CHAPTER III. The Nature of Narcotic Drug Addiction-Disease

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.

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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.