>
-This eBook is for the use of anyone anywhere in the United States and
-most other parts of the world at no cost and with almost no restrictions
-whatsoever. You may copy it, give it away or re-use it under the terms
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-at <a href="https://www.gutenberg.org">www.gutenberg.org</a>. If you
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-country where you are located before using this eBook.
-</div>
-
-<p style='display:block; margin-top:1em; margin-bottom:1em; margin-left:2em; text-indent:-2em'>Title: The narcotic drug problem</p>
-<p style='display:block; margin-top:1em; margin-bottom:0; margin-left:2em; text-indent:-2em'>Author: Ernest S. Bishop</p>
-<p style='display:block; text-indent:0; margin:1em 0'>Release Date: October 20, 2022 [eBook #69186]</p>
-<p style='display:block; text-indent:0; margin:1em 0'>Language: English</p>
-  <p style='display:block; margin-top:1em; margin-bottom:0; margin-left:2em; text-indent:-2em; text-align:left'>Produced by: Charlene Taylor and the Online Distributed Proofreading Team at https://www.pgdp.net (This file was produced from images generously made available by The Internet Archive/American Libraries.)</p>
-<div style='margin-top:2em; margin-bottom:4em'>*** START OF THE PROJECT GUTENBERG EBOOK THE NARCOTIC DRUG PROBLEM ***</div>
-<h1>  THE NARCOTIC DRUG PROBLEM</h1>
-
-
-<hr class="chap x-ebookmaker-drop" />
-
-<div class="chapter">
-<p class="center p2"><span class="figcenter"  id="img001">
-<img src="images/001.jpg" class="w10"  alt="Publisher logo" />
-</span></p>
-</div>
-
-<p class="center">
-<span class="big">THE MACMILLAN COMPANY</span><br />
-NEW YORK · BOSTON · CHICAGO · DALLAS<br />
-ATLANTA · SAN FRANCISCO<br />
-<br />
-<span class="big">MACMILLAN &amp; <abbr title="company">CO.</abbr>, <span class="smcap">Limited</span></span><br />
-LONDON · BOMBAY · CALCUTTA<br />
-MELBOURNE<br />
-<br />
-<span class="big">THE MACMILLAN <abbr title="company">CO.</abbr> OF CANADA, <span class="smcap"><abbr title="limited">Ltd.</abbr></span></span><br />
-TORONTO<br />
-</p>
-
-
-
-
-
-<hr class="chap x-ebookmaker-drop" />
-
-<div class="chapter">
-<p class="center xbig">
-THE NARCOTIC DRUG PROBLEM<br />
-</p>
-<p class="center p2">
-BY<br />
-<span class="big">ERNEST S. BISHOP, M.D., F.A.C.P.</span><br />
-<br /><span class="small">
-Clinical Professor of Medicine, New York Polyclinic Medical School;
-Member Narcotic Committee, Conference of Judges and Justices
-of New York State; Committee on Habit Forming Drugs,
-Section on Food and Drugs, American Public
-Health Association.<br />
-<br />
-Formerly Resident Physician, Alcoholic, Narcotic and Prison Service,
-Bellevue Hospital; Formerly Visiting Physician and President of
-the Medical Board, Workhouse Hospital. New York Department
-of Corrections; Fellow Academy of Medicine, Visiting
-Physician <abbr title="saint">St.</abbr> Joseph Tuberculosis Hospital, Consulting
-Physician to <abbr title="saint">St.</abbr> Mark’s Hospital,
-etc., etc.</span>
-</p>
-<p class="center p4">
-<span class="big">New York<br />
-THE MACMILLAN COMPANY</span><br />
-1920<br />
-<br />
-<i>All rights reserved</i><br />
-</p>
-</div>
-
-
-
-
-<hr class="chap x-ebookmaker-drop" />
-
-<div class="chapter">
-<p class="center">
-<span class="smcap">Copyright</span>, 1920<br />
-<span class="smcap">By</span> THE MACMILLAN COMPANY</p>
-<hr class="r5" /><p class="center small">
-Set up and electrotyped. Published January, 1920.<br />
-</p>
-
-
-</div>
-
-
-<hr class="chap x-ebookmaker-drop" />
-
-<div class="chapter">
-<p class="center">
-TO<br />
-MY WIFE,<br />
-<br />
-WHO HAS SHARED MY BURDENS AND HELPED IN
-MY WORK, AND WHOSE INTEREST IN AND SYMPATHY
-WITH MY WORK HAS MADE MUCH OF IT
-POSSIBLE,
-THIS BOOK IS INSCRIBED.<br />
-</p></div>
-
-<hr class="chap x-ebookmaker-drop" />
-
-<div class="chapter">
-<p><span class="pagenum" id="Page_vii">[Pg vii]</span></p>
-
-<h2 class="nobreak" id="PREFACE">PREFACE</h2>
-</div>
-
-
-<p>This book has been prepared in response to a growing demand that the
-author group together under one cover some of the material collected
-out of a varied experience with many aspects and phases of narcotic
-drug addiction, and with activities in the attempted solution of its
-problems.</p>
-
-<p>Some of this experience has been previously presented in many addresses
-before scientific and other societies and in articles in the medical
-press.</p>
-
-<p>The author is not associated with nor interested in any hospital or
-institution active in the care of these cases for financial return or
-pecuniary benefit. He is not the exponent or mouthpiece or proponent of
-any special or specific “remedy” or “treatment” or method of so-called
-“cure.” He has no axe to grind.</p>
-
-<p>He is not a “specialist” in the treatment of narcotic drug addiction.
-He is a practitioner of diagnostic and clinical medicine, in whose
-professional work the care of the narcotic addict has constituted much
-the smaller part of his activities and studies, and that part has been
-largely carried on without recompense and often at his personal expense.</p>
-
-<p>Some years ago, through hospital affiliations and duties, the writer
-was brought to face this problem of opiate addiction and after a while
-saw in it very important and very interesting clinical problems of
-physical disease and physical reactions upon which he made observations
-and studies.</p>
-
-<p>Hospital connections and the publishing of various articles have
-since that time brought him into association with practically all
-phases and aspects of activity in the<span class="pagenum" id="Page_viii">[Pg viii]</span> consideration and handling
-of the narcotic drug problem. He has listened to discussions of the
-subject by promoters; by reformers of various sorts; by those engaged
-in legislative, judiciary, administrative, custodial, penological,
-sociological, psychological or psychiatrical, medical and other lines
-of work, and by narcotic addicts from all classes and types of people
-and their friends and relatives, etc., in groups, or as individuals.</p>
-
-<p>Two vital elements seem to the author to have received insufficient
-consideration in the efforts to solve the narcotic drug problem. One
-of these elements is the sufferings and struggles and problems of the
-narcotic addict, and the other is the nature of the physical disease
-with which he is afflicted.</p>
-
-<p>This book is an effort to accomplish two things, first to present
-the two elements above stated, and second to outline, discuss and
-correlate various elements and conflicting activities so that each
-of us can appreciate the relation of his own endeavor to the whole
-narcotic drug problem, can realize the comparative importance of
-his own observations, and can cooperate with the others for the
-benefit of humanity, for the welfare of society and posterity and for
-the increased health and happiness and economic usefulness of the
-individual.</p>
-<hr class="chap x-ebookmaker-drop" />
-
-<div class="chapter">
-<p><span class="pagenum" id="Page_ix">[Pg ix]</span></p>
-
-<h2 class="nobreak" id="CONTENTS">CONTENTS</h2>
-</div>
-
-
-<table class="autotable">
-<tr><th>CHAPTER</th><th></th><th class="tdr page">PAGE</th></tr>
-<tr><td></td><td class="tdl">
-<a href="#PREFACE"><span class="smcap">Preface</span></a></td>
-<td class="tdr page"><a href="#Page_vii">vii</a></td></tr>
-<tr><td class="tdr">
-<a href="#CHAPTER_I">I.</a></td>
-<td class="tdl"><a href="#CHAPTER_I"><span class="smcap">Introduction</span></a></td>
-<td class="tdr page"><a href="#Page_1">1</a></td></tr>
-<tr><td class="tdr">
-<a href="#CHAPTER_II">II.</a></td>
-<td class="tdl"><a href="#CHAPTER_II"><span class="smcap">Fundamental Considerations</span></a></td>
-<td class="tdr page"><a href="#Page_11">11</a></td></tr>
-<tr><td class="tdr">
-<a href="#CHAPTER_III">III.</a></td>
-<td class="tdl"><a href="#CHAPTER_III"><span class="smcap">The Nature of Narcotic Drug Addiction-Disease</span></a></td>
-<td class="tdr page"><a href="#Page_23">23</a></td></tr>
-<tr><td class="tdr">
-<a href="#CHAPTER_IV">IV.</a></td>
-<td class="tdl"><a href="#CHAPTER_IV"><span class="smcap">The Mechanism of Narcotic Drug Addiction-Disease</span></a></td>
-<td class="tdr page"><a href="#Page_35">35</a></td></tr>
-<tr><td class="tdr">
-<a href="#CHAPTER_V">V.</a></td>
-<td class="tdl"><a href="#CHAPTER_V"><span class="smcap">Remarks on Methods of Treating Narcotic Drug Addiction</span></a></td>
-<td class="tdr page"><a href="#Page_50">50</a></td></tr>
-<tr><td class="tdr">
-<a href="#CHAPTER_VI">VI.</a></td>
-<td class="tdl"><a href="#CHAPTER_VI"><span class="smcap">The Rational Handling of Narcotic Drug Addiction-Disease</span></a></td>
-<td class="tdr page"><a href="#Page_61">61</a></td></tr>
-<tr><td class="tdr">
-<a href="#CHAPTER_VII">VII.</a></td>
-<td class="tdl"><a href="#CHAPTER_VII"><span class="smcap">Relation of Narcotic Drug Addiction to Surgical Cases and Intercurrent Diseases</span></a></td>
-<td class="tdr page"><a href="#Page_85">85</a></td></tr>
-<tr><td class="tdr">
-<a href="#CHAPTER_VIII">VIII.</a></td>
-<td class="tdl"><a href="#CHAPTER_VIII"><span class="smcap">Laws, and Their Relations to Narcotic Drugs</span></a></td>
-<td class="tdr page"><a href="#Page_95">95</a></td></tr>
-<tr><td class="tdr">
-<a href="#CHAPTER_IX">IX.</a></td>
-<td class="tdl"><a href="#CHAPTER_IX"><span class="smcap">Some Comments upon the Legitimate Use of Narcotics in Peace and War</span></a></td>
-<td class="tdr page"><a href="#Page_114">114</a></td></tr>
-<tr><td class="tdr">
-<a href="#CHAPTER_X">X.</a></td>
-<td class="tdl"><a href="#CHAPTER_X"><span class="smcap">General Survey of the Situation and the Need of the Hour</span></a></td>
-<td class="tdr page"><a href="#Page_122">122</a></td></tr>
-<tr><td></td>
-<td class="tdl"><a href="#APPENDIX"><span class="smcap">Appendix: Human Documents,—Statements of Sufferers from Narcotic Drug Addiction-Disease</span></a></td>
-<td class="tdr page"><a href="#Page_137">137</a></td></tr>
-</table>
-<p><span class="pagenum" id="Page_1">[Pg 1]</span></p>
-
-
-<hr class="chap x-ebookmaker-drop" />
-
-<div class="chapter">
-<p class="center xbig">THE NARCOTIC DRUG PROBLEM</p>
-</div>
-
-
-<hr class="chap x-ebookmaker-drop" />
-
-<div class="chapter">
-<h2 class="nobreak" id="CHAPTER_I">CHAPTER I<br /><span class="small">INTRODUCTION</span></h2>
-</div>
-
-
-<p>It is a fact becoming more and more obvious that too little study and
-effort to interpret their physical condition have been given to those
-unfortunates suffering from narcotic drug addiction.</p>
-
-<p>We have neglected their disease in its origin and subsequent progress
-and formed our conception of its character from fully developed
-conditions and spectacular end-results. We have seen some of them
-during or after our fruitless efforts at treatment, their tortures and
-poor physical condition overcoming their resolutions, until they plead
-for and attempted to obtain more of their drug. We have seen others
-exhausted, starved, with locked-up elimination, toxic from self-made
-poisons of faulty metabolism, worn with the struggle of concealment and
-hopeless resistance, and for the time being more or less irresponsible
-beings, made so, not because of their addiction-disease itself, but
-because they were hopeless and discouraged and did not know which way
-to turn for relief.</p>
-
-<p>What literature has appeared on the subject has usually pictured them
-as weak-minded, deteriorated wretches, mental and moral derelicts,
-pandering to morbid sensuality; taking a drug to soothe them into
-supposed dream states and give them languorous delight; held by most
-of us in dislike and disgust, and regarded as so depraved that their
-rescue was impossible and they unworthy of its attempt.</p>
-
-<p><span class="pagenum" id="Page_2">[Pg 2]</span></p>
-
-<p>We have overlooked, ignored or misinterpreted intense physical agony
-and symptomatology, and regarded failure to abstain from narcotics as
-evidence of weak will-power or lack of desire to forego supposed morbid
-pleasure. We have prayed over our addicts, cajoled them, exhorted them,
-imprisoned them, treated them as insane and made them social outcasts;
-either refused them admission to our hospitals or turned them out after
-ineffective treatment with their addiction still fastened to them. To a
-great extent the above has been their experience and history.</p>
-
-<p>In great numbers they have realized our failure to appreciate their
-condition and to remedy it, and have after desperate trials of quacks,
-charlatans and exploited “cures,” finally accepted their slavery and
-by regulation of their drug and life, their addiction unsuspected,
-maintained a socially and economically normal existence. Some failing
-in this, perhaps broken and impoverished, their addiction recognized,
-have become social and economic derelicts and often public charges.</p>
-
-<p>From these last, together with the addicted individuals from the class
-of the fundamentally unfit, we have painted our addiction picture.
-Confined and observed by the custodial official and the doctor of
-the institution of correction and restraint, or concealed as family
-skeletons in many homes, descriptions of them have given to the
-narcotic addicts as a whole their popular status—cases of mental and
-moral disorder due to supposed drug action or habit deterioration, and
-based upon inherent lack of mental and moral stamina.</p>
-
-<p>It was with the above conception of these addiction conditions that
-I began my work in the Alcoholic, Narcotic and Prison Service of
-Bellevue Hospital, attracted to the service not by hope of helping nor
-by interest in “jags” and “dope fiends” as I then considered them, but
-by the mass of clinical material available for surgical and medical
-diagnosis and study which was daily admitted<span class="pagenum" id="Page_3">[Pg 3]</span> to those wards. When I
-left the service after sixteen months of day and night observation,
-with personal oversight and attempt to care for in the neighborhood
-of a thousand admissions a month, my early and faulty conception of
-narcotic addicts was replaced by a settled conviction that these
-cases were primarily medical problems. I realized that these patients
-were people sick of a definite disease condition, and that until we
-recognized, understood and treated this condition, and removed the
-stigma of mental and moral taint from those cases in which it did not
-exist, we should make little headway towards solution of the problem of
-addiction.</p>
-
-<p>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.</p>
-
-<p>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.</p>
-
-<p><span class="pagenum" id="Page_4">[Pg 4]</span></p>
-
-<p>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.</p>
-
-<p>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.</p>
-
-<p>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<span class="pagenum" id="Page_5">[Pg 5]</span> of it necessary and much of it wisely
-planned, we have made but little progress in the real remedy of
-conditions.</p>
-
-<p>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.</p>
-
-<p>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.</p>
-
-<p>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<span class="pagenum" id="Page_6">[Pg 6]</span> “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.</p>
-
-<p>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.</p>
-
-<p>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<span class="pagenum" id="Page_7">[Pg 7]</span> 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.</p>
-
-<p>Abundant evidence of what I have written is easily found among the many
-sufferers from the disease of opiate addiction who have maintained for
-years a personal, social and economic efficiency—their affliction
-unknown and unsuspected. These cases are not widely known but there
-are a surprising number of them. When one of them becomes known his
-success in handling his condition and its problems is generally
-attributed to his being on a rather higher moral and mental plane than
-his fellow sufferers and possessed of will-power sufficient to resist
-temptation to over-indulge his so-called appetite. We have not as a
-rule considered any other explanation nor sought more at length for the
-cause of his apparent immunity to the hypothetical opiate stigmata. It
-would have been wiser and more profitable for us to have respectfully
-listened to his experiences and learned something about his disease.</p>
-
-<p>The facts in such cases are that instead of being men of unusual
-stamina and determination, they are simply men who have used their
-reasoning ability. They have tried various methods of cure without
-success. They have realized the shortcomings and inadequacy of the
-usual understanding and treatment of their condition. Being average
-practical men, and making the best of the inevitable, they have made
-careful and competent study of their own cases and have achieved
-sufficient familiarity with the actions of their opiate upon them and
-their reactions to the opiate to keep themselves in functional balance
-and competency and control. The success of these people is not due to
-determined moderation in the indulgence of a morbid appetite. It is due
-to their ability<span class="pagenum" id="Page_8">[Pg 8]</span> to discover facts; to their wisdom in the application
-of common-sense to what they discover; and to rational procedure in
-the carrying out of conclusions reached through their experiences.
-They have simply learned to manage their disease so as to avoid
-complications. When I tried to account for some of the things I saw by
-questioning these men who had studied and learned upon themselves, I
-soon obtained a clearer conception of what opiate addiction was.</p>
-
-<p>When we eliminate the distracting and misleading complications, mental
-and physical, and study the residue of physical symptomatology left, we
-make some very surprising and striking observations.</p>
-
-<p>We find that we are dealing fundamentally with a definite condition
-whose disease manifestations are not in any way dependent in their
-origin upon mental processes, but are absolutely and entirely physical
-in their production, and character. These symptoms and physical signs
-are clearly defined, constant, capable of surprisingly accurate
-estimation, yielding with a sureness almost mathematical in their
-response to intelligent medication and the recognition and appreciation
-of causative factors; forming a clean-cut symptom-complex peculiar to
-opiate addiction. Any one—whether of lowered nervous, mental and moral
-stamina, or a giant of mental and physical resistance—will, if opiates
-are administered in continuing doses over a sufficient length of time,
-develop some form of this symptom-complex. It represents causative
-factors, and definite conditions which are absolutely and entirely due
-to changed physical processes which fundamentally underlie all cases
-of opiate addiction, and which proceed to full development through
-well-marked stages.</p>
-
-<p>During the past years I have had under my care a number of excellent
-and competent physicians of unusual mental and nervous balance and
-control in whom there could be no hint of lack of courage, nor of
-deficient will-power,<span class="pagenum" id="Page_9">[Pg 9]</span> nor of lack of desire to be free from their
-affliction. Possessing, some of them, unusual medical training and
-scientific ability, having added to this the actual experiences of
-opiate addiction, they with others have co-operated and aided in
-experiment, study and analysis, and the result has been in their minds
-as in mine, complete confirmation of the facts above stated.</p>
-
-<p>Primarily, there are two phrases I should like to see eliminated from
-the literature of opiate drug addiction. I believe they have worked
-great injustice to the opiate addict and have played no small part in
-the making of present conditions. It seems to me that to speak and
-write as we still often do of “drug habit” and “drug fiends” is placing
-upon the opiate addict a burden of responsibility which he does not
-deserve. If long ago we had discarded the word “habit” and substituted
-the word “disease” I believe we would have saved many people from the
-hell of narcotic drug addiction. I believe if it had not been for
-the use of the word “habit” that the medical profession would long
-ago have recognized and investigated this condition as a disease. A
-man, physician or layman, believes that he can control a habit when
-he would fear the development of a disease. Until now, however, the
-description has been “drug habit.” And the man who acquires one of the
-most terrible diseases to be encountered in the practice of medicine
-is unconscious of his being threatened with a physical disease process
-until this process has become so developed and so rooted that it is
-beyond average human power to resist its physical demands.</p>
-
-<p>In the near future, I earnestly hope the true story and the real
-facts concerning the opiate drug addict will become universally
-known. Without familiarity with them and understanding of them, and
-comprehension and appreciation of their disease, we shall never make
-real progress in the solution of the narcotic drug problem. From<span class="pagenum" id="Page_10">[Pg 10]</span> the
-present day trend of articles and stories in the newspapers and lay
-and medical magazines it cannot be doubted that the time is not far
-distant when in the lay press will appear, in plain, sober, unvarnished
-truth, the true story of the experiences and struggles of the opiate
-drug addict. I have marked a rapidly growing appreciation of fact and
-a steadily increasing activity in the investigation of conditions.
-This is sooner or later bound to be followed by intelligent public
-and scientific demand for competent and common-sense explanation and
-solution.</p>
-<hr class="chap x-ebookmaker-drop" />
-
-<div class="chapter">
-<p><span class="pagenum" id="Page_11">[Pg 11]</span></p>
-
-<h2 class="nobreak" id="CHAPTER_II">CHAPTER II<br /><span class="small">FUNDAMENTAL CONSIDERATIONS</span></h2>
-</div>
-
-
-<p>My earliest efforts in the handling of narcotic addicts were
-institutional. They were along the lines of forcible control, based
-upon the theory that I could expect no help nor co-operation from my
-patients.</p>
-
-<p>While this theory is undoubtedly true as applied to many of those who
-have developed opiate addiction, it is true of them as individuals
-whose personal characteristics are such that they require forcible
-control for the accomplishment of desirable ends in general. It is not
-true of them simply because of narcotic addiction. It is equally true
-of these same people afflicted with other diseases. Their successful
-handling for tuberculosis, venereal disease, cardiac conditions, or
-anything else requires for its successful issue constant oversight
-and what practically amounts to custodial care. I shall refer to them
-later. They are fundamentally custodial or correctional cases and
-success in their handling will never be accomplished in any other way,
-whether they are being treated for narcotic addiction or for anything
-else, mental, moral or physical.</p>
-
-<p>What appears in this chapter does not solve the problem of the handling
-of the narcotic addict of this type. There are many factors and
-elements in their mental and physical make-up other than drug addiction
-which should be considered, and these factors and elements lie at the
-bottom of their irresponsibility and the real difficulty of their
-handling.</p>
-
-<p>Experience and the analysis of unsuccessful effort and results showed
-that, however necessary forcible control might be in the handling
-of some narcotic addicts, it was<span class="pagenum" id="Page_12">[Pg 12]</span> not successful nor sufficient nor
-even the most important factor in the treatment of most cases of
-addiction-disease.</p>
-
-<p>I soon came to see that I had an erroneous conception of my medical
-and clinical problems and an unjust attitude towards many if not most
-of my addiction patients. Studying them—not as drug addicts, but as
-individual human beings—I found them in their personal, mental, moral
-and other characteristics, as various as people suffering from any
-other disease condition. There were no narcotic laws at that time and
-opiates were easily and cheaply obtainable. Very many, perhaps most of
-those who came to my wards were not forced in either by fear of the
-law or by scarcity of opiate supply. They did not have to come for
-treatment, but voluntarily presented themselves in the hope of cure.
-Something was wrong with my theories.</p>
-
-<p>In seeking for solution I began to realize that the narcotic addict
-of average individual characteristics obtained no enjoyment from the
-use of his opiate, and that he co-operated as a rule to the extent of
-his ability and endurance in efforts to relieve him of his condition,
-so long as he had any hope of possible ultimate success. I learned,
-trained and experienced physician though I was, that I was far more
-ignorant of the clinical manifestations and physical reactions of
-narcotic drug addiction than many of the patients I was trying to
-treat. It was soon evident to me, moreover, that the man who recognized
-my ignorance above all others was my patient. I came to see that what I
-had interpreted as lack of co-operation was largely due; first to his
-memory of previous experience, second to recognition of my ignorance,
-and third to his anticipation of useless and harmful suffering which he
-expected from my care and treatment of his case.</p>
-
-<p>Looking back over that period, I am free to confess that my efforts,
-though honestly made, amply realized his expectations.</p>
-
-<p><span class="pagenum" id="Page_13">[Pg 13]</span></p>
-
-<p>I began to see that I knew nothing of this disease or how to treat
-it as a problem of clinical disease. I saw that addict after addict
-sneezed and trembled, jerked and sweated, vomited and purged,
-became pallid and collapsed, that his heart and circulation were
-profoundly and alarmingly disturbed, that he had the unquestionable
-facies or expression of intense physical suffering, and the many
-constant and obvious signs which attend physical need for opiate
-drug. I could not escape the conclusion that here were tangible,
-material, incontrovertible physical facts for which I had no physical
-explanation. It seemed unreasonable to be satisfied with any
-explanation of them that did not have a physical basis; and it seemed
-a logical conclusion that the establishment of a basis of physical
-disease mechanism could offer the only hope of remedy. I therefore
-ignored for the time being my past teachings and ideas of the drug
-addict, and I looked to the patient himself, questioning him as to his
-experiences and studying the symptomatology and physical phenomena
-he presented. In short, I adopted the attitude which must be widely
-adopted before the medical problem of the clinical handling of drug
-addiction will be solved—in my attitude towards these cases I became
-the clinical student and practitioner of internal medicine, treating my
-patient to the best of my ability as I would a sufferer from any other
-disease, and studying his case.</p>
-
-<p>Struck by clinical facts which did not accord with past teaching,
-I tried to seek out from my personal study and observation of the
-individual case data upon which to form theories which would accord
-with clinical facts and with verified histories and, if possible, give
-a basis of help to these unfortunates.</p>
-
-<p>Gradually since then I have gotten together, from my own work and that
-of others, and with some success attempted to interpret and explain
-and apply, what seemed to me facts about opiate addiction. To my mind
-and<span class="pagenum" id="Page_14">[Pg 14]</span> in my experience these facts offer a beacon-light of hope and
-assure ultimate rescue to a very large proportion if not most of those
-suffering from narcotic drug addiction-disease.</p>
-
-<p>It is well to state here that of late some of these facts have
-secured recognition in medical and lay authoritative announcement and
-literature. The Preliminary Report of a special investigating committee
-of the New York State Legislature is quoted from elsewhere in this
-book, and the report in June, 1919, of a special committee appointed
-by the Secretary of the Treasury speaks of, “the more or less general
-acceptance of the old theory that drug addiction is a vice or depraved
-taste, and not a disease, as held by modern investigators.”</p>
-
-<p>It is on account of “the more or less general acceptance of the old
-theory” that it is necessary in this place to discuss some of the
-tenets of that theory for the benefit of those whose interests or
-emergencies have not led them to investigation of and familiarity with
-the scientific and other writings on this subject of recent years.</p>
-
-<p>It has been demonstrated to be a fact that description of narcotic
-drug addiction as “habit,” “vice,” “morbid appetite,” etc., absolutely
-fails to give any competent conception of its true characteristics, and
-clinical and physical phenomena. A large majority of opiate users are
-gravely wronged in a wide-spread opinion still prevalent. This opinion,
-as previously outlined, is that chronic opiate addiction is a morbid
-habit; a perverted appetite; a vice; that only he who is mentally or
-morally defective will allow it to get a hold upon him; and that its
-main and characterizing manifestations are those of mental, physical
-and moral degeneration. Opiate addicts are supposed to have irrevocably
-lost their self-respect, their moral natures and their physical
-stamina. They are still painted by many, as inevitable liars, full of
-deceit, and absolutely untrustworthy—people who are supposed to use a
-dream and<span class="pagenum" id="Page_15">[Pg 15]</span> delight producing drug for the sensuous enjoyment it gives
-them, and who do not want to discontinue its use. They are thought
-of as physical, mental and moral cowards who, after realizing their
-deplorable condition, refuse to exert “will-power” enough to stop the
-administration of opiates.</p>
-
-<p>With these views I did my early work on this condition. On these
-hypotheses, trying to follow current available literature and teaching,
-I treated my patients for a considerable time with results which
-superficially interpreted seemed to corroborate both literature and
-teaching. Many of them managed to get their drugs even while in the
-institution, and practically all of them left uncured with but an
-exceedingly small number of possible exceptions.</p>
-
-<p>From my patients themselves, and from watching and studying them,
-I later learned the truth, which has since been continually
-strengthened—that the so-called “discomforts” we think of them as
-suffering upon withdrawal of their drug, are actually unbearable
-suffering, accompanied by physical manifestations sufficient to prove
-this to be so. I also learned that the supposed delightful sensations
-which have formed the background of most pictures painted of them, had
-in many, if not in most of the cases with which I came in contact,
-never been experienced. If they had ever existed they had long ago been
-lost and all that remained in opiate effect was support and balance to
-organic processes necessary to the continuance of life and economic
-activity. As I have written, these sensations seem to be, “part of the
-minor toxic action of the opiate against which the addict is nearly or
-completely immune and to the securing of which very many and probably
-a majority of the innocent or accidental addicts have never carried
-their dosage.” In plain English the sufferer from opiate addiction has,
-in many if not a majority of cases, never experienced any enjoyment
-as a result of the drug and has endured indescribable agony in its
-non-supply.</p>
-
-<p><span class="pagenum" id="Page_16">[Pg 16]</span></p>
-
-<p>I do not want to be understood as claiming that opiates will not
-produce pleasant sensations, nor that they are never used to the end
-of experiencing these sensations. There is a class of the inherently
-or otherwise defective or degenerate, who first indulge in opium or
-its products from a morbid desire for sensuous pleasures, just as they
-would and do indulge in any form of perversion or gratify any idle
-curiosity. They are mentally incapable of self-restraint, indulging
-jaded appetite with new stimuli. They yield themselves to any and all
-forms of self-indulgence and gratification of appetite. There comes a
-time when for them opiates, from increasing tolerance and dependence
-lose power to give pleasurable sensations and become simply a part of
-their daily sustenance, exacting physical agony as a result of their
-non-administration. When this occurs they make no effort to control
-amount or method or use; and overdosage together with conditions
-incidental to and attendant upon their mode of life soon relieves
-society of the menace of their membership. As a class they have
-been regarded as incurable and hopeless—socially, economically and
-personally unworthy of salvage. To whatever extent this may be true,
-however, it is not true simply because they happen to have acquired
-opiate addiction, but because they are fundamentally what they are,
-diseased, degenerate and defective.</p>
-
-<p>The opiate element is as incidental to their fundamental condition as
-are the venereal and other diseases from which many if not most of
-them suffer. Observations and conclusions upon addicts from this type
-of humanity have been given great prominence in the public press and
-elsewhere and have had an unwarranted influence in the status of opiate
-addiction and the conception of and attitude towards the addiction
-sufferer. Because addicts of this class began to use opium or its
-derivatives and products to secure sensuous gratification is no reason
-for stigmatizing the mass of those afflicted with addiction-disease as
-people of perverted<span class="pagenum" id="Page_17">[Pg 17]</span> appetites. No one should study addiction in them
-unless he is possessed of sufficient ability in clinical observation to
-separate physical signs of opiate addiction from the manifestations of
-defective mentality—and unless he has enough insight and breadth of
-vision to see behind end-results, primary causative factors; and unless
-he has enough common-sense to refrain from applying to the worthy many
-the observations he has made upon the unworthy few.</p>
-
-<p>It is only fair to state in passing, however, that from my experiences
-as Visiting Physician in the wards of the Workhouse Hospital, New York
-Department of Correction, I am convinced that we all too often casually
-include in the above generally considered derelict class of society,
-many who under intelligent and humane handling could be restored to or
-converted into useful citizens.</p>
-
-<p>There are some above this class, of the type of spoiled and idle youth,
-who indulge first in opiates in a spirit of bravado or curiosity. The
-tremendous increase in addiction since its spectacular incidental and
-morbid aspects became so widely published is largely contributed to
-from this class.</p>
-
-<p>There are some who first used opiates to temporarily boost them over an
-emergency, post-alcoholic excesses, severe mental strain, etc.</p>
-
-<p>The majority of narcotic addicts, however, and especially those
-developing previous to the activities of the past few years, present
-a very different history. Mentally and morally they are of the same
-average equipment as other people. They form a class which might
-be called “accidental or innocent” addiction-disease sufferers.
