CHAPTER VII

RELATION OF NARCOTIC DRUG ADDICTION TO SURGICAL CASES AND INTERCURRENT DISEASES

It is a common idea in the minds of both surgeons and physicians that an addict to narcotic drug is a difficult case for surgical handling and is a poor surgical risk. Numerous instances of surgeons refusing to operate upon a narcotic addict until the addict should have “stopped” the use of the drug, voice the almost prevailing attitude.

Very many, if not most, internists and practitioners view with gravest concern the presence of addiction in a serious illness coming under their care.

That the addict has borne this undeserved reputation as a poor surgical and medical risk, and that this reputation has been seemingly merited by previous medical and surgical experience, is not to be laid at the door of the existence of addiction in the patient. It is to be laid at the door of insufficient medical comprehension of addiction-disease and its mechanism in its material manifestations, and in its functional and organic influences, and at the door of inadequate clinical study into the analysis, estimation and control of these. Like much else that has been for generations generally accepted as true about narcotic drug addiction, the belief is erroneous that the addict is a poor surgical and medical risk because he is an addict.

As a surgeon once stated “These addicts have no resistance, and they go right out.” Swayed by the old conception of addiction, this more than ordinarily humane and generous-hearted man had not the slightest suspicion as to why the addicts that he had operated upon had displayed no resistance and had tended to “go right out.” He had in his mind simply the then prevailing and practically unquestioned conception of the narcotic addict, and he had not the slightest suspicion that a definite physical disease, whose mechanism should have received intelligent clinical handling and control was complicating the surgical cases of the addicts who went right out. He had based, as all of us once did, his opiate medication on his materia medica conception of therapeutic dosage instead of on the demands of an addiction-disease mechanism. It is rumored that more than one illustrious life, full of past accomplishment and potential future benefit to humanity and society, has ended in this way.

The above statements do not apply to surgery alone. They are equally true of medical conditions. Dominated by their teachings as to opiate dosage in ordinary therapeutics, and by the older “habit” conception of addiction, with little or no instruction as to the dosage indications of addiction-disease, most practitioners, institutional and private, do not adequately conceive and have no basis for determination of opiate dosage in this disease. They do not believe that the addict physically needs nor do many of them realize that the addict can physically tolerate what seems to them such dangerous and lethal amounts, and they tend to ascribe his statements of usual dosage to mental “cravings” to which they refuse to pander. Many appreciate that such patients have often to be very carefully watched to prevent their suicide and that many of them die, but fail to comprehend that these events may be ascribed to inability to longer endure the suffering and physical incompetency of body-need for opiate medication.

The recent epidemic of influenza and pneumonia furnishes examples of the importance of recognizing addiction-disease mechanism in intercurrent diseases. A number of instances have come to my attention. One of them is of particular interest because of the graphic picture presented by a series of sphygmographic tracings showing the physical organic dependence upon opiate in the circulation of an addict. It may be said in passing that these tracings and others made upon addicts in partial or complete opiate withdrawal parallel similar tracings by other clinical observers, and also those made by experimental laboratory workers upon addicted dogs.

The subject of these tracings was a man well-known and prominent in his community, 63 years of age, suffering from pneumonia with marked and persisting cardiac and circulatory deficiency which did not respond to the administration of the usual circulatory stimulants even in very large doses. I was called in consultation. Found the patient very weak and exhausted, with facial expression of protracted suffering and anxiety and despondency. Morphine in usual therapeutic doses had been daily administered for relief of pain, restlessness and sleeplessness, being insufficient however to control those manifestations. Pulse was, as shown in tracing number 1, very weak and intermittent. It was impossible to account for the whole clinical picture and history on the grounds of a typical pneumonia, present or resolving. Opiate addiction was suspected and the patient questioned. He had been suffering from opiate addiction-disease for many years, his addiction developing unsuspected by him as a result of medication for a painful and protracted condition many years previous. He begged to be allowed to die without his wife and son being told of his affliction. The following tracings made upon him are very instructive and significant, and cannot be interpreted upon any grounds of psychical explanation of addiction phenomena.

