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PREFACE vii

THE NARCOTIC DRUG PROBLEM

INTRODUCTION

It is a fact becoming more and more obvious that too little study and effort to interpret their physical condition have been given to those unfortunates suffering from narcotic drug addiction.

We have neglected their disease in its origin and subsequent progress and formed our conception of its character from fully developed conditions and spectacular end-results. We have seen some of them during or after our fruitless efforts at treatment, their tortures and poor physical condition overcoming their resolutions, until they plead for and attempted to obtain more of their drug. We have seen others exhausted, starved, with locked-up elimination, toxic from self-made poisons of faulty metabolism, worn with the struggle of concealment and hopeless resistance, and for the time being more or less irresponsible beings, made so, not because of their addiction-disease itself, but because they were hopeless and discouraged and did not know which way to turn for relief.

What literature has appeared on the subject has usually pictured them as weak-minded, deteriorated wretches, mental and moral derelicts, pandering to morbid sensuality; taking a drug to soothe them into supposed dream states and give them languorous delight; held by most of us in dislike and disgust, and regarded as so depraved that their rescue was impossible and they unworthy of its attempt.

We have overlooked, ignored or misinterpreted intense physical agony and symptomatology, and regarded failure to abstain from narcotics as evidence of weak will-power or lack of desire to forego supposed morbid pleasure. We have prayed over our addicts, cajoled them, exhorted them, imprisoned them, treated them as insane and made them social outcasts; either refused them admission to our hospitals or turned them out after ineffective treatment with their addiction still fastened to them. To a great extent the above has been their experience and history.

In great numbers they have realized our failure to appreciate their condition and to remedy it, and have after desperate trials of quacks, charlatans and exploited "cures," finally accepted their slavery and by regulation of their drug and life, their addiction unsuspected, maintained a socially and economically normal existence. Some failing in this, perhaps broken and impoverished, their addiction recognized, have become social and economic derelicts and often public charges.

From these last, together with the addicted individuals from the class of the fundamentally unfit, we have painted our addiction picture. Confined and observed by the custodial official and the doctor of the institution of correction and restraint, or concealed as family skeletons in many homes, descriptions of them have given to the narcotic addicts as a whole their popular status--cases of mental and moral disorder due to supposed drug action or habit deterioration, and based upon inherent lack of mental and moral stamina.

It was with the above conception of these addiction conditions that I began my work in the Alcoholic, Narcotic and Prison Service of Bellevue Hospital, attracted to the service not by hope of helping nor by interest in "jags" and "dope fiends" as I then considered them, but by the mass of clinical material available for surgical and medical diagnosis and study which was daily admitted to those wards. When I left the service after sixteen months of day and night observation, with personal oversight and attempt to care for in the neighborhood of a thousand admissions a month, my early and faulty conception of narcotic addicts was replaced by a settled conviction that these cases were primarily medical problems. I realized that these patients were people sick of a definite disease condition, and that until we recognized, understood and treated this condition, and removed the stigma of mental and moral taint from those cases in which it did not exist, we should make little headway towards solution of the problem of addiction.

It is a fact that the narcotic drugs may afford pleasurable sensations to some of those not yet fully addicted to them, and that this effect has been sought by the mentally and morally inferior purely for its enjoyment for the same reasons and in the same spirit that individuals of this type tend to yield themselves to morbid impulses, curiosities, excesses and indulgences. Experience does not teach them intelligence in the management of opiate addiction and they tend to complicate it with cocaine and other indulgence, increasing their irresponsibility and conducing to their earlier self-elimination.

Wide and varied experience, however, hospital and private, with careful analysis of history of development, and consideration of the individual case, demonstrates the fact that a majority of narcotic addicts do not belong to this last described type of individuals. It will be found upon careful examination that they are average individuals in their mental and moral fundamentals. Among them are many men and women of high ideals and worthy accomplishments, whose knowledge of narcotic administration was first gained by "withdrawal" agonies following cessation of medication, who have never experienced pleasure from narcotic drug, are normal mentally and morally, and unquestionably victims of a purely physical affliction.