-They had no voice nor conscious part in the early administration of
-opiate, realizing no desire or need for it by name, but only wishing
-for the unknown medicine which relieved their sufferings. Very many
-addiction patients have received their first knowledge of opiate
-administration in<span class="pagenum" id="Page_18">[Pg 18]</span> the withdrawal symptoms which followed the attempted
-discontinuance of its use. There is in these sufferers no element
-of lack of will-power; no trace of desire to indulge appetite or to
-pander to sensuous gratification. In some, before their condition was
-recognized, their tolerance for or dependence upon opiate had proceeded
-to a point where their bodies’ demand for morphine was imperative and
-their withdrawal suffering unendurable. In others, before body need
-was completely established—with their stamina and nervous resistance
-below par from sickness and suffering—they have been unable to forego
-opiate’s supportive and sedative and pain-relieving action, or to
-endure the nervous and other symptoms attendant upon its withdrawal
-after even a brief period of administration.</p>
-
-<p>As to what the addict is;—the tendency and effect of legislative,
-administrative, police and penological activities in general have
-been to place the sufferer from addiction-disease in the position
-of the criminal and vicious. The tendency of the psychologist and
-psychiatrist is to analyze him from the viewpoint of mental weakness,
-defect or degeneration, and to so classify and regard him. The average
-practitioner of internal medicine, and even the recognized leaders
-and authorities in this field of medical science will tell you that
-narcotic drug addiction is a condition to which they have given but
-little attention and have no clean-cut ideas of its physical disease
-problems. The addict himself, whose testimony has been all too little
-consulted or sought, will tell you that he is sick with some kind of
-a physical condition which causes suffering and incapacity whenever a
-sufficient amount of narcotic is not administered.</p>
-
-<p>In the above attitudes and statements the administrative, police and
-penological authorities are right in some cases;—the psychologists and
-psychiatrists have good basis for their opinions in some cases;—the
-addict has<span class="pagenum" id="Page_19">[Pg 19]</span> physical grounds for his statement in all cases—he is
-always sick, sick with addiction-disease.</p>
-
-<p>In my experience with and study of narcotic drug addiction and the
-narcotic drug addict, an experience touching practically every phase
-of the narcotic situation and giving me opportunity to observe the
-condition in practically every type of individual, the one constant
-and more and more strikingly emphasized observation has been constant
-physical symptomatology and the manifestations of pain and suffering
-and of fear. I have in my possession histories of addicts taken from
-all walks of life and from all classes and conditions of men. Some of
-my histories are of patients who were primarily defective, degenerate,
-weak or vicious. Some of my histories are of people of high mentality;
-of high ethical and moral standards; of high economic efficiency and
-social standing. These histories, stripped of names and possibilities
-of personal recognition, would form a very instructive collection of
-material for the man, physician, psychologist, sociologist, legislator
-or administrator who wishes to study the addict as he really is and to
-get some conception of the diversity of the problems which he presents.</p>
-
-<p>Neglect of this study and absence of this conception is the chief
-cause of past failure. We have tended to regard and handle and treat
-and legislate concerning narcotic addicts simply as narcotic addicts,
-instead of appreciating that different individuals and different types
-and classes of people who may suffer from addiction-disease present
-entirely different problems, and require entirely different handling.</p>
-
-<p>If we are going to consider all narcotic addicts as in one class we can
-with justice only consider those characteristics which are common to
-all members of that class. There is just one fact and characteristic
-that stands out as of striking and paramount importance in every one
-of my histories—it<span class="pagenum" id="Page_20">[Pg 20]</span> is the fact of physical suffering upon complete
-withdrawal of opiate drug, or a supply of that drug which does not
-meet the requirements of the physical body-need. Whatever or whoever
-the narcotic addict was before his use of opiate drugs—whatever had
-been the character and circumstances of the initial administration of
-narcotic drug—after a time, as I have repeatedly written elsewhere,
-after addiction-disease has once developed, the history of every opiate
-addict is that of suffering and of struggle. After addiction-disease
-is once developed the addict loses whatever euphoric sensation he may
-possibly have experienced, and all that narcotic administration spells
-for him is relief from suffering. Without the drug of his addiction
-he endures intense physical suffering and misery. Without the drug
-of his addiction he cannot pursue a social, economic, or physically
-endurable existence. He may have been primarily defective, degenerate,
-depraved or vicious; his primary administration of the drug may have
-been deliberate indulgence, disreputable associations, idle curiosity,
-any combination of conditions which may be stated;—he may have been
-an upright, honest and intelligent, hard-working, self-supporting,
-worthy and normal citizen in whom the primary administration of opiate
-drug was a result of unwise, ignorant or unavoidable medication;—he
-may have been an ignorant purchaser of advertised patent medicines
-containing addiction-forming drugs. Whatever his original status,
-mental, moral, physical or ethical, and whatever the circumstances
-of his primary indulgence; once addiction-disease has developed in
-his body the vital fact of his history is the same—subsequent use of
-opiate drug means not pleasure, not vice, not appetite, not habit—it
-means relief of physical suffering and the control of physical symptoms.</p>
-
-<p>My present definition of narcotic drug addiction is as follows; a
-definite physical disease condition, presenting constant and definite
-physical symptoms and signs, progressing<span class="pagenum" id="Page_21">[Pg 21]</span> through clean-cut clinical
-stages of development, explainable by a mechanism of body protection
-against the action of narcotic toxins, accompanied if unskillfully
-managed by inhibition of function, autotoxicosis and autotoxemia, its
-victims displaying in some cases deterioration and psychoses which
-are not intrinsic to the disease, but are the result of toxemia, and
-toxicosis, malnutrition, anxiety, fear and suffering.</p>
-
-<p>To express this somewhat differently—a narcotic drug addict is an
-individual in whose body the continued administration of opiate drugs
-has established a physical reaction, or condition, or mechanism, or
-process which manifests itself in the production of definite and
-constant symptoms and signs and peculiar and characteristic phenomena,
-appearing inevitably upon the deprivation or material lessening in
-amount of the narcotic drug, and capable of immediate and complete
-control only by further administration of the drug of the patient’s
-addiction.</p>
-
-<p>In plain English, the sufferer from narcotic drug addiction-disease is
-one who experiences the symptoms and signs referred to above and which
-will be discussed later, as a result of lack of supply or physically
-insufficient supply of opiate drug. I know of no definition along
-any other lines which will include all who suffer from narcotic drug
-addiction. This symptomatology, and the mechanism or process which
-produces it, are the only common and characteristic attributes and
-possession of all opiate addicts.</p>
-
-<p>How these are developed and how they may be controlled and arrested is
-the demand which the sufferer from narcotic drug addiction, and society
-as a whole, are making. Until a competent and acceptable answer to
-this demand is in the general possession of those handling narcotic
-addiction, all other discussions will remain inconclusive, and all
-other considerations incidental, for purposes of definite and final
-solution. This is the medical problem of narcotic drug addiction, and
-until those who handle narcotic addicts,<span class="pagenum" id="Page_22">[Pg 22]</span> and those who control the
-handling of narcotic addicts, have recognized it, are familiar with it,
-and can to some working measure explain and control its sufferings,
-physical phenomena and symptoms and signs, they are unprepared to
-assist intelligently and competently in the solution of a problem which
-now as never before menaces the welfare of society.</p>
-<hr class="chap x-ebookmaker-drop" />
-
-<div class="chapter">
-<p><span class="pagenum" id="Page_23">[Pg 23]</span></p>
-
-<h2 class="nobreak" id="CHAPTER_III">CHAPTER III<br /><span class="small">THE NATURE OF NARCOTIC DRUG ADDICTION-DISEASE</span></h2>
-</div>
-
-
-
-<p>It is a pertinent question to ask, “What type or class of individuals
-become narcotic addicts?” The only correct answer unquestionably
-is, any type or class or individual to whom opiates are given for a
-sufficiently long time. It has yet to be demonstrated that there is
-any warm-blooded animal, which following sufficiently prolonged and
-constant administration of opiate drug, is immune to the development of
-the symptomatology and constant physical phenomena of addiction-disease.</p>
-
-<p>Color, nationality, social or economic position, age, mental and moral
-attributes of whatever sort are no bar to the development of the
-condition. These may influence, of course, the conduct and incidental
-manifestations of the individual addicted, just as they do in any
-other condition. The addicted judge, or the addicted physician, or the
-addicted clergyman, or the addicted man of business or other affairs,
-or the addicted clerk or industrial worker reacts differently to
-the sufferings and trials of narcotic drug addiction than does the
-addict of the underworld, or the heroin “sniffer” of idle and curious
-adolescence, or the addicted defective, degenerate, or criminal. Also
-he reacts differently to everything else. What is true of one man who
-has opiate addiction may be absolutely false of another. One narcotic
-addict is honest, competent, truthful and intelligent. Another is
-dishonest, incompetent, untruthful and incapable of appreciation or
-self-control. Neither the one set of attributes, nor the other, is
-peculiar to narcotic addicts. They are simply personal attributes<span class="pagenum" id="Page_24">[Pg 24]</span>
-possessed by different men and types of men who may or may not be
-narcotic addicts. If the addict of a higher type displays at times
-attributes not typical of his preaddicted days, and seems to show a
-lowering of his mental and ethical tone, it is well to estimate in
-his case the influences of past worry, fear, suffering, strain and
-struggle, the attitude of society, medical and lay, towards him, and
-the manner in which he has been handled, before blaming it all upon the
-mere presence and effects of narcotic drug addiction, or of narcotic
-drug. If such changes were inherent in the action of continued narcotic
-drug medication, they would be found in all addicts, whereas the fact
-is that they most decidedly are not.</p>
-
-<p>As to age in addicts there is no limit. I have seen an infant
-newly-born of an addicted mother, displaying the characteristic
-physical symptoms, signs and phenomena of body-need for opiate a
-few hours after birth. This case is discussed more in detail in the
-transcribed testimony of the New York State Legislative Investigation
-hearings, (Whitney Committee) pages 1524 to 1529, at which I reported
-it. The infant undoubtedly developed addiction-disease prenatally,
-reacting in its unborn body against the presence of opiates, supplied
-through its mother’s blood, exactly, as is now demonstrated through
-experimental laboratory animals and by clinical study upon adults, this
-disease is always developed—through physical and constant reaction
-of the body to the continued presence of opiates, however supplied.
-There have been many such cases, some of which are matters of medical
-record. This condition of prenatal development of addiction-disease
-exists beyond dispute and certainly cannot be explained upon grounds of
-conscious appetite or deliberate self-indulgence. I am told that there
-are or until very recently have been old soldiers, veterans of the
-Civil War, whose addiction dated from medication for wounds received
-during that struggle. The late Doctor T. D. Crothers told<span class="pagenum" id="Page_25">[Pg 25]</span> me once that
-opiate addiction in this country received its first wide dissemination
-in that way. This points to the serious consideration of what may be an
-urgent and important medical problem of modern warfare.</p>
-
-<p>This brings us up to the origin of addiction. There is only one actual
-origin of addiction, and that is the continued administration of an
-addiction-developing drug sufficiently long to develop the physical
-manifestations symptomatology, and phenomena and body need for that
-drug. This statement is the only one which can be made as generally
-inclusive. I have many records and histories, much correspondence, and
-other data, collected from addicts, relatives, friends and associates
-of addicts, physicians, official conferences and workers in the
-various fields of narcotic endeavor. My material covers an active
-interest of many years duration, and an experience which has dealt
-with various types and classes of patients under various conditions.
-I have held different beliefs at different times, influenced by the
-demands of my immediate position, and by my best interpretation of my
-own experience, by the conditions under which I happened to be working
-and by the class of people coming to my attention under the conditions
-of my work. At one time I believed that all addicts were defective,
-irresponsible, degenerated, unreliable and liars, made addicts by
-curiosity, environment and morbid appetite. At one time I believed
-that the narcotic addict did not physically need narcotic drug under
-any circumstances, and that he could get along without it if he only
-had the will and the desire to do so. I proceeded on that theory for a
-while in the handling of my cases, and have to thank the illicit supply
-which is present in all institutions that my mortality was no higher,
-for it is agreed and on record by many competent authorities that
-forcible deprivation of opiate drug may at times cause death.</p>
-
-<p>These are examples of a few of the various beliefs and<span class="pagenum" id="Page_26">[Pg 26]</span> ideas I have
-held at various times, and upon which I used to generalize, as is the
-habit and tendency of those who as yet lack experience or breadth
-of experience. I have in time found many of my beliefs wholly or
-partly erroneous, or to apply only to selected groups of cases or to
-incidental phases and aspects of the main problem. They all have their
-bearings on the general situation, and may be of primary importance in
-the immediate handling and control of certain phases of it. I have come
-now to keep my general statements to the solid rock of basic disease
-and draw on my past experience for the measure and estimation of
-associated problems and complications as they arise.</p>
-
-<p>The actual origin of addiction is the administration of opiate
-drugs continuously over a sufficient length of time. The incidental
-details in their early administration to those who become addicted
-vary widely. In the origin of some proportion of addicts, we of the
-medical profession must sooner or later come to recognize and assume
-our part, unconscious and innocent, but none the less beyond question.
-What this proportion is is variously estimated by various authorities
-and statisticians and investigators. It is now beyond dispute that
-many cases of addiction-disease had their origin in medication during
-illness, the condition developing unsuspected by either physician or
-by patient until its physical manifestations had passed the bounds of
-control.</p>
-
-<p>The old fallacy that an opiate might be administered safely to a
-sufferer so long as the patient did not know what was being given him
-is completely disproven by the evidence of addicted infants, and by the
-excellent and exhaustive laboratory experiments upon addicted animals
-by such men as Giofreddi, Hirschlaff and more recently Valenti of
-Italy whose work, published in 1914, should have widest recognition.
-This fallacy has been responsible for many a case of addiction. Very
-many opiate addicts have passed into the stage of fully established
-addiction-disease<span class="pagenum" id="Page_27">[Pg 27]</span> before they were aware that they had ever taken an
-opiate.</p>
-
-<p>Clinical familiarity with the symptoms and signs of beginning and
-developing addiction should be the possession of every physician
-and surgeon. It would save from the physical sufferings, and mental
-tortures and fears of narcotic addiction many human beings. It has
-been my experience when called in as a medical consultant upon medical
-and surgical cases whose progress towards recovery seems unaccountably
-tedious and unsatisfactory, to detect as the basis for the lack
-of function and recuperative power, unsuspected developing opiate
-addiction in time to prevent its further progress. Unwisely prolonged
-opiate medication makes more opiate addicts than we have realized.</p>
-
-<p>The addict in whom it is most profitable to study addiction origin
-and development and handling, if we are to get a clean-cut picture of
-addiction-disease, is the individual who is primarily normal, mentally,
-morally and physically, whose addiction condition is a result of
-ignorant, misguided or unavoidable medication, either professionally or
-self-administered. Their number is far greater than is yet generally
-appreciated. Many if not most of them are unsuspected and unknown and
-they include eminent people in all walks of life. They are social, and
-economic assets whose interests and welfare we cannot ignore when we
-are considering the disposition and handling of the narcotic addict.</p>
-
-<p>Many of them have gone from one institution to another, and have
-attempted, in desperate effort to be cured, each newly-discovered and
-announced specific or theory of treatment. They have never derived any
-pleasure from narcotic use. For them the narcotic drug has been only
-necessary medication to relieve physical suffering and to maintain
-economic existence and the support of themselves and their families.
-They should be classed as innocent or<span class="pagenum" id="Page_28">[Pg 28]</span> accidental addicts—normal and
-worthy sick people. They earnestly desire treatment and help, and once
-their addiction process is completely arrested do not tend to return
-to narcotic drug use. Whatever associations they may have had with
-the unworthy or unfit of the so-called “underworld” and with illicit
-and illegitimate traffic has been the result of desperate necessity,
-in their best judgment, in the obtaining of opiate supply when it has
-seemed to them to be otherwise denied them, and which was necessary to
-them for the relief and avoidance of suffering and for the maintaining
-of a condition making possible self-support and the avoidance of
-revelation and disgrace.</p>
-
-<p>The narcotic addict of this type presents primarily and fundamentally a
-purely medical problem. Competent and complete arrest of the physical
-mechanism of narcotic drug need permanently removes him from the
-ranks of the narcotic drug user. The problem of his handling is one
-falling within the province of medical practice. His care is purely and
-simply a matter of the treatment of disease with medical intelligence
-and judgment on the established lines of medical practice in disease
-conditions generally. His after-care is simply such management of
-convalescence as is needed in ordinary medical cases. The length of his
-convalescence will depend entirely, just as in other diseases, upon
-the competency and intelligence of his medical handling and upon his
-physical condition, reaction, and recuperative ability.</p>
-
-<p>For such a man custodial care and institutional handling under
-conditions of enforced restraint are undesirable and harmful. His
-withdrawal from self-supporting citizenship should be for the
-shortest time commensurate with adequate therapeutic results.
-He should be restored to normal personal, social, and economic
-environment and activity at as early a time as possible following
-his clinical<span class="pagenum" id="Page_29">[Pg 29]</span> treatment and the arrest of his physical mechanism of
-addiction-disease. Given intelligent clinical handling, with rational
-therapeutic treatment, and a comprehensive meeting of the indications
-of disease in his case, he is no more a subject for unusual restraint
-and custodial care than is a case of malaria or pneumonia or other
-medical condition. He is in most cases a clinically curable medical
-case. He presents the true picture of addiction-disease uncomplicated
-by the distracting and confusing incidentals often met with in the
-types of cases more commonly discussed. The development of addiction in
-a case of this type is a purely physical matter, and is the addiction
-which should be considered in the fundamental comprehension of basic
-facts.</p>
-
-
-<h3><i>Stages of Addiction Development</i></h3>
-
-<p>Every case of well-developed addiction has followed in its development
-a course through several stages, definitely marked by clinical signs
-and reaction phenomena. I shall not exhaustively discuss all of these
-stages and their phenomena. The ones I shall mention will be recognized
-by most of those who have gone through them or have watched them
-develop.</p>
-
-<h4>
-1. <i>Stage of Normal Reaction to Therapeutic and Toxic Doses.</i>
-</h4>
-
-<p>The manifestations of this state in morphine administration for example
-are more fully described in our text-books of materia medica than I
-can take space for in this book, and are familiar to all physicians.
-The narcotic and analgesic effect with therapeutic doses; the euphoric
-and inhibitory action of doses in excess of the therapeutic; the
-toxic action manifested by the slowed pulse, slowed respiration, and
-generally arrested metabolism and function are too familiar to need
-elaboration.</p>
-
-<p><span class="pagenum" id="Page_30">[Pg 30]</span></p>
-
-<h4>
-2. <i>Stage of Increased Tolerance.</i>
-</h4>
-
-<p>Following continuous and consecutive administration of morphine (and
-the same is true of other opiates) comes failure to secure the effect
-which followed the early administration. Larger doses are needed for
-the relief of pain or other symptoms, or the original doses give relief
-for a shorter time. Toxic manifestations do not follow what would
-formerly have been a toxic dose. The patient requires what was formerly
-a toxic dose to secure the former therapeutic effect. The phenomena of
-this stage are familiar to every observing clinician who has used or
-seen morphine used for continued therapeutic action. The patient has
-acquired an increased tolerance of the drug and a beginning immunity
-to its toxic action. He does not, however, suffer appreciable hardship
-from drug deprivation. Discontinuance of the drug causes little or none
-of the symptoms to be described as “withdrawal signs.”</p>
-
-<h4>
-3. <i>Stage of Beginning Addiction.</i>
-</h4>
-
-<p>Following the stage of increased tolerance comes a stage where
-discontinuance or lack of administration of the narcotic drug gives
-definite signs and symptoms, beginning “withdrawal signs,” due to some
-beginning physical body demand for the drug and completely relievable
-only by its administration. These signs are identical with the first
-appearing withdrawal signs in a case of established addiction but as
-yet do not go beyond the beginning manifestations of “withdrawal”
-in a completely developed addiction. They are limited to a peculiar
-nervousness, restlessness, weakness, depression, etc. They persist for
-a few days only if the drug is denied and are endurable.</p>
-
-<p>As to length of time required for the passage through each of these
-previous stages or through both of them—dogmatic statement is
-impossible. The time is apparently<span class="pagenum" id="Page_31">[Pg 31]</span> influenced by a number of factors.
-Of course the varying inherent resistance or susceptibility of
-different individuals to any given disease condition must be considered
-in this disease. It varies also with different forms of opiates used
-and their modes of administration. The probable physical factors I am
-not yet ready to discuss. The recent Report of the Special Committee
-of the Treasury Department says, “Any one repeatedly taking a narcotic
-drug over a period of 30 days, in the case of a very susceptible
-individual for 10 days, is in grave danger of becoming an addict.”
-Certainly a physician should look for the signs and symptoms of
-tolerance and beginning addiction throughout his opiate administration.
-It is also well to exhaustively inquire into possible past history of
-unrecognized addiction in any of its three general stages. Some of
-those patients who have demonstrated an apparent unusual susceptibility
-and very rapid development will be found on careful analysis to have
-experienced an unrecognized or forgotten addiction in some stage of
-development. I have interesting data on this point.</p>
-
-<h4>
-4. <i>Stage of Established Addiction.</i>
-</h4>
-
-<p>In this stage the “withdrawal” symptoms and signs become more evident
-as results of opiate deprivation. They proceed through the mild
-discomfort and nervousness of the previous stage to the definite
-manifestations and constant unmistakable withdrawal phenomena to be
-described. The patient endures physical suffering and displays all
-the clinical evidence of it. There can be no question of will-power
-in this stage, nor of desire for narcotic drug for any other purpose
-than to escape physical suffering. Whether the patient was primarily an
-innocent and unconscious recipient of the drug, or of the class of the
-vicious and weak, he is now fundamentally a sick man, afflicted with
-a physical disease. Whether or not he ever experienced any euphoria
-or sensuous enjoyment, he now<span class="pagenum" id="Page_32">[Pg 32]</span> gets nothing of pleasure from narcotic
-administration. He gets, <em>simply</em>, relief from suffering. The
-opiate drug has become his <em>only</em> immediate means of securing and
-maintaining a physical efficiency, a semblance of normality. No other
-drug will take its place. He can take tremendous doses without toxic
-effect. In this stage, if the drug is denied or withdrawn without
-competent handling, his suffering and incompetency is not, as in the
-previous stage, a matter of days but may persist for weeks or months
-after no narcotic has been administered.</p>
-
-<p>The general stages of addiction-disease development as above rather
-superficially outlined are not of course sharply marked in their
-transitions. They slowly merge one into the next and taken together
-constitute a gradual development from normal reaction to opiate to
-established addiction-disease.</p>
-
-<p>Most patients are in or nearing the stage of developed addiction when
-they are recognized or come for treatment. Developed addiction for
-narcotic drug means physical, bodily need for that drug; functional
-incompetency and suffering without that drug; comparative normality
-and efficiency only to be immediately secured and maintained by the
-continued use of that drug.</p>
-
-<p>This is the situation of the sufferer from addiction-disease until such
-time as the activity of his addiction-disease mechanism is arrested.</p>
-
-<hr class="tb" />
-
-<p>Before I attempt exposition of the mechanism which seems to me best to
-explain addiction-disease and offer a basis for its rational handling,
-I shall offer several observations bearing upon physical or body
-reaction in the state of addiction.</p>
-
-<p>1. Experience of addicts and observations upon them show that the
-length of time over which an addiction sufferer is free from his
-“withdrawal” manifestations is in proportion to the amount he has
-recently taken.<span class="pagenum" id="Page_33">[Pg 33]</span> Under conditions eliminating various factors, outside
-of the addiction mechanism, which may influence this general rule,
-the ratio between the amount of recent dosage and the interval of
-freedom is almost mathematical. For example, if under given conditions
-one grain of morphine will keep an addict free from withdrawal
-manifestations for four hours, two grains will do this for nearly eight
-hours and three will have the same effect for about eleven hours. It
-would almost seem as if there were some substance produced in definite
-amount in each individual case at a given time, and neutralized or
-opposed by or in some way negatived in its action by a definite amount
-of opiate drug.</p>
-
-<p>2. Each addict shows a definite and approximately measurable daily
-minimum need for the drug of his addiction. If he is suffering from the
-deprivation of his drug, he will require a certain dose, measurable
-by its effect upon his symptomatology, before he is made physically
-comfortable and physically efficient again.</p>
-
-<p>3. The narcotic drug administered to an addict suffering withdrawal
-phenomena and symptomatology will relieve those manifestations exactly
-in proportion to the amounts of drug administered. Each addict has a
-constant sequence of symptoms attending the so-called “dying-out” of
-the drug. These symptoms are relieved in constant reverse sequence by
-the administration of the drug, and in exact proportion to the amount
-of drug administered, various incidental influences being eliminated.
-A small amount of the opiate will relieve the symptoms last appearing;
-another insufficient amount will relieve another proportion of the
-withdrawal signs, and so on, until the opiate drug administered
-balances in amount the extent of the addict’s deprivation, or physical
-need.</p>
-
-<p>This is almost mathematical in its working, and the average intelligent
-addict, after a few trials, can tell within a very close margin just
-how much opiate, in his accustomed<span class="pagenum" id="Page_34">[Pg 34]</span> form, has been administered by the
-extent to which it relieves his withdrawal signs. It almost seems as
-if the narcotic drug acted as some sort of an antidote for some poison
-present in definite amounts in the addict’s body.</p>
-<hr class="chap x-ebookmaker-drop" />
-
-<div class="chapter">
-<p><span class="pagenum" id="Page_35">[Pg 35]</span></p>
-
-<h2 class="nobreak" id="CHAPTER_IV">CHAPTER IV<br /><span class="small">THE MECHANISM OF NARCOTIC DRUG ADDICTION-DISEASE</span></h2>
-</div>
-
-
-
-<p>I have in previous chapters referred to what are known as “withdrawal
-signs.” By this term has come to be known the manifestations displayed
-by a sufferer from addiction-disease at such times as his opiate is
-taken away or “withdrawn,” either totally or in part to such an extent
-that its amount does not meet the requirements of his physical needs.</p>
-
-<p>In observing opiate addicts over a length of time no one can escape the
-recognition of a chain of constantly present physical manifestations
-inevitably following the non-administration of the drug of addiction.
-These may vary in priority of onset, in sequence, and in relative
-violence of manifestation in different cases, but they are the
-inevitable result of non-administration of opiate to an opiate addict.
-I described them as follows in a paper on “Narcotic Addiction—A
-Systemic Disease Condition,” which was published in the <i>Journal of
-the American Medical Association</i>, February 8, 1913. “In a general
-way they may be said to begin with a vague uneasiness and restlessness
-and sense of depression; followed by yawning, sneezing, excessive
-mucous secretion, sweating, nausea, uncontrolled vomiting and purging,
-twitching and jerking, intense cramps and pains, abdominal distress,
-marked circulatory and cardiac insufficiency and irregularity, pulse
-going from extremes of slowness to extremes of rapidity with loss
-of tone, facies drawn and haggard, pallor deepening to greyness,
-exhaustion, collapse, and in some cases death.”</p>
-
-<p><span class="pagenum" id="Page_36">[Pg 36]</span></p>
-
-<p>These manifestations have been noted in various ways and to various
-extents and have been casually commented upon by most writers of the
-past. The conception of drug addiction as a “habit” has, however, in
-the past so overwhelmingly dominated the attitude of writers both
-medical and lay, that consideration of withdrawal signs as physical
-phenomena, and the analysis of their origin and mechanism on the basis
-of physical disease and constant body reaction has received all too
-little attention. The tendency has been to casually regard or belittle
-them as a part of the essential picture of narcotic addiction, and to
-place overwhelming emphasis upon mental desire as an explanation of the
-drug addict’s inability to discontinue the administration of opiate
-drugs. That these physical manifestations have had such incidental
-place and consideration in the general handling of the narcotic
-addict and in the consideration of the drug problem is to my mind the
-basic cause for past failure. Non-appreciation of them unquestionably
-explains in part the almost uniform lack of success which attended my
-own earliest efforts.</p>
-
-<p>One of the obstacles to an appreciation of narcotic drug
-addiction-disease has been the casual assumption on the part of the
-average person, both lay and scientific, that opiate drugs act upon
-the addict, and that he reacts to them similarly to the actions and
-reactions in the non-addicted individual. Morphine action, however,
-as commonly observed following therapeutic administration or in
-experimentation upon un-addicted animals gives no conception of its
-manifestations in the man or woman grown tolerant to its use. Many
-of the actions and reactions of opiate upon the un-addicted are
-practically lost in the addicted, and absolutely new reactions, unfound
-in the un-addicted individual, become the dominating factors in the
-opiate medication of the addict.</p>
-
-<p>To some extent the fallacies connected with the general conception
-of narcotic addiction have arisen from the mistaken<span class="pagenum" id="Page_37">[Pg 37]</span> application
-to addicts of opiate experience, experimental or otherwise, of the
-non-addicted. In the matter of sensations, for example, supposed
-to follow opiate administration, and to the enjoyment of which is
-widely attributed the addict’s indulgence—in practically none of the
-opiate addicts, once tolerance and organic dependence are completely
-established, do these sensations occur. The immediate effect of opiate
-to the addict, depending upon the extent of tolerance, and the reaction
-of the patient, in dosage not too much in excess of physical body need,
-is apparently support to function, the restoration or maintaining of
-normal circulation and nerve and glandular balance, prevention or
-relief of the agonizing withdrawal pains and manifestations and of
-impending collapse.</p>
-
-<p>Opiate is used by the large majority of opiate addicts simply and
-solely for its supportive action, and a certain amount for each addict
-becomes as much of a definite need and a necessary and integral part
-of his daily sustenance as food or air. The dream states and other
-sensuous results, occasionally observed, are when they occur as part of
-the minor toxic action of the drug, against which the developed addict
-is nearly or completely immune, and to the experiencing of which very
-few of the honest, innocent or accidental addicts have ever carried
-their dosage. They are commonly found only in the opium pipe smokers,
-an entirely different problem from that of the average narcotic addict.</p>
-
-<p>As has been stated, it is a fact that for each addict, a definite
-amount, varying with his condition of health, elimination, physical and
-mental activity, etc., meets a definite body-need. On this amount he
-can be put and kept in good physical and mental condition under normal
-circumstances of environment, exertion, and general hygiene. Years
-of efficient activity and upright responsible lives, accomplished by
-well-known men and women, unsuspected addicts, bear witness to this
-fact. An addict neither<span class="pagenum" id="Page_38">[Pg 38]</span> underdosed nor overdosed practically defies
-detection. Less than the definite amount required for nervous and
-glandular and circulatory support and organic balance deprives the
-patient of reaction, places his vitality and energy far below par and
-for a long time hinders his betterment. More than this amount displays
-the inhibitory effects of opiates, locks up or slows secretions and
-body functions, and causes malnutrition, autotoxemia, autotoxicosis,
-and the consequent mental and physical deterioration commonly and
-erroneously attributed to the direct action of opiate drug.</p>
-
-<p>In 1912 I wrote that so far as I knew the symptomatology attending
-insufficient supply of morphine (or other opiate) to an opiate
-addict had never received the amount of detailed study and analysis
-that it deserved and was not adequately interpreted. W. Marme had
-attributed the symptoms of morphine addiction to the toxic action
-of oxydimorphine. Rudolph Kobert, however, stated that Ludwig Toth
-subjected Marme’s claims to subsequent testing and was unable to
-confirm them, and that his own findings agreed with those of Toth. They
-found that oxydimorphine was inert by subcutaneous injection and that
-when thrown into the blood-stream it formed an insoluble substance
-causing emboli, and so producing the symptoms observed by Marme.