The last dose of morphine prior to these tracings was one-eighth of a grain given at 3:30 P. M.

First tracing (number 1) was made about 6:00 P. M.

Tracings 2, 3 and 4 were made at about fifteen minute intervals. They were made following experimental hypodermic injections of morphine sulphate to determine the extent of opiate need and organic dependence upon opiate medication, and the amount of opiate required to restore organic function and tone.

Tracing number 4, taking into consideration the asthenic and exhaustion condition of the patient, shows full support to circulation with some overaction.

Tracing number 5 was taken an hour or two after tracing number 4 to determine the holding power of the dosage administered, after the circulation had reacted from the immediate stimulation of the opiate medication. This tracing, interpreted and considered together with the clinical manifestations at the time, was decided to be about normal for that patient at that time.

This patient would have died, not from pneumonia with cardiac complications, but from insufficient control of the mechanism of opiate addiction-disease.

On balanced and indicated daily morphine dosage, patient made very rapid recovery and has continued well and active.

Such cases as this, where addiction-disease co-exists or is intercurrent with other medical or with surgical conditions, are not as uncommon as may be supposed. That they are frequently unrecognized the histories of many narcotic addicts demonstrates, and is discussed later. Board of Health and Insurance mortality statistics are undoubtedly very incomplete upon this situation. Addiction, regarded as a habit or indulgence, may easily be overlooked or disregarded as a cause of death, direct or contributing. It may easily be omitted from returns made out, however actually important a part in the final issue may have been played by the influences, upon body function and upon physical resistance and recuperation, of an unappreciated and inadequately controlled addiction-disease.

It is earlier stated that the common idea of the addict to narcotic drugs as a poor risk is an undeserved reputation, and is not to be laid at the door of addiction existence itself. In very many cases of opiate addiction, the opposite of the popular belief is true. The opiate addict, if his addiction mechanism is competently appreciated, its reactions accurately estimated, and its influences wisely controlled, is quite other than a bad risk. Indeed the mechanism of addiction and the opiate which caused it can often be handled in such a way in the control of glandular, circulatory, nervous and other function and reaction as to aid in the carrying over of emergencies, medical and surgical. A case in point is an emergency operation on the pancreas, performed upon a man in extremis, whose unexpected recovery and convalescence astonished all observers by being remarkedly rapid and uncomplicated, due unquestionably in large part to the early recognition and clinical handling of his addiction-disease, and the possibilities it created for unusual opiate medication.

It has been my experience at times, when called in medical consultation upon post-operative cases whose lack of repair and slowness of recovery could not be accounted for, to discover an unsuspected addiction, and to find that the lack of repair and slowness of recovery was due simply and slowly to the want of comprehension of, or to inadequate control of addiction mechanism existing in the patient.

Many opiate addicts when about to undergo operation, have provided for possible contingencies by the concealment of, or by outside provision for, a supply of opiate sufficient in amount to meet their physical needs. There are very many addicts who have, out of their past experience and study upon themselves, competently controlled their own narcotic-drug-disease during treatment for other conditions, operative or medical. The number of narcotic addicts is not few who have been cared for medically with nursing attention, or have undergone operations for the remedy of various surgical conditions, have recovered, convalesced and been discharged without the physician or surgeon becoming aware that his patient was addicted. This is not a comment in criticism upon my professional brethren. In my own experience such a case is a matter of quite recent occurrence. A patient treated by me in a hospital, for conditions other than addiction, one day unexpectedly revealed to me the fact of long standing addiction. The patient had been afraid to tell me about this condition until thoroughly convinced of my attitude towards it, and had secured opiate medication elsewhere.

It seems strange that a condition of as powerful influence over body function and metabolism as is exerted by the addiction mechanism of narcotic drug-disease should not long ago have received exhaustive and complete clinical and laboratory study along the lines of its manifestations and influences, as well as along the line of reduction and deprivation of the drug of addiction. In view of the above it would seem to be of vastly more importance at the present time that the mass of practitioners of surgery as well as of medicine should understand and be able to control action and reaction in a narcotic addict as a result of his addiction-disease mechanism, than it is that they should attempt the mere reduction or denial of the drug of addiction.

