Title: The narcotic drug problem
Author: Bishop, Ernest S.
Language: English
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  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?


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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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