-Kobert seems to be in accord with the early findings of Magendie, that
-oxydimorphine is non-toxic. The experiments of Faust on dogs concerning
-increased power of the body to destroy morphine are well-known. It is
-still a matter of scientific dispute as to what extent the body of the
-opiate addict has developed the power to limit or destroy the poisonous
-properties of opiates by the conversion of these poisons through
-oxidation or other chemical action.</p>
-
-<p>The explanation of tolerance and withdrawal phenomena on the basis of
-something akin to an antitoxin or antitoxic substance circulating in
-the blood of the addict, has also,<span class="pagenum" id="Page_39">[Pg 39]</span> like the oxidation explanation,
-been a subject of controversy. Hirschlaff claimed to have produced
-an antitoxic serum against morphine. Morgenroth failed to confirm
-Hirschlaff’s findings, and argued against the existence of an
-antitoxin. The animal experimental and laboratory work and findings,
-however, of such men as Hirschlaff, Giofreddi and Valenti have helped
-to influence the trend of modern thought towards what may be regarded
-as the present strong tendency in scientific conception of the physical
-mechanism of narcotic drug addiction-disease—an autogenous antidotal
-or antitoxic substance.</p>
-
-<p>A recent paper by DuMez of the United States Public Health Service
-gives a comprehensive review of the work which has been done in
-connection with the study of increased tolerance and withdrawal
-phenomena, and shows conclusively the gradual inclination of modern
-opinion.</p>
-
-<p>There is considerable literature discussing various theories and
-experiments and observations, which has, however, not had widespread
-recognition.</p>
-
-
-<h3>REFERENCES</h3>
-
-<div class="blockquot">
-
-<p>Bishop, E. S., “Narcotic Addiction—A Systemic Disease Condition,”
-<i>Journal A. M. A.</i>, Feb. 8, 1913.</p>
-
-<p>Marme, W., “<span lang="de" xml:lang="de">Untersuchungen zur acuten und chronischen
-Morphinvergiftung,</span>” <i lang="de" xml:lang="de">Deutsch. med. Wchnschr.</i> 9: 197-198.</p>
-
-<p>Kobert, R., “<span lang="de" xml:lang="de">Lehrbuch der Intoxikationen</span>,” Stuttgart, 2; 995, 1906.</p>
-
-<p>Toth, L., “<span lang="de" xml:lang="de">Bemerkungen zur Erklärung der chronischen Morphium
-Intoxikation</span>,” Schmidt’s Jahrb. 229: 135, 1891.</p>
-
-<p>Faust, E. S., “<span lang="de" xml:lang="de">Über die Uraschen der Gewöhnung an Morphin” Arch. f.
-exper. Path. u. Pharmakol.</span> 44: 217-238, 1900.</p>
-
-<p>Hirschlaff, L., “<span lang="de" xml:lang="de">Ein Heilserum zur Bekämpfung der Morphinsucht und
-Ähnlicher Intoxikationen,</span>” <i lang="de" xml:lang="de">Berl. klin. Wchnschr.</i> 39: 1149-1152
-and 1174-1177, 1902.</p>
-
-<p><span class="pagenum" id="Page_40">[Pg 40]</span></p>
-
-<p>Gioffredi, C, “<span lang="fr" xml:lang="fr">L’immunite artificielle par les alcaloides</span>,” 28,
-402-407, and 31, fasc. 3, 1897.</p>
-
-<p>Valenti, A., “<span lang="de" xml:lang="de">Experimentalle Untersuchungen über den chronischen
-Morphinismus; Kreislaufstörungen hervorgerufen durch das Serum
-morphinistscher Tiere in der Abstinenzperiode</span>,” Arch. f. exper. Path
-u. Pharmakol., 75: 437-462, 1914.</p>
-
-<p>DuMez, A. G., “Increased Tolerance and Withdrawal Phenomena in Chronic
-Morphinism, A Review of the Literature,” <i><abbr title="journal">Jour.</abbr> A. M. A.</i>, 72:
-1069-1072, 1919.</p>
-</div>
-
-<p>My own present opinion and conception remains as expressed in a
-paper, “Narcotic Addiction—A Systemic Disease Condition,” written
-in 1912 and published in the <i>Journal of the American Medical
-Association</i>, Feb. 8, 1913, as follows, “It is my opinion that,
-however much increased oxidation aids in the handling of morphine, it
-is to the formation of an antitoxic substance that we must look for
-explanation of our clinical manifestations and for the classification
-of morphine-addiction as a definite medical entity. This opinion is
-based on certain clinical manifestations of morphine effect and the
-symptomatology attending insufficient supply of morphine to those
-addicted, on certain phenomena observed during and following treatment,
-on the persistence of tolerance and on the susceptibility of the cured
-patient to the re-formation of addiction.”</p>
-
-<p>Before elaborating this conception of addiction-disease, I think it
-desirable to repeat the enumeration of the principal manifestations of
-“withdrawal” or body-need for opiate drug. In a general way, they may
-be said to begin with a vague uneasiness and restlessness and sense
-of depression and weakness; followed by yawning, sneezing, sweating,
-excessive mucous secretion, nausea, uncontrollable vomiting and purging
-or diarrhea, twitching and jerking, sometimes violent jactitation,
-intense muscular cramps and pains (described as if the flesh were
-being<span class="pagenum" id="Page_41">[Pg 41]</span> torn from the bones), abdominal pain and distress, marked
-cardiac and circulatory insufficiency, and irregularity (often with
-marked dyspnea), pulse going from extremes of slowness to extremes of
-rapidity, with lowered blood-pressure and loss of tone, facies drawn
-and haggard, pallor deepening to greyness, exhaustion, collapse and in
-some cases, death.</p>
-
-
-<h3><i>Essential Mechanism of Narcotic Drug Addiction-Disease</i></h3>
-
-<p>If such clean-cut, strikingly apparent, constant, and undeniably
-physical phenomena and symptomatology as I have described are to be
-adequately explained, there must be some physical mechanism, some
-definite body process working upon fundamental principles of disease
-reaction. They certainly are not psychiatric manifestations nor the
-expressions of habit, appetite, vice, nor morbid indulgence. Enjoyment
-of morphine for itself, even in such patients as have ever experienced
-such enjoyment, is lost long before the stage of rooted or completely
-developed addiction is reached. Physical results must be explained by
-physical cause.</p>
-
-<p>Tolerance of and immunity to the toxic effects of narcotic drugs are
-primary and striking characteristics in the development of addiction.
-An antitoxin or antidotal substance is the recognized mechanism
-of their production in most diseases admittedly developing these
-characteristics. I have adopted the hypothesis, therefore, that an
-antidotal substance is manufactured by the body as a protection against
-the poisonous effects of narcotic drugs constantly administered. Such
-a substance, manufactured in the body, being antidotal to morphine,
-might well possess toxic properties of its own, exactly opposite in
-manifestation to those possessed by morphine and other opiates. Toxic
-substances exactly opposite to opiate in their action might readily
-account for the severe withdrawal signs, parallel in their extent
-to the extent of opiate insufficiency,<span class="pagenum" id="Page_42">[Pg 42]</span> and resembling in their
-characteristics the manifestations of acute poisoning.</p>
-
-<p>A hypothetical antidotal toxic substance, manufactured by the body as
-a protection against the toxic effects of continued administration of
-an opiate drug, will therefore explain the well-known development of
-tolerance and immunity in these cases, and will account for the violent
-physical withdrawal signs. In a word, it will explain the disease
-fundamentals on a definite physical basis.</p>
-
-<p>Such an hypothesis will explain the stages of development of
-addiction before outlined. In the stage of tolerance the antidotal
-toxic substance has begun to make its appearance in the body and
-to protect it against slight narcotic excess, but its manufacture
-is not sufficiently established to continue longer than necessary
-to neutralize the narcotic administered. In the stage of beginning
-addiction, or beginning narcotic-need, its manufacture has become
-more developed and more constant and proceeds for a longer time
-after the discontinuance of the narcotic drug. In the stage of fully
-developed addiction, or absolute narcotic need, the manufacture of
-the antidotal toxic substance has become practically an established
-pseudo-physiological body-process, and will continue long after the
-administration of the narcotic drug for reasons into which I have gone
-elsewhere. In other words, in narcotic drug addiction some antidotal
-toxic substance has become the constantly present poison, and the
-narcotic drug itself has become simply the antidote demanded for its
-control. In brief, fundamentally and basically, narcotic drug addiction
-is a condition presenting definite physical phenomena, symptoms, and
-signs, due to the presence within the body of some autogenous poison
-requiring narcotic drug for neutralization of it or of its effects.</p>
-
-<p>This explains the phenomena of the mathematical exactness with which
-the minimum daily need can be estimated under experimental conditions,
-and with which doses<span class="pagenum" id="Page_43">[Pg 43]</span> less than the amount of actual body need relieve
-existing withdrawal signs in definite proportion to the amount of
-opiate administered. In exact proportion as the drug of addiction is
-present in the body to neutralize or oppose some antidotal poison, is
-the patient free from withdrawal symptoms and from physical craving for
-the narcotic drug.</p>
-
-<p>The development and existence of such mechanism in the body of the
-opiate addict is suggested also by the apparent continuance of
-tolerance to opiate existing after long periods without drug in
-individuals who had previously suffered from addiction-disease, and in
-the susceptibility of the former sufferer subsequent to the arrest of
-his physical need for opiate, to the re-establishment of that need by
-the subsequent administration of the drug.</p>
-
-<p>Illustrative of this phenomenon is a case who, after about two years
-of relief from addiction-disease, developed pneumonia and to whom in
-delirium and threatened death, opiates were administered as unavoidable
-medication. After cessation of his delirium, he was dismayed to
-discover addiction-manifestations and body-need for opiate drug had
-been re-established. This history is one of a number in my possession,
-and has been verified.</p>
-
-<p>The case demonstrating the longest persistence of susceptibility among
-my records, is that of a man in the early fifties who underwent an
-emergency operation for infected gall-bladder. A day or two following
-operation he developed excruciating pain in his right side just under
-the ribs. It had been necessary to administer opiates since a day or
-two before the operation. I was called in consultation for the purpose
-of determining the character and origin of the pain, and diagnosed a
-pleurisy, the pain of which subsided on the following day. Opiates were
-discontinued with a result of precipitating unmistakable withdrawal
-phenomena. To his great anger and surprise, I accused the patient of
-being an opiate addict. He indignantly declared that he had never
-used opiates in his<span class="pagenum" id="Page_44">[Pg 44]</span> life. Subsequent investigation with the aid of
-older members of his family disclosed a distinct and typical history
-of addiction manifestations following opiate administration in the
-course of treatment of a complicated fracture of his thigh in early
-boyhood. The drug had been withdrawn at that time and the addiction
-manifestations finally disappeared, he never having been aware of the
-facts. His reawakened addiction-manifestations were easily and quickly
-checked.</p>
-
-<p>It is evident from many histories that large dosage robbed of or
-modified in its toxic effect, and even in the opiate manifestations
-usual in subjects who have never been made tolerant, and small dosage
-being sufficient to re-awaken physical need for opiates are conditions
-which do exist and persist for indefinite periods. The resemblance
-between this continued tolerance and the conditions existing in
-diseases which confer immunity and having a generally accepted
-antitoxin mechanism is too close to be ignored.</p>
-
-<p>Evidence of a toxic substance in the body of a narcotic-addict is
-further presented by the similarity of the clinical pictures presented
-by these cases of acute opiate need and extremely severe cases of
-acute poisoning from materials such as the ptomains and some other
-poisons. Acute opiate need is clinically typical of intense suffering
-and prostration from the action of some powerful poison. Its symptoms
-cannot be due to opiate, for the reason that the administration of
-opiate relieves them, and relieves them exactly in ratio to the
-amount of opiate administered. They can be held at any given stage by
-gradation of the opiate dosage. Their manifestations, moreover, are
-exactly opposite to opiate effect. They are to my mind best explained
-as due to the action of some toxic substance, antidotal to opiate,
-prepared by the body for its protection in response to continued opiate
-presence in the body, as antitoxins are prepared for the neutralization
-of or opposition<span class="pagenum" id="Page_45">[Pg 45]</span> to the organic poisons of invading bacteria. The
-chemical or physical character or nature of such substance has not been
-yet determined.</p>
-
-<p>The presence of such a substance would explain the establishing of
-tolerance, the manifestations following opiate administration and the
-apparent definiteness of the amount of opiate needed. It would explain
-the results of under-dosage and the results of over-dosage, and the
-practical non-interference with function or general health when a
-dosage is maintained exactly sufficient in amount to neutralize the
-effect of some exactly antidotal body or substance.</p>
-
-<p>An antidotal substance would also explain the after effects of and
-the so-called “relapses” which occur after most of the cases treated
-by whatever method or procedure, without due appreciation and proper
-estimation of the clinical manifestations and indications of addiction
-symptoms and physical body need, and without due consideration of the
-patient’s reactive abilities and physical condition. These patients are
-in a condition of restlessness, discomfort, vague pains, mental and
-physical depression, lowered physical vitality and weakness. They have
-a sense of a physical lack of support. They cannot endure nor react to
-over-exertion, worry, strain, etc. This condition may persist for weeks
-and months after no opiate has been administered. The above seem to be
-mild withdrawal symptoms of an incompletely arrested addiction-disease
-mechanism and might be explained by a continued manufacture of small
-amounts-of antidotal toxic substance, causing a low grade chronic
-poisoning. They can be duplicated in active opiate addiction before
-withdrawal by administering an amount of opiate slightly below the
-amount of need and so leaving unneutralized a small amount of the
-antidotal toxic substance.</p>
-
-<p>If continued production of a toxic antidotal substance, after
-discontinuance of the drug which called it into being<span class="pagenum" id="Page_46">[Pg 46]</span> is to explain
-the existence of the condition I have just described, the causation
-of this continued production must be accounted for. It is conceivable
-that in the development of addiction-disease mechanism a tolerance
-of and slowness to eliminate opiate or some product of opiate is
-acquired by all the cells of the body, perhaps especially by the
-liver, and that these tolerant and atonic cells are extremely slow of
-opiate elimination. Under this condition, a residue of opiate or some
-product of opiate capable of antidotal substance stimulation might
-remain unresponsive, or very slow of response, to ordinary cellular
-and other elimination. If this should prove to be the fact, it would
-account for a continued production of antidotal toxic substance, and
-might, moreover, in any given case, either before or after cessation of
-opiate medication, be one of the determining factors in the amount of
-antidotal substance produced, or, in other words, in the measure of the
-extent of body-need for opiate drug.</p>
-
-
-<h3><i>Inhibition of Function</i></h3>
-
-<p>What characteristic action exists in opiate or narcotic drugs which
-gives them this power to establish the above described mechanism?
-It seems to me that it is, above all, their power to inhibit body
-function. They tend markedly to arrest metabolic processes. They
-inhibit glandular activity. They inhibit unstriped muscle activity and
-hence peristalsis. They, therefore, cause a slowing up of glandular
-function and intestinal activity, and of elimination. This results in
-an accumulation of opiate in the body. It is this constant accumulation
-to which the body must become tolerant by the development of some
-mechanism for its protection.</p>
-
-
-<h3><i>Autointoxication and Autotoxicosis</i></h3>
-
-<p>It is to the element of inhibition of function also that we must look
-for explanation of what is by far the most<span class="pagenum" id="Page_47">[Pg 47]</span> important element in the
-immediate picture presented by most individual cases. I refer to
-autotoxicosis and to auto- and intestinal toxemia. The same power that
-locks up within the body the opiate drug, locks up the toxic products
-of tissue activity and tissue waste, of intestinal poisons and of
-insufficient metabolism. Autotoxemia itself is markedly inhibitory in
-its action, and contributes no little to its own increase and to the
-further development of narcotic disease.</p>
-
-<p>It is not at all impossible that any inhibiting poison constantly
-present in the body will some day be found to establish a mechanism of
-protection, similar to that of opiate addiction, and that some of the
-states now popularly and loosely classified under the general head of
-“autointoxications” will be recognized as really addiction-states, in
-which the body has become progressively tolerant of its own poisons.
-I believe that it can be demonstrated that some of the phenomena and
-manifestations at times observed in chronically inhibited and autotoxic
-individuals in whom there can be no suspicion of any opiate or narcotic
-element are analogous to the phenomena of narcotic addiction mechanism.
-It is not inconceivable that any inhibiting poison or toxin is capable
-of producing its own addiction-mechanism, and it has seemed to me that
-my own clinical familiarity with the action and reaction of narcotic,
-inhibiting, or addiction-forming drugs and of addiction-mechanism upon
-circulation, glandular and intestinal and other function has been of no
-little assistance in the interpretation, control and remedy of other
-chronic intoxications.</p>
-
-<p>Upon the extent of inhibition of function and autointoxication,
-therefore, depend some of the immediately predominating manifestations
-in individual cases. They must be reckoned with and eliminated in
-the measure of addiction-disease in the individual sufferer. In many
-cases they contribute the immediate and compelling indications<span class="pagenum" id="Page_48">[Pg 48]</span> for
-rational therapeutic endeavor. To a considerable extent they determine
-circulatory efficiency and metabolic and glandular activity and
-balance. They largely control physical tone and physical reaction.
-Inhibition and intestinal and autotoxemia cause most of the physical
-and mental deterioration, and much of the incidental symptomatology
-so widely ascribed directly to narcotic drug effect. Upon the extent
-of their presence, therefore, depends greatly the clinical picture in
-the individual case. This doubtless accounts for the acidosis, noted
-by Jennings and others, inasmuch as it has been definitely proved that
-acidosis is commonly present in all conditions of functional depression
-and exhaustion.</p>
-
-<p>With inhibition and auto and other toxemia eliminated or reduced to
-a minimum, the patient can go through many years, an apparent normal
-man, well-nourished, reactive, in good physical tone, mentally sane
-and physically competent. Under these conditions he shows practically
-nothing abnormal as long as he gets properly administered, his
-accustomed narcotic drug, in the amount of its minimum physical
-requirement or body-need. His condition is often unsuspected by those
-nearest and dearest to him, and the popularly held opinion that
-narcotic addiction shortens life does not seem to be upheld by the
-facts in his case. Such cases as his are far more numerous than has as
-yet been realized.</p>
-
-<p>In the types of narcotic addicts most widely recognized inhibition
-of function and autointoxication is marked, and the opiate drug is
-used in excess of body-need. The addict of this description becomes a
-deteriorated wreck, requiring high doses of opiate for the satisfaction
-of abnormal body-need, mentally and physically incompetent—the
-generally accepted picture of the so-called “dope-fiend,” a
-deteriorated, degenerated, malnourished wretch, degraded, avoided and
-condemned.</p>
-
-<p>Inhibition of function and autointoxication should not<span class="pagenum" id="Page_49">[Pg 49]</span> be vague
-terms. They cause and are measurable by definite clinical evidence.
-They display manifest phenomena and symptoms, and become increasingly
-defined material entities as the clinician looks for them as such.
-Much of inhibition of function and autointoxication and of their
-manifestations, has been recognized and taught under their own
-heading and in connection with conditions other than narcotic drug
-addiction-disease. That the influence and importance of inhibition of
-function and autointoxication in the development, and manifestations
-of the narcotic drug addict has escaped general and widespread
-recognition, is evidence of the small amount of unbiased clinical
-study, and of analytical clinical interpretation of material physical
-phenomena, hitherto accorded to narcotic drug cases.</p>
-
-<p>I would not have it concluded that all symptoms and manifestations
-arising in the handling of a drug addict are due to the factors and
-elements I have discussed in this chapter. It must be always in the
-mind of the intelligent and conscientious physician, that he has in his
-care a human being with the same medical and psychical possibilities
-that must be taken into careful and complete account, as in the
-handling of any other sick person. There is an unfortunate tendency to
-overlook concurrent, or complicating or pre-existing conditions in the
-handling of the narcotic drug addict. These cases are often extremely
-complex and difficult to analyze, and for adequate comprehension and
-handling of them, the symptoms and manifestations they show should be
-appreciated in their true origin and character as they occur in each
-individual case.</p>
-<hr class="chap x-ebookmaker-drop" />
-
-<div class="chapter">
-<p><span class="pagenum" id="Page_50">[Pg 50]</span></p>
-
-<h2 class="nobreak" id="CHAPTER_V">CHAPTER V<br /><span class="small">REMARKS ON METHODS OF TREATING NARCOTIC DRUG ADDICTION</span></h2>
-</div>
-
-
-
-<p>Most physicians have at some time or other in the course of their
-practice encountered cases of narcotic addiction. Most addicts have
-appealed to the physician for advice and help. A very large proportion
-of them have at different times made effort to obtain relief from
-their affliction through the avenues of various forms of treatment,
-advertised and otherwise. Most physicians have at some time or other
-made effort to rescue some victim from drug addiction, and as a rule
-have given over the effort as hopeless, because even when they had
-succeeded in taking his narcotic away from the patient, usually after
-an experience trying and exhausting to both, the patient has resumed
-narcotic administration—according to the patient, because he had
-to—according to the average observer, because he wanted to. Frequently
-the patient has refused to persevere to the end of treatment and has
-abandoned his attempts before the treatment has reached the point of
-cessation of opiate medication—the patient stating that he could
-not—the observer believing that he would not, continue, and did not
-have the courage or stamina or will to endure the necessary suffering.
-The medical profession as a whole has adopted a cynical attitude
-towards the possibility of permanent “cure,” and towards the efficacy
-of medical treatment, which has tended to send the addict to quacks and
-charlatans and various advertised remedies.</p>
-
-<p>It is not my purpose to discuss in this book in detail<span class="pagenum" id="Page_51">[Pg 51]</span> the various
-methods, and treatments and cures advocated and employed in the
-handling of the drug addict. This alone would require a volume in
-itself.</p>
-
-<p>Three broad lines of procedure have been employed; so-called
-“slow-reduction,” “sudden withdrawal,” and withdrawal accompanied by
-the administration of various drugs, such as those in the belladonna
-group and its alkaloids.</p>
-
-<p>Slow reduction or “gradual reduction” as a “method” is employed by
-slowly or gradually, reducing the patient’s accustomed dosage to the
-point of discontinuance of opiate medication. Interpreted by a great
-many to mean that the fact of reduction is the principal indication in
-clinical procedure, successful in the hands of a few who have acquired
-unusual technical skill and clinical ability in the interpretation
-of addiction manifestations, I believe it to have failed as a method
-of cure in the hands of the average. Practically every addict has
-attempted it one or more times. As a method of procedure in some
-stages and under some conditions of addiction treatment, slow or
-gradual reduction of dosage has its value. In my opinion, however,
-all other considerations aside, there are very few who are possessed
-of sufficient understanding of narcotic addiction and ability in the
-interpretation of clinical indications, and have the technical skill
-required to carry it through to a clinically successful culmination.
-As a method of routine or forcible application it has many serious
-objections as well as potentialities for damage to the patient. In
-cases whose opiate intake is in excess of actual physical-need, gradual
-reduction as often practiced is perfectly easy and unnecessarily
-slow down to the amount demanded as a minimum by the patient’s
-addiction-disease requirements. Then must come withdrawal, nagging,
-exhausting and protracted, if unskillful reduction is persisted in,
-and the wrench of actual final withdrawal is nearly as severe from a
-very small dosage as from a<span class="pagenum" id="Page_52">[Pg 52]</span> moderate one, other conditions in the
-case, physical and mental, being equal. Prolonged “withdrawal” without
-rare technical skill and without unusual and not commonly available
-environment and conditions of life, means subjecting the patient to
-the continued strain of persistent self-denial and self-control in the
-face of continued suffering, discomfort, and physical need and constant
-desire for their relief. It is my opinion that this experience has
-in many cases tended to deeply impress upon the mind of the patient
-so-called “craving” for the drug, and has converted many a case of
-simple physical addiction-disease into a more or less mental state
-which may be described as “morphinomania” or “narcomania.”</p>
-
-<p>This last observation does not apply to the method of gradual reduction
-only, but is equally true of protracted suffering under any other
-procedure in which the individual is cognizant of the existence of
-means of immediate if only temporary relief.</p>
-
-<p>In the comprehension of this a physician has only to glance back over
-his professional experience and recall cases of various conditions
-other than addiction which have come to him, and whose histories
-present the effect of long protracted suffering and discomfort in the
-conversion of an average normal, self-supporting human being into a
-dependent neurasthenic.</p>
-
-<p>The histories given by most narcotic addicts of their efforts to get
-relieved of addiction, show that following the withdrawal of opiate
-drug in many if not most instances has come weeks and months of
-weakness, and discomfort, nervousness, sleeplessness, and pain which
-have persisted for weeks and months, establishing the basis for the
-much emphasized “after care,” of some investigators.</p>
-
-<p>While so-called “after care” is unquestionably as important as
-convalescence from any other disease, it is my belief that as
-understanding of addiction as a clinical disease becomes more general,
-and more attention is paid<span class="pagenum" id="Page_53">[Pg 53]</span> to the study and scientific management of
-the disease itself, the stage of “after care” will come to assume less
-importance. Addiction is not the only disease which furnishes examples
-of cases in which incomplete and unsatisfactory results have been
-merely a low-grade continuation of the fundamental disease and have
-been interpreted as a protracted convalescence.</p>
-
-<p>“After care,” or convalescence, following satisfactory results of
-clinical treatment and complete arrest of addiction-mechanism activity
-has no terrors for either physician or patient. It is very short and
-does not require any more restraint than any other convalescence,
-unless conditions exist following active treatment which should have
-been recognized and handled and eliminated earlier from the picture. I
-shall discuss this again later.</p>
-
-<p>“Sudden” or “forcible” withdrawal, or immediate deprivation of opiate
-drug is still advocated by some investigators, fewer and fewer of
-them, however, among medical men. There are cases of, and stages in
-addiction-disease and its development where this means of procedure may
-be pursued without all of the serious objections with which it must be
-regarded as a routine method of general enforcement.</p>
-
-<p>That forcible deprivation of opiate drug may end in death is a matter
-of too easily found and authoritative medical record to be ignored. It
-has been discussed as one of the possibilities by medical writers over
-many years. Even the newspaper reports of deaths and suicides following
-sudden deprivation of opiate should be sufficient to give pause to
-those who would still advocate this measure as a desirable procedure.</p>
-
-<p>Reference to the previous enumerations of the physical manifestations
-of body-need for opiate, or “withdrawal signs,” should be sufficient
-for the comprehension of its tortures and easily explains the suicides
-which have attended sudden deprivation. Any one who has watched a<span class="pagenum" id="Page_54">[Pg 54]</span>
-well-developed case of addiction-disease in the agonies of opiate
-deprivation should hesitate to prolong them if possibly avoidable.
-While under some conditions, and in some cases, it may be argued that
-“the ends will justify any means,” as a routine procedure of wide
-application, it must be stated that both in its immediate torment and
-in its end results, mere forcible sudden withdrawal is not a procedure
-of election. Some of its supporters still cling to and quote the old
-fallacy that after seventy-two hours without opiate a narcotic addict
-no longer physically requires it. This fallacy is probably based upon
-the estimated maximum time of opiate elimination in normal human
-beings and experimental animals. It is most decidedly false doctrine
-as applied to the well-developed case of addiction-disease in whom the
-mechanism of disease, and not the mere administration or elimination of
-opiate has become what should be the dominating consideration.</p>
-
-<p>As stated before, the mere withdrawal of opiate drug does not arrest
-the activity of addiction-disease, nor prevent the endurance of the
-exhausting and incapacitating and protracted low-grade manifestations
-before referred to. Its potentialities of permanent damage, moreover,
-are attested by and displayed by many who show for years shattered
-nerves, premature old age, etc.</p>
-
-<p>It is perhaps wise to state again in this place that in this book
-the consideration of narcotic or opiate addiction, its mechanism
-symptomatology and handling, is not to be applied to cocaine and
-alcohol use nor to the various other drugs often loosely grouped
-with opiates as “habit-forming.” Until a distinct physical disease
-mechanism, attended by analogous characteristic and constant physical
-phenomena, can be demonstrated as resulting from the action of one of
-these drugs or substances, its continued use should not be classed with
-opiate addiction-disease.</p>
-
-<p>The third general method of procedure is that in which<span class="pagenum" id="Page_55">[Pg 55]</span> effort is
-made to utilize other drugs than opiates, or other measures than mere
-reduction or withdrawal or deprivation to secure cessation of opiate
-medication. The efforts have been, in a general plan, either to oppose
-or replace the action of opiate by substance or substances seemingly
-to have physiologically antagonistic or substitution properties—or to
-combat, offset or benumb the sufferings of what is described as the
-“withdrawal period.” Such agents have been employed in this disease
-for very many years, and in their variety include most of the known
-analgesic, sedative, antispasmodic, hypnotic or anesthetic agents and
-measures.</p>
-
-<p>Prominent among the drugs mentioned have been the preparations and
-alkaloids of belladonna, of hyoscyamus, pilocarpine, and some others.
