Opiate addiction; its handling and treatment

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Introduction

About ten years ago the use of narcotics / became the subject of popular agitation in vthe United States. There were good rea- n sons for this agitation. The responsibility^ for a series of spectacular crimes occurring in the South was attributed to narcotic addiction. And criminal acts in varying degrees of atrocity occurring everywhere j throughout the country, and with apparently increasing frequency, $ were laid at the door of drug habitues. \ Thus public attention was focused upon the evils of the abuse of narcotics, and the inadequacy / of our legal measures for controlling the situation. As a result, the Harrison Narcotic Law was enacted by the Federal gov-/ ernment on December 17, 1914.

This law was not a hastily conceived statute rushed through as an emergency measure. On the contrary, it was the

VI INTRODUCTION

result of the mature deliberation of persons intimately familiar with the narcotic situation. It was formulated with the knowledge and assistance of medical men, and of medical associations, thus bearing the stamp of approval of the very persons who, next to the narcotic users themselves, were most vitally affected by its provisions. For this law placed restrictions upon members of the medical profession and, in effect, dictated the manner of practicing the profession of medicine to an extent scarcely approached by any legislation in recent years.

The law not only transgressed ancient customs heretofore held sacred to the judgment of physicians alone, but made it necessary for every physician to engage in irksome details and exacting clerical work quite foreign to the usual medical regime. All this with the approval and cooperation of the members of the medical profession who appreciated the importance of, and the difficulties involved in stemming the rapidly rising tide of opiate addiction.

INTRODUCTION Vll

Nor was it alone those most directly affected who approved the new statute. Popular approval was almost universal. And, as would be expected in the case of any law having such a background and such a backing, this statute became actively operative from the day of its enactment. Never for one moment has its enforcement been neglected. On the contrary, a veritable army of specially appointed officials — Federal, State, County, and City officials — have devoted their energies to the law's rigid enforcement.

From time to time the various courts have interpreted certain points in the law. And almost without exception these rulings have tended to tighten the net about the narcotic law breakers. There has been no trend toward leniency. So that, at the present time, practically every prescription written by a physician for a narcotic comes under the careful scrutiny of a com- j petent inspector; practically every grain \ of narcotic dispensed by every pharmacy in the land must be accounted for to Federal and State inspectors ; and a majority

Vlll INTRODUCTION

of the habitual narcotic users are known to the authorities even to the extent of knowing approximately the amount of drug they are taking and the length of time they have been taking it.

Nor is this narcotic knowledge a mere formality. Prosecutions of offenders who have broken the Harrison Narcotic Law^^l^y or are suspected of having done so, fill the calendars of the Federal" courts. And" other courts are equally well patronized.

In short, the Harrison Narcotic Law has been a popular measure for something more than five years, and as actively enforced as is humanly possible. ^ t <k* >s - < h#£i***V

What is the result of these years of almost unprecedented legislative activity?

The question cannot be answered in a sentence. But it seems to be the consensus of opinion of Federal, State, and County officials, who are most closely in touch with the situation, that the number of drug takers and the amount of drug consumed today, after five years of this active legislation, is just as great as, if

INTRODUCTION* IX

not, indeed, considerably greater than, it was five years ago. - / ) .v

There is, however, a radical change in the method of obtaining opiates by the drug addicts. The closure of the legitimate channels for obtaining narcotics has brought into existence an illicit traffic of tremendous proportions. The elusive underworld "pedlar," well supplied with drugs, now exacts his pounds of flesh from his helpless victims, and tempts guileless "prospects" with free samples for the sake of future profits. Thus, without vitally affecting the actual evil, we have added criminality to what was formerly simply immorality. MvMtte^

With this situation existing after five years of active legislation it behooves us to take inventory of our weapons and fighting equipment against the narcotic evil. Why has the Harrison Narcotic Act failed to accomplish the purpose for which it is formulated?/ Certainly this failure cannot be laid at the door of inactivity on the part of officials, or lack of interest and cooperation by the public. "Wherefore, it

X INTRODUCTION

appears that there must be something fundamentally wrong with the inception of the law itself. A law that fails to effect its purpose when vigorously enforced, and after a sufficient length of time to give it fair trial, must be lacking in something not visualized in its original conception. There seems to be no other logical conclusion.