The neurologist, the alienist, the psychologist, the law-maker, the moralist, the sociologist and the penologist have worked in the field of narcotic addiction in the lines of their special interests, and interpreted in the lights of their special experiences. Each has reported conditions and results as he saw them, and advised remedies in accordance with his understanding. With very few exceptions little has been heard from the domain of clinical medicine and from the internist. It is only here and there that the practitioner of internal medicine has been sufficiently inspired by scientific interest to seriously consider narcotic drug addiction and to make a clinical study of its actual physical manifestations and phenomena.

The idea that narcotic drug addiction should be accorded a basis of weakness of will--neurotic or otherwise, inherent or acquired--and should be classed as a morbid appetite, a vice, a depraved indulgence, a habit, has been generally unquestioned and the prevailing dogma for many years. It is very unfortunate that we have paid so little attention to material facts and have made so little effort to explain constant physical symptomatology on a basis of physical cause, and that there has not been a wider recognition and more general acceptation of scientific work that has been done.

Despite the years of effort that have been devoted to handling the narcotic addict on the basis of inferiority and neurotic tendencies, and of weakness of will and perverted appetite--in spite of exhortation, investigation, law-making and criminal prosecution--in spite of the various specific and special cures and treatments--narcotic addiction has increased and spread in our country until it has become a recognized menace calling forth stringent legislation and desperate attempts at administrative and police control. And though a large amount of money has been spent in custodial care and sociological investigation on the prevailing theories, and in various legislation, much of it necessary and much of it wisely planned, we have made but little progress in the real remedy of conditions.

It is becoming apparent that in spite of all the work which has been done--in spite of all the efforts which have been made--there has been practically no change in the general situation, and there has been no solution of the drug problem.

In analyzing results of efforts and arriving at causes for failure, it seems to me that it is always wise to begin at the beginning, and to ask ourselves whether we have not started out with an entirely erroneous conception of our basic problem. Is it not possible that instead of punishing a supposedly vicious man, instead of restraining and mentally training a supposedly inherent neuropath and psychopath, we should have been treating an actually sick man? Is it not possible that the addict did not want his drug because he enjoyed it but that he wanted it because his body required it? This is not only possible--it is fact--and the whole secret of our failure has been the misconception of our problem based on our lack of understanding of the average narcotic drug addict and his physical conditions.

In my own experience as a medical practitioner I know that non-appreciation of this fact was the cause of my early failures; and I further know that from the beginning of appreciation of this fact dates whatever progress I have made and whatever success I have attained. In my early efforts as Resident Physician to the Alcoholic and Prison Wards of Bellevue Hospital, devoid of previous experience in the treatment of narcotic addiction, directed by my available literature and by the teachings of those in my immediate reach, I followed the accepted methods. I tried the methods of the alienist; I tried the exhortations of the moralist; I tried sudden deprivation of the drug; I tried rapid withdrawal of the drug; I tried slow reduction of the drug; I tried well-known special "treatment." In other words I exhausted the methods of handling narcotic drug addiction of which I knew. My results were, in these early efforts, one or two possible "cures," but as a whole suffering and distress without relief; in a word failure.

The blame I placed not where it belonged--on the shoulders of my medical inefficiency and lack of appreciation and knowledge of the disease I was treating--but upon what I supposed was my patient's lack of co-operation and unwillingness to forego what I supposed to be the joys of his indulgence. In discouragement and despair I held the addict to be a degenerate, a deteriorated wretch, unworthy of help, incurable and hopeless. Strange as it seems to me now, possessing as I did good training in clinical observation and being especially interested in clinical medicine, in calm reliance upon the correctness of the theories I followed, I ignored the presence of obvious disease.