-These drugs have by reason of more or less supposed specific action,
-alone, or in various combinations or in conjunction with purgatives,
-etc., formed the basis for many if not most of the various special
-treatments and “cures.” For example, what is described as the “specific
-mixture” of one of the most widely-known treatments contains as its
-active agents belladonna and hyoscyamus. These drugs are not mentioned
-here in condemnation of their employment as therapeutic measures
-in the hands of those skilled in the estimation of their values,
-indications and actions—and dangers if unskillfully employed. They
-have unquestioned therapeutic value in their proper places, as and when
-properly indicated, in individual cases. Routinely used, as specific
-curative agents, they seem to me to be demonstrating their failure. In
-the conception of addiction-disease herein outlined it is difficult to
-attribute to them specific properties.</p>
-
-<p>In a paper, “The Rational Handling of the Narcotic Addict” read before
-the Section on Pharmacology and Therapeutics, Annual Session of the
-American Medical Association, 1916, I stated, “It is not my purpose
-to enter<span class="pagenum" id="Page_56">[Pg 56]</span> into discussion of the various therapeutic methods and
-therapeutic measures which have been advocated and employed in the
-treatment of narcotic addiction. Their number is legion, and they
-include most of the therapies known to lay as well as to medical
-literature.</p>
-
-<p>“Their multitude is conclusive proof of lack of conception and of
-understanding of addiction-disease in the past. They have been directed
-towards incidental and complicating manifestations. They have no more
-place in the treatment of the addict than they have in the treatment
-of any other disease condition. I know of no medication that can be
-called ‘specific’ in the arrest of the mechanism of narcotic drug
-addiction-disease. There is no more of a specific remedy for narcotic
-drug addiction than there is for typhoid or pneumonia. The wide
-advertisement of treatments based on supposed ‘specific’ action of
-the products of the belladonna and hyoscyamus and similar groups is
-unfortunate. They have in my opinion, no action as curative agents in
-narcotic drug addiction-disease which can entitle them to consideration
-as specific or special curative remedies. The drugs of this group
-are useful in many cases, intelligently applied to meet therapeutic
-indications. They exhibit wide variation of action and reaction in
-narcotic drug addicts at different clinical stages and under different
-clinical conditions, and their dosage presents an extremely wide range
-of individual measure. They are dangerous drugs in the hands of the
-inexpert or careless, or used in a routine manner or dosage. The status
-which they have acquired as specific medication in narcotic addiction
-disease I hold to be a medical fallacy which should be strongly opposed
-and early remedied.”</p>
-
-<p>The search for panaceas, specifics and routine treatments has
-constituted a stage in the therapeutic history of most disease
-conditions. It marks the effort to make wide and general application
-of a partial comprehension<span class="pagenum" id="Page_57">[Pg 57]</span> of facts and imperfect recognition
-of fundamentals and is successful only as an individual case is
-occasionally capable of responding, perhaps by clinical accident, to
-the specific routine employed.</p>
-
-<p>Undue insistence and publicity secured for or given to a procedure of
-this description, is a real obstacle to the development of clinical
-and scientific understanding of the condition treated. It distracts
-attention from broad clinical consideration of disease itself, from
-scientific investigation into pathology and disease mechanism, from
-determination and observation of fundamental facts, whose comprehension
-and analysis form the essential factor in the widespread successful
-handling of any condition, and from proper conception and appreciation
-of the addiction patient and the addiction problem as a whole with its
-many and varied aspects.</p>
-
-<p>Various procedures in themselves, however, are not to be utterly
-discredited and condemned. They have performed a function in a
-transitional stage of education and progress. They can all bring
-evidence in support of some “cures.” In their origin and inception
-they represent honest effort, study and original thought. In analysis
-of them can be seen, in the minds of those who first evolved them,
-recognition and application of one or another of the basic elements,
-reactions or facts of addiction-disease. Each generation builds upon
-and adds to the work of the previous one, discards or adopts according
-to its more complete knowledge. We are building upon the various
-procedures of the past just as our successors will build upon our work
-of the present and will discard or adopt our various instruments and
-theories.</p>
-
-<p>We are nearing the end of consideration of routinely applied
-procedures, in all diseases. In addiction we are entering upon a
-stage of attitude and handling in which there shall be in each case
-comprehension of intrinsic elements and appreciation of their relative
-importance,<span class="pagenum" id="Page_58">[Pg 58]</span> and in which there shall be competent interpretation of
-symptomatology and competent selection and application of therapeutic
-measures, placing our efforts on a rational basis and adapting handling
-and treatment to the needs of the individual.</p>
-
-<p>Our stumbling-block in the past has been that our minds have been too
-much focused upon the mere use of narcotic drug and upon the stopping
-of drug use and too little upon the individual we were treating and the
-mechanism of his disease. We have tended to apply our remedial efforts
-to narcotic use instead of to narcotic drug addiction-disease.</p>
-
-<p>This may explain the paucity of clinical and scientific information
-as to addiction-disease coming from the institutions in which these
-cases are gathered. It seems to be the fact that the narcotic wards of
-our great charity hospitals and institutions of custody and correction
-still in great measure proceed with their handling of narcotic addicts
-on the basis of mental or moral degeneracy or deficiency or weakness of
-will, or morbid appetite, etc., or apply one or another of the various
-remedies or combinations of remedies. Their internes and nurses do not
-seem to graduate with a conception of addiction as a definite physical
-disease, with clinically significant symptomatology and constant
-physical reactions and phenomena. That these institutions have after
-many years given us so little information as to the definite physical
-symptoms and phenomena which their patients constantly manifest is
-in large measure the result of attention directed to control of drug
-use instead of to alleviation of physical addiction-disease. There
-has been much discussion over various methods of treatment and over
-measures for the control of patient and of narcotic drug, and there
-has been insufficient study and analysis of the clinical details
-of addiction-disease manifestations and their possible therapeutic
-significance.</p>
-
-<p>There has been of late, however, signs of change in<span class="pagenum" id="Page_59">[Pg 59]</span> this situation,
-and in this change lies one of the greatest hopes of solution of the
-narcotic drug problem. The attitude towards addiction is beginning to
-follow the trend of modern medicine in getting away from special or
-routine treatments, and the search for specifics and panaceas, and in
-aiming at and devoting great effort to the searching out, consideration
-of, and treatment of fundamental cause and underlying condition. When
-this method of approach is applied widely to addiction-disease, and
-the facilities of our great hospitals and institutions of research
-properly directed to its furtherance, there will come a re-arrangement
-of conception of opiate addiction. Restraint and custodial care,
-and psychologic and psychiatric classification will be applied more
-sparingly. Many worthy sick people will—instead of being refused
-treatment, or turned back upon their own resources after inadequate
-treatment—thus adding to the public and private burden of the care of
-the unfit—be rationally treated as sick people and returned to health
-and self-supporting competency.</p>
-
-<p>The one great point to be kept in mind is that narcotic addicts are
-sick; sick of a definite and now demonstrable disease. This disease is
-variously complicated and widely variable as it occurs in individual
-patients. Although some individuals, afflicted with this disease, may
-require custodial or correctional handling—the fundamental physical
-disease cannot be properly arrested nor handled successfully by
-mental, moral, sociological or penological methods only. Any toxic,
-worried, fear-ridden or suffering sick man may show psychological or
-even psychiatrical manifestations or complications, but observing and
-attempting to control complications only will not cure basic disease.</p>
-
-<p>Even if it should some day develop that a serum can be produced
-against the underlying toxins of addiction-disease; and this is not
-beyond the bounds of possibility;<span class="pagenum" id="Page_60">[Pg 60]</span> its usefulness and application must
-remain for the present matters of academic speculation. Other than
-this possibility, there seems practically no hope of a properly called
-“specific medication” in narcotic drug addiction-disease. Even with its
-discovery, it is highly improbable that a routine treatment applicable
-to all cases could ever be successfully adopted. In the very few
-disease conditions in which we can properly be said to have “specific”
-medication, routine handling and treatment of all cases is inadvisable
-and unsatisfactory.</p>
-
-<p>There is not and probably never will be any specific routine treatment
-successfully applicable to all cases of any complex and variable
-disease condition. We shall save much public money, and personal
-effort and time, and shall save the narcotic addict much suffering and
-discouragement, and shall add much to human health, competency and
-happiness when we realize these facts as applied to addiction-disease,
-and proceed upon them in a spirit of broad humanity and of rational
-clinical study and remedy of obvious disease symptomatology. Narcotic
-drug addiction-disease is a definite, and in most cases arrestable
-disease. It should be widely so regarded and studied and treated.</p>
-<hr class="chap x-ebookmaker-drop" />
-
-<div class="chapter">
-<p><span class="pagenum" id="Page_61">[Pg 61]</span></p>
-
-<h2 class="nobreak" id="CHAPTER_VI">CHAPTER VI<br /><span class="small">THE RATIONAL HANDLING OF NARCOTIC DRUG ADDICTION-DISEASE</span></h2>
-</div>
-
-
-<p>If anything has been demonstrated conclusively concerning narcotics it
-is that the methods of the past, legal, administrative, and medical,
-have not solved the narcotic drug problem, nor controlled the narcotic
-drug situation, nor been successful in the handling of the narcotic
-drug addict.</p>
-
-<p>Some factor or element of great and fundamental importance has
-obviously been neglected. This lacking element is general recognition
-of the presence of disease processes which cause the symptomatology
-and phenomena of body-need for opiate drug. One of the essentials for
-the practical solution and management of the narcotic drug problem is
-the realization by the medical profession, legislators, administrators
-and laity that opiate drug addiction is a definite disease entity, to
-be treated as such, and calling for extensive clinical and laboratory
-investigation and study such as have been accorded other diseases over
-which we have gained the mastery. One of the most needed achievements
-in the line of practical remedy is the admission of narcotic drug
-addiction-disease to its legitimate place as an accepted part of
-the practice of internal medicine and the stimulating of education
-concerning it among medical practitioners, medical students and nurses.</p>
-
-<p>As was stated in the last chapter, too much emphasis has been placed
-on drug use and drug withdrawal, as if the drug itself were the most
-important element in the clinical picture of addiction. In the handling
-and treatment<span class="pagenum" id="Page_62">[Pg 62]</span> of addiction-disease it should be constantly borne in
-mind that the ultimate withdrawal of opiate from the addict is simply
-one stage, and not by any means the most important consideration
-in his rational handling. Its management in most cases is a matter
-of scientific clinical certainty and satisfactory accomplishment
-by the physician who understands the disease he is treating and
-who is clinically proficient in the control of its elements by
-indicated therapeutic procedure. The ease of handling the stage of
-final withdrawal, the extent to which suffering, nervous strain and
-exhaustion can be avoided in it, and its final issue depend greatly
-upon the physical and reactive condition of the man from whom drug
-is withdrawn. Like the stage of crisis in pneumonia, its course
-and conduct and results are largely influenced by the condition in
-which the patient approaches the withdrawal. It is of vastly more
-importance to measure and control reactions and treat a patient so as
-to get him into the fittest possible condition for final withdrawal
-and rapid convalescence, than it is to focus attention on the mere
-reduction or withdrawal of drug, or on the mere amount of drug used.
-Final withdrawal of drug, like an operation of election, is to be
-done when the patient is in the fittest condition and ready for it.
-With the addict who is well nourished, non-inhibited, and physically
-and glandularly reactive, it can be accomplished with little or no
-discomfort, in a very short time, leaving practically nothing to demand
-a protracted and difficult stage of convalescence or of so-called
-“after care.”</p>
-
-<p>It becomes evident, therefore, that the handling of an opiate addict,
-preliminary to withdrawal of the drug to which he is addicted is
-of greatest importance. The ease of withdrawal and rapidity and
-completeness of subsequent recuperation, is largely commensurate
-with the extent of organic dependence upon the drug and the physical
-condition of the patient. One man using the same amount<span class="pagenum" id="Page_63">[Pg 63]</span> as another is
-dependent upon its effects for the support of his organic processes
-to a much greater extent. The evident solution lies in a preliminary
-stage, removing inhibition, reducing in so far as possible organic
-and functional dependence upon drug, and putting the patient into the
-best possible reactive condition. I believe that in many cases it is
-imperative for successful issue to train the patient for the shock and
-strain of opiate withdrawal and in practically all other cases, though
-less imperative, most desirable.</p>
-
-<p>It has been objected that this will prolong treatment. My experience
-has been that it very much facilitates withdrawal treatment, and not
-only renders it easier and more uniformly successful and complete, but
-that it tends to shorten and make less troublesome, and in some cases
-practically eliminates, convalescence.</p>
-
-<p>I have therefore instituted as an important part of my procedure, a
-Preliminary Stage of study and handling and treatment of my patient
-before attempting withdrawal of the drug. During this time I study my
-patient, regarding him not simply as a narcotic addict but as a sick
-man to be investigated as carefully as a cardiac or any other patient,
-and all his organic and functional conditions appreciated, and all of
-his functional and glandular actions estimated in their competency
-and balance and their reactions both to the drug of addiction and to
-the influences of addiction disease mechanism. Conditions long masked
-by opiates, and forgotten, even by the patient himself, may seriously
-affect treatment, convalescence and prognosis if undetected before
-withdrawal is instituted. Their relations to and possible influence
-upon addiction and its treatment, and fully as important—the possible
-effect of treatment and withdrawal of drug upon them, should be very
-carefully estimated. If advisable or possible they should be remedied
-before withdrawal of the drug of addiction.</p>
-
-<p><span class="pagenum" id="Page_64">[Pg 64]</span></p>
-
-<p>Also such mental or psychical disturbances as may exist in a given
-case should be traced to their origin, estimated and reckoned with.
-Very often they will be found to be not inherent but a result of past
-suffering and present worry and fear. The patient’s confidence in
-his physician’s ability to treat the disease from which he suffers
-should be strengthened, and his doubts and fears allayed. Addiction
-patients are well informed concerning opiates and are acquainted with
-the manifestations of addiction-disease, and have had experience with
-or full information concerning the various methods of cure. They are,
-like any other chronic sick person, suspiciously and keenly analytic of
-themselves and of the physician, and unless handled with appreciation
-of their condition are naturally the prey of constant worry and fear.
-Co-operation and confidence between patient and physician vastly
-influence the amount of nervous energy expended by both, and in this,
-as in other diseases are big factors in treatment and in convalescence.</p>
-
-<p>Another advantage of a preliminary stage is one which has been too
-little considered, but which will before long come to demand the same
-intelligent attention and measure as is given to the contemplation
-of operations in and treatment for chronic other conditions. It
-is this—in what condition will withdrawal of opiate even though
-skillfully conducted and successfully accomplished, leave the
-individual in his value to himself, and to his family and to the
-community, in view of co-existing physical conditions? Withdrawal of
-opiate drug has been in not a few cases the cause of transforming of
-a capable and useful citizen into an invalid incompetent, for whose
-ultimate salvation and competent physical and mental function and
-organic and glandular control resumption of opiate medication was
-determined to be a therapeutic necessity.</p>
-
-<p>Such considerations as this should be all taken, analyzed<span class="pagenum" id="Page_65">[Pg 65]</span> and
-estimated in a preliminary stage and if treatment is only going to
-injure a patient he should be instructed how to handle his addiction,
-and advised to continue his opiate medication, and not be subjected to
-useless expense and trials.</p>
-
-
-<h3><i>Basic Principles of Addiction-disease Handling</i></h3>
-
-<p>Intelligent addicts well know that, other factors being equal, the less
-number of times in a day they take their drug, the less inhibited, the
-less constipated and more normal they are, and the smaller amount of
-narcotic drug they require to maintain them physically and mentally
-competent. It is unfortunate that this therapeutic principle so widely
-recognized among intelligent addicts has not received full recognition
-and therapeutic employment by all of those who handle and treat
-addiction-disease. Its probable explanation is very simple—apparently
-a period of inhibition follows the administration of narcotic or opiate
-drugs; and the length of this period is not in ratio to the size of the
-dose administered. Consequently, the fewer number of times in a day a
-dose of narcotic drug is administered, the greater amount of competent
-metabolism is present—the more adequate is the patient’s elimination
-and nutrition—the smaller amount of opiate or its product lies stored
-in inhibited and atonic cells, and the smaller amount of antidotal
-substance is manufactured for the protection of the body, and to some
-extent, the smaller amount of opiate is required.</p>
-
-<p>In caring for the narcotic addict, therefore, one of the most important
-therapeutic measures is the regulation of the interval of his narcotic
-drug administration. I have repeatedly experimented upon addicts who
-were not confined or under restraint in any way. I explained to them
-the inhibitory effects of too frequent dosage and instructed them to
-use the amount of drug they found necessary for twenty-four hours in
-larger doses at longer intervals.<span class="pagenum" id="Page_66">[Pg 66]</span> This procedure alone, in many cases
-transforms the pallid, starved, constipated and deteriorated addict
-within a surprisingly short time into a well-nourished, well-reactive
-and practically normally functioning individual. With the return of
-health, vitality, and normal nutrition and elimination, his body
-requires still less drug and he voluntarily and without mental struggle
-and nervous strain reduces the amount of drug used. I wish to emphasize
-that in these experimental cases there were no other therapeutic
-measures employed in the way of medication.</p>
-
-<p>The practical therapeutic application of wide-interval administration
-of opiate drug is made possible by the fact that the narcotic addict
-can tolerate without harm large doses of the drug of addiction. It is
-made controllable by the fact, that, within certain limits, the length
-of time over which a dose of narcotic drug will maintain a patient in
-narcotic drug balance—or free from the symptomatology of drug need—is
-in mathematical ratio to the size of the dose administered. Each addict
-requires, under the conditions of his daily life at a given time, to
-satisfy the demands of his physical addiction-disease mechanism, and
-to maintain him in narcotic drug balance, an amount of drug which can
-be estimated in terms of twenty-four hours and which I have called the
-amount of minimum daily need. The most important consideration in the
-administration of narcotic drug to a narcotic addict is to supply the
-amount of minimum daily need and maintain narcotic drug balance with
-the least inhibition of function.</p>
-
-<p>Failure to maintain narcotic drug balance and a degree below the amount
-of minimum daily need renders the addict functionally and physically
-incompetent. He is in a condition of physical and nerve incapacity
-and exhaustion. He has no physical tone; he has markedly impaired
-circulation; he cannot react, he has no recuperative powers; he has
-constantly in his body, according to modern<span class="pagenum" id="Page_67">[Pg 67]</span> theory, unneutralized
-autogenous poison which robs him of vitality, reaction and functional
-efficiency even though it may not be present in sufficient amounts
-to give rise to the violent spectacular and agonizing manifestations
-of complete narcotic deprivation. In other words, as I have written
-elsewhere, “the reduction of the drug of addiction below the amount
-of body-need robs the addict of his most valuable asset in securing
-and maintaining recuperative powers.” In no other disease would an
-intelligent physician persist in the application of measures which
-robbed his patient of recuperative powers and expect satisfactory issue
-of the case he was trying to treat. Until the physician and patient are
-ready and prepared for the institution of the stage of final withdrawal
-of drug, the patient should never be allowed to drop below the amount
-of minimum daily need in his opiate intake.</p>
-
-<p>It is evident therefore, that upon the intelligent and competent
-estimation, measure and control of physical narcotic drug balance and
-inhibition of function depend the reaction, well being and therapeutic
-progress of the man who has narcotic drug addiction-disease. These
-factors also markedly influence the action of all medication,
-including the drug of addiction, upon the body of the opiate addict.
-They influence the reaction of the addict’s body to all medication.
-Medication cannot be intelligently administered to the opiate addict
-unless those who administer it have understanding and clinical
-appreciation of the widely varying reaction of the addict under
-different conditions of drug balance and inhibition of function.
-Failure to recognize and appreciate this fact explains a considerable
-portion of the past failures and the past mortality attending specific
-and special methods and treatments, and so-called “cures.” The dosage
-of medication administered and the time of its administration should
-therefore be determined upon with watchful eye to<span class="pagenum" id="Page_68">[Pg 68]</span> the reaction of the
-patient, and with intelligent comprehension of the possibilities in
-reactionary change.</p>
-
-<p>The actions and the dosage of therapeutic agents have been largely
-determined by experimentation on individuals and animals of average
-normal reaction. The toxic, the inhibited and the narcotic addicted
-do not display the normal reaction to therapeutic agents. Under some
-conditions they over-react both physically and nervously, and under
-other conditions they under-react. Detailed consideration of this
-matter is not possible in this book. It offers for investigation a
-field well worthy of exploration both clinical and laboratory. It
-will only state that as the manifestations and influences of toxemia,
-functional exhaustion, inhibition, and, in the addicted, of varying
-physical drug balance, have become increasingly definite and tangible
-and capable of clinical measure and determination, my medication of the
-toxic and the exhausted and the inhibited individual, as well as of
-the narcotic addicted, has become progressively more effective. These
-observations apply to conditions other than opiate drug addiction, and
-are worthy of consideration in all toxic, and exhaustion and depression
-states.</p>
-
-<p>I have already spoken of the imperative physical need for the drug of
-addiction. I have also referred to the amount of minimum daily need for
-the drug of addiction. The recognition of factors which influence these
-is of great importance. Many of these factors are so commonplace and
-so obvious in their relation to the extent of body need that they are
-appreciated by most intelligent addicts. Anything which increases the
-expenditure of physical and nervous energy increases the addict’s need
-for opiate drug. Among the most potent influences are worry, fear and
-physical suffering. They consume physical fuel; and an important part
-of the addict’s physical fuel is the drug of his addiction. In addition
-to this, worry and fear and suffering are also markedly inhibitory
-of glandular and<span class="pagenum" id="Page_69">[Pg 69]</span> peristaltic function. The expenditure of energy in
-mental and muscular work also calls for increased supply of the drug of
-addiction. I need not enlarge upon this important fact. Its application
-to the handling and treatment of the addict is evident. Narcotic drug
-should be supplied to meet the physical needs of the individual case,
-and only be decreased as intelligent handling of the factors which
-determine that need have lessened it.</p>
-
-<p>The method of gradual reduction of dose to the point of ultimate
-discontinuance is practical and feasible under conditions and at an
-expense of time and money which are possible to but very few addicts.
-The forcible reduction of dose without regard to the environmental,
-mental, economic, physical or other conditions of the average and
-individual addict, and absolutely ignoring the considerations of the
-mechanism and symptomatology of his addiction-disease is barbarous,
-harmful and futile. Enforced reduction of dose below the point of
-body need is not worth what it costs in nerve-strain, suffering, and
-physical inadequacy. The extent of addiction-disease and the degree of
-progress in its remedy cannot be measured in terms of amount of drug
-administered. It must be measured in terms of clinical symptomatology,
-just as progress is measured in any other disease. Reduction of dose
-below the amount of body need, prior to the stage of final withdrawal,
-constitutes a serious therapeutic handicap and is most decidedly
-contra-indicated. Withdrawal of opiate from an addict whose physical
-reaction and strength and nerve force have been reduced and depleted by
-continued reduction of amount of drug without commensurate reduction
-in the extent of body need is harder than withdrawal from a reactive
-individual with reserve nerve and physical force who may be taking a
-much larger dose.</p>
-
-<p>The average addict must support himself and his family. His physical
-well-being and economic efficiency should be considerations in
-the welfare of the community in which<span class="pagenum" id="Page_70">[Pg 70]</span> he lives. Legislative and
-other investigation has shown that we are entirely unequipped both
-institutionally and professionally for the successful immediate
-withdrawal of opiate from even a small proportion of our present
-census of the opiate addicted. In view therefore, of the practical
-impossibility of immediate successful withdrawal treatment, and in
-view of what is known and can be demonstrated and taught in the
-accomplishment of final withdrawal, I do not hesitate to state that,
-until we are prepared and in a position to skillfully and competently
-handle the stage of final withdrawal to assured successful issue, it
-is much wiser to supply to the addict who is not a public menace the
-drug of his addiction to the extent of his physical needs, and to teach
-him how to use the drug of addiction in such a way as will maintain
-his physical and economic efficiency, than it is by enforced reduction
-of dose to deprive him for a long time of working ability and his
-family of his support. Furthermore, the addict who is insufficiently
-supplied with the opiate of his addiction, turns in desperation to the
-use of things far more harmful to him than the drug of his addiction.
-This he does in the vain hope of obtaining mental and nervous and
-physical stimulus and support and some surcease of his misery. The
-many wrecks of addicts to be seen trying through insufficient supply
-of narcotic drug, self-poisoned with other drugs which they have
-purchased, alcohol, bromides, coal tar products, cocaine, and of late
-hyoscine—their addiction disease unrelieved and undiminished—are
-sufficient argument against mere reduction of dose, below physical body
-need.</p>
-
-<p>The personal attitude of the physician towards opiate addicted patients
-is of great importance. The medical man who is to treat a case
-suffering from addiction-disease successfully to the end of relieving
-this condition, or who is treating addiction-disease as an intercurrent
-condition complicating another disease, must first of all make<span class="pagenum" id="Page_71">[Pg 71]</span> his
-patient realize that the physician himself knows something about
-addiction as a disease. He must never give his patient any hint or
-reason to suspect that he regards opiate addiction as a habit, a vice,
-a degrading indulgence which can be to any curative or even therapeutic
-extent, combatted by the exercise of will-power.</p>
-
-<p>In their desperation and ignorance, the vast majority of addicts
-have repeatedly exercised will-power in self-denial of their drug to
-the limits of their physical endurance, and they know the futility
-and suffering of attempts based simply and solely upon the exercise
-of will-power. Experience has taught them actual facts concerning
-the physical action of narcotic drugs and concerning the results of
-insufficient supply of narcotic drug in a man who is addicted. The
-addict knows that he does not take a drug because he enjoys it. He
-knows that he experiences no sensuous gratification or other pleasure
-from its administration. He knows that he uses a narcotic drug simply
-and solely because he has to use it to escape physical incompetence and
-physical agony. As I said before, almost without exception the narcotic
-addict has proceeded of his own accord, or under the direction and
-advice of others, on the theory of exercising will power, and resisting
-temptation. With the few exceptions of those made in a very early stage
-and before addiction mechanism had become strongly developed and rooted
-in his physical processes, such efforts on the basis of this theory
-have been useless.</p>
-
-<p>It is practically impossible to argue successfully on the basis of
-theory with the man who has experienced facts. Narcotic addiction
-furnishes a class of patients who know more about their own disease
-than any other class of people. They can accurately estimate the extent
-of understanding and knowledge possessed by the man who is treating
-them, and they are desperately critical. Almost without exception,
-except for some of the true “underworld,”<span class="pagenum" id="Page_72">[Pg 72]</span> they desire above all else
-to escape from their condition. I know that this is not the popular
-conception and for the present may be by some regarded as heresy.
-Therefore, it is of essential importance that between the doctor who
-treats an addict of average intelligence and that addict must exist
-co-operation and understanding. As soon as this patient realizes two
-things—that the doctor does not believe his expressed wish to be
-cured, and that he interprets the patient’s desire for relief from
-suffering as simply a desire for more opiate and the expression of
-habit, vice or degraded appetite which should be controlled by the
-exercise of “will-power,”—there is an end to that patient’s confidence
-in that doctor, and to the help that that doctor can give to that
-patient. As I have written elsewhere, the opiate addict of average
-intelligence will co-operate with his medical adviser to the extent of
-his physical endurance, so long as he has any belief in that adviser’s
-understanding of his condition, and ability to help him.</p>
-
-<p>In my own work, and as a result of my own experience I have found
-that as a rule the extent to which an intelligent addiction patient
-cooperates with me has been a measure of the understanding and
-technical ability with which I handled him, rather than a measure
-of his desire to be helped. It is held by many that a majority of
-addiction-patients are not possessed of average intelligence and are
-not honest in their statements. I will simply say that even in the
-Alcoholic and Prison Wards of Bellevue and in the narcotic wards
-of the New York Workhouse Hospital I came more and more to seek in
-faults of medical and nursing handling the explanation of apparent
-lack of cooperation. In the Annual Report of the New York Department
-of Correction for 1915, in commenting upon the work of the narcotic
-wards, is stated, “In ratio as there has been at any given time
-among our interne and nursing staff comprehension and understanding
-of the manifestations<span class="pagenum" id="Page_73">[Pg 73]</span> and underlying principles of narcotic drug
-addiction-disease and of its rational handling in the individual case,
-our results have been good or bad.”</p>
-
-<p>Several years ago I wrote as follows: “As to the existing opinion that
-the morphinist does not want to be cured and that while under treatment
-he cannot be trusted and will not cooperate but will secretly secure
-and use his drug, I can only quote from personal experience with these
-cases. During my early attempts, 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 upon their supposed weakness of will and lack of determination
-to get rid of their malady. Later I realized the fact that the blame
-rested entirely upon the shoulders of my medical inefficiency and my
-lack of understanding and ability to observe and interpret my patient’s
-condition. The morphinist as a rule will cooperate and will suffer
-to the limit of his endurance. Demanding cooperation of a case of
-morphinism during and following incompetent withdrawal of the drug is
-much like asking a man to cooperate for an indefinite period in his
-own torture. There is a limit to every one’s power of endurance of
-suffering.”</p>
-
-<p>Of primary importance, then, if a physician, institutional or
-practitioner, is to have any success in handling a case of opiate
-addiction-disease, is his attitude towards his patient—divesting
-himself of all conception of habit, appetite or vice as explanation
-of characteristic physical manifestations and symptomatology, and
-approaching the patient as a man with a definite disease requiring and
-deserving intelligent clinical handling. The patient will be the very
-first to mark a physician’s shortcomings. If he has not confidence in
-the doctor’s ability and understanding of his illness the doctor can
-help him but little. This statement applies not to addiction-disease
-alone but to every medical condition.</p>
-
-<p><span class="pagenum" id="Page_74">[Pg 74]</span></p>
-
-<p>There are three clinical demonstrable elements to be determined,
-measured and controlled in the actual therapeutic handling of cases of
-narcotic addiction-disease. The first of these is the actual amount
-of drug which the patient’s body demands to maintain functional and
-organic efficiency and to escape physical distress. The second of these
-is the extent of auto- and intestinal-intoxication, autotoxicosis
-and malnutrition. The third of these, which is both a result of and
-a causative element in the other two, is the extent of inhibition of
-function.</p>
-
-<p>In the successful handling of a case of addiction-disease, therefore,
-the first effort should be to determine approximately the amount of the
-patient’s minimum daily physical need for the drug of his addiction.
-This need is clinically recognizable and definitely measurable. It
-should be met to whatever extent it is present so long as it exists,
-and dosage diminished only as competent treatment diminishes the extent
-of need. This physical need can be demonstrated and accurately measured
-by clean-cut symptomatology. It can be expressed in mathematical
-terms of amounts of drug required in twenty-four hours. Work, worry,
-strain—anything which consumes physical or nervous energy increases
-this need. If this physical need is not met the patient is robbed of
-physical tone and physical reaction. He is robbed of metabolic balance
-and functional competency. He is, in short, robbed of the basic ability
-which his body has to regain health.</p>
-
-<p>In the estimation of this amount of physical need the procedure is
-very simple. Have administered to the patient who is manifesting the
-symptomatology of drug-need, sufficient drug to remove the symptoms
-and restore him to complete physical, functional and nerve balance.
-Have the length of time observed which elapses before the symptoms of
-drug need reappear. Have this repeated several times and information
-is secured as to what quantity of opiate under the existing conditions
-will hold that<span class="pagenum" id="Page_75">[Pg 75]</span> patient in drug-balance for a known length of time.
-In this way can be mathematically estimated the extent of physical
-drug-need. The average need for twenty-four hours can be easily
-computed from the data obtained. It is merely a matter of arithmetic.</p>
-
-<p>The regulation of dosage can also be estimated with approximate
-accuracy. As has been stated before, the interval of freedom from
-withdrawal manifestations is found to be, in a general way and within
-certain limits, in ratio to the size of the dosage. For example, if
-in a given case, under given conditions of fear, worry, physical or
-nervous strain, pain, etc., as discussed elsewhere—one grain of
-morphine will last a given patient at a given time for four hours;
-under the same conditions two grains will last for approximately eight
-hours. There are limits to the application of this rule. It is stated
-as the general operating of an addiction-disease phenomenon which is
-useful as a therapeutic guide.</p>
-
-<p>The amount of actual physical body need as capable of approximate
-estimation in the above manner should be administered to the patient,
-any reduction being guided by the fact that his clinical symptomatology
-and physical manifestations demonstrate that the amount required by his
-addiction-disease has been reduced. It is much wiser for the progress
-of the average addiction case to have the drug administered in the
-amount of estimated physical need than it is to attempt to reduce
-the amount of drug before his reactions show reduction in physical
-drug-need. The success of outcome and the measure of progress in
-such a case is not to be estimated by the amount of drug the patient
-is receiving, but is to be measured by the patient’s condition and
-clinical manifestations. The mere fact that a physician has reduced a
-narcotic addict’s opiate intake from a large dosage to a very small
-dosage, or indeed has denied him any opiate at all for a considerable
-length of time, is no evidence that he is curing or<span class="pagenum" id="Page_76">[Pg 76]</span> has cured his
-patient of addiction-disease. Unless the physical mechanism of
-body-need for an opiate has been completely and actually quieted, the
-patient may have in his body for perhaps weeks and months after the
-last administration of the drug, a physical demand for it. <em>The
-taking of opiate does not constitute opiate addiction-disease</em>.