From a medical viewpoint the law has the fundamental defect of not giving sufficient consideration to the underlying cause of opiate addiction. In effect, it regards narcotic addiction as a purely criminal act willfully indulged in by normal individuals, with only scant consideration of the possibility that disease may be a cause as well as a result of the condition. Stated in another way, the law emphasizes the legal aspect of the problem and subordinates the medical features.

Now, in point of fact, the vast majority of opiate addicts present an abnormal mental and physical condition closely akin in many respects to the condition known as insanity. And our present narcotic

INTRODUCTIOK XI

legislation presents many features similar to the older legislation for the control of mental diseases.

It is not medical men alone, however, who believe that narcotic addiction is often the result of an abnormal mental state, not merely a "bad habit." The veteran officers of the law eventually reach this conclusion, almost without exception. In the beginning, when their duties first bring the officers in contact with this class of persons, they usually regard the drug addict as a self-willed and responsible criminal offender. Their opinion is based on the popular conception of addiction, not upon practical experience. But later, after they have been closely in touch with every phase of drug habituation, their viewpoint changes almost invariably. Their original conception was based on ignorance; their later point of view is the result of experience. And no one will question that experience is a better teacher than ignorance.

A precisely similar change in mental attitude occurs in persons who are brought closely in contact with the insane. The

Xll INTRODUCTION

novice in insane hospital work invariably thinks that a high percentage of his patients are not insane — that " there is nothing wrong with them." But as he gains in experience his viewpoint changes, just as in the case of the officers who are brought closely in contact with narcotic addiction. And thus we find the experienced narcotic officer inclined to deal leniently with the non-criminal type of drug addicts, because he realizes that he is dealing with persons who are not wholly responsible for their shortcomings.

It is apparent, therefore, that the comparison between insanity and drug addic T f// tion is not overdrawn. And in this con- ^/ ytu nection we should remember that it is only within the lapse of a century that insanity has been legally recognized as a disease. Christian nations, for a period of more than fifteen centuries, had regarded insanity as a "possession by demons" — a crime. The unfortunate insane were imprisoned and subjected to every kind of cruelty, just as in the case of the vilest criminal. Yet persons continued to be-

INTRODUCTION Xlll

come insane, and usually incurably insane, in the face of the most hideous punishments.

America, the great haven of liberty, offered no sanctuary. Lunatics were beaten, imprisoned, chained in filthy dungeons and specially maltreated here, just as in monarchy- ridden Europe. And as a culminating touch of persecution, our ancestors burned at the stake that pitiful little group of old mad- women at Salem.

But even this did not stop people from "going crazy." And at last even the law itself stood aghast at its futile folly.

Then a great French physician, Pinel, proclaimed the heresy that madness is a disease, not a crime. And with the courage of his convictions, and fortunately, with an influence that could not be disregarded, he struck the shackles from the inmates chained in their madhouse hovels. And behold ! many of these mad creatures regained normal reason! The era of rational treatment of insanity had dawned. Lunacy had evolved from a state of incur-

XiV INTRODUCTION

able criminality to the condition of a curable disease, t ? ^ 44^ titiut&tj*.^****.

There is an analogy between our present attitude toward opiate addiction and the lunacy situation of one hundred years ago. Insanity was not thoroughly understood then, and, naturally, the lunacy laws of that time were inadequate and unjust.

The opiate addict, like the psychopath, is an abnormal individual. But in most instances his physical and mental abnormalities are not apparent to casual observation so long as his system is supplied with a sustaining quantity of the drug. When this necessary stabilizing narcotic is withdrawn, however, the abnormal physical and mental conditions quickly assert themselves with absolute certainty. Yet even when the similarity between insanity and opiate addiction is recognized, our attitude toward the two conditions is utterly different and is determined by the supposed underlying cause of each condition, rather than by the conditions themselves. We punish the opiate addict because his infirmity is often self-imposed,

INTRODUCTION XV

just as formerly lunatics were punished because it was believed that they willfully associated themselves with evil spirits.

