CHAPTER V. Remarks on Methods of Treating Narcotic Drug Addiction

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.