-Also the mere fact that an addict is no longer taking opiate does
-not constitute proof that he is “cured” of opiate addiction. The
-non-recognition of this fact lies at the root of much past failure. The
-general axiomatic statement might be that an addict should be supplied
-with the drug of his addiction to the complete extent of his physical
-need at any given time until conditions are right for the undertaking
-of assuredly competent opiate withdrawal and complete arrest of his
-addiction-disease mechanism.</p>
-
-<p>The mere amount of drug used by a patient in twenty-four hours is
-a matter of minor importance compared with the general health,
-physical tone, nervous glandular and functional balance, reaction
-and resistance of that patient. Also the amount of drug taken by a
-patient in twenty-four hours is absolutely no adequate measure of the
-strength or stage of development of his addiction-disease. If he does
-not get enough opiate he cannot competently functionate; he cannot be
-adequately nourished; he cannot sufficiently eliminate. He is subjected
-to the influences of constant discomfort and nerve strain in the
-endurance of low-grade withdrawal manifestations. He is worried and
-becoming exhausted. It becomes apparent that by continued maintenance
-of narcotic administration below the amount of physical body-drug-need
-the very factors are created which have been described as increasing
-body-drug-need. It is difficult to see any therapeutic advantage in
-such a situation. Moreover, as has been stated before, it is far easier
-to eradicate completely and successfully<span class="pagenum" id="Page_77">[Pg 77]</span> narcotic drug need in a short
-time and without marked discomfort, from a functionally competent and
-organically healthy man who is taking a physically sufficient amount,
-than it is from a nerve-racked, worried and physically, nervously, and
-functionally exhausted wreck who is under-dosed.</p>
-
-<p>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.</p>
-
-<p>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<span class="pagenum" id="Page_78">[Pg 78]</span> large doses at wide intervals permit greatest freedom from
-functional inhibition and as well, if not better, supply the demands of
-physical drug need.</p>
-
-<p>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 <em>per se</em>. 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.</p>
-
-<p>The control of auto and intestinal intoxication in narcotic<span class="pagenum" id="Page_79">[Pg 79]</span> 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.</p>
-
-<p>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.<span class="pagenum" id="Page_80">[Pg 80]</span> 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.</p>
-
-<p>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.</p>
-
-<p>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<span class="pagenum" id="Page_81">[Pg 81]</span> 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.</p>
-
-<p>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.</p>
-
-<p>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<span class="pagenum" id="Page_82">[Pg 82]</span> 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.</p>
-
-<p>As to final withdrawal of the drug, and ultimate arrest of the disease,
-I shall say but little in this book.</p>
-
-<p>I follow no “routine” and have no set procedure. I am guided, as in my
-handling of the other stages of addiction-disease, by the condition of
-my patient and his clinical requirements. There is no one procedure
-applicable to all cases of any condition in medicine and surgery. In
-narcotic addiction-disease, as in all other conditions of medicine
-and surgery, the man who will have the best results is the man who
-is possessed of the widest and most varied experience combined with
-intelligent observation, technical skill and clinical judgment in the
-selection of procedure best adapted to the needs of the individual
-case. Familiarity and experience with different methods and procedures
-reveals in each and nearly all of them some advantages and some
-defects. The wise man and the man whose results will most approach
-uniform success is he who can make intelligent selection and use of
-whatever is most applicable to the needs of the case he treats, either
-out of his own experience and discoveries, or out of his familiarity
-with the work of others.</p>
-
-<p>An element in successful withdrawal of narcotic must also remain, as
-in everything else, the inherent personal gifts and qualifications of
-the individual operator. A man works best with the tools most adapted
-to his hand, and operators of different temperaments and of different
-experience and training will always disagree on points of procedure and
-technique. My own procedure in final withdrawal is determined largely
-by my study and measure of my patient and my patient’s reactions,
-addiction and otherwise, during my preliminary or preparatory work,<span class="pagenum" id="Page_83">[Pg 83]</span>
-selecting the time for final withdrawal of drug by consideration of
-similar factors as would be taken into account in an operation of
-election.</p>
-
-<p>After a preliminary stage, or stage of preparation, in which I have
-gotten rid of all possible abnormalities, physical and psychical, with
-my patient robust and reactive, confident and expectantly happy, with
-autointoxication, and inhibition removed and the possible residues of
-opiate or opiate product no longer stored in atonic body cells—the
-addiction-mechanism, therefore, only kept in activity by the current
-intake of opiate, which if properly handled and the patient not
-subjected to exhausting strain and struggle and suffering, can be
-eliminated in a very short time. With these conditions consummated,
-I hasten elimination, keeping well away from exhausting purgation,
-maintaining my patient’s circulatory and other functions, and
-conducting as rapid a withdrawal as is compatible with my patient’s
-reactive condition and the reactions of his disease.</p>
-
-<p>In other words, I endeavor by my conduct of the case to reverse the
-process of development of the physical addiction-disease with its
-concomitants and complications, as I find it in the individual case,
-arresting the addiction-disease mechanism only after I have cleared the
-clinical picture in so far as possible of all other considerations.</p>
-
-<p>In a majority of cases by experienced choice of clinical procedure,
-combined with judgment and technical skill, the arrest of
-addiction-mechanism and the restoration of the narcotic addict to
-health and freedom from both opiate need and thought of opiate drug is
-a matter of assured accomplishment attended by little if any nervous
-strain and physical suffering.</p>
-
-<p>Ability to accomplish this is not beyond the power or any competent
-practitioner, whether he reside in a hospital or is in private
-practice. All that is required is instruction<span class="pagenum" id="Page_84">[Pg 84]</span> or information as to
-the mechanism of addiction-disease, clinical demonstration of its
-manifestations and reactions and the same amount of experience in their
-handling as is expected of a man who treats any other disease.</p>
-
-<p>I have purposely refrained in this book from discussion of technical
-details of therapeutic procedures, and of various medications, and of
-their various indications, contraindications, applications, dosage,
-etc. Such discussion, to be adequate and competent, would require much
-space and would distract from the general presentation of the problem,
-which is the purpose of this volume.</p>
-
-<p>I have learned from experience in teaching and in treatment of cases
-that before there has been established appreciation of the whole
-personal and clinical problem and picture, and conception of its
-disease mechanism, and ability clinically to recognize and interpret
-symptomatology, discussion of technical details is premature and
-misleading.</p>
-<hr class="chap x-ebookmaker-drop" />
-
-<div class="chapter">
-<p><span class="pagenum" id="Page_85">[Pg 85]</span></p>
-
-<h2 class="nobreak" id="CHAPTER_VII">CHAPTER VII<br /><span class="small">RELATION OF NARCOTIC DRUG ADDICTION TO SURGICAL CASES AND INTERCURRENT
-DISEASES</span></h2>
-</div>
-
-
-<p>It is a common idea in the minds of both surgeons and physicians that
-an addict to narcotic drug is a difficult case for surgical handling
-and is a poor surgical risk. Numerous instances of surgeons refusing to
-operate upon a narcotic addict until the addict should have “stopped”
-the use of the drug, voice the almost prevailing attitude.</p>
-
-<p>Very many, if not most, internists and practitioners view with gravest
-concern the presence of addiction in a serious illness coming under
-their care.</p>
-
-<p>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.</p>
-
-<p>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<span class="pagenum" id="Page_86">[Pg 86]</span> 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.</p>
-
-<p>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.</p>
-
-<p>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<span class="pagenum" id="Page_87">[Pg 87]</span>
-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.</p>
-
-<p>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.</p>
-
-<p>The last dose of morphine prior to these tracings was one-eighth of a
-grain given at 3:30 <span class="allsmcap">P. M.</span></p>
-
-<p class="center p2"><span class="figcenter"  id="img002">
-<img src="images/002.jpg" class="w50"  alt="Chart of Sphygmographic Tracings" />
-</span></p>
-<p class="center caption">(Chart of Sphygmographic Tracings)<br /></p>
-
-<p>First tracing (number 1) was made about 6:00 <span class="allsmcap">P. M.</span></p>
-
-<p>Tracings 2, 3 and 4 were made at about fifteen minute<span class="pagenum" id="Page_89">[Pg 89]</span> intervals. They
-were made following experimental hypodermic injections of morphine
-sulphate to determine the extent of opiate need and organic dependence
-upon opiate medication, and the amount of opiate required to restore
-organic function and tone.</p>
-
-<p>Tracing number 4, taking into consideration the asthenic and exhaustion
-condition of the patient, shows full support to circulation with some
-overaction.</p>
-
-<p>Tracing number 5 was taken an hour or two after tracing number 4 to
-determine the holding power of the dosage administered, after the
-circulation had reacted from the immediate stimulation of the opiate
-medication. This tracing, interpreted and considered together with the
-clinical manifestations at the time, was decided to be about normal for
-that patient at that time.</p>
-
-<p>This patient would have died, not from pneumonia with cardiac
-complications, but from insufficient control of the mechanism of opiate
-addiction-disease.</p>
-
-<p>On balanced and indicated daily morphine dosage, patient made very
-rapid recovery and has continued well and active.</p>
-
-<p>Such cases as this, where addiction-disease co-exists or is
-intercurrent with other medical or with surgical conditions, are not
-as uncommon as may be supposed. That they are frequently unrecognized
-the histories of many narcotic addicts demonstrates, and is discussed
-later. Board of Health and Insurance mortality statistics are
-undoubtedly very incomplete upon this situation. Addiction, regarded
-as a habit or indulgence, may easily be overlooked or disregarded as
-a cause of death, direct or contributing. It may easily be omitted
-from returns made out, however actually important a part in the final
-issue may have been played by the influences, upon body function and
-upon physical resistance and recuperation, of an unappreciated and
-inadequately controlled addiction-disease.</p>
-
-<p><span class="pagenum" id="Page_90">[Pg 90]</span></p>
-
-<p>It is earlier stated that the common idea of the addict to narcotic
-drugs as a poor risk is an undeserved reputation, and is not to be
-laid at the door of addiction existence itself. In very many cases
-of opiate addiction, the opposite of the popular belief is true. The
-opiate addict, if his addiction mechanism is competently appreciated,
-its reactions accurately estimated, and its influences wisely
-controlled, is quite other than a bad risk. Indeed the mechanism of
-addiction and the opiate which caused it can often be handled in such
-a way in the control of glandular, circulatory, nervous and other
-function and reaction as to aid in the carrying over of emergencies,
-medical and surgical. A case in point is an emergency operation on the
-pancreas, performed upon a man in extremis, whose unexpected recovery
-and convalescence astonished all observers by being remarkedly rapid
-and uncomplicated, due unquestionably in large part to the early
-recognition and clinical handling of his addiction-disease, and the
-possibilities it created for unusual opiate medication.</p>
-
-<p>It has been my experience at times, when called in medical consultation
-upon post-operative cases whose lack of repair and slowness of recovery
-could not be accounted for, to discover an unsuspected addiction, and
-to find that the lack of repair and slowness of recovery was due simply
-and slowly to the want of comprehension of, or to inadequate control of
-addiction mechanism existing in the patient.</p>
-
-<p>Many opiate addicts when about to undergo operation, have provided
-for possible contingencies by the concealment of, or by outside
-provision for, a supply of opiate sufficient in amount to meet their
-physical needs. There are very many addicts who have, out of their
-past experience and study upon themselves, competently controlled
-their own narcotic-drug-disease during treatment for other conditions,
-operative or medical. The number of narcotic addicts is not few
-who have been cared for<span class="pagenum" id="Page_91">[Pg 91]</span> medically with nursing attention, or have
-undergone operations for the remedy of various surgical conditions,
-have recovered, convalesced and been discharged without the physician
-or surgeon becoming aware that his patient was addicted. This is
-not a comment in criticism upon my professional brethren. In my
-own experience such a case is a matter of quite recent occurrence.
-A patient treated by me in a hospital, for conditions other than
-addiction, one day unexpectedly revealed to me the fact of long
-standing addiction. The patient had been afraid to tell me about this
-condition until thoroughly convinced of my attitude towards it, and had
-secured opiate medication elsewhere.</p>
-
-<p>It seems strange that a condition of as powerful influence over body
-function and metabolism as is exerted by the addiction mechanism of
-narcotic drug-disease should not long ago have received exhaustive
-and complete clinical and laboratory study along the lines of its
-manifestations and influences, as well as along the line of reduction
-and deprivation of the drug of addiction. In view of the above it would
-seem to be of vastly more importance at the present time that the mass
-of practitioners of surgery as well as of medicine should understand
-and be able to control action and reaction in a narcotic addict as a
-result of his addiction-disease mechanism, than it is that they should
-attempt the mere reduction or denial of the drug of addiction.</p>
-
-<p>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<span class="pagenum" id="Page_92">[Pg 92]</span> 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.</p>
-
-<p>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.</p>
-
-<p>The establishing and maintaining of adequate drug balance, therefore,
-is one of the most important elements to<span class="pagenum" id="Page_93">[Pg 93]</span> 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.</p>
-
-<p>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.</p>
-
-<p>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<span class="pagenum" id="Page_94">[Pg 94]</span> 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.</p>
-<hr class="chap x-ebookmaker-drop" />
-
-<div class="chapter">
-<p><span class="pagenum" id="Page_95">[Pg 95]</span></p>
-
-<h2 class="nobreak" id="CHAPTER_VIII">CHAPTER VIII<br /><span class="small">LAWS, AND THEIR RELATIONS TO NARCOTIC DRUGS</span></h2>
-</div>
-
-
-
-<p>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.</p>
-
-<p>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.</p>
-
-<p><span class="pagenum" id="Page_96">[Pg 96]</span></p>
-
-<p>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.</p>
-
-<p>In the minds of most lay and of many medical workers the only
-consideration was the stopping of drug use <em>per se</em>, 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.</p>
-
-<p>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<span class="pagenum" id="Page_97">[Pg 97]</span> 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.</p>
-
-<p>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.</p>
-
-<p>That these sick people have been commonly regarded<span class="pagenum" id="Page_98">[Pg 98]</span> 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.</p>
-
-<p>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.”</p>
-
-<p>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<span class="pagenum" id="Page_99">[Pg 99]</span> 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<span class="pagenum" id="Page_100">[Pg 100]</span> 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.</p>
-
-<p>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.</p>
-
-<p>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.</p>
-
-<p>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<span class="pagenum" id="Page_101">[Pg 101]</span> 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.</p>
-
-<p>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<span class="pagenum" id="Page_102">[Pg 102]</span> 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.</p>
-
-<p>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<span class="pagenum" id="Page_103">[Pg 103]</span> belongs. And this is where the
-medical profession would have it placed in so far as the medical
-profession supplies narcotic drugs.</p>
-
-<p>The honest physician has no desire to dodge responsibility for his
-handling of narcotic addicts to the best of his ability, nor should he
-have any objection to a reasonable responsibility and accounting for
-narcotic drugs used in that handling; especially since the taking of
-narcotic drugs has in certain of its phases, developed as a serious
-situation entirely outside of the medical profession, in which
-situation these drugs are non-professionally supplied and used to such
-an extent as to constitute a public menace. The non-medical supplying
-and administering of such drugs should not, however, be controlled
-in such a way as to unduly hamper their honest and legitimate use by
-medical men, and to deprive the honest, worthy and innocent sufferer
-from addiction-disease of their legitimate therapeutic administration.</p>
-
-<p>One of the chief and most serious phases of the narcotic drug problem,
-which for obvious reasons has especially called for legislation, is
-the illicit and illegitimate commerce in narcotic drugs. The class
-of addicts which constitutes a public menace is largely so supplied.
-This fact is recognized in the recent report of the Special Committee
-of Investigation Appointed by the Secretary of the Treasury, in which
-is stated, “This illegitimate traffic has developed to enormous
-proportions in recent years, and is a serious menace at the present
-time. It is through these channels that the addict of the underworld
-now secures the bulk of his supplies.”</p>
-
-<p>This Report further states that “there is the so-called ‘underground’
-traffic which is estimated to be equal in magnitude to that carried
-on through legitimate channels. This trade is in the hands of the
-so-called ‘Dope peddlers,’ who appear to have a national organization
-for procuring and disposing of their supplies. For the most<span class="pagenum" id="Page_104">[Pg 104]</span> part it is
-thought that they obtain their supplies by smuggling them from Mexico
-or Canada, although smaller quantities of these drugs are obtained from
-unscrupulous dealers in this country or by theft,” etc. There should
-be some way to dissociate entirely, conclusively and finally in the
-minds of the public the illegitimate and underworld traffic in narcotic
-drugs from the efforts of the honest physician to practice rational and
-scientific medicine in the help of the worthy and deserving addict.
-The regulation of the narcotic drug traffic of the underworld or
-“underground” is not the business of the medical profession, and the
-burden of responsibility for it should not be placed upon the shoulders
-of the medical profession or the consequences of it made to react upon
-the head of the honest physician and innocent addiction sufferer. There
-is a tremendous number of excellent and worthy and even illustrious
-people in whom addiction is in no way associated with vice, or other
-morbidity of mental or environmental origin, who are merely, solely
-and simply sick people suffering from addiction-disease, whose problem
-is the control of that disease until it can be arrested by competent
-therapeutic procedure, for which they constantly seek. Misconception
-of them and neglect of sufficient consideration of them is the tragic
-aspect of the narcotic drug situation, and causes tremendous individual
-and economic wastage. They do not in any way associate with underground
-traffic unless or until driven to it by failure of legitimate sources
-of opiate medication, or by the surrounding of legitimate sources with
-such restrictions as make the man of standing and reputation, afflicted
-with addiction-disease, fear possible publicity and economic detriment.</p>
-
-<p>It is the duty of the medical organizations to see to it that these
-deserving purely medical problems and worthy sick people and their
-honest medical advisers shall no longer than avoidable be permitted
-to remain confused<span class="pagenum" id="Page_105">[Pg 105]</span> in the minds of the laity and of the medical
-profession itself with the problems of regulation of “underground”
-traffic and the control of the “underworld” addict. It is the duty of
-the medical organizations also to see to it that in the public press
-and elsewhere, and especially in their own scientific journals, the
-acts of the occasional individual with medical degree who prostitutes
-his medical standing and the aims and ideals of his profession in the
-commercial exploitation of the drug addict are not presented in such
-a way as to cause by inference or otherwise, their confusion with the
-honest efforts of honest medical men who are engaged to the best of
-their ability in the humane and ethical help of the deserving sufferer
-from addiction-disease.</p>
-
-<p>It is, furthermore, the duty of the medical organizations to see to it
-that whatever laws and regulations are promulgated in the control of
-criminal and unworthy shall not be framed or administered in such a
-way as to unnecessarily jeopardize the reputation and liberties of the
-honest practitioner and to interfere with his conscientious efforts to
-care for his honest and innocent addiction-disease patients to such an
-extent as makes that care impossible.</p>
-
-<p>Legislation or administrative regulation which limits to responsible
-and authorized persons possession and distribution of narcotic drugs
-and which compels from such persons reasonable accounting for such
-possession and distribution, is under conditions which have long
-existed but only recently been sufficiently recognized necessary and
-desirable. The Harrison Law was a definite response to an obvious
-need, in its obvious intent and draughting a wise and unobjectionable
-legislation. It provided for responsible possession and distribution
-and it enforced an accounting for the same, but did not unwisely
-restrict, in its text, nor hamper the legitimate possession and
-honest therapeutic employment of narcotic drugs. From the<span class="pagenum" id="Page_106">[Pg 106]</span> medical
-organizations and educational and scientific institutions should
-be available scientific study and understanding of narcotic drug
-addiction-disease available for the information of conscientious
-executives and administrators, who must exercise their best judgment
-in the light of available and prevailing teaching. It is the duty of
-the medical organizations to see to it that available and prevailing
-addiction-disease information and teaching is honest, unbiased and
-competent.</p>
-
-<p>Those who are responsible for our laws should remember that the
-possible interpretation and administration of the laws they draught are
-very important considerations, and determine the real effect of the
-laws often more than does the intent of the makers. Legislation which
-is unduly stringent or is capable of unduly stringent administration
-may have unfortunate reaction and influence upon honest effort in
-the care of the deserving sick. Restricting beyond reasonable limits
-the care of the honest narcotic drug addict simply tends to make
-it impracticable and dangerous for the average medical man to have
-anything to do with narcotic addicts, and to drive the honest and
-deserving patient into the underworld, into the insane asylum or to
-suicide. Until we have provided scientific and clinical study, and
-have thoroughly investigated present and possible medical treatment
-and handling of narcotic-drug addiction-disease, and have established
-humane and effective therapeutic measures and procedures in the control
-and remedy of this disease, we should not deprive the majority of
-honest addicts of the only medication and means by which they can at
-present remain self-supporting citizens. The handling of the problem
-of the underworld and of underground supply is not going to be solved
-by too restrictive regulation of the honest physician. Legislation
-or regulation which makes it practically impossible for the honest
-physician to care for the honest case of<span class="pagenum" id="Page_107">[Pg 107]</span> addiction-disease is a boon
-to charlatans, and medical shysters, and the illicit underworld traffic.</p>
-
-<p>It is the opinion of some that the handling and treatment of narcotic
-addiction should be taken out of the hands of the practitioner of
-medicine. The statement is made that the practitioner of medicine is
-not competent to handle a case of this disease. It has been advised
-that the treatment of narcotic addicts should be restricted to a small
-number of specially designated and licensed men and institutions. How
-and by whom are those special men and institutions to be selected?
-In the present state of chaotic and widely diversified medical and
-lay opinion as to narcotic addiction and the narcotic addict it would
-be a very difficult matter to select the men or the institutions for
-such absolute control. The comprehension, study and investigation
-of narcotic drug addiction has entered a stage of evolution and
-development in which new facts and new truths—both as to the addict
-and as to the condition from which he suffers—are being recognized
-and must be threshed out, correlated and coordinated with hitherto
-existing opinion before too restrictive measures will be anything but
-narrow-visioned, premature and harmful.</p>
-
-<p>There are undoubtedly institutions, many of them not widely known,
-in which is available skillful, humane, intelligent and successful
-handling of this disease. From personal observation and experience
-in institutional work, and from analysis and investigation of many
-histories, it is my opinion that the results of institutional treatment
-depend more upon the quality of its medical and nursing staff than upon
-any other consideration. That the mere fact that addiction-disease is
-handled in an institution is a very minor consideration in comparison
-with the intelligence of that handling, is amply attested to in the
-testimony of the Whitney Hearings and by the experience of many
-addicts. Unquestionably, unknown and large<span class="pagenum" id="Page_108">[Pg 108]</span> numbers of narcotic addicts
-have been relieved of their addiction in reputable sanitaria conducted
-by skillful and competent medical men. Also unquestionably, large
-numbers of addicts have been relieved of their addiction through the
-honest efforts of practitioners of medicine, in private practice.
-Unfortunately these efforts and their results have received entirely
-too little recognition.</p>
-
-<p>The average physician may be inexpert and not as completely educated
-in the appreciation, understanding and clinical handling of narcotic
-drug addiction-disease as he is in other diseases. The common-sense
-remedy for this situation, however, is not to drive the addict out of
-his hands, but to make him as competent in that addict’s handling as
-he is in any other clinical condition. It is only a matter of time
-and education before the competent practitioner of internal medicine
-can be brought to a comprehension of and ability to intelligently
-handle addiction-disease. It is largely a matter of securing general
-appreciation of and ability to clinically recognize, and interpret
-physical symptomatology, and to meet the indications of individual
-disease manifestations.</p>
-
-<p>The ultimate solution of the problem of handling the narcotic addict
-lies largely in the education of medical men, both in institutions and
-in private practice, and through them securing lay appreciation of
-disease facts. Any legal or administrative restrictions which drive the
-care of the honest addict out of the hands of the honest medical man
-simply postpone the day when this ideal may be consummated.</p>
-
-<p>Some addicts, as individuals and types, will of course always require
-institutional and custodial handling. The handling of the addict who
-is criminal or vicious belongs within the province of the penological
-authorities, just as does the handling of any other man who is criminal
-or vicious. The handling of the addict who is fundamentally degenerate,
-defective or mentally weak may require the<span class="pagenum" id="Page_109">[Pg 109]</span> attention of the alienist
-and institutional restraint, just as may the handling of any other man
-who is degenerate or defective. Narcotic drug addiction-disease in the
-man who is vicious or criminal or defective or degenerate should be
-treated as narcotic drug addiction-disease, as any other disease is
-treated in the same individual.</p>
-
-<p>To our legislators and administrators and forces of penology, custody
-and correction rightfully belongs the problem of looking after the
-criminal and vicious addict as well as providing for the eradication of
-illicit, irresponsible, and “underground” traffic in narcotic drugs.
-If the illicit trafficker happens to be a physician he should have no
-more consideration at the hands of the law than any other criminal and
-in its action the law should have complete co-operation of the medical
-profession, which should see to it also that conscientious endeavor
-of its honest members is not confused in its consideration with
-illicit traffic and that the acts of the doctor shall be determined
-and estimated upon broad principles of medical practice and not upon
-violation of incidental technicalities. Great care should be taken that
-the sins of a guilty few are not visited upon the heads of a deserving
-many.</p>
-
-<p>Until there is available competent and adequate medical care for the
-honest narcotic addict sufficient in extent to meet the needs of the
-thousands of sufferers, and encouragement and protection as well as
-restriction is afforded to the honest physician, the illicit traffic
-will continue and grow, including in its toils many who would not
-otherwise seek it. Before we have further medical restrictions, we
-should have both medical and lay and official education. Over-emphasis
-on any aspect resulting in premature, narrow, ill-considered and
-ill-advised action only increases the complexity of the situation and
-defers final remedy. For as great and complicated a problem as narcotic
-drug addiction there will be found no special or specific panacea.</p>
-
-<p><span class="pagenum" id="Page_110">[Pg 110]</span></p>
-
-<p>In conclusion I feel that a great deal more thought and attention
-should be paid to the testimony of the public hearings of the New York
-Legislative Investigating Committee, under the leadership of Senator
-George H. Whitney, Chairman of the Committee. A vast amount of valuable
-data was produced. It showed for the first time to my knowledge an
-official effort to secure the true story of the narcotic addict in
-all of its applications and circumstances. It is significant that the
-Preliminary Report of the Whitney Committee gave official recognition
-of the fact that narcotic drug addiction is a physical disease. So
-important and enlightening was the above mentioned report, that it is
-deemed desirable to quote from it in part as follows:</p>
-
-<p>“Lack of understanding and appreciation of the disease of narcotic
-drug addiction and its treatment by a large majority of the medical
-profession has fostered conditions which make it impossible to
-determine a rational procedure for treating and curing the addicted by
-the State at this time.</p>
-
-<p>“Such absence of uniformity of opinion has worked great hardship upon
-the public and has laid the narcotic drug addict open to misconception,
-misunderstanding and medical treatment which, in many instances, has
-resulted in harm rather than good.</p>
-
-<p>“Evidence offered by physicians shows that many addicts have died under
-the methods of treatment existing to-day and that a large percentage of
-those discharged from institutions as ‘cured’ are driven back to use
-of narcotics through unbearable physical torture induced by improper
-withdrawal of their drug.</p>
-
-<p>“Evidence from physicians was adduced which denied that any cure
-for narcotic drug addiction existed in any of the private or public
-institutions of this State. Evidence from other eminent physicians was
-adduced which<span class="pagenum" id="Page_111">[Pg 111]</span> bore testimony to the fact that the disease of narcotic
-drug addiction was curable.</p>
-
-<p>“The difference of medical opinion existing in medical circles
-regarding this vitally important question should be made the subject
-of a thorough and searching investigation as a matter of the greatest
-importance to the welfare of a large number of people in the State of
-New York.</p>
-
-<p>“Your Committee has found that narcotic drug addiction bears no
-relation in point of character and seriousness to any other known habit
-induced by the use of stimulants. Narcotic drug addicts, according
-to evidence adduced, should not be classed with the alcoholic or the
-tobacco addict or the cocaine habitue.</p>
-
-<p>“The constant use of narcotics produces a condition in the human body
-that many physicians of medical authority now recognize as a definite
-disease, which diseased condition absolutely requires a continued
-administration of narcotics to keep the body in normal function unless
-proper treatment and cure is provided.</p>
-
-<p>“Withdrawal of the drug of addiction induces such fundamental physical
-disorganization and unbearable pain that addicts are driven to
-any extreme to obtain narcotic drugs and allay their suffering by
-self-administration.</p>
-
-<p>“Testimony of physicians coming in contact with the addicts and
-statements of addicts themselves show that those afflicted with this
-disease express every desire to secure humane and competent treatment
-and cure and that most narcotic drug users are willing to undergo
-physical torture and often do voluntarily undergo such torture, in an
-effort to be rid of their so-called habit.</p>
-
-<p>“In the present chaotic condition of medical opinion on this subject,
-it is impossible for the addict to-day to either secure authentic
-information on the subject of his disease and its treatment, or to
-procure at the hands of<span class="pagenum" id="Page_112">[Pg 112]</span> the average physician competent treatment for
-his malady.</p>
-
-<p>“It has further been stated by competent authorities before your
-Committee that drug addiction is not confined to the criminal or
-defective class of humanity.</p>
-
-<p>“This disease, however contracted, is prevalent among members of every
-social class. Some physicians estimate that addicts of the so-called
-underworld are far out-numbered by unfortunate drug users drafted from
-social circles of refinement and intelligence in the State of New York,
-who have become addicted to the constant use of narcotic drugs, but who
-are able to hide their affliction from the public.</p>
-
-<p>“The attitude of the public toward the narcotic drug addict, fostered
-by the increasing prevalence of the disease in the criminal classes and
-by the apparent lack of medical help, has forced such drug users to
-keep their affliction a secret.</p>
-
-<p>“This necessity in turn, your Committee finds, has apparently
-contributed to the existence of many unsound nostrums for the cure
-of narcotic drug addiction and many private institutions where this
-disease is purported to be cured which exist solely for the purpose of
-preying upon the addict.</p>
-
-<p>“State investigation and regulation of such cures and institutions is
-recommended by your Committee.</p>
-
-<p>“Your Committee is inclined to criticize the medical profession for its
-lack of study of the increasingly important subject of narcotic drug
-addiction. The only excuse which can be offered for this unfortunate
-condition lies in the fact that there has not been medical appreciation
-of conditions and that legislation, both State and Federal, has forced
-upon the physician a situation for which he was wholly unprepared.</p>
-
-<p>“The testimony taken by your Committee shows that those charged with
-the sale and distribution of narcotic drugs are in the main observing
-the law, and that the<span class="pagenum" id="Page_113">[Pg 113]</span> legal distribution of these drugs is less than
-before the enactment of existing narcotic laws, Federal and State.</p>
-
-<p>“On the other hand it is apparent from this testimony that public
-consumption of narcotic drugs has increased to an alarming extent. The
-inevitable conclusion is that the unfortunate addict has been forced to
-and does obtain his supply illegally.</p>
-
-<p>“This condition arises very largely from the fact that many physicians
-and pharmacists, either through misunderstanding of the law or the true
-nature of the addict’s disease, have refused to prescribe or dispense
-narcotic drugs to the sufferer.</p>
-
-<p>“Your Committee contends that any member of the medical or
-pharmaceutical professions who refuses either to prescribe or to
-dispense narcotic drugs to the honest addict to alleviate the suffering
-and pain occasioned by lack of narcotics is not living up to the high
-standards of humanity and intelligence established by these great
-professions.”</p>
-<hr class="chap x-ebookmaker-drop" />
-
-<div class="chapter">
-<p><span class="pagenum" id="Page_114">[Pg 114]</span></p>
-
-<h2 class="nobreak" id="CHAPTER_IX">CHAPTER IX<br /><span class="small">SOME COMMENTS UPON THE LEGITIMATE USE OF NARCOTICS IN PEACE AND WAR</span></h2>
-</div>
-
-
-
-<p>Before commenting upon the legitimate use of narcotics, it is desirable
-to emphasize again that the term “narcotics” as used in this volume
-refers particularly to the preparations and derivatives of opium,
-because as the term “narcotics” has come to be used it is synonymous
-in the minds of many with “habit-forming drugs,” a phrase often
-loosely used and grouping under its title a number of drugs of widely
-dissimilar action and properties.</p>
-
-<p>Although many of these drugs have narcotic properties, their action
-upon the human body is in many respects totally unlike the action
-of the opiates themselves. Also the condition resulting from their
-prolonged and continuous administration is an entirely different
-condition clinically and physiologically from that manifested in the
-case of opiate addiction-disease. The problems associated with the use
-of alcohol, cocaine, chloral, cannabis, the various coal tars, etc.,
-differ from each other and all of them are, in their basic medical
-principles, of an entirely different character from the problems
-associated with the use of opiates. As has been previously stated,
-it has not yet been demonstrated that any of them form the basis for
-an addiction-disease mechanism such as clinical study and laboratory
-experiment seem to demonstrate in opiate addiction-disease.</p>
-
-<p>In considering legitimate as well as illegitimate use of opiates,
-therefore, it is important not to confuse them<span class="pagenum" id="Page_115">[Pg 115]</span> with the drugs above
-mentioned and to be sure that in the mind of the reader there shall
-not exist any lingering impression that attributes popularly supposed
-to be associated with so-called “habit-forming drugs” are of necessity
-displayed in the opiate group.</p>
-
-<p>The habitual use of cocaine for example, may be regarded as an
-indulgence of appetite and the obtaining of sensation and artificial
-stimulation and not as based upon the demands of a specific physical
-addiction-disease mechanism. The therapeutics of its discontinuance
-are entirely different. Habitual indulgence in cocaine tends to
-result in mental and moral deterioration. In the addict of the
-so-called “underworld” it is the coincident use of cocaine with its
-manifestations of mental, moral and physical deterioration that has
-led to the wide and erroneous attributing of characteristics of this
-class of cocaine habituates to the average opiate addict. The habitual
-use of cocaine is an entirely different matter from the continued
-administration of opiate in the case of an opiate addict, and its
-manifestations should be completely dissociated from the clinical
-picture and problem of opiate addiction-disease.</p>
-
-<p>Some writers, especially those associated with municipal or state
-institutions of penology and correction, lay emphasis upon the case
-of the so-called “mixed addict.” The crimes of violence with which
-addiction has become associated in the popular mind are practically
-never connected with the action of opiate drug. They are, however,
-characteristic of the cocaine crazed individual. When they are
-performed by a so-called “mixed addict” they are the result of cocaine
-habituation rather than of opiate addiction. Such crimes of violence as
-are committed by the opium or morphine addict are well explained in the
-Report of the Treasury Investigation Committee in the following words,
-“There are many instances of cases where victims of this disease were
-among people of the<span class="pagenum" id="Page_116">[Pg 116]</span> highest qualities morally and intellectually, and
-of the greatest value to their communities, who, when driven by sudden
-deprivation of their drug, have been led to commit felony or violence
-to relieve their misery.”</p>
-
-<p>This erroneous grouping of so-called “habit forming drugs” is to some
-extent responsible for a misconception of opiates and of opiate use and
-opiate result to such an extent that, there is unfortunately manifested
-at times a lack of appreciation of the very important legitimate uses
-of these drugs.</p>
-
-<p>The paramount issue of legitimate narcotic medication is that of the
-opiates. Opiates form and must continue to form the most indispensable
-medication, emergency and otherwise, for shock, wounds and allied
-conditions. It may be safely stated that of all emergency medication,
-the opiates would be the last to be surrendered by the intelligent
-physician or surgeon. This is true of every day civil practice and its
-importance is increased tremendously under conditions of active warfare.</p>
-
-<p>The opiates possess combined actions and powers not found in any
-other group of drugs. In therapeutic doses they support the heart and
-circulation, they relieve pain, they hold in check excessive activity
-of the glands of internal secretion with all their associated phenomena
-of exhaustion and collapse; they control spasm and they give sleep.