But the present legal attitude is not consistent even if we accept the dictum that the result of self-imposed vices should be punished, while unavoidable misfortunes should not. For it so happens that one of the most important and prevalent forms of insanity, general paresis, is the result of venereal vice — a self-imposed condition. At least ten per cent, of all cases of insanity are attributable to this vicious cause. Yet the law makes no distinction between paretic patients, with their virtually self-imposed disease, and any other types of insane persons. The paretic is not punished, although in acquiring the specific infection which is the cause of his condition, he gratified a willful indulgence scarcely more compelling, and generally regarded as far more reprehensible, than the craving for a drug.

It is evident, therefore, that the cause of insanity does not influence the legal attitude toward this disease. Such is not the

XVI INTRODUCTION

case with opiate addiction. A drug addict is a malefactor in the eyes of the law whether he acquired his habit through pure viciousness, or whether, as is often the case, his addiction was thrust upon him unwillingly as in the case of many maimed veterans from France.

It is true that there is a somewhat vaguely phrased distinction in the legal attitude toward persons who are criminally insane and other demented individuals. All insanity is a disease, but in some States special hospitals are provided for the care of persons suffering from "criminal insanity.' ' But even so, a very great distinction is made between this type of insanity and ordinary criminality. No such distinction is made in the case of drug addicts. Yet we know that there are addicts whose drug taking makes them criminals ; and others who regard criminal tendencies and criminal acts with just as great abhorrence as the highest type of normal individuals. It is just as inconsistent to put these persons in the same class as it would be to place ordinary crim-

INTRODUCTION XV11

inals and insane criminals on the same level.

The important thing about the existing narcotic laws, however, regardless of inconsistencies, is the fact that they do not appear to be getting adequate results.

One modification of the present law that naturally suggests itself is to increase still further the scope and stringency of the statute. But it would seem that this is scarcely possible without curtailing the legitimate use of opium. .And opium, bear in mind, is our most useful and most important drug. Curtailing its legitimate use would cause untold suffering among countless numbers of innocent persons afflicted with painful diseases. These persons far outnumber the addicts. So that even the complete elimination of this relatively small handful of drug habitues would be scant recompense for such a sacrifice.

A less objectionable plan would be some slight modification in the existing narcotic laws tending to emphasize the medical side of the narcotic problem. There is nothing c

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novel in this suggestion. Indeed, a practical step in this direction was taken in certain cities recently. For example, the Narcotic Clinics, conducted in the cities of Los Angeles and San Diego for a brief period in 1920, were based on this principle, and produced results that were encouraging, to say the least.

The Los Angeles clinic was started as a department of the Board of Health, with the approval and assistance of the municipal authorities, for the purpose of giving preliminary medical treatment to the narcotic addicts. This clinic endeavored to supply persons who required the constant use of an opiate with the necessary amount of their narcotic in gradually decreasing doses at a nominal price. It was conducted by physicians detailed by the Health Commissioner, and under the immediate direction of a Narcotic Board composed of prominent physicians, public spirited citizens, and Federal, State, and Municipal officers who volunteered their time and services.

It was not the purpose of this clinic

INTRODUCTION XIX

merely to supply the opiate addicts of the community with narcotics. On the contrary, the clinic was established for the purpose of medical treatment, with gradual withdrawal of the drug, and final cure when possible. Complete cure by this method would not be possible in most cases, of course; but it was possible to reduce the amount of drug used, and improve the patients' physical condition so that they could be treated successfully in some suitable institution at the proper timer %i \ I /U> *+»**i u** - ^*~~-f f>«* The things actually accomplished by this clinic attained, in a measurable degree, the object for which it was created. During the five months of its activity, more than five hundred drug addicts applied for treatment. It was a motley company representing every walk and condition of life. Every degree of financial status was represented, every shade of dishonesty, as well as every grade of intellect. Some came from purely criminal motives, others with the exalted purpose of being cured of their habit. Still others, in the hope that

XX INTRODUCTION

they could escape the clutches of the illicit pedlar and his extortionate prices.

