CHAPTER II. Fundamental Considerations

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.