-In no other drugs or group of drugs are these properties combined
-as they are in the opiate group. In emergency medication, opium and
-its alkaloids, especially morphine, are the medications often most
-responsible for the saving of life and reason. It is not necessary to
-argue this point with any intelligent physician or surgeon. For the
-benefit of the laity, however, and for the benefit of the occasional
-fanatic and hysterical reformer it is well to state that without the
-use of morphine and other opiates the mortality among the sick and
-wounded would be vastly greater, and many of those who might survive
-in spite<span class="pagenum" id="Page_117">[Pg 117]</span> of its non-administration to them would bear for the rest
-of their lives physical and mental and nerve consequences of gravest
-character. The lives and minds that have been saved by the timely
-administration of an opiate drug are incalculable. One has only to talk
-with those who have worked under the stern necessities and emergency
-conditions of warfare to appreciate this fact. There is no known drug
-which will replace clinically and therapeutically the opiate group. At
-present it is as indispensable in meeting emergency indications as is
-the scalpel of the surgeon.</p>
-
-<p>It would be entirely unnecessary to discuss or to apparently defend
-the use of narcotics in peace as well as in war-time medication if it
-were not for the fact of recent recognition of the wide existence of
-opiate addiction in the civilized world. Combined with this is the
-belief, often met, that as a result of prolonged opiate administration,
-a certain proportion of soldiers have developed this condition. If
-the facts of addiction-disease were widely known and applied to its
-proper handling and remedy, there should be no hysteria concerning
-and no criticism against legitimate opiate medication; even if
-unavoidably continued to the point of creating this condition. That
-opiate-addiction is one of the medical problems of war is recognized
-and must be openly met. In many cases, just as in private civil
-practice, the physician is confronted by a choice of evils. To save
-life or reason he must continue opiate medication even into and
-past the danger zone of beginning opiate addiction. Lack of popular
-recognition, appreciation and comprehension of this fact, in the
-present status of narcotic addiction, contains grave dangers of
-hysteria and of undeserved and irresponsible criticism. That this
-criticism is based on ignorance makes it none the less unpleasant and
-hampering to efficient service.</p>
-
-<p>It should be at once and widely taught that the cases<span class="pagenum" id="Page_118">[Pg 118]</span> of opiate
-addiction that follow war time administration of opiate do not
-constitute a new medical problem, but simply constitute additional
-cases of a disease which has existed insufficiently appreciated in
-this country for over half a century. When the conditions under which
-wounded and sick must be handled in the emergencies of war, and the
-higher percentage of urgent and severe cases are taken into account,
-it will be found that the proportion of wounded and sick soldiers with
-this addiction-disease is no greater and is very probably not so great
-as the proportion of people in civil life and practice who have in the
-past contracted this disease, and are even at present contracting it as
-a result of opiate medication, unavoidably or otherwise continued to
-the point of addiction.</p>
-
-<p>As the facts of addiction-disease development as a result of
-unavoidable military therapeutics become known it will be well to
-remember that the conditions are no different in character and exist in
-no greater relative proportion than the same conditions in civil life
-and practice. The principal difference lies in the greater opportunity
-for early recognition.</p>
-
-<p>As to the illegitimate or non-therapeutic contraction of addiction
-within the army, its dangers are no greater and possibly not as
-great as in civil life. Some non-medical cases of addiction may have
-developed within the ranks of the army. It may be said of them,
-however, that army life and activity and training probably saved
-many more or less idle and ignorant youths imbued with a spirit of
-curiosity, and with lack of normal outlet for physical and nervous
-surplus energies, from the associations and environments which have
-been taken advantage of by those associated with illicit commerce
-in the creation of the addict of non-medical origin, which has so
-increased in the past four or five years.</p>
-
-<p>It is my belief that the gathering together of young men presents an
-opportunity for the education of the<span class="pagenum" id="Page_119">[Pg 119]</span> youth as to the physical and
-disease facts of opiate addiction which should be of incalculable
-benefit in the solution of the narcotic problem and in the suppression
-and prevention of “underground” and underworld narcotic traffic.</p>
-
-<p>The foregoing opens to discussion another legitimate use of narcotics.
-This use is the intelligent administration of opiate in the control and
-therapeutic handling of whatever cases of addiction are found to exist.
-The situation within the army as regards addiction is in the general
-indications for its handling, identical with the situation existing in
-civil life. The man who has fully developed opiate addiction-disease
-will have to have his opiate supplied to him intelligently and
-with proper appreciation of the symptomatology and reactions of
-addiction-disease until there is equipment and educated personnel
-provided for his intelligent and competent handling. Under any other
-immediate arrangements, the addicted soldier, just as the addicted
-civilian, will in his desperation and physical torments of bodily need
-for opiate drug, endeavor to smuggle, steal or otherwise obtain in any
-way possible this medication.</p>
-
-<p>In brief then, and to recapitulate, the legitimate use of narcotics
-will be roughly divided under two broad heads. The first is the
-necessary administration of opiate to those who are not addicted for
-the control of emergency or other indication with which every competent
-physician or surgeon is familiar. To use opiate as indicated in such
-cases is not only legitimate, but failure to use it would be inhuman
-and barbarous and result in the loss of many lives and in the making
-of wrecks of many others. The second is the administration of opiates
-to those unfortunates, who either through their own ignorance or
-carelessness, or through unavoidably or otherwise prolonged legitimate
-or necessary medication have developed in their body the condition of
-opiate addiction-disease,<span class="pagenum" id="Page_120">[Pg 120]</span> until such time as their disease can be
-arrested by competent medical care of their addiction-disease mechanism.</p>
-
-<p>As to addiction created in war time, there is considerable amount of
-information. This is not the time nor the place for detailed discussion
-of that information. Calm consideration of it should, however, suffice
-to still the voice of any objections and irrefutably answer arguments
-criticizing existence of war-time addiction. The greatly lacking and
-needed element in its consideration and handling is appreciation of it
-as physical, controllable and arrestable disease. The laity and the
-mothers and other relatives and the friends of those in the Army and
-Navy will not exhibit panic and fear once the intangible horror and
-vague and morbid and erroneous picture of the “dope fiend” is in its
-application to opiate addiction erased from popular conception and
-replaced by comprehension of a definite physical disease clinically
-controllable and in most cases therapeutically remediable.</p>
-
-<p>To what extent narcotic drug addiction-disease will prove to be a
-medical sequela of war and of necessary war-time medication may
-never be made a matter of accurate statistics. The popular and
-prevailing attitudes towards and conception of the condition and
-of its possessor tend to influence towards desperate concealment
-rather than to encourage self-revelation. As has been stated before
-addiction-disease followed the Civil War, occasional cases recently
-existing and possibly still existing among the few remaining veterans
-of that struggle, addiction dating back to Civil War medication. The
-Spanish War and necessary medication added to the list of war-time
-contracted addiction-disease. Of addiction among those participating in
-the last war, it is at present wise to simply recognize the condition,
-and to hope that as the addiction-disease sufferer, developed through
-necessary war-time medication becomes known, he will not have to<span class="pagenum" id="Page_121">[Pg 121]</span>
-carry the addiction stigma of past attitudes and conceptions, and
-that we shall be in a position to accord him intelligent and humane
-consideration and handling as a deserving sick man, whose disease was
-contracted in our defense.</p>
-<hr class="chap x-ebookmaker-drop" />
-
-<div class="chapter">
-<p><span class="pagenum" id="Page_122">[Pg 122]</span></p>
-
-<h2 class="nobreak" id="CHAPTER_X">CHAPTER X<br /><span class="small">GENERAL SURVEY OF THE SITUATION AND THE NEED OF THE HOUR</span></h2>
-</div>
-
-
-
-<p>From the foregoing it is easy to see that the sooner the
-established facts of the fundamental physical basis and reactions
-of the addiction-states become matters of medical, sociological,
-administrative, and lay knowledge, the earlier there will be a rational
-and practical consideration of the use as well as of the abuse of
-narcotic drugs, and a beginning of solution of the narcotic drug
-problem.</p>
-
-<p>Lack of knowledge of the fundamental and constant physical reactions
-and phenomena, and of the characteristic clinical manifestations of
-this disease, and of the physical suffering of drug deprivation is in a
-very large measure responsible for failure in its therapeutic handling
-in the past, and indirectly responsible for whatever is unjust and
-misdirected in the framing of the various laws, and also for a great
-part of whatever incompetency and lack of wisdom has appeared in their
-administration.</p>
-
-<p>Lack of knowledge of the disease facts of narcotic addiction is also
-responsible for the practical absence of widespread provision for
-humane and intelligent handling, for much of the jeopardy and fear on
-the part of the medical practitioner towards these cases, and for the
-existence of conditions resulting in the rapid growth and increase of
-the worst evils of the present situation.</p>
-
-<p>The worst evils of the narcotic drug situation are not, as is widely
-taught, rooted in the inherent depravity and moral weakness of those
-addicted. They find their origin in opportunity, created by ignorance,
-neglect and fear,<span class="pagenum" id="Page_123">[Pg 123]</span> for commercial and other exploitation of the
-physical suffering resulting from denial of narcotic drug to one
-addicted. The many widely advertised drug cures derive their prosperity
-from the desperate desire of the narcotic addict to be cured of the
-condition which may at any time cause him intense physical suffering.
-The worst evil of the narcotic situation in the past few years, and
-especially since the enforcement of restrictive legislation, without
-provision for complete investigation of the whole situation, for
-education, and adequate treatment of disease aspects, is the rapid
-growth and spread of criminal and underworld and illicit traffic in
-narcotic drugs. This exists to its present extent because conditions
-have been created which make smuggling and street peddling and criminal
-and illicit traffic tremendously profitable, and it would not exist to
-its present extent otherwise. It is simply and plainly the exploitation
-of human suffering by the supplying to desperate and diseased
-individuals, at any price which may be demanded, one of the necessities
-of their immediate existence.</p>
-
-<p>Such exploitation would become unprofitable on any large scale if the
-disease created by continued administration of opiates were recognized
-as it exists and its physical demands comprehended and provided for in
-more legitimate and less objectionable ways.</p>
-
-<p>One of the most important and immediately available of these
-ways is the honest practitioner of medicine. If the average
-practitioner of medicine were made familiar with the physical facts
-of addiction-disease, and its phenomena and reactions, and were
-encouraged by both legal and medical authoritative support to admit
-addiction-disease patients to his practice, to be cared for just as
-other patients to the best of his honest therapeutic ability and
-judgment—if he were taught to regard them as sick people whom he could
-help—if he were relieved of uncertainty as to the meaning and possible
-interpretation of<span class="pagenum" id="Page_124">[Pg 124]</span> laws and regulations, and as to the possible action
-or lack of action and attitude of his medical brethren and medical
-organizations towards him—the best available, honest, humane and
-intelligent machinery would be set in motion for the immediate care
-of the average honest sufferer from addiction-disease, and for the
-discouragement of underworld or underground exploitation. This has been
-demonstrated. It would react furthermore as a stimulus to the education
-of the physician, to familiarize himself with the scientific and
-medical facts of this disease.</p>
-
-<p>Another immediate provision is the establishing under proper
-supervision and management, especially as to competent medical
-management, and without possibilities of humiliation and interference
-with self-support, of stations or clinics at which those who for
-financial or other reasons are unable to secure reputable and honest
-medical help, may obtain their necessary opiate at minimum expense and
-in physically necessary amounts to enable them to work and support
-themselves and families, without resorting to underworld associations
-and illicit commerce. Such clinics might be established in connection
-with the various hospitals on the same basis as their other medical and
-surgical clinics or dispensaries, and in connection with various health
-departments. In them the narcotic addict could not only be supplied
-with opiate medication, but taught the nature of his disease and the
-elements and principles of its control and be given such medication
-other than opiate for the relief of such associated or intercurrent
-conditions as might exist. Such clinics would have great educational
-value, as well as fulfilling a therapeutic need.</p>
-
-<p>Pending further study and investigation and education into narcotic
-drug addiction-disease and the conditions surrounding it, and pending
-the widespread acceptance and recognition of practical and desirable
-procedures in the handling of the disease, and pending the provision
-of<span class="pagenum" id="Page_125">[Pg 125]</span> sufficient and scientifically adequate accommodations for the army
-of those who seek relief—legitimate supply of the drug of addiction
-under medically competent and intelligent direction fulfills a great
-economic and sociologic and medical need.</p>
-
-<p>The financial possibilities of commercial exploitation of the
-sufferings of addiction-disease, combined with general ignorance of
-the true nature of the addiction condition, are responsible for the
-tremendous increase of late of narcotic addiction, of non-medical
-or non-therapeutic origin, among the youth. In ignorance of actual
-physical results, not knowing nor ever having been told that they
-are contracting a disease of torturing manifestations, actuated by
-curiosity and search for adventure, in some cases stimulated by
-unfortunate spectacular publicity, the youths fell easy prey to the
-agents, male and female, of the drug trafficker. The trafficker’s
-intended consummation is reached when these youths finally become,
-to their surprise and consternation, through the development of
-addiction-disease and physical dependence upon narcotic drug, enforced
-and continued customers and in some cases, virtual slaves.</p>
-
-<p>Those who are interested in prostitution and in so-called
-“white-slavery” would do well to turn their attention to the chains
-forged by the suffering, and the fear of suffering, experienced by
-those who have developed narcotic drug addiction-disease.</p>
-
-<p>It is this class of youthful addicts that has so alarmingly increased
-since the enforcement of the various narcotic laws. I have previously
-called attention to this situation, and also to the fact that for
-this increase the laws themselves are not so much to be blamed as
-is the totally inadequate meeting of the clinical and therapeutic
-and educational needs of the narcotic drug situation. There has been
-practically no organized scientific, medical or public health activity,
-so far as I know, directed towards<span class="pagenum" id="Page_126">[Pg 126]</span> the clinical and laboratory
-investigation of this disease—towards a dispassionate review, analysis
-and testing out of the truths and errors of its literature—towards an
-investigation of the scientific and other qualifications and experience
-of those whose utterances or writings influence medical and lay opinion
-and action, towards the establishing of pathological and physical
-facts and reactions and of clinical symptomatology and phenomena as
-fundamental bases for its rational handling and therapeutics, and for
-practical education of the public as to its sufferings and dangers.</p>
-
-<p>The neglect of this education is largely indirectly responsible for
-illicit traffic in narcotic drugs. Illicit and underground traffic
-exists because it is profitable. This is the direct and immediate
-reason for its existence. Every new addict made of an adventurous youth
-means a new customer for the smugglers and vendors. If that adventurous
-youth had been taught the facts of the physical hell of the “withdrawal
-signs” of opiate addiction-disease—if he knew the sufferings attendant
-upon body-need for opiate drug—if he knew that any red-blooded animal
-will develop this physical body need if opiate drug is administered
-for a sufficiently prolonged period—that no living being is immune
-to the development of this disease—if he thought of addiction as
-he thinks of tuberculosis, and as he is now being taught to regard
-venereal-disease, instead of it as being something vague and surrounded
-by a halo of adventure and experience, he would not fall an easy
-victim to the agents of the trafficker. In other words, the most
-potent activity in the arrest of development of even the vicious and
-criminal aspects of the narcotic addiction situation lies in education.
-Laws and their enforcement in the control of the incorrigible and
-vicious will always be a necessity, but laws and their administration
-alone are not sufficient for the control of the many-sided addiction
-situation. Even in the control<span class="pagenum" id="Page_127">[Pg 127]</span> of smuggling and illicit traffic we
-need the application of every available influence capable of exertion,
-not only upon its end results but upon the machinery of its origin
-and development. As so much of it originates and develops through
-ignorance, the method of its remedy lies in education, education as to
-the facts of narcotic drug addiction-disease.</p>
-
-<p>It is ignorance also that has stamped the honest and innocent,
-worthy and intelligent, and often illustrious sufferer from narcotic
-addiction-disease with the attributes and characteristics of the
-inherently irresponsible or otherwise incapable of self-guidance and
-self-restraint. The ignorance of the facts of addiction-disease has
-taken from these people even their ordinary legal and public rights in
-any issue which involved the possible revelation of their addiction. It
-has placed them in a position where any procedure which might reveal
-their narcotic medication would expose them to public gaze as members
-of a popularly despised and unworthy class of individuals. Until very
-recently the testimony of a known narcotic addict has been almost as
-a rule of no value in a court of law. Irrespective of a life-time of
-honesty and accomplishment, the revelation of a minute might destroy
-the reputation and standing of many years. Whatever the injustices
-or grievances suffered by an addict, he could not hope to evoke the
-protection or rights accorded an ordinary individual under statute law
-without the practical certainty, if his addiction became revealed, of
-personal, social and economic detriment far in excess of the legal
-rights to which he was entitled. The continuation of whatever is
-spurious or unworthy in methods of handling, advertised or otherwise,
-lies partly in the fact that the former patient cannot afford, however
-great his physical or other damage, to make public the existence of
-addiction-disease by the instituting of a suit for malpractice or other
-civil or criminal procedure. This alone has<span class="pagenum" id="Page_128">[Pg 128]</span> been one of the factors
-in lack of progress and in the persistence of narrow vision or false
-conception. He is in effect, however high his personal, moral and other
-status, deprived of some of his constitutional rights, simply because
-he has developed addiction-disease.</p>
-
-<p>The great numbers of innocent and worthy unsuspected sufferers from
-this disease, who could not by any stretch of wildest imagination, be
-regarded as mentally or morally abnormal or subnormal have therefore
-been placed in a position where they could not afford to demand their
-rights or state their case. Their problems are only recently beginning
-to receive general consideration. Their cases have compelled us to
-revise our conception of the narcotic addict, and to question ourselves
-as to the necessity for their continued addiction over the years of
-their addiction. For their own good and that of society, what shall
-we do with them, and what can we do for them? In the present state of
-public opinion and public attitude towards narcotic addicts in general
-would it benefit either them or society to class them merely as “drug
-addicts” along with the drug-users of other types of individuals and
-other personal characteristics for administrative handling by detailed
-administrative supervision and control? Can the same administrative and
-other methods which admittedly must be employed to protect society from
-the manifestly unfit accomplish anything of good in the cases of these
-responsible and valuable citizens?</p>
-
-<p>Until there is a truer understanding of addiction-disease, and a wider
-appreciation of the facts that the personal attributes of its victims
-differ as widely as those of cardiac or any other disease condition,
-and that merely because a man has contracted this disease is no reason
-for regarding him as in any way unworthy or unfit—will stringent
-and drastic forcible regulative measures directed against mere use
-of narcotics work out to the advancement or hindrance of ultimate
-solution and to the ultimate benefit<span class="pagenum" id="Page_129">[Pg 129]</span> or harm of society? These are the
-questions to be applied to all restrictive administrative activities.
-The problem of the care of the worthy and innocent addict in such a way
-as not to unnecessarily harm him nor deprive his family and society
-of his competent activity is just as important as the handling of the
-addict of the type of individual from whom society must be protected.
-The large numbers of worthy and valued citizens who are individually
-and personally social and economic assets and who are sufferers from
-addiction-disease constitute a very important consideration in the
-narcotic problem.</p>
-
-<p>They certainly are not fit subjects for enforced custodial and
-correctional handling, and if such were forced upon them they would be
-seriously harmed, personally, socially, economically and physically.
-Very many of them our equals or betters, we have no right to subject
-them to associations and experiences which we ourselves would rebel
-against and be humiliated by simply because they have developed a
-disease condition from which no one of us is immune.</p>
-
-<p>Where is the blame for their continued addiction? Certainly not because
-of lack of effort on their part. Addicted for years, they have tried
-one after another of the various and diverse treatments and so-called
-cures without success or benefit. Is the blame theirs for lack of
-success and cure, or has there been something wrong in our treatment
-and handling of them? Did we know enough about addiction-disease to
-treat them intelligently and to exercise upon their cases the same
-professional skill and technical ability that we have been educated
-and trained to apply to other diseases? In the light of present
-available clinical information and study, and in the light of recent
-and competent laboratory research, we are forced to admit that we have
-not treated our addiction sufferers with sympathetic understanding
-and clinical competency, and that the blame for past failure to
-control the<span class="pagenum" id="Page_130">[Pg 130]</span> narcotic drug problem rests largely upon the educational
-inadequacy of the past.</p>
-
-<p>We are in a stage of transition in our concepts of, attitude towards,
-and handling of the narcotic addict. Serious consideration of drug
-addiction as a problem of clinical and internal medicine, and of
-experimental laboratory research is a comparatively new thing to a
-majority of the medical profession, and of course also to legislators
-and administrators. We should all remember that no matter how strong
-we are in our beliefs and theories, there are many others whose
-experiences and results have caused them to hold just as strongly
-to opposite theories and beliefs, and that we are all on trial for
-the validity and extent of practical application of our beliefs and
-theories.</p>
-
-<p>Each new theory or belief that is brought forward should be taken
-simply for record and investigation. Much that we believe to-day we
-know to-morrow to be based upon misinterpretation and lack of complete
-information. Much that we believed in the past to apply to and solve
-conditions, we found later to have been merely based upon observations
-of distracting incidentals or non-basic aspects and phases. What we
-need is competent, disinterested, and honest effort to get together
-and evaluate all available material of whatever sort and from whatever
-source. If it were possible of accomplishment, it would be of advantage
-to get together in open and frequent discussion the various workers
-in the field. We are all partly wrong and partly right. There is no
-one of us who cannot learn from any one of the others. The real end
-of effort should be, not to prove one or another of us right, but to
-take each from the other whatever is of value and all to contribute in
-true scientific spirit of broad tolerance towards the ideas of others
-and of willingness to correct or modify ideas and theories of our
-own, searching for no panaceas or specifics, medical, legislative or
-administrative, simply hunting for truth wherever we may<span class="pagenum" id="Page_131">[Pg 131]</span> find it and
-applying it intelligently to meet the needs of the individual.</p>
-
-<p>There is too much work to be done, and the situation is too urgent for
-remedy, to permit of longer delay in scientific approach. Under present
-conditions, no man’s announcement of theory or of remedy is to be taken
-as ultimate authority, but simply as his opinion based on his personal
-deductions, and his personal experience, to be evaluated in accordance
-with the extent and variety of his personal experience in the light of
-his individual ability and training.</p>
-
-<p>Education and training are the best hopes we have as a foundation for
-the alleviation of present conditions and the prevention of their
-further spread. Lack of appreciation of and of ability to recognize and
-meet varied and various clinical and other indications for treatment
-and handling under widely different circumstances and in widely
-differing individuals means failure in a majority of cases, and throws
-a burden upon society and a complexity of problems upon municipal,
-state and federal authorities which they are unable to meet. Each class
-of workers should be working in its own field in co-operation with
-those working in other fields, none trying to dominate the rest, but
-each giving to the others credit for honest effort and appreciation of
-difficulties to be made easier if possible.</p>
-
-<p>All possible forces should be encouraged to the work of study
-and investigation and education. A campaign of medical and lay
-investigation and education will require a much shorter time than a
-continuous trying out of various panaceas, medical, legislative or
-administrative. Also, it will bring far more satisfactory and earlier
-results. The narcotic wards of our great charity hospitals should be
-made use of for honest unbiased and trained clinical and laboratory
-study. The narcotic addict himself should be given a much wider hearing
-than he has in the past received.<span class="pagenum" id="Page_132">[Pg 132]</span> The mass of honest and intelligent
-narcotic addicts should be encouraged to tell their stories and their
-experiences, and should receive a fair and unbiased hearing as to
-the reactions upon them of various measures proposed. We, doctors,
-legislators, administrators are in truth as much on trial with the
-narcotic addict and with society for our understanding and handling of
-the narcotic addict and his problems as the addict is for his condition.</p>
-
-<p>The remedy is plain, and the necessity for immediate activity is
-obvious. Education—scientific medical and lay, administrative and
-public health education is the lacking element or factor in the
-solution of the many sided narcotic drug problem. Appreciation of
-addiction-disease and what it may mean in the individual should be
-as widespread and as comprehensive as possible and at the earliest
-possible moment.</p>
-
-<hr class="tb" />
-
-<p>Without a basis of generally recognized and widely appreciated
-fundamental facts, there can be no competent treatment, legislation,
-administration or judicial decision. There can be no competent
-evaluation of the merits and defects of various measures promulgated,
-medical, legislative or administrative. There can be no competent
-selection of those in whose hands shall lie the handling of a
-tremendous problem, a problem of disease, of sociology, of economics,
-of public health and welfare. There can be no competent evaluation of
-the remedies advanced, nor of the qualifications and true authority of
-those who recommend them. Under such conditions various measures or
-procedures in their adoption or discarding or application must depend
-more upon the publicity and other influence of their proponents than
-upon their intrinsic values.</p>
-
-<p>There are always some things about any condition which either are or
-are not, some things which are physically determinable. The basic facts
-of addiction-disease are<span class="pagenum" id="Page_133">[Pg 133]</span> now physically determinable. There are many
-material and obvious and easily demonstrable physical facts of greatest
-value to the medical profession and to the laity, facts which are still
-but little appreciated, and not widely known.</p>
-
-<p>These facts in addiction-disease could be easily investigated. The
-various conflicting statements of different schools of thought or
-of observers working from different angles should be investigated,
-evaluated and correlated—taking from each whatever is useful,
-determining its true sphere of application and making it available
-to all. Every possible interest or worker should be encouraged, and
-every source of information sought out, not least among them the
-honest and intelligent sufferer from addiction-disease of many years
-duration whose knowledge of the facts of his condition, and efforts
-to control it, and search for and trial of remedy and remedies for
-it, and the experiences and problems, social, economic and personal,
-which its possession has forced upon him would constitute a touchstone
-of greatest value for the determination of validity of promulgated
-measures and procedures.</p>
-
-<p>The wards of the great charity hospitals, the institutions of science
-and medical experiment and research, the Departments of Health, and
-the Public Health Services are in existence and are equipped for the
-early determination of clinical, and laboratory facts, and for their
-dissemination. These are the things towards which their activities are
-directed in other diseases and conditions affecting public welfare
-and public health. It would take a very short time to determine
-the physical facts of addiction-disease—to establish finally and
-conclusively its clinical symptomatology and constant reactions and
-phenomena for authoritative and educational dissemination. Every one
-of us who has written in description or exposition of his study and
-observations, together with what we have written and taught, should
-be made the subject<span class="pagenum" id="Page_134">[Pg 134]</span> of critical and unbiased investigation, and
-whatever of truth we have stated should be made the possession of
-all. The experimental development of addiction-disease in dogs and
-other experimental laboratory animals, the symptoms and phenomena
-observed in them recorded by instruments such as the sphygmomanometer
-and the sphygmograph and paralleling similar records and observations
-upon the addicted human, the reactions of the serum of these animals
-injected into the non-addicted of their species are not to be lightly
-ignored, and should be matters of common scientific knowledge. The
-manifestations of addiction-disease in the new-born developed in the
-infant’s body prenatally long before vice or habit or appetite can
-be possibly considered as causative factors, demand more than casual
-consideration and have a significance much deeper than as occasional
-curiosities.</p>
-
-<p>An educational campaign as to the facts of addiction would save many
-an innocent person from the contraction of the disease, and many a
-present sufferer from unintelligent handling. Authoritative bodies
-with sufficient power and independence might easily institute unbiased
-review of what is written, and trial and proving out of what is stated
-by various writers, and give out their findings for the guidance of
-future work and action. Hospitals and public institutions for the
-handling of narcotic addicts may be erected. Without comprehension
-of addiction-disease and full and complete familiarity with its
-manifestations, the possession of those who work in them, will they
-accomplish anything of good?</p>
-
-<p>The deduction from the testimony of the Whitney Investigation and from
-other sources leads to the conclusion that one of the reasons why
-the narcotic addict does not go to many of our present institutions
-is that he is more afraid of them, and anticipates more suffering
-in them than he cares to face in view of the fact that neither from
-previous personal experience or from repute he has little<span class="pagenum" id="Page_135">[Pg 135]</span> hope of
-being discharged from them in a condition of physical competency with
-his addiction mechanism arrested. He sees no use in going through
-them only to come out in a condition where he will have to revert
-to his opiate to enable him to endure and work. This is not an
-all-inclusive statement. It expresses, however, the frequent response
-of the addict seeking advice when asked why he does not go to the
-municipal institutions for treatment. Again then the work of those in
-the institutions will be the determinating factor in their success
-or failure, and their education is the dominant element required for
-success. Some interesting observations upon this point will be found in
-the Yearly Report for the Department of Correction of New York City,
-1915.</p>
-
-<p>Of public clinics the same thing may be said. Whether they react to
-the benefit of the addict and of the community, or to the harm of the
-addict and community will depend upon their intelligent understanding
-and competent management.</p>
-
-<p>Hospitals and clinics might be made into sorely needed educational
-centers for the training of doctors and nurses to go out and take up
-the work of the care of the addict—either private or institutional.</p>
-
-<p>Education is the great need of the hour. Until it is accomplished all
-else will fail. Until we all know what we are dealing with, how can we
-hope to successfully handle it? It is to be hoped that the time is not
-far distant when in every medical school and hospital will be taught
-in principle and practice, in class-room and clinic all that is known
-or will be known of the pathology, symptomatology, physical phenomena
-and rational therapeutics of narcotic addiction-disease. It is to be
-hoped that in school and college, in pulpit and press, the facts of
-addiction will be presented in their practical existence, stripped of
-spectacularity; a calm, cold presentation of basic facts. There is no
-subject upon which philanthropy<span class="pagenum" id="Page_136">[Pg 136]</span> can better expend its forces than to
-this end of education as to addiction-disease and humane help to its
-sufferer.</p>
-
-<p>In the past the problem of control of addiction has been “What shall be
-done <em>with</em> or what shall be done <em>to</em> the narcotic addict to
-make him stop using drugs?” It is now gradually coming to be realized
-that the true problem is “What can be done <em>for</em> the narcotic
-addict to relieve him of the physical necessity of using drugs?”
-and “What can be done to so educate the public as to the facts of
-addiction, so that this disease will claim as few victims as possible?”</p>
-
-<p>In this change of attitude lies the hope for the future. Some of the
-narcotic addicts will have to be done <em>with</em> or done <em>to</em>.
-They are the inherently irresponsible, vicious or defective. They
-demand care and restraint irrespective of their addiction. The mass
-of addicts, however, need something done <em>for</em> them. They are
-clinical problems of internal medicine, victims of a definite disease,
-characteristic in its symptomatology, reactions and phenomena, a
-disease which will before long come to be known as clinically and
-therapeutically controllable and arrestable.</p>
-<hr class="chap x-ebookmaker-drop" />
-
-<div class="chapter">
-<p><span class="pagenum" id="Page_137">[Pg 137]</span></p>
-
-<h2 class="nobreak" id="APPENDIX">APPENDIX<br /><span class="small">HUMAN DOCUMENTS—PERSONAL STATEMENTS</span></h2>
-</div>
-
-
-<p>The great importance of the real story of the sufferer from narcotic
-drug addiction-disease has been referred to several times in this
-book. It had been my first intention to include in the course of the
-various discussions, stories and statements of narcotic drug addicts
-illustrative of the various matters discussed, and to take them from my
-own collection of addiction histories.</p>
-
-<p>That I might avoid any personal controversy, however, as to their
-personality or reliability, and also to make such statements free from
-any possible hint of influence or bias, I have taken them from medical
-literature and am using them as an appendix.</p>
-
-<p>In December, 1917, <i>American Medicine</i> published a special
-addiction number, containing statements written for it by addicts
-of evident and vouched for intelligence and standing, stating their
-personal experiences and personal views.</p>
-
-<p>Through the courtesy of <i>American Medicine</i> and its editors, I am
-reproducing these, believing that they are of great value and that they
-illustrate many of the discussions which appear in this book.</p>
-
-<hr class="tb" />
-
-<h3>HUMAN DOCUMENTS<a id="FNanchor_1" href="#Footnote_1" class="fnanchor">[1]</a></h3>
-
-<div class="footnote">
-
-<p><a id="Footnote_1" href="#FNanchor_1" class="label">[1]</a> For obvious reasons the names of the authors of these
-contributions are not given. The editor, however, has every one of
-them, and has taken especial care to establish the authenticity and
-good faith of each article. Each contribution appears as received.</p>
-
-</div>
-
-<h4>THE PERSONAL SIDE OF DRUG ADDICTION</h4>
-
-<h5><span class="smcap">Some Views on Drug Addiction—Personal and Legal</span></h5>
-
-<p class="center"><span class="smcap">By A Prominent Member of the New York Bar</span></p>
-
-<p>A half dozen years ago I had a long, severe attack of gallstones<span class="pagenum" id="Page_138">[Pg 138]</span> and
-inflammation of the gall-bladder. I suffered so much pain that the
-physicians gave me morphine for nearly a year. When I got better I
-tried my very best to get along without the drug, but could not. I
-came to a physician in New York for treatment who had made a special
-study of drug addiction and is a recognized authority on that subject.