A record of the obstacles that had to be overcome in putting this experimental clinic into practical running order, the mistakes that were made, the trickery and deceptions that were practiced, as well as the honest endeavors of the deserving addicts and persons suffering from painful bodily afflictions, would make a volume of intensely interesting and variegated narrative. But the important things accomplished may be summarized in a few paragraphs. For one thing, illicit peddling was reduced to a minimum. When the patient could get morphine honestly for ten cents a grain, why be dishonest at ten times that price with a good chance of landing in jail into the bargain? The pedlars complained, almost openly, that they were " being ruined" by the Clinic.

To the class of persons suffering from painful afflictions, such as tuberculosis and cancer, whose condition made the continued use of an opiate an absolute necessity, the clinic was a veritable Godsend.

INTRODUCTION XXI

For it enabled them to procure their necessary drug at a reasonable price and in a legitimate manner. Thus they were able to reduce the amount of the narcotic, since, curiously enough, the uncertainty of being able to get a supply of the drug always tends to make the addict use more of it. / The clinic made it possible for several individuals to engage in honest occupations for the first time in many months. Heretofore the uncertainty of the source of supply, and the ruinous prices demanded by the pedlar, had kept these patients in / such a state of physical dilapidation that they were unable to work. Thus the Clinic enabled many of these victims to become again honest breadwinners. Several of them were now able to provide for their families and again live in a respectable and self-respecting manner. And meanwhile their general health was improved by the gradually reduced doses dispensed at the Clinic, and the release from the harassing anxiety about obtaining their drug.

It is a fact well known to persons famil-

Xxii INTRODUCTION

iar with the subject, but not appreciated by the generality of people, that almost every drug addict wishes to be freed from his bondage. In many instances the desire is an inadequate and feeble one, of course, while in others it is insistent and compelling. The members of the Clinic exemplified this in an amazing degree, all things considered. Within two months after opening the Clinic, twenty-four individuals had made earnest application to be placed in some institution for the final treatment and cure of their addiction. And it is most illuminative that after the Clinic was closed no less than twenty-six persons were given this curative treatment in private institutions from the accumulated funds; and fully as many more had filed applications for taking similar treatment and were bitterly disappointed when they found that no more funds were available. This alone, the fact that half a hundred persons out of a total of five hundred were sufficiently earnest in their desire to be cured that they were willing to surrender themselves for radical treatment, is con-

INTRODUCTION XX111

vincing evidence of the usefulness of this experimental Clinic.

Moreover, the Clinic enabled the officers to determine pretty accurately the number of drug addicts in the community, particularly the class of drug takers likely to become a public menace. And the surprisingly small number of these individuals seems to refute the popular idea that drug ! addiction is running riot in our communities.

The fact that so many of these clinic patients were anxious to take a final curative treatment in some proper institution, and that such a relatively large number of them actually did so, is an indication of what might be accomplished with a clinic having hospital facilities at its disposal. Such an arrangement is of course the one now in vogue for treating almost all physical ailments; and even mental diseases are now so cared for in certain favored communities.

A similar arrangement, modified to meet the various conditions, would put the legal and medical authorities closely in touch

XXIV INTKODUCTION

with the addicted patients and with the narcotic situation in a manner similar to our arrangements for controlling other serious diseases, such as tuberculosis. ; *This factor alone, it seems to me, justifies the reestablishment of clinics along similar lines to the experimental ones tried with such a measure of success in Los Angeles and San Diego. Undoubtedly great modifications would be necessary. But great modifications are always necessary in any progressive experimental work.

In addition, some special hospital provisions should be made, just as in the case of insanity. And there should be some governing body of specially qualified medical examiners to determine the requirements of each case, similar to the medical commissions that determine the status and dictate the treatment in insanity cases.