As to the existing opinion that the addict does not want to be cured, and that while under treatment he cannot be trusted and will not co-operate, but will secretly secure and use his drug--I can only quote from my personal experience with these cases. During my early attempts with the commonly known and too frequently routinely followed procedures of sudden deprivation, gradual reduction and special or specific treatment, etc., 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 on their supposed weakness of will and lack of determination to get rid of their malady. Later I realized the fact that the blame rested almost entirely upon the shoulders of my medical inefficiency and my lack of understanding and ability to observe and interpret. The narcotic addict as a rule will co-operate and will suffer if necessary to the limit of his endurance. Demanding co-operation of a completely developed case of opiate addiction during and following incompetent withdrawal of the drug is asking a man to co-operate for an indefinite period in his own torture. There is a well-defined limit to every one's power of endurance of suffering.

Abundant evidence of what I have written is easily found among the many sufferers from the disease of opiate addiction who have maintained for years a personal, social and economic efficiency--their affliction unknown and unsuspected. These cases are not widely known but there are a surprising number of them. When one of them becomes known his success in handling his condition and its problems is generally attributed to his being on a rather higher moral and mental plane than his fellow sufferers and possessed of will-power sufficient to resist temptation to over-indulge his so-called appetite. We have not as a rule considered any other explanation nor sought more at length for the cause of his apparent immunity to the hypothetical opiate stigmata. It would have been wiser and more profitable for us to have respectfully listened to his experiences and learned something about his disease.

The facts in such cases are that instead of being men of unusual stamina and determination, they are simply men who have used their reasoning ability. They have tried various methods of cure without success. They have realized the shortcomings and inadequacy of the usual understanding and treatment of their condition. Being average practical men, and making the best of the inevitable, they have made careful and competent study of their own cases and have achieved sufficient familiarity with the actions of their opiate upon them and their reactions to the opiate to keep themselves in functional balance and competency and control. The success of these people is not due to determined moderation in the indulgence of a morbid appetite. It is due to their ability to discover facts; to their wisdom in the application of common-sense to what they discover; and to rational procedure in the carrying out of conclusions reached through their experiences. They have simply learned to manage their disease so as to avoid complications. When I tried to account for some of the things I saw by questioning these men who had studied and learned upon themselves, I soon obtained a clearer conception of what opiate addiction was.

When we eliminate the distracting and misleading complications, mental and physical, and study the residue of physical symptomatology left, we make some very surprising and striking observations.

We find that we are dealing fundamentally with a definite condition whose disease manifestations are not in any way dependent in their origin upon mental processes, but are absolutely and entirely physical in their production, and character. These symptoms and physical signs are clearly defined, constant, capable of surprisingly accurate estimation, yielding with a sureness almost mathematical in their response to intelligent medication and the recognition and appreciation of causative factors; forming a clean-cut symptom-complex peculiar to opiate addiction. Any one--whether of lowered nervous, mental and moral stamina, or a giant of mental and physical resistance--will, if opiates are administered in continuing doses over a sufficient length of time, develop some form of this symptom-complex. It represents causative factors, and definite conditions which are absolutely and entirely due to changed physical processes which fundamentally underlie all cases of opiate addiction, and which proceed to full development through well-marked stages.

During the past years I have had under my care a number of excellent and competent physicians of unusual mental and nervous balance and control in whom there could be no hint of lack of courage, nor of deficient will-power, nor of lack of desire to be free from their affliction. Possessing, some of them, unusual medical training and scientific ability, having added to this the actual experiences of opiate addiction, they with others have co-operated and aided in experiment, study and analysis, and the result has been in their minds as in mine, complete confirmation of the facts above stated.

Primarily, there are two phrases I should like to see eliminated from the literature of opiate drug addiction. I believe they have worked great injustice to the opiate addict and have played no small part in the making of present conditions. It seems to me that to speak and write as we still often do of "drug habit" and "drug fiends" is placing upon the opiate addict a burden of responsibility which he does not deserve. If long ago we had discarded the word "habit" and substituted the word "disease" I believe we would have saved many people from the hell of narcotic drug addiction. I believe if it had not been for the use of the word "habit" that the medical profession would long ago have recognized and investigated this condition as a disease. A man, physician or layman, believes that he can control a habit when he would fear the development of a disease. Until now, however, the description has been "drug habit." And the man who acquires one of the most terrible diseases to be encountered in the practice of medicine is unconscious of his being threatened with a physical disease process until this process has become so developed and so rooted that it is beyond average human power to resist its physical demands.