Appreciation of the above would make available to narcotic addicts, suffering from other conditions, hospital and professional treatment and remedy of those conditions. Under present prevailing conceptions of addiction, many honest and worthy people addicted to opiates dare not avail themselves of needed treatment for medical conditions or operation for surgical conditions because of their uncertainty regarding the attitude towards and handling of addiction-disease existing in and carried out by the institution or practitioner to whom they would ordinarily appeal for help. The addict lives in constant fear of some injury or illness which may necessitate his coming into the hands of those whose conception of addiction is not in accord with the addict’s experience of addiction-disease facts.

As I have emphasized in previous chapters, the actual withdrawing of opiate from an addict is simply one stage, and by no means the most important stage in the rational consideration and handling of a case of narcotic drug addiction. The fact that a patient is using an opiate drug, and that he uses, within reasonable limits, a larger or smaller amount of that drug, is a matter of very minor importance as compared with his general functional, nutritional, and metabolic efficiency. This is true as a general proposition in the handling of any case of narcotic drug addiction, and is vastly more true in the handling of cases of other conditions or diseases, operative or otherwise, that are complicated by narcotic drug addiction-disease. The physician or surgeon should realize that the use of a narcotic drug by a patient under his care is of very little immediate importance compared with the satisfactory recovery of his patient from the condition for which he is treating him. The physician or the surgeon who has in his care a narcotic drug addict whom he is treating for another disease condition should remember that the patient’s recovery from the condition for which the doctor was consulted, depends to a great extent upon the amount of functional balance and organic and metabolic adequacy which exists in that patient, and he should realize that functional balance and organic and metabolic adequacy in a narcotic addict are largely under the control of, and vary with the extent to which that patient is kept in, adequate narcotic drug balance.

The establishing and maintaining of adequate drug balance, therefore, is one of the most important elements to be considered in the conduct of a case of narcotic addiction undergoing operation or treatment for a condition other than the cure of his addiction. In handling such a patient, the physician or surgeon should completely put out of his mind any idea of at the same time trying to “cure” the addiction with which his patient is afflicted. I have repeatedly heard of many, and have personally come into contact with cases where the physician or surgeon was trying to withdraw opiate drug from a patient with addiction-disease, as an incidental in the course of treatment of other disease conditions. There are cases of addiction-disease in which this may be successfully accomplished. In the majority of cases, however, this procedure is too harmful to be anything but condemned. Not only will the surgeon or physician ordinarily fail in his attempt to remedy the addiction condition, but he may very severely handicap his other work on that patient and very seriously jeopardize the success of his efforts in the remedy of the condition which he was originally called upon to treat.

It must be remembered that addiction-disease is a chronic condition, and that it is practically never indicated as a matter of clinical emergency, in a case of established addiction, that the opiate be immediately withdrawn. As has been previously stated, drug withdrawal is very much like an operation of election to be done when the patient is ready for it and by whatever procedure is indicated when the proper time arrives. The getting of the patient ready for it often determines, just as is the case in the operation of election, to a great measure, the success of the work and the freedom from complications and sequelae.

Since the final withdrawal of drug is to be regarded as comparable to an operation of election, and the best time for its execution is a matter of arrangement and of preceding preparation, it is obvious that it should not be undertaken with expectation of satisfactory issue in the course of treatment for an ailment or condition which demands and expends much physical resistance and recuperative powers. Recuperative forces should be maintained and directed towards whatever is the indication of paramount importance at any given time. In the conduct of a surgical case or a serious medical case, the indication of paramount importance is recovery from the condition for which the patient applies to the surgeon or physician. All other conditions present should be handled in such a way as to interfere as little as possible with the successful accomplishment of the main issue. The proper control of narcotic addiction-disease mechanism and of its influences upon the patient addicted is the important problem presented by narcotic addiction as met in the field complicating surgical and general medical conditions.