Unlike the existing laws governing insanity, however, the final decision about any case should not be left to the judgment of juries composed of laymen. For the average layman knows less about opiate addiction than he does about the

INTRODUCTION XXV

psychoses. And one can scarcely expect intelligent assistance and cooperation from any body of men who know practically nothing about the subject they are called upon to decide.

Perhaps the best practical solution of the whole narcotic problem would be to place it unreservedly in the hands of the United States Public Health Service. This would bring it under control of intelligent physicians who also have legal authority to enforce any clinical or custodial measures that seem necessary, and facilities to work out its laboratory and clinical problems without hindrance.

In any event, the narcotic addict is with us, and like the poor, and the bad, and the unfortunate, he is likely to remain with us. Only the visionary idealist, or persons ignorant of human nature and of human history, can believe otherwise. No great compelling human vice or disease has ever been completely stamped out. And the best that we can hope to do by our most concerted efforts, for the present at least, is to reduce narcotic addiction to a state of reasonable control.

CHAPTEE 1.

THE NATUEE OF OPIATE ADDIC- TION.

ITS HANDLING AND TREATMENT CHAPTER I.

THE NATURE OF OPIATE ADDICTION.

The term "opiate addiction" implies a definite pathological condition. The mere taking of morphin or heroin, even for quite a protracted period, need not necessarily constitute addiction. It will lead to it eventually and inevitably, of course, but the exact length of time required cannot be predetermined in any given case. Some patients suffering from protracted painful conditions may be given opiates for several weeks without showing the characteristic "withdrawal" symptoms when the drug is withheld. They suffer merely from the original cause of the pain, not the pains caused by want of the narcotic. Others, particularly the neurotic type of individ-.

uals, become addicted very quickly, as shown by a rather definite train of symptoms when the administration of the opiate is stopped. Indeed, these symptoms are so definite in character as to justify the term "narcotic drug addiction disease" given it by some observers.

*Bishop recently gave these symptoms, and the order in which they appear, about as follows :

There is at first a feeling of uneasiness, a " nervousness' ' as the patient expresses it, with an increasing sense of depression and apprehension of some impending calamity. This is followed quickly by yawning, sneezing, watering of the eyes and excessive mucous secretions from the nose. The extremities become cold, and there is clammy sweating, nausea, vomiting, and purging, with tremors and muscular twitchings. These symptoms accompany or are quickly followed by intense abdominal pains, shooting leg pains, cramps, and a general feeling of abject

* ' ' The Narcotic Drug Problem, ' ' Macmillan Company, 1920.

THE NATURE OF OPIATE ADDICTION O

misery and dilapidation. In this condition the pulse rate varies between extreme slowness and extreme rapidity, usually with a marked drop in the blood pressure. In short, the patient looks, acts, and is a very sick as well as a very miserable individual. And occasionally he justifies his appearance by collapsing and passing on. These symptoms appear in just about the sequence given in a very high percentage of patients; but there are, of course, all manner of variations in individual cases. Thus, one patient describes his first withdrawal symptoms as feeling as though his ears were tunneled out — a feeling as if some instrument had bored out two cavities from his throat to the ears, the cavities resounding with weird noises and disagreeable sensations. Another patient has a boring pain in the left elbow as the first indication of withdrawal. Still another loses control of the sphincters at the very beginning of the withdrawal of the narcotic before there are any other symptoms whatsoever. And one might multiply this list almost indefinitely. Yet even the

D OPIATE ADDICTION

patients of this class eventually develop pretty much the same sequence of symptoms as those just described, even though their initial symptoms are different.

The peculiarity of this withdrawal condition is that it is relieved almost instantly by even a very small dose of narcotic. When relief is not at hand, however, these symptoms continue and increase in intensity for a period of time ranging from about thirty-six hours as the minimum, to an extreme limit of about five days. The average time would be perhaps sixty hours. And during that time the patient suffers the very limit of mental and physical agony. Indeed, the Inquisition missed what would certainly have been one of its choicest torture-devices by passing out of fashion before morphin came in.