In the near future, I earnestly hope the true story and the real facts concerning the opiate drug addict will become universally known. Without familiarity with them and understanding of them, and comprehension and appreciation of their disease, we shall never make real progress in the solution of the narcotic drug problem. From the present day trend of articles and stories in the newspapers and lay and medical magazines it cannot be doubted that the time is not far distant when in the lay press will appear, in plain, sober, unvarnished truth, the true story of the experiences and struggles of the opiate drug addict. I have marked a rapidly growing appreciation of fact and a steadily increasing activity in the investigation of conditions. This is sooner or later bound to be followed by intelligent public and scientific demand for competent and common-sense explanation and solution.

FUNDAMENTAL CONSIDERATIONS

My earliest efforts in the handling of narcotic addicts were institutional. They were along the lines of forcible control, based upon the theory that I could expect no help nor co-operation from my patients.

While this theory is undoubtedly true as applied to many of those who have developed opiate addiction, it is true of them as individuals whose personal characteristics are such that they require forcible control for the accomplishment of desirable ends in general. It is not true of them simply because of narcotic addiction. It is equally true of these same people afflicted with other diseases. Their successful handling for tuberculosis, venereal disease, cardiac conditions, or anything else requires for its successful issue constant oversight and what practically amounts to custodial care. I shall refer to them later. They are fundamentally custodial or correctional cases and success in their handling will never be accomplished in any other way, whether they are being treated for narcotic addiction or for anything else, mental, moral or physical.

What appears in this chapter does not solve the problem of the handling of the narcotic addict of this type. There are many factors and elements in their mental and physical make-up other than drug addiction which should be considered, and these factors and elements lie at the bottom of their irresponsibility and the real difficulty of their handling.

Experience and the analysis of unsuccessful effort and results showed that, however necessary forcible control might be in the handling of some narcotic addicts, it was not successful nor sufficient nor even the most important factor in the treatment of most cases of addiction-disease.

I soon came to see that I had an erroneous conception of my medical and clinical problems and an unjust attitude towards many if not most of my addiction patients. Studying them--not as drug addicts, but as individual human beings--I found them in their personal, mental, moral and other characteristics, as various as people suffering from any other disease condition. There were no narcotic laws at that time and opiates were easily and cheaply obtainable. Very many, perhaps most of those who came to my wards were not forced in either by fear of the law or by scarcity of opiate supply. They did not have to come for treatment, but voluntarily presented themselves in the hope of cure. Something was wrong with my theories.

In seeking for solution I began to realize that the narcotic addict of average individual characteristics obtained no enjoyment from the use of his opiate, and that he co-operated as a rule to the extent of his ability and endurance in efforts to relieve him of his condition, so long as he had any hope of possible ultimate success. I learned, trained and experienced physician though I was, that I was far more ignorant of the clinical manifestations and physical reactions of narcotic drug addiction than many of the patients I was trying to treat. It was soon evident to me, moreover, that the man who recognized my ignorance above all others was my patient. I came to see that what I had interpreted as lack of co-operation was largely due; first to his memory of previous experience, second to recognition of my ignorance, and third to his anticipation of useless and harmful suffering which he expected from my care and treatment of his case.

Looking back over that period, I am free to confess that my efforts, though honestly made, amply realized his expectations.

I began to see that I knew nothing of this disease or how to treat it as a problem of clinical disease. I saw that addict after addict sneezed and trembled, jerked and sweated, vomited and purged, became pallid and collapsed, that his heart and circulation were profoundly and alarmingly disturbed, that he had the unquestionable facies or expression of intense physical suffering, and the many constant and obvious signs which attend physical need for opiate drug. I could not escape the conclusion that here were tangible, material, incontrovertible physical facts for which I had no physical explanation. It seemed unreasonable to be satisfied with any explanation of them that did not have a physical basis; and it seemed a logical conclusion that the establishment of a basis of physical disease mechanism could offer the only hope of remedy. I therefore ignored for the time being my past teachings and ideas of the drug addict, and I looked to the patient himself, questioning him as to his experiences and studying the symptomatology and physical phenomena he presented. In short, I adopted the attitude which must be widely adopted before the medical problem of the clinical handling of drug addiction will be solved--in my attitude towards these cases I became the clinical student and practitioner of internal medicine, treating my patient to the best of my ability as I would a sufferer from any other disease, and studying his case.

