CHAPTER VI. The Rational Handling of Narcotic Drug Addiction-Disease

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avoided in it, and its final issue depend greatly upon the physical and reactive condition of the man from whom drug is withdrawn.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.