This picture of the withdrawal symptoms in cases of drug addiction is not an overdrawn one. And even after this period of acute distress is passed the patient's troubles are not ended by any means. He will still be obsessed by mental cravings for the drug at times, and occa-

THE NATUKE OF OPIATE ADDICTION 7

sional attacks of stabbing pains will come as very tangible reminders. It is not until these painful sensations and the craving for the drug have entirely disappeared that the patient can be considered as clinically cured.

But even though this patient is apparently entirely free from all opiate addiction symptoms, and returned to a normal condition, he is not really so in point of fact. His system still remains sensitized to the action of opiates. And if at any time in the future, even after several years, he is given a few doses of any opium preparation he is likely to exhibit the characteristic symptoms of narcotic addiction disease. Thus it may happen at any time that these former drug-users may become the innocent victims of ignorant or careless medication. Indeed, many of them are thus victimized. I have personal knowledge of cases of recurrent drug addiction that were precipitated by cough mixtures, prescribed by physicians, which contained small doses of an opiate.

The clinical picture presented by these various groups of withdrawal symptoms is that of a definite pathological disturbance. The toxic action of the opiate is neutralized by some substance prepared for this purpose in the body (call it an "antitoxin' ' if you will, for convenience) and in such definite amounts that an artificial balance closely approximating normality is established. This balance is maintained only by the administration of a definite amount of the accustomed narcotic, the exact quantity differing, of course, in each individual. Too much or too little of the narcotic disturbs the balance, and complete withdrawal causes the violent symptoms just described.

These symptoms, then, are actual physical symptoms. I wish to emphasize this because the impression prevails quite generally outside of medical circles that drug addiction is merely a "habit" — a thing that is "all in the patient's mind." This is a mistake. And, it so happens, it is a mistake that the Christian Scientists have been very helpful in demonstrating. For sooner or later, particularly in communi-

THE NATUEE OF OPIATE ADDICTION \)

ties where the Christian Science bug is rampant, quite a high percentage of drug addicts take a fling at this so-called mental healing. But, so far as I have been able to learn, no drug addict has ever been cured by this particular variety of innocuous therapy. There is no dose of mental treatment strong enough to counteract the terrible nausea, depression, and stabbing, boring pains that follow morphin withdrawal.

There is, of course, a marked psychic element in all cases of narcotic addiction. Many opiate addicts are of the unstable type, usually with a background of bad heredity that accounts for such cases. In a way, then, such addicts are born, not made — that is, born with an inherent and fundamental mental instability which makes them crave some form of stimulant or narcotic.

We have a closely similar analogy in inebriety. There seems to be no question that constitutional instability is responsible for practically all cases of inebriety. The mere matter of being able to obtain alcoholic drinks easily is not the real reason why a few persons are inebriates while the majority of people are not. For, until recently, alcoholic beverages were about the cheapest and most available things on the market. Yet the majority of people did not become inebriates, just as most persons do not become gluttons simply because there is an abundance of food.

So with drug addiction. There was a time when narcotics could be obtained anywhere and by any one for a few cents. Yet the percentage of drug addiction was no higher than at present — indeed, it was not nearly so high if we may place any dependence upon statistics. And thus it is a natural inference that drug addiction, like inebriety, is not merely the result of the abundance of the substance that produces the condition.

As a matter of fact, since many of the present day addicts were formerly inebriates, it is a natural inference that addiction has been increased, in a measure at least, by the fact that alcoholic beverages are so expensive and so difficult to obtain at present. They are also conspicuously

THE NATURE OF OPIATE ADDICTION 11

bulky for transportation, while narcotics are temptingly condensed.

There is this marked difference between inebriety and drug addiction : Inebriety is often a periodic affair, with long intervals of total abstinence intervening. Such is not the case with drug addiction. There is no such thing as a "periodic" drug addict. Once the victim has become "hooked," he must have his particular narcotic continuously and in fairly uniform doses. And he must do this, not in order to "get on a jag," but to maintain himself at something that approaches the normal human level.