Struck by clinical facts which did not accord with past teaching, I tried to seek out from my personal study and observation of the individual case data upon which to form theories which would accord with clinical facts and with verified histories and, if possible, give a basis of help to these unfortunates.

Gradually since then I have gotten together, from my own work and that of others, and with some success attempted to interpret and explain and apply, what seemed to me facts about opiate addiction. To my mind and in my experience these facts offer a beacon-light of hope and assure ultimate rescue to a very large proportion if not most of those suffering from narcotic drug addiction-disease.

It is well to state here that of late some of these facts have secured recognition in medical and lay authoritative announcement and literature. The Preliminary Report of a special investigating committee of the New York State Legislature is quoted from elsewhere in this book, and the report in June, 1919, of a special committee appointed by the Secretary of the Treasury speaks of, "the more or less general acceptance of the old theory that drug addiction is a vice or depraved taste, and not a disease, as held by modern investigators."

It is on account of "the more or less general acceptance of the old theory" that it is necessary in this place to discuss some of the tenets of that theory for the benefit of those whose interests or emergencies have not led them to investigation of and familiarity with the scientific and other writings on this subject of recent years.

It has been demonstrated to be a fact that description of narcotic drug addiction as "habit," "vice," "morbid appetite," etc., absolutely fails to give any competent conception of its true characteristics, and clinical and physical phenomena. A large majority of opiate users are gravely wronged in a wide-spread opinion still prevalent. This opinion, as previously outlined, is that chronic opiate addiction is a morbid habit; a perverted appetite; a vice; that only he who is mentally or morally defective will allow it to get a hold upon him; and that its main and characterizing manifestations are those of mental, physical and moral degeneration. Opiate addicts are supposed to have irrevocably lost their self-respect, their moral natures and their physical stamina. They are still painted by many, as inevitable liars, full of deceit, and absolutely untrustworthy--people who are supposed to use a dream and delight producing drug for the sensuous enjoyment it gives them, and who do not want to discontinue its use. They are thought of as physical, mental and moral cowards who, after realizing their deplorable condition, refuse to exert "will-power" enough to stop the administration of opiates.

With these views I did my early work on this condition. On these hypotheses, trying to follow current available literature and teaching, I treated my patients for a considerable time with results which superficially interpreted seemed to corroborate both literature and teaching. Many of them managed to get their drugs even while in the institution, and practically all of them left uncured with but an exceedingly small number of possible exceptions.

From my patients themselves, and from watching and studying them, I later learned the truth, which has since been continually strengthened--that the so-called "discomforts" we think of them as suffering upon withdrawal of their drug, are actually unbearable suffering, accompanied by physical manifestations sufficient to prove this to be so. I also learned that the supposed delightful sensations which have formed the background of most pictures painted of them, had in many, if not in most of the cases with which I came in contact, never been experienced. If they had ever existed they had long ago been lost and all that remained in opiate effect was support and balance to organic processes necessary to the continuance of life and economic activity. As I have written, these sensations seem to be, "part of the minor toxic action of the opiate against which the addict is nearly or completely immune and to the securing of which very many and probably a majority of the innocent or accidental addicts have never carried their dosage." In plain English the sufferer from opiate addiction has, in many if not a majority of cases, never experienced any enjoyment as a result of the drug and has endured indescribable agony in its non-supply.