-However, he could not help me at that time on account of a recurrence
-of my gall-bladder inflammation with severe jaundice and fever.</p>
-
-<p>Since that time I have tried repeatedly to stop and reduce the quantity
-of the drug, but have found it impossible because of the physical pain
-and exhaustion due to the lack of the drug. This is unbearable. I have
-since then kept my daily amount of morphine medication at a minimum
-which permitted me to work and to maintain good health and bodily
-function. The idea which I have heard so often expressed, that addicts
-tend to increase their daily intake of narcotic, is certainly untrue
-in my case, and there seems to me no reason nor temptation to do so. I
-have simply found the smallest amount which would keep me from physical
-suffering, and have experienced no difficulty in maintaining that
-dosage, except in occasional emergencies of gall-bladder attacks or
-other crises, after which I found it a simple matter to discontinue the
-excess dosage. As I have never experienced the slightest pleasurable
-or sensually enjoyable sensations from the administration of morphine,
-there seems to me no foundation for this prevalent idea of tendency to
-increase. It may be true of the degenerate who has become addicted, but
-it certainly is untrue in my case, and must be untrue of the thousands
-like me whose misfortune it has been to become afflicted with this
-condition.</p>
-
-<p>Recently I have again consulted specialists, and it seems that with
-my condition I must continue the administration of morphine for the
-present, and perhaps for the rest of my life. Physical conditions
-render present attempts to discontinue its use impractical, undesirable
-and dangerous.</p>
-
-<p>Now what am I to do under the present “Drug Habit” laws of this State?
-I am a lawyer long past middle age—have held important state and
-judicial positions, and many<span class="pagenum" id="Page_139">[Pg 139]</span> positions of responsibility and trust. It
-would be ruinous to me if my addiction condition became public.</p>
-
-<p>This law was enacted to control the drug traffic and to stop the evils
-which are connected with it. In many respects it is an excellent law,
-but the provisions which require the record of the name, age and
-residence of the addict to be filed in the Board of Health Office is
-outrageous. It does not affect the underworld, for they don’t care and
-avoid registration by not going to those who have to register them. But
-see the position of a man who has a good reputation and standing in the
-community—forever recorded in the records of the State Board of Health
-as a “dope fiend,” even though his condition is not the result of his
-own acts or desires and absolutely beyond his control.</p>
-
-<p>This part of the law which requires the recording of the name, age
-and residence of the addict should be repealed. The only effect of
-these provisions is to record the addict as what everybody considers a
-“dope fiend” or force him to go to the smugglers for his drug. He must
-either place his good name and social and economic position in constant
-jeopardy or in some way or other evade the law with its attendant
-penalty, and constant fear of detection. I should not be surprised if
-it finally develops to be the fact that a majority of decent sufferers
-from this condition have chosen the latter course as the lesser of
-evils.</p>
-
-<p>I am informed that the Health Department has recently issued monthly
-registration blanks to physicians, demanding, in addition to the
-name, age and residence of the addict, the date and amounts of each
-prescription together with other information as to the individual cases
-treated. This makes conditions still more obnoxious and unbearable.
-Furthermore, this action of the authorities of the Board of Health
-is unwarranted and illegal. There is nothing in the powers of the
-Board of Health which permits them such action, and such action is
-without any justification in the letter of the law or in any possible
-interpretation of the spirit and intent of the law.</p>
-
-<p>The data demanded were submitted to the Legislature as provisions in
-the law when the bill was being considered, and<span class="pagenum" id="Page_140">[Pg 140]</span> were rejected. The
-Health Department is usurping the powers of the Legislature, which
-it has no authority to do. The law plainly states what the physician
-shall report and the Board of Health has no power to require additional
-matters. Such action constitutes illegal interference with the
-rights of physician and patient as to matters of treatment and as to
-violation of professional confidence. It is my opinion that a narcotic
-addict might have grounds for legal procedure against a physician who
-furnished such information as the Health Department demands.</p>
-
-<p>Conditions in New York today, affecting the honest addict, constitute
-in effect persecution of the sick. It is bad enough to be afflicted
-with this disease. Agonizing as gall-stone attacks have been, the
-physical suffering from lack of morphine in an addict is worse. Added
-to this is the knowledge that your name is on file at Albany, and
-perhaps elsewhere, as an addict. You know that disclosure of your
-condition will ruin you and disgrace your family. You are potentially
-subject to leakage from those records and the attendant possibilities
-of blackmail and other persecution. Such conditions tend to force and
-undoubtedly have forced many innocent and honest addicts of good social
-and economic standing to become criminals by obtaining their necessary
-opiate medicine through illegal channels.</p>
-
-<p>Something certainly should be done to remedy existing conditions
-and existing laws. The great State of New York should not place its
-unfortunate sick in their present position.</p>
-
-<hr class="tb" />
-
-<h5><span class="smcap">The Personal History of a Medical Addict</span></h5>
-
-<p class="center"><span class="smcap">By a Well-known American Physician</span></p>
-
-<p>When the suggestion was first made by a medical friend that I should
-write a short account of my personal experience as a drug addict,
-particularly in reference to my status as a practitioner of medicine,
-the idea, for obvious reasons, was repellent, notwithstanding the
-fact that my identity should not be disclosed. But after mature
-deliberation, I realized that it is largely due to this natural
-reticence on the part of those in position to speak, that the
-unfortunate addict is regarded<span class="pagenum" id="Page_141">[Pg 141]</span> as a social pariah by the general
-public, and that until the medical profession shall acquire more
-accurate and less distorted knowledge of this serious question, we
-cannot hope for any improvement along these lines. Until this is done,
-cruel and unjust laws will be enforced, wretched victims will be
-imprisoned as felons, and what is more distressing, these unfortunates
-will, in many instances, be subjected to torture to which death is
-preferable—and not infrequently results. All this is based upon the
-accepted theory that drug addiction is a vicious habit requiring only
-a little fortitude and strength of will on the part of the wretched
-victim to rid himself of it, while the saddest feature of it all is
-that this canker, eating at the very heart of the nation itself,
-blighting and destroying the lives of many useful men and women, is not
-being reached.</p>
-
-<p>That the average medical men can remain so hopelessly, I might say
-criminally, negligent of the true conditions of drug addiction is
-a cause for wonder as well as condemnation. If the perusal of my
-paper induces even one conscientious physician to seek more definite
-information upon this tremendously vital subject, my efforts shall not
-have been in vain. And now for my story.</p>
-
-<p>At the age of 24 I had finished my medical and hospital courses and was
-ready to begin my career. My plans had long been formed with reference
-to entering the army as a surgeon; the decision having been made for
-two reasons, first as a matter of predilection; secondly, for lack of
-means to sustain me during the time usually required to establish a
-private practice.</p>
-
-<p>Then a tragedy occurred that blasted my hopes for the army and altered
-my entire future.</p>
-
-<p>The examinations were scheduled for the late spring; in January I
-had come down from my home in New England to New York to complete
-some clinical work. Generally, I was in bad shape, and about that
-time I began having attacks very suspicious of angina pectoris.
-Finally I consulted a great specialist, who after thorough and
-repeated examinations, frankly told me that from overwork and long
-hours of study my heart had become enlarged and badly disordered
-functionally—that<span class="pagenum" id="Page_142">[Pg 142]</span> I need never hope to pass the physical examination
-required for entrance to the army. He prescribed rest and freedom from
-care—two remedies entirely beyond my reach.</p>
-
-<p>It was then that I went to a far distant city in the West to begin my
-career on a small amount of borrowed capital. It would be useless to
-dwell upon my struggles, hampered as I was by lack of funds and ill
-health, but in due time I became established. During the first few
-years my heart attacks were infrequent, but as work increased they
-returned, especially after an attack of typhoid fever which left my
-heart in a most disturbed state. Naturally, all remedies were tried
-with an occasional rest, but to no avail. One night after a very trying
-day I was called to an obstetrical case; while hurriedly dressing I
-felt the premonitory symptoms of a heart attack; it was then in a state
-of desperation T took my first hypodermic. The attack was aborted, but
-the next day I was desperately sick. I may here add that at no time did
-I ever experience any of the ecstatic sensations described by some from
-a dose of morphine—it steadied my heart, but for some time after it
-was followed by a general malaise.</p>
-
-<p>My obstetrical work increased rapidly and I frequently found it
-necessary to resort to the one remedy that proved efficacious. As was
-natural the time came when I found that the daily necessity had become
-fixed.</p>
-
-<p>Having been taught that it was only a habit that required self will and
-force of character to abandon—both of which I knew I possessed—I was
-not particularly worried, as I had planned a long vacation when summer
-came, which I would devote to the accomplishment of my purpose. But for
-certain unavoidable reasons the vacation became impossible, and the
-next winter found me with added responsibilities.</p>
-
-<p>During all this time I had constantly struggled against the increase of
-the drug. If under great pressure I was obliged to take an additional
-amount, as soon as it was over I began to reduce. There were occasions
-when I succeeded in taking only a fraction of my accustomed dose, but
-if a call came, I was either obliged to refuse it, or resort to the
-needle.</p>
-
-<p>While naturally I had taken no one into my confidence, the habit
-had been so insidious and gradual that I had failed<span class="pagenum" id="Page_143">[Pg 143]</span> to realize how
-necessary it was that it should not be suspected. I did not consider
-myself an addict and only awaited a propitious occasion to relieve
-myself of it, but that winter I awoke to the realization that some
-radical step must be taken or my professional reputation would be
-damaged.</p>
-
-<p>In the midst of this perplexity I developed an attack of la grippe and
-judging from past experience I felt that I would be confined to the
-house for some time, so resolved to take advantage of the enforced rest
-and abandon the use of the drug.</p>
-
-<p>It was a hazardous and probably unwise decision, but I reasoned it
-was for the best. At the end of three weeks, after days and nights of
-physical and mental torture, I was able to leave my bed, freed from
-the specter that had haunted me, but for the time a wretched type of
-humanity. Four weeks of rest in the country enabled me to return to
-my practice, and although the heart attacks mercifully remained in
-abeyance, it was only by sheer force of will that I could accomplish my
-routine work, resting every spare moment that was afforded me, often
-refusing calls.</p>
-
-<p>At the end of six months my work had so increased that the heart
-symptoms began to trouble me. The situation was desperate. Besides a
-wife and two children depending upon me I had other obligations, and
-was still in debt from my illness. I was unfitted for any other form of
-business.</p>
-
-<p>I shall not enter into a discussion of the ethics of my act, but after
-sleepless nights of deliberation I reached the decision to return to
-the remedy that alone would enable me to attend to my duties, knowing
-all that it involved, but hoping that by constant vigilance to lessen
-the baneful effects of the drug until some day when I should be free to
-leave off work and again be cured.</p>
-
-<p>During the years that followed, this object was ever before me,
-always fighting against an increase, devoting my vacations always
-to the same cause. In a measure I succeeded. I never progressed to
-extremely large doses, and I watched for and combatted any possible
-symptoms of peculiarity or degeneration that are supposed to obtain
-with the addict. I felt no sense of moral inferiority or degradation,
-nor did I deplete<span class="pagenum" id="Page_144">[Pg 144]</span> my strength with useless anticipation of dreaded
-possibilities. I would do all that lay in my power to preserve myself
-and the future lay in the hands of fate.</p>
-
-<p>During these years success came to me. My clientele grew both in size
-and character. Positions of trust were conferred upon me, such as
-the examinership for some of the most important insurance companies,
-presidency of the County Medical Society, etc. I was elected visiting
-physician to two of our largest hospitals, and for some years did
-special work for the federal government, the nature of which for
-obvious reasons I do not care to mention.</p>
-
-<p>In mentioning these facts, I do so with no vainglorious idea
-of boasting, but simply to record the history of my career. At
-the same time I used sometimes to ponder over the anomaly of my
-position—realizing with what horrified promptness the public would
-strip me of my honors, and transform its patronage and good will
-to contempt and pity, if it suspected the truth, although from its
-continued patronage my work was evidently entirely satisfactory. Even
-my intimate friends would shrink from me if the truth were known. Yet
-my philosophy and natural optimism sustained me.</p>
-
-<p>It was at the end of about fifteen years that my circumstances were
-such that I felt in position to leave off work and take the long
-anticipated “cure.” The institution selected was one whose methods
-seemed most reasonable. I stated to the specialist that I was anxious
-to be cured as rapidly as possible, and was willing to undergo whatever
-was necessary, to the limit of my endurance.</p>
-
-<p>The three weeks that followed I remember as a horrid nightmare of
-mental and physical agony. The method was not intended to be harsh, and
-the physician was well-intentioned, though far from scientific.</p>
-
-<p>In my desire for rapid recovery I overestimated my powers of endurance
-and my nervous system sustained a shock from which it has never
-recovered, but I persisted, with the assistance of my wife who remained
-with me and without whose assistance I should have lost my reason.</p>
-
-<p>When I left the sanitarium I was no longer an “addict,” but a wretched
-neurasthenic. Naturally the possibility of returning<span class="pagenum" id="Page_145">[Pg 145]</span> to my practice
-in this condition was not to be thought of so I began making plans
-to spend the winter in southern California. Here again the fates
-interposed. It was the autumn when the sudden financial panic swept the
-country, wrecking the fortunes of so many and tying up the resources
-of so many others. I was among the latter. There was nothing for me to
-do but to return to practice which I did after a further rest of six
-weeks—I need not add that in a short time I was again depending upon
-the drug to sustain me in the work that I was obliged to resume.</p>
-
-<p>During the next five years I directed every energy towards shaping my
-affairs with the one end in view—that of retiring from practice and
-getting permanently well. By this time my two sons had finished their
-education and were established. My income was sufficient to provide
-us with the comforts, if not the luxuries of life. So with a heavy
-heart, but with a feeling of gratification, I abandoned the practice
-that I had acquired and sustained through so many years of bitter and
-sometimes heart-rending struggles.</p>
-
-<p>My hopes for speedy restoration were doomed to disappointment. I should
-have realized that when release suddenly came from the long years of
-daily combat with so powerful an antagonist, a decided reaction must
-be the natural sequence. It came in the form of an almost complete
-prostration, that only by force of will prevented from permanently
-overcoming me; but more than two years elapsed before I felt equal to
-the effort of again submitting myself to treatment.</p>
-
-<p>This time I selected a well-known specialist in the Middle West. I
-bared my entire life to his scrutiny, placing myself absolutely in his
-hands. Forty-eight hours as an inmate of the institution convinced me
-that I had made an unfortunate selection; but from a sense of false
-pride at being a “quitter” and a belief in my own powers I remained.
-The methods were absolutely crude and unscientific, the food poor and
-unsuitable, and the entire environment unfitted to the well being of
-such patients as I was.</p>
-
-<p>At the end of seven weeks I was visited by the one most interested in
-me, who took me from my bed, from which I could not have arisen without
-assistance, and brought me<span class="pagenum" id="Page_146">[Pg 146]</span> East. It is true that the amount of the
-drug that I had been taking had been reduced to a very small amount,
-but at the expense of a badly shattered nervous system which required
-many months to regain even its partial normal status.</p>
-
-<p>This fall I am in New York and have placed myself under the care of a
-physician who, while not claiming to be a specialist has, in my opinion
-and the opinion of many others, the clearest conception of the meaning
-of drug addiction and its pathology. His opportunities for the study
-of these cases have been most unusual. His methods are both humane and
-scientific. Through him I have the hope that should time be allowed
-me I shall when I am summoned to the great unknown, be freed from the
-chains that so long oppressed but failed in the end to overwhelm me and
-compass my ruin.</p>
-
-<hr class="tb" />
-
-<h5><span class="smcap">Drug Addiction from the Viewpoint of an Afflicted Physician</span></h5>
-
-<p class="center"><span class="smcap">By a Prominent Medical Man, Formerly a Health Official of an
-American City</span></p>
-
-<p>Maximum efficiency of every individual member of this nation is
-necessary today as never before in its history. Hence any condition
-responsible for lessened efficiency on the part of thousands of
-citizens is a thing to be seriously considered, especially when among
-these are to be found a large proportion of men and women who would
-otherwise be useful workers in every important field of activity.</p>
-
-<p>Addiction to narcotic drugs is today depriving the country, either
-wholly or partially, of the services of thousands of individuals who
-but for this handicap would be entirely fit (many of them preeminently
-so) for work of the utmost importance. This is a problem of the first
-magnitude and one which will have to be solved largely by the medical
-profession.</p>
-
-<p>But the medical profession as a whole is utterly lacking at the present
-time in such knowledge of addiction as is needed to enable them to
-attack the problem. For these reasons I feel it to be my duty to do my
-“bit” as a medical man, to put on record some of the lessons which,
-from years of personal experience, I have learned as to addiction
-itself, and the<span class="pagenum" id="Page_147">[Pg 147]</span> methods of treatment with which I have had experience
-in my efforts to be cured.</p>
-
-<p>The subject is too important to excuse anything but the utmost
-frankness in speaking of the serious misconception which medical men
-only too generally share with the masses in regard to the subject of
-addiction. Unless the profession realizes its own ignorance, all point
-will be taken from the appeal which I wish to make to the physicians of
-this country to lose no time in equipping themselves to deal adequately
-with this great problem.</p>
-
-<p>It may well be imagined that the task which I have thus set myself is
-no easy one, viewed from any one of half a dozen angles. Yet, if I am
-correct, in believing that I can thereby make a small contribution to
-the cause which now means so much to all of us, I must do so regardless
-of every difficulty.</p>
-
-<p>Addiction with me goes back a number of years, covering in fact, almost
-my entire career as a physician. During this entire time, as will be
-more fully referred to, I have tried cure after cure, besides having,
-time and again, sought by own efforts to rid myself of this burden. I
-have naturally during these years studied and thought much about the
-problem which has meant so much to me. All this by way of showing why I
-believe that my experiences and opinions should have some value.</p>
-
-<p>First of all, let it be clearly understood that the addiction which
-I shall discuss is limited strictly to opium and its derivatives;
-first, because my own experience is limited to this group and, second,
-because much that I shall have to say does not apply to all so-called
-habit-forming drugs to an equal extent, and to some of them not at all.
-Addiction as thus limited is as true a disease as any with which the
-human body is afflicted.</p>
-
-<p>To look on the opium addict as a man with a vicious habit which
-he could quit if only he truly cared to do so displays a profound
-misunderstanding of plain facts. As well claim that a man with typical
-malarial infection has simply become so accustomed to having chills and
-fever at a given hour on certain days that when this hour arrives he
-quakes through mere habit as to claim that the equally characteristic<span class="pagenum" id="Page_148">[Pg 148]</span>
-and even more pronounced and distressing symptoms which manifest
-themselves when the addict is deprived of his drug are due to habit,
-that is, to “a condition which by repetition has become spontaneous.”</p>
-
-<p>We would, as a matter of fact, be less absurd in the former instance
-than in the latter; for we could argue the case out with our malarial
-friend, telling him he could conquer his “habit” by the exercise of
-will power, and—provided we argued long enough—we might convince
-ourselves that we were right because he would cease to shake, his fever
-would subside and until the next crop of parasites was turned loose
-in his blood stream, he would to all intents and purposes feel a well
-man, while in the latter case the more we talked of habit—that is, the
-longer the addict was deprived of his dose—the plainer would become
-the picture of a disease-racked body and a tormented mind.</p>
-
-<p>I do not, of course, mean to offer the above comparison as either
-perfect in itself, or as sufficient to establish the claim that
-addiction is a true disease. The fact that it is a disease has
-impressed itself on all competent observers of a sufficient number of
-cases, and must be accepted. Yet it is astonishing to find that many
-educated physicians do not know this, while an even larger number,
-though readily admitting that addiction is a disease, nevertheless
-show, both by their manner of discussing the subject and by their
-attitude towards addicts seeking their advice, that this is little more
-than a verbal concession on their part.</p>
-
-<p>If, however, it be argued that the contention as to addiction being a
-disease is vitiated by the fact that an occasional addict stops taking
-his drug by “will power,” that is, without taking treatment, we can
-point to an even larger proportion of mild cases of malarial fever in
-which spontaneous cure has come about. But this does not prove that the
-one, any more than the other, is not a disease.</p>
-
-<p>Indeed, there could be no stronger argument in favor of the fact that
-addiction is an actual disease than the very phenomena presented by the
-occasional addict who stops taking the drug by “will power.” Neither
-medical writers nor literary geniuses, whether themselves addicts or
-mere observers,<span class="pagenum" id="Page_149">[Pg 149]</span> have yet succeeded in presenting a true picture of
-the tortures which this involves. There could be no greater error than
-to regard cure as dating from the time the last dose was taken. When,
-in these cases, cure comes at all, it is only after weeks, or months,
-of horrible existence, during which kind nature brings about a more or
-less complete restoration of body and mind not alone from the disease
-of addiction, but also from the profound shock of unskilled or unwise
-withdrawal. Will power has enabled the addict to abstain from taking
-the drug, while nature cured the disease.</p>
-
-<p>There has been no time during all the years of my addiction that I have
-not earnestly longed to be free from its clutches. This is sufficiently
-proved by the many efforts which I have made to find a cure, each time
-at great personal sacrifice and expense, each time only to have my
-hopes shattered, after untold suffering and fresh disillusionment.</p>
-
-<p>But a real cure I have thus far been unable to find. I have tried
-everything that seemed to offer a chance: gradual reduction,
-self-conducted and at institutions, the Keeley cure several times,
-and since then all of the vaunted cures, as each appeared in turn,
-advocated by men of high standing in the medical profession. Concerning
-this last class, I have each time hoped that such men could not
-be totally in error as to the practical results of their methods,
-notwithstanding what has seemed to me the most bizarre pathology on
-which they have claimed these methods to be based.</p>
-
-<p>I might, perhaps, have been warned by certain palpable danger signs,
-but I have been too anxious to find the cure. I cared not at all how
-mistaken their pathology; for I could not believe that men of such
-standing could be equally mistaken as to the success or failure of what
-went on under their very eyes.</p>
-
-<p>And right here let me set down what has impressed me as inexcusable
-neglect of these cases by most of these self same “big” men of the
-medical profession. One after another I have found physicians who
-receive and undertake to treat cases of addiction brought to them by
-the lure of high professional reputation and medical articles in which
-is painted<span class="pagenum" id="Page_150">[Pg 150]</span> a glowing picture of some new and wonderful cure. And, one
-after another, I have found these men of high professional standing
-giving to their cases not even enough time and attention to enable them
-to form an intelligent opinion as to their condition and progress, much
-less what would be needed for the proper study and treatment of one of
-the most difficult and distressing ailments which afflict mankind.</p>
-
-<p>Moreover, comparing notes with medical men who have been fellow
-patients under similar circumstances (many of them, I may remark, of
-the highest type, as men and as physicians), there has been among us a
-universal sense of shame and indignation that men with such reputation
-and standing should lay the medical profession open to the justly
-founded criticism of extortion and neglect of duty, frequently of
-seemingly rank commercialism, even including the splitting of fees with
-quacks and charlatans of the worst sort.</p>
-
-<p>In saying that I have found no cure, I do not mean that I have never
-succeeded in getting to the point where I could get along for shorter
-or longer periods without the drug. Many times I have succeeded by
-myself in gradually reducing the dose to a minimum and then making the
-final plunge and taking none at all for some time. What this has meant
-I will not undertake to describe. Several times I have managed to keep
-from using the drug for a while after taking treatment of one kind or
-another. But have I been cured?</p>
-
-<p>Let no one thoughtlessly reply that the very fact of my having on
-each of these occasions reached a point where, according to my own
-statement, I was able to live without the drug, constitutes proof
-that I was cured, or that when I started to use it again I was merely
-yielding weakly.</p>
-
-<p>What has actually happened has been this. Each time that I have
-succeeded, in one way or another, in reaching a point where I was no
-longer taking the drug, I have, even while the suffering was still
-acute, been filled with a sense of happiness and hope that enabled me
-to stand it thankfully. I have argued with myself that, being then
-able even to exist without the drug and, for a while finding this
-existence day by day a little less of torture, I might reasonably hope
-for continued improvement. I have not expected miracles, but I<span class="pagenum" id="Page_151">[Pg 151]</span> have
-felt that each week should be easier, until, after a period of some few
-months, I should again be normal.</p>
-
-<p>But this has not come about. Always I have reached a point where
-progress seemed to stop, and beyond this point my system refused to
-react. Occasionally this standstill has been quickly reached, that is,
-I could not react beyond a point where I was unable to sleep, where
-my legs ached atrociously, and where I was so completely unstrung
-that life was unendurable. At best, progress has continued for a few
-weeks, after which, though resting well, having a prodigious appetite
-and not undergoing marked physical suffering, I have actually been far
-from normal. This was shown, on these special occasions, chiefly by my
-inability to do satisfactory work, by my tiring altogether too easily
-and by a general feeling of unrest and disquietude.</p>
-
-<p>I realize the difficulty of so describing my condition during these
-most favorable occasions as to show at all convincingly that I was not
-actually cured and that, in consequence, my resuming the taking of the
-drug was anything but a relapse. This, however, I must not attempt to
-do, since the main contention which I wish to make is here directly led
-up to.</p>
-
-<p>And, hard as is the whole task I have set myself in writing this
-account, this special part of it is peculiarly difficult, involving
-the risk of appearing to set a false value on certain personal
-considerations.</p>
-
-<p>My life has been an active and useful one. I have done work which I
-know to be good and which has brought recognition. Successful work,
-even in a given line of endeavor, is not always due to the same
-qualities in different men. My own work has been characterized by
-the exercise of careful judgment and the power of accurate analysis,
-qualities which I have always been credited with possessing. Now, after
-the most favorable of the so-called treatments which I have taken,
-and after allowing considerable time for complete recovery, I have
-in no instance regained these most essential requisites for my work,
-and thus I have been placed in a position where I would either have
-had to discontinue my work, or else do the only thing which made the
-resuming of that work possible. And always there has been the absolute<span class="pagenum" id="Page_152">[Pg 152]</span>
-conviction that this state of affairs was due to my not having been
-actually cured. On this point there has not been one iota of doubt.</p>
-
-<p>Perhaps if I had been able at such times to take a complete rest of
-six months or even a year, I might have been fully restored, but this
-has not been possible. I have not been able to remain away from work
-for over five or six weeks after the “cure” proper, and even this has,
-as may well be understood, been a severe drain, when I have taken some
-cure or other at as short intervals as I could manage to get together
-sufficient funds and the opportunity to leave my practice.</p>
-
-<p>Of course it may be argued that, rather than return to the use of
-the drug and thus again be able to live a life as nearly approaching
-normal as is possible for an addict, it would be better to refrain
-from using the drug, even though this involved never again being able
-to do those things which, to the ambitious man, are essential to make
-life worth the living. I submit that it is a high motive and not a
-low one which makes a man willing to pay the price rather than live a
-vegetative existence when he knows himself capable of better things.
-To understand this point of view it must be remembered that the addict
-gets no rosy dreams, no wonderful journeys into a beautiful and unreal
-world, no artificially enhanced powers beyond those of the non-addict,
-but at best only such equanimity and energy as are the latter’s happy
-possessions.</p>
-
-<p>My point, therefore, is that my resorting to the drug after having
-stopped its use a number of times does not mean that I have many
-times been cured, and many times relapsed, but that I have not been
-truly cured. When the latest “cure” which I have taken has left me,
-even after weeks, still suffering acutely and continuously, and not
-improving in the slightest so far as I could see, I have taken the
-drug again for relief from torture no longer bearable. After “cures”
-which have left me in decidedly better plight but in the intolerable
-condition last described above, and with progress at a standstill, I
-have taken the drug only after calmly surveying the situation, and as
-the lesser of two evils.</p>
-
-<p><span class="pagenum" id="Page_153">[Pg 153]</span></p>
-
-<p>I must reiterate my strong desire to find a cure, a real cure, one
-deserving the name; that is, a cure which will leave me normal, without
-need of the drug, and able to do the work which I must do in the world
-unless I am willing to be a slacker. But until I can find such a cure
-(and, in spite of my unhappy experiences, I will keep up the quest) I
-would have only contempt for myself as a physician and as a rational
-being if I failed meanwhile to make the best compromise possible,
-namely, to take each day, just as I would take thyroid substance were
-I suffering from hypothyroidism, a sufficient amount of morphine to
-enable me to attend to life’s duties and to occupy in the world that
-useful place which my qualifications enable me to occupy.</p>
-
-<p>One of the great hardships under which every addict suffers is the
-constant dread lest his affliction become known and he be branded a
-“morphine fiend,” a term which should be prohibited, or at least never
-used by an intelligent physician. What this exposure would mean to a
-man of standing in his community I need not explain. This risk he must
-always run, but it would be robbed of some of its terror if the nature
-of addiction were better understood.</p>
-
-<p>Therefore the law now existing in some states requiring the
-registration of addicts is little short of barbarous. So little
-possible good can be accomplished by this law that one is tempted
-to believe that its passage was not instigated primarily by honest,
-though misguided zealots but by quite another class. The addict, in his
-efforts to find a cure, has learned something of a class of men, who,
-posing as public benefactors, are in reality a shrewd set of rascals,
-capitalizing the misfortunes of the addict most successfully. If such
-men were not the originators of the idea of registration, certainly
-they, and not the body politic, are its chief beneficiaries, since it
-affords them an authentic list of prospective victims.</p>
-
-<p>As for the effect of this law on the addict, it merely adds further to
-his dread of exposure. Think of the position of a man of prominence
-and respected in his community, having his own feelings as have other
-men, holding equally dear the sensibilities of those he loves, living
-under the constant dread that his necessities may any day force him to
-seek aid in a<span class="pagenum" id="Page_154">[Pg 154]</span> state in which his name will, as it were, be added to a
-rogues’ gallery!</p>
-
-<p>My plea is for realization of the great need for finding some means
-whereby the individual addict may get real relief and whereby addicts
-collectively may be restored to such condition as will render them
-capable of performing those services of which our country is now in
-need.</p>
-
-<p>I am confident that I am understating the case when I say that nine
-addicts out of ten earnestly desire to be cured. Why should they not?
-They get no pleasure out of taking the drug, but only relief from
-intolerable suffering which they must otherwise endure. Hence to be
-free both from this suffering and from the necessity of getting this
-relief by artificial, and at present exceedingly costly, means is bound
-to appeal to them. Most addicts, I am confident, are willing to go
-through whatever acute suffering may be involved in any really rational
-treatment which will, after a reasonable time, restore them to normal
-condition.</p>
-
-<p>Experiences such as I have described above are, I know, the rule and
-not the exception with those who have tried the various so-called
-cures. They can hardly be called satisfactory. Even admitting that they
-may prove successful in a small proportion of cases, relatively few
-addicts are able to find the means of taking them, such as I have been
-able to make for myself in the midst of a very active life.</p>
-
-<p>Surely a disease having so definite a symptomatology and, I believe,
-so plain a pathology, must be susceptible of rational cure. That such
-a cure has not yet been found by those who so loudly proclaim to
-have found one I honestly believe. Whether others have devised more
-promising lines of treatment I frankly do not know.</p>
-
-<p>But a cure must be found which does more than any I have succeeded in
-finding. In what other disease would a patient who, after reaching a
-certain point, beyond which he could not progress towards recovery, be
-told that from then on everything rested with him, although he himself
-knew that his need for help was really as great as it ever was? In what
-other disease would any physician worthy of the name calmly tell a
-patient that, having taken a “cure,” he was, <i lang="la" xml:lang="la">ipse facto</i>,<span class="pagenum" id="Page_155">[Pg 155]</span> cured,
-and become highly incensed when the patient pleaded that his condition
-was in many respects more desperate than before treatment?</p>
-
-<p>The medical profession must seriously study addiction. Of material
-there is, unfortunately, an abundance. Some high authority should see
-that every facility is afforded the proper persons for employing it.