I do not want to be understood as claiming that opiates will not produce pleasant sensations, nor that they are never used to the end of experiencing these sensations. There is a class of the inherently or otherwise defective or degenerate, who first indulge in opium or its products from a morbid desire for sensuous pleasures, just as they would and do indulge in any form of perversion or gratify any idle curiosity. They are mentally incapable of self-restraint, indulging jaded appetite with new stimuli. They yield themselves to any and all forms of self-indulgence and gratification of appetite. There comes a time when for them opiates, from increasing tolerance and dependence lose power to give pleasurable sensations and become simply a part of their daily sustenance, exacting physical agony as a result of their non-administration. When this occurs they make no effort to control amount or method or use; and overdosage together with conditions incidental to and attendant upon their mode of life soon relieves society of the menace of their membership. As a class they have been regarded as incurable and hopeless--socially, economically and personally unworthy of salvage. To whatever extent this may be true, however, it is not true simply because they happen to have acquired opiate addiction, but because they are fundamentally what they are, diseased, degenerate and defective.

The opiate element is as incidental to their fundamental condition as are the venereal and other diseases from which many if not most of them suffer. Observations and conclusions upon addicts from this type of humanity have been given great prominence in the public press and elsewhere and have had an unwarranted influence in the status of opiate addiction and the conception of and attitude towards the addiction sufferer. Because addicts of this class began to use opium or its derivatives and products to secure sensuous gratification is no reason for stigmatizing the mass of those afflicted with addiction-disease as people of perverted appetites. No one should study addiction in them unless he is possessed of sufficient ability in clinical observation to separate physical signs of opiate addiction from the manifestations of defective mentality--and unless he has enough insight and breadth of vision to see behind end-results, primary causative factors; and unless he has enough common-sense to refrain from applying to the worthy many the observations he has made upon the unworthy few.

It is only fair to state in passing, however, that from my experiences as Visiting Physician in the wards of the Workhouse Hospital, New York Department of Correction, I am convinced that we all too often casually include in the above generally considered derelict class of society, many who under intelligent and humane handling could be restored to or converted into useful citizens.

There are some above this class, of the type of spoiled and idle youth, who indulge first in opiates in a spirit of bravado or curiosity. The tremendous increase in addiction since its spectacular incidental and morbid aspects became so widely published is largely contributed to from this class.

There are some who first used opiates to temporarily boost them over an emergency, post-alcoholic excesses, severe mental strain, etc.

The majority of narcotic addicts, however, and especially those developing previous to the activities of the past few years, present a very different history. Mentally and morally they are of the same average equipment as other people. They form a class which might be called "accidental or innocent" addiction-disease sufferers. They had no voice nor conscious part in the early administration of opiate, realizing no desire or need for it by name, but only wishing for the unknown medicine which relieved their sufferings. Very many addiction patients have received their first knowledge of opiate administration in the withdrawal symptoms which followed the attempted discontinuance of its use. There is in these sufferers no element of lack of will-power; no trace of desire to indulge appetite or to pander to sensuous gratification. In some, before their condition was recognized, their tolerance for or dependence upon opiate had proceeded to a point where their bodies' demand for morphine was imperative and their withdrawal suffering unendurable. In others, before body need was completely established--with their stamina and nervous resistance below par from sickness and suffering--they have been unable to forego opiate's supportive and sedative and pain-relieving action, or to endure the nervous and other symptoms attendant upon its withdrawal after even a brief period of administration.

As to what the addict is;--the tendency and effect of legislative, administrative, police and penological activities in general have been to place the sufferer from addiction-disease in the position of the criminal and vicious. The tendency of the psychologist and psychiatrist is to analyze him from the viewpoint of mental weakness, defect or degeneration, and to so classify and regard him. The average practitioner of internal medicine, and even the recognized leaders and authorities in this field of medical science will tell you that narcotic drug addiction is a condition to which they have given but little attention and have no clean-cut ideas of its physical disease problems. The addict himself, whose testimony has been all too little consulted or sought, will tell you that he is sick with some kind of a physical condition which causes suffering and incapacity whenever a sufficient amount of narcotic is not administered.

In the above attitudes and statements the administrative, police and penological authorities are right in some cases;--the psychologists and psychiatrists have good basis for their opinions in some cases;--the addict has physical grounds for his statement in all cases--he is always sick, sick with addiction-disease.

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