-It is not unlikely that many of the “cures” which have been advocated
-have in them some elements of good, properly selected and properly
-applied in each individual case. Possibly competent investigation,
-furnished with every facility, might result in the discovery of a truly
-specific cure. I have long thought that there was such a possibility in
-more than one direction, but investigation of these would involve very
-careful and laborious work, as well as considerable cost. Here indeed,
-would seem to be a wonderful opportunity for philanthropy.</p>
-
-<p>But while such a specific cure would be an untold blessing, we need
-not find one in order to meet the situation—at least, much more
-successfully than it is being met at present. Coordination of the
-entire problem of addiction, in the hands of the few men whose work in
-this field is most promising (and the men I have in mind are not those
-with whose vaunted cures I have had such unhappy experiences) would
-almost certainly lead to valuable results.</p>
-
-<p>While every effort should be exerted to determine the best lines of
-treatment, meanwhile there is a great deal which should be done in
-other directions. Let the medical profession help in bringing about
-better understanding of addiction—first, of course, learning this
-themselves. Until the addict can be offered rational treatment, the
-profession should do what it can in making the lives of addicts
-less unbearable by removing from the public mind some of the gross
-misconceptions concerning addiction, seeing to it, especially, that
-these unfortunates are not stigmatized as “morphine fiends” and that
-they are given the means of obtaining, without risk and hardship and
-almost prohibitive cost, the supply of their drug which, until they are
-cured, is to them as necessary as the air they breathe.</p>
-
-<p>But the finding of a real cure or treatment—not necessarily<span class="pagenum" id="Page_156">[Pg 156]</span> specific,
-not a thing to be applied indiscriminately in every case, but a
-rational method of handling addiction as other well known diseases are
-handled—is the great aim, or, if it be that sufficient is already
-known by some men in the profession as to the rational handling of
-addicts, let these men be found and their services subsidized by the
-government and used to the fullest extent, in teaching others, and
-these still others, until there is built up a system extending over
-the entire country, capable and equipped for giving to every addict
-the opportunity for cure. This is a crying need in our country today.
-Surely there must be somewhere recognition of this fact and resources
-enough to make it possible for this need to be supplied.</p>
-
-<hr class="tb" />
-
-<h5><span class="smcap">A Plea for the Broader Consideration of Narcotic Drug Addiction by
-the Medical Profession</span></h5>
-
-<p class="center"><span class="smcap">By a Practicing Physician Who Has Met the Problem in His Own
-Family</span></p>
-
-<p>In view of a recent experience of mine in seeking intelligent medical
-help for a near relative whom I learned was a narcotic drug addict, I
-take pleasure in recounting experiences of the past few months in the
-handling of such a case, and in calling attention to the conditions
-which my investigations have shown me to exist in our profession.</p>
-
-<p>My line of professional activity had not brought me knowingly into
-touch with narcotic drug addiction, and I entertained the prevailing
-medical opinions in regard to it.</p>
-
-<p>About five months ago I received a letter couched in apologetic
-language from a practitioner in another state informing me that a
-younger brother of mine had been under his care for a number of days
-suffering from withdrawal symptoms occasioned by inability to purchase
-morphine, and advising me to place him in some institution where he
-could be restrained.</p>
-
-<p>I immediately began asking my colleagues where I could send such a
-case, and was amazed at the general lack of knowledge in regard to and
-sympathy for these unfortunates. In truth no one could point out a
-single institution where<span class="pagenum" id="Page_157">[Pg 157]</span> such a patient could be sent with any hope
-that he might be handled in a humane and intelligent manner.</p>
-
-<p>My investigations of the institutions they suggested showed this to be
-the fact.</p>
-
-<p>Most every one seems to regard those suffering from this condition as
-being of a lower order of humanity, unwilling or too weak-minded to
-help themselves and fit subjects only for association with what is
-commonly known as the “underworld.” I wish to say that I myself have
-undergone a very complete revision of mind regarding these cases since
-the case of my brother has compelled me to investigate them. I have
-known my brother too well and for too many years to believe that he can
-possibly be placed in any such category.</p>
-
-<p>I have made careful inquiries into the circumstances and origin of his
-addiction, and the results are absolutely convincing that the first
-administrations of the narcotic were to meet therapeutic indications
-and were continued without his knowledge or appreciation of its actions
-or ultimate results. I know that he has never experienced any pleasure
-from the narcotic, and I know that when the condition of addiction
-manifested itself he did not know what was the matter with him. He only
-knew that narcotic relieved intense suffering. I had never seen a case
-of addiction to my knowledge before I went to see him in response to
-the letter I received. The clinical symptomatology of withdrawal of
-an opiate was truly a revelation to me. That the condition from which
-these patients suffer is a distinct disease cannot be questioned by any
-intelligent observer.</p>
-
-<p>I have found that the majority of patients who begin the use of
-opiates do so in search of relief from pain, and are not aware of the
-fact for a long time that the suffering they endure when the drug is
-discontinued is due to a disease they have contracted. Apparently the
-medical profession is also ignorant of this fact.</p>
-
-<p>A more pathetic sight I have never seen than one of these patients who
-has been suddenly deprived of his medicine. They will tell you that
-they will become insane or be driven to suicide if they cannot obtain
-relief from their suffering. Hence their willingness to obtain the drug
-at any cost. I<span class="pagenum" id="Page_158">[Pg 158]</span> have come to believe that any man is justifiable in
-lying or stealing to escape the agonies I have witnessed.</p>
-
-<p>It seems a crime that we of the profession have gone so long without
-any attempt to study or understand the disease which we in our daily
-rounds are constantly creating. Certainly our standard medical
-literature contains little if anything of value in regard to this
-condition, and investigation of the claims and procedure of the widely
-advertised so-called “treatments” and “cures” readily convinces one of
-their unworthiness.</p>
-
-<p>I know that much can be done for the cure of these patients by an
-intelligent effort on the part of the medical profession, and a
-willingness to open their minds to the clinical facts of this condition
-and to handle it like other diseases.</p>
-
-<p>In search of information I have gotten into touch with cases of
-addiction other than my brother’s, and I find that the majority of
-them are desperately anxious to be cured. They tell me, however, that
-institutions such as jails, workhouses, lunatic asylums, alcoholic
-wards of the charity hospitals, and those that they have tried of the
-advertised cures are places of insufferable torture from which they
-emerge in worse condition than that in which they entered.</p>
-
-<p>There are estimated to be as many as 500,000 or more addiction cases in
-the State of New York alone. I ask in all earnestness, is it not worth
-while to try to do something more than we are doing for these sufferers?</p>
-
-
-<p class="center p2">PRINTED IN THE UNITED STATES OF AMERICA</p>
-<hr class="chap x-ebookmaker-drop" />
-
-<div class="chapter">
-<p><span class="pagenum" id="Page_159">[Pg 159]</span></p>
-
-<h2 class="nobreak" id="INDEX">INDEX</h2>
-</div>
-
-
-<ul class="index">
-<li class="ifrst">Abnormalities, getting rid of, in preliminary stage, <a href="#Page_83">83</a></li>
-
-<li class="ifrst">Acidosis in opiate addiction, <a href="#Page_48">48</a></li>
-
-<li class="ifrst">Addict, criminal or vicious, handling of, <a href="#Page_108">108</a></li>
-<li class="isuba">drug, as a surgical and medical risk, <a href="#Page_85">85</a></li>
-<li class="isubb">coöperation of, <a href="#Page_72">72</a></li>
-<li class="isubb">often unknown and unsuspected, <a href="#Page_7">7</a></li>
-<li class="isuba">honest, and need of competent medical care, <a href="#Page_109">109</a></li>
-<li class="isubb">and custodial care, <a href="#Page_28">28</a></li>
-<li class="isuba">medical, personal history of, <a href="#Page_140">140</a></li>
-<li class="isuba">mixed, <a href="#Page_115">115</a></li>
-<li class="isuba">narcotic, failure to understand, <a href="#Page_5">5</a></li>
-<li class="isubb">will coöperate and suffer, <a href="#Page_6">6</a></li>
-
-<li class="ifrst">Addicts, drug, accidental or innocent, <a href="#Page_28">28</a></li>
-<li class="isubb">age of, <a href="#Page_24">24</a></li>
-<li class="isubb">and influenza and pneumonia, <a href="#Page_86">86</a></li>
-<li class="isubb">majority of, <a href="#Page_17">17</a></li>
-<li class="isubb">often understand own cases, <a href="#Page_7">7</a></li>
-<li class="isubb">what type or class become, <a href="#Page_23">23</a></li>
-<li class="isuba">innocent and worthy, what shall we do with them? <a href="#Page_129">129</a></li>
-<li class="isuba">narcotic, average individuals, <a href="#Page_3">3</a></li>
-<li class="isubb">often men and women of high ideals, <a href="#Page_3">3</a></li>
-<li class="isuba">worthy and innocent, problem of, <a href="#Page_128">128</a></li>
-<li class="isuba">youthful, <a href="#Page_125">125</a></li>
-
-<li class="ifrst">Addiction, author’s definition of, <a href="#Page_20">20</a></li>
-<li class="isuba">beginning stage of, <a href="#Page_30">30</a></li>
-<li class="isuba">development of, <a href="#Page_29">29</a></li>
-<li class="isuba">disease, author’s conclusions, <a href="#Page_40">40</a></li>
-<li class="isubb">a chronic condition, <a href="#Page_93">93</a></li>
-<li class="isubb">in newly born infant, <a href="#Page_24">24</a></li>
-<li class="isubb">may afflict all classes, <a href="#Page_19">19</a></li>
-<li class="isubb">mechanism of, <a href="#Page_36">36</a>, <a href="#Page_41">41</a></li>
-<li class="isubb">rational handling of, <a href="#Page_61">61</a></li>
-<li class="isubb">treatment of, and legitimate medical practice, <a href="#Page_99">99</a></li>
-<li class="isuba">drug, a medical problem, <a href="#Page_28">28</a></li>
-<li class="isubb">among soldiers, <a href="#Page_117">117</a></li>
-<li class="isubb">and defectives, <a href="#Page_16">16</a></li>
-<li class="isubb">a plea for broader consideration of, <a href="#Page_156">156</a></li>
-<li class="isubb">and the average person, <a href="#Page_17">17</a></li>
-<li class="isubb">as a sequelae of war, <a href="#Page_120">120</a></li>
-<li class="isubb">contraction of, in the army, <a href="#Page_118">118</a></li>
-<li class="isubb">in surgical cases, <a href="#Page_85">85</a></li>
-<li class="isubb">medical problem of, <a href="#Page_21">21</a></li>
-<li class="isubb">methods of treating, <a href="#Page_50">50</a></li>
-<li class="isubb">origin of, <a href="#Page_25">25</a></li>
-<li class="isubb">so-called specific, treatment of, <a href="#Page_55">55</a></li>
-<li class="isubb">unsuspected, <a href="#Page_26">26</a></li>
-<li class="isubb">viewpoint of physician afflicted with, <a href="#Page_146">146</a></li>
-<li class="isubb">wrongly described, <a href="#Page_14">14</a></li>
-<li class="isuba">established, stage of, <a href="#Page_31">31</a></li>
-<li class="isuba">narcotic, a demonstrable disease, <a href="#Page_59">59</a></li>
-<li class="isubb">a recognized menace, <a href="#Page_4">4</a></li>
-<li class="isubb">classed as a vice or morbid appetite, <a href="#Page_4">4</a></li>
-<li class="isuba">opiate, as a war problem, <a href="#Page_117">117</a></li>
-<li class="isubb">complicated with cocaine, <a href="#Page_3">3</a></li>
-<li class="isuba">picture wrongly painted, <a href="#Page_2">2</a></li>
-
-<li class="ifrst">Adequacy, metabolic and organic, relation to other disease conditions, <a href="#Page_92">92</a></li>
-
-<li class="ifrst">Administration, narcotic drug, regulation of, <a href="#Page_65">65</a></li>
-
-<li class="ifrst">“After Care” or convalescence, <a href="#Page_53">53</a></li>
-
-<li class="ifrst">Age of addicts, <a href="#Page_24">24</a></li>
-
-<li class="ifrst">American Medicine, human documents from, <a href="#Page_137">137</a></li>
-
-<li class="ifrst">Antidotal substance, <a href="#Page_42">42</a></li>
-
-<li class="ifrst">Any one liable to drug addiction, <a href="#Page_8">8</a></li>
-
-<li class="ifrst">Attempts at administrative and police control, <a href="#Page_4">4</a></li>
-
-<li class="ifrst">Attitude of drug addict, <a href="#Page_71">71</a></li>
-<li class="isuba">of lawmakers to drug addiction, <a href="#Page_102">102</a></li>
-<li class="isuba">of medical profession, <a href="#Page_50">50</a></li>
-<li class="isuba">personal, of physician to drug addict, <a href="#Page_70">70</a></li>
-<li class="isuba">to drug addicts, author’s unjust, <a href="#Page_12">12</a></li>
-
-<li class="ifrst">Auto-intoxication and autotoxicosis, <a href="#Page_46">46</a></li>
-</ul>
-<ul class="index">
-<li class="ifrst">Balance, drug adequate, importance of establishing and maintaining, <a href="#Page_92">92</a></li>
-<li class="isuba">narcotic drug, and minimum daily need, <a href="#Page_66">66</a></li>
-<li class="isubb">and operative procedure, <a href="#Page_92">92</a></li>
-<li class="isubb">necessity of maintaining, <a href="#Page_67">67</a></li>
-
-<li class="ifrst">Basis of success, <a href="#Page_132">132</a></li>
-
-<li class="ifrst">Beacon-light of hope for drug addicts, <a href="#Page_14">14</a></li>
-
-<li class="ifrst">Belladonna, use of, <a href="#Page_55">55</a></li>
-
-<li class="ifrst">Bellevue Hospital, early work in alcoholic and narcotic wards, <a href="#Page_2">2</a></li>
-</ul>
-<ul class="index">
-<li class="ifrst">Care, custodial, and the honest addict, <a href="#Page_28">28</a></li>
-
-<li class="ifrst">Cases demonstrating presence of antidotal substance, <a href="#Page_43">43</a></li>
-
-<li class="ifrst">Catharsis, non-irritating, <a href="#Page_79">79</a></li>
-
-<li class="ifrst">Cause of withdrawal symptoms, <a href="#Page_38">38</a></li>
-
-<li class="ifrst">Causes of failure in solving drug problem, <a href="#Page_5">5</a></li>
-
-<li class="ifrst">Clinics, drug, need for, under competent medical direction, <a href="#Page_124">124</a></li>
-<li class="isuba">public, <a href="#Page_135">135</a></li>
-
-<li class="ifrst">Cocaine, habitual use of, <a href="#Page_115">115</a></li>
-
-<li class="ifrst">Committee appointed by Secretary of Treasury, report, <a href="#Page_14">14</a></li>
-
-<li class="ifrst">Complications, avoided by intelligent patients, <a href="#Page_78">78</a></li>
-
-<li class="ifrst">Conclusions of author, <a href="#Page_40">40</a></li>
-
-<li class="ifrst">Condition, another disease, relation of functional balance to, <a href="#Page_92">92</a></li>
-<li class="isuba">drug patient’s, as index of successful treatment, <a href="#Page_75">75</a></li>
-
-<li class="ifrst">Considerations, fundamental, <a href="#Page_11">11</a></li>
-
-<li class="ifrst">Convalescence, and “after care,” <a href="#Page_53">53</a></li>
-
-<li class="ifrst">Coöperation of drug addict, factors which determine, <a href="#Page_72">72</a></li>
-
-<li class="ifrst">Cure of drug addiction, What constitutes? <a href="#Page_76">76</a></li>
-
-<li class="ifrst">“Cures,” basis of, <a href="#Page_55">55</a></li>
-
-<li class="ifrst">Custodial care and the honest addict, <a href="#Page_28">28</a></li>
-</ul>
-<ul class="index">
-<li class="ifrst">Danger of restrictive legislation, <a href="#Page_123">123</a></li>
-
-<li class="ifrst">Dangers of belladonna, hyoscine, pilocarpine, etc., <a href="#Page_80">80</a></li>
-
-<li class="ifrst">Data, institutional, lack of, <a href="#Page_58">58</a></li>
-
-<li class="ifrst">Defectives and drug addiction, <a href="#Page_16">16</a></li>
-
-<li class="ifrst">Definition of term “narcotics,” <a href="#Page_114">114</a></li>
-
-<li class="ifrst">Deprivation, forcible, danger of, <a href="#Page_53">53</a></li>
-
-<li class="ifrst">Development of addiction stage, <a href="#Page_29">29</a></li>
-
-<li class="ifrst">Discontinuance of narcotic drug, difficulties of, <a href="#Page_69">69</a></li>
-
-<li class="ifrst">Disease, addiction, rational handling of, <a href="#Page_61">61</a></li>
-<li class="isuba">drug addiction, nature of, <a href="#Page_23">23</a></li>
-
-<li class="ifrst">Documents, human, <a href="#Page_137">137</a></li>
-
-<li class="ifrst">Dosage, narcotic drug, in relation to withdrawal symptoms, <a href="#Page_75">75</a></li>
-
-<li class="ifrst">Doses, therapeutic, and toxic stage of normal reaction to, <a href="#Page_29">29</a></li>
-
-<li class="ifrst">Drug, narcotic, balance, <a href="#Page_67">67</a></li>
-<li class="isuba">definite body need for, <a href="#Page_37">37</a></li>
-
-<li class="ifrst">Drugs, narcotic, and the physical condition established, <a href="#Page_21">21</a></li>
-<li class="isuba">may afford pleasure, <a href="#Page_3">3</a></li>
-<li class="isuba">legitimate use of, in peace and war, <a href="#Page_114">114</a></li>
-<li class="isuba">prescribing and dispensing of, <a href="#Page_100">100</a></li>
-<li class="isuba">relations of laws to, <a href="#Page_95">95</a></li>
-
-<li class="ifrst">Du Mez’s recent paper, <a href="#Page_38">38</a></li>
-</ul>
-<ul class="index">
-<li class="ifrst">Education and training, <a href="#Page_131">131</a></li>
-<li class="isuba">lay, medical and official, needed, <a href="#Page_109">109</a></li>
-<li class="isuba">neglect of, and illicit traffic, <a href="#Page_126">126</a></li>
-
-<li class="ifrst">Efficiency, functional, nutritional and metabolic importance of, <a href="#Page_92">92</a></li>
-
-<li class="ifrst">Efforts, author’s early, <a href="#Page_11">11</a></li>
-
-<li class="ifrst">Elimination, competent, not measured in bowel movements, <a href="#Page_81">81</a></li>
-<li class="isuba">of opiate, and cell tolerance, <a href="#Page_46">46</a></li>
-
-<li class="ifrst">Evils, chief, of present drug situation, <a href="#Page_122">122</a></li>
-
-<li class="ifrst">Exploitation, commercial, and its financial possibilities, <a href="#Page_125">125</a></li>
-<li class="isuba">of physical suffering, <a href="#Page_123">123</a></li>
-</ul>
-<ul class="index">
-<li class="ifrst">Facts concerning drug addiction, necessity for unbiased medical investigation of, <a href="#Page_101">101</a></li>
-<li class="isuba">significant, <a href="#Page_13">13</a></li>
-
-<li class="ifrst">Fear, constant, addict lives in, <a href="#Page_92">92</a></li>
-
-<li class="ifrst">Function, inhibition of, <a href="#Page_46">46</a></li>
-</ul>
-<ul class="index">
-<li class="ifrst">Gioffredi, investigation of, <a href="#Page_26">26</a>, <a href="#Page_38">38</a></li>
-</ul>
-<ul class="index">
-<li class="ifrst">Handling, institutional and custodial, and certain types of addicts, <a href="#Page_108">108</a></li>
-<li class="isuba">of criminal or vicious addict, <a href="#Page_108">108</a></li>
-<li class="isuba">preliminary to withdrawal, <a href="#Page_62">62</a></li>
-<li class="isuba">rational, of addiction disease, <a href="#Page_61">61</a></li>
-
-<li class="ifrst">Harrison Law, effect on medical profession, <a href="#Page_96">96</a></li>
-<li class="isuba">reasons for failure of, <a href="#Page_96">96</a></li>
-<li class="isuba">wise in purpose, <a href="#Page_95">95</a></li>
-
-<li class="ifrst">Hirschlaff’s experiments, <a href="#Page_26">26</a>, <a href="#Page_38">38</a></li>
-
-<li class="ifrst">History of medical addict, <a href="#Page_140">140</a></li>
-
-<li class="ifrst">Hyoscyamus, use of, <a href="#Page_55">55</a></li>
-</ul>
-<ul class="index">
-<li class="ifrst">Ignorance, the harmful effects of, <a href="#Page_127">127</a></li>
-
-<li class="ifrst">Immunity to narcotic drugs, <a href="#Page_4">4</a></li>
-
-<li class="ifrst">Inefficiency, medical, <a href="#Page_6">6</a></li>
-
-<li class="ifrst">Infant, newly-born, and addiction disease, <a href="#Page_24">24</a></li>
-
-<li class="ifrst">Influenza and pneumonia in drug addicts, <a href="#Page_86">86</a></li>
-
-<li class="ifrst">Information, clinical, paucity of, <a href="#Page_58">58</a></li>
-
-<li class="ifrst">Intervals, long, between doses, desirable, <a href="#Page_77">77</a></li>
-
-<li class="ifrst">Introduction, <a href="#Page_1">1</a></li>
-</ul>
-<ul class="index">
-<li class="ifrst">Jennings’ studies of acidosis, <a href="#Page_48">48</a></li>
-</ul>
-<ul class="index">
-<li class="ifrst">Kobert’s and Toth’s studies, <a href="#Page_38">38</a></li>
-</ul>
-<ul class="index">
-<li class="ifrst">Law, Harrison, failure of, <a href="#Page_96">96</a></li>
-<li class="isuba">makers, attitude to drug addiction, <a href="#Page_102">102</a></li>
-<li class="isuba">What has it done for the addict? <a href="#Page_102">102</a></li>
-
-<li class="ifrst">Laws and old conceptions of drug addiction, <a href="#Page_96">96</a></li>
-<li class="isuba">and their relations to narcotic drugs, <a href="#Page_95">95</a></li>
-<li class="isuba">drug, enforcement and increased suffering of addicts, <a href="#Page_96">96</a></li>
-</ul>
-<ul class="index">
-<li class="ifrst">Magendie’s findings, <a href="#Page_38">38</a></li>
-
-<li class="ifrst">Marme and oxydimorphine, <a href="#Page_38">38</a></li>
-
-<li class="ifrst">Mechanism, essential, of addiction disease, <a href="#Page_41">41</a></li>
-<li class="isuba">of narcotic drug addiction disease, <a href="#Page_36">36</a></li>
-<li class="isuba">of protection, <a href="#Page_47">47</a></li>
-
-<li class="ifrst">Medication, ignorant or unavoidable, and drug addiction, <a href="#Page_27">27</a></li>
-<li class="isuba">opiate, indispensable and legitimate, <a href="#Page_116">116</a></li>
-<li class="isuba">“specific,” fallacy of, <a href="#Page_56">56</a></li>
-
-<li class="ifrst">Misunderstanding of addict, cause of early failures in treatment, <a href="#Page_5">5</a></li>
-</ul>
-<ul class="index">
-<li class="ifrst">“Narcotics,” definition of term, <a href="#Page_114">114</a></li>
-
-<li class="ifrst">Need, drug, minimum daily, <a href="#Page_66">66</a></li>
-<li class="isuba">of the hour in study of drug addiction, <a href="#Page_130">130</a></li>
-<li class="isuba">narcotic drug, and mental and muscular work, <a href="#Page_69">69</a></li>
-</ul>
-<ul class="index">
-<li class="ifrst">Observation in Bellevue, sixteen months, day and night, <a href="#Page_3">3</a></li>
-
-<li class="ifrst">Observations on physical or body reaction, <a href="#Page_32">32</a></li>
-
-<li class="ifrst">Opiate, withdrawing, simply one stage, <a href="#Page_92">92</a></li>
-
-<li class="ifrst">Opiates, and their unique properties, <a href="#Page_116">116</a></li>
-
-<li class="ifrst">Organizations, medical duty of, <a href="#Page_104">104</a></li>
-
-<li class="ifrst">Origin of addiction, <a href="#Page_25">25</a></li>
-
-<li class="ifrst">Oxydimorphine and Marme theory, <a href="#Page_38">38</a></li>
-</ul>
-<ul class="index">
-<li class="ifrst">Panaceas, search for, <a href="#Page_56">56</a></li>
-
-<li class="ifrst">Patients, intelligent, and the avoidance of complications, <a href="#Page_78">78</a></li>
-
-<li class="ifrst">People, eminent, and drug addiction, <a href="#Page_27">27</a></li>
-
-<li class="ifrst">Philanthropy and its opportunity, <a href="#Page_135">135</a></li>
-
-<li class="ifrst">Physician, average, is inexpert in handling addiction disease, <a href="#Page_108">108</a></li>
-<li class="isuba">suffering from drug addiction, viewpoint of, <a href="#Page_146">146</a></li>
-
-<li class="ifrst">Physicians, honest, and their responsibility, <a href="#Page_103">103</a></li>
-
-<li class="ifrst">Pilocarpine, use of, <a href="#Page_50">50</a></li>
-
-<li class="ifrst">Practice, legitimate medical, <a href="#Page_95">95</a></li>
-
-<li class="ifrst">Practitioner, honest, and control of illicit drug traffic, <a href="#Page_123">123</a></li>
-
-<li class="ifrst">Principles, basic, of addiction-disease handling, <a href="#Page_65">65</a></li>
-
-<li class="ifrst">Problem, drug, still unsolved, <a href="#Page_5">5</a></li>
-<li class="isuba">of drug addiction, ultimate solution of, <a href="#Page_108">108</a></li>
-<li class="isuba">of the care of the innocent and worthy addict, <a href="#Page_129">129</a></li>
-
-<li class="ifrst">Profession, medical, attitude of, <a href="#Page_50">50</a></li>
-
-<li class="ifrst">Prostitution and “white-slavery,” <a href="#Page_125">125</a></li>
-
-<li class="ifrst">Protection, bodily, against opiate, <a href="#Page_42">42</a></li>
-<li class="isuba">mechanism of, <a href="#Page_47">47</a></li>
-
-<li class="ifrst">Pulpit and press, duty of, <a href="#Page_135">135</a></li>
-
-<li class="ifrst">Purgation, excessive, warning against, <a href="#Page_81">81</a></li>
-
-<li class="ifrst">Purpose, chief, of most lay and medical workers, <a href="#Page_96">96</a></li>
-</ul>
-<ul class="index">
-<li class="ifrst">Questions that confront the American people, <a href="#Page_136">136</a></li>
-</ul>
-<ul class="index">
-<li class="ifrst">Reaction, normal, stage of, <a href="#Page_29">29</a></li>
-<li class="isubb">to therapeutic and toxic doses, <a href="#Page_29">29</a></li>
-<li class="isuba">of drug addicts to therapeutic agents, <a href="#Page_68">68</a></li>
-
-<li class="ifrst">Reduction, enforced, below bodily need, dangers of, <a href="#Page_69">69</a></li>
-<li class="isuba">slow, <a href="#Page_51">51</a></li>
-
-<li class="ifrst">References to recent literature, <a href="#Page_39">39</a></li>
-
-<li class="ifrst">Regulation, legislative and administrative, <a href="#Page_105">105</a></li>
-<li class="isuba">of intervals of narcotic drug administration, <a href="#Page_66">66</a></li>
-
-<li class="ifrst">“Relapses” and production of antidotal substance, <a href="#Page_45">45</a></li>
-
-<li class="ifrst">Report, 1915, of New York Dept. of Correction, <a href="#Page_72">72</a></li>
-<li class="isuba">Preliminary, of Whitney Committee, <a href="#Page_110">110</a></li>
-
-<li class="ifrst">Responsibility for drug addiction laid on medical profession, <a href="#Page_102">102</a></li>
-
-<li class="ifrst">Restoration of drug addict to health, <a href="#Page_83">83</a></li>
-</ul>
-<ul class="index">
-<li class="ifrst">Side, personal, of drug addiction, <a href="#Page_137">137</a></li>
-
-<li class="ifrst">Solution of drug problem, ultimate, <a href="#Page_108">108</a></li>
-
-<li class="ifrst">Stage of study, preliminary to withdrawal, <a href="#Page_63">63</a></li>
-<li class="isuba">preliminary, abnormalities in, <a href="#Page_83">83</a></li>
-
-<li class="ifrst">Stages of addiction development, <a href="#Page_29">29</a></li>
-
-<li class="ifrst">Stool, “typical,” of Towns treatment, <a href="#Page_79">79</a></li>
-
-<li class="ifrst">Study, clinical and laboratory, lack of, <a href="#Page_91">91</a></li>
-<li class="isuba">of patient, essential as preliminary to withdrawal, <a href="#Page_63">63</a></li>
-
-<li class="ifrst">Substance, antidotal, to opiate, and bodily protection, <a href="#Page_42">42</a></li>
-
-<li class="ifrst">Suffering, physical, and drug addiction, <a href="#Page_20">20</a></li>
-
-<li class="ifrst">Survey of the situation, <a href="#Page_122">122</a></li>
-</ul>
-<ul class="index">
-<li class="ifrst">Terms that should be eliminated, <a href="#Page_9">9</a></li>
-
-<li class="ifrst">Testimony of Whitney Committee, deductions from, <a href="#Page_134">134</a></li>
-
-<li class="ifrst">Theories, author’s wrong, <a href="#Page_12">12</a></li>
-
-<li class="ifrst">Tolerance, explanation of, <a href="#Page_38">38</a></li>
-<li class="isuba">increased, stage of, <a href="#Page_30">30</a></li>
-
-<li class="ifrst">Traffic in narcotic drugs, illicit, <a href="#Page_103">103</a></li>
-
-<li class="ifrst">Treatment, importance of regulating intervals of narcotic drug administration in, <a href="#Page_65">65</a></li>
-<li class="isuba">rational, of addiction disease, <a href="#Page_61">61</a></li>
-<li class="isuba">so-called specific, <a href="#Page_55">55</a></li>
-<li class="isuba">specific, author’s disbelief in, <a href="#Page_80">80</a></li>
-</ul>
-<ul class="index">
-<li class="ifrst">“Underworld” and desperate necessity of addict, <a href="#Page_28">28</a></li>
-
-<li class="ifrst">Use, legitimate, of narcotics in peace and war, <a href="#Page_114">114</a></li>
-</ul>
-<ul class="index">
-<li class="ifrst">Valenti’s studies, <a href="#Page_26">26</a>, <a href="#Page_38">38</a></li>
-
-<li class="ifrst">Veterans, Civil War and drug addiction, <a href="#Page_24">24</a></li>
-
-<li class="ifrst">Views, personal and legal, of drug addiction, <a href="#Page_137">137</a></li>
-</ul>
-<ul class="index">
-<li class="ifrst">Whitney Committee. Hearings, testimony of, <a href="#Page_107">107</a></li>
-
-<li class="ifrst">Withdrawal accompanied by use of various drugs, <a href="#Page_51">51</a></li>
-<li class="isuba">forcible, and suicide, <a href="#Page_53">53</a></li>
-<li class="isuba">stage of, <a href="#Page_62">62</a></li>
-<li class="isuba">sudden, <a href="#Page_53">53</a></li>
-<li class="isuba">symptoms, <a href="#Page_35">35</a></li>
-
-<li class="ifrst">Withdrawing of opiate simply one stage, <a href="#Page_92">92</a></li>
-</ul>
-
-
-<p class="center p2">PRINTED IN THE UNITED STATES OF AMERICA</p>
-
-
-<hr class="chap x-ebookmaker-drop" />
-
-<div class="chapter transnote">
-<h2 class="nobreak" id="Transcribers_Notes">Transcriber’s Notes</h2>
-
-
-<p>Errors and omissions in punctuation have been fixed.</p>
-
-<p><a href="#Page_27">Page 27</a>: “physicial sufferings” changed to “physical sufferings”</p>
-
-<p><a href="#Page_39">Page 39</a>: “Deutch. med” changed to “Deutsch. med”</p>
-
-<p><a href="#Page_66">Page 66</a>: “normally functionating individual” changed to “normally
-functioning individual”</p>
-
-<p><a href="#Page_76">Page 76</a>: “continued maintainance” changed to “continued maintenance”</p>
-
-<p><a href="#Page_100">Page 100</a>: “oppose as illegitimatc” changed to “oppose as illegitimate”</p>
-
-<p><a href="#Page_101">Page 101</a>: “he is forccd” changed to “he is forced” “physical nced”
-changed to “physical need” “should mcet” changed to “should meet”
-“would be eagcrly” changed to “would be eagerly”</p>
-</div>
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