H. J. ANSLINGER
United States Commissioner of Narcotics
WILLIAM F. TOMPKINS
United States Attorney for the District of New Jersey Former Chairman, Legislative Commission to Study Narcotics, General Assembly of New Jersey
THE INDIVIDUAL: METHODS OF TREATMENT
DRUG ADDICTION IS FUNDAMENTALLY A SYMPTOM OF A PERSONALITY disturbance, and Kolb and Felix have set forth four general personality types as examples of the kinds of personality disorders upon which addiction is based.
Briefly, the first group consists of what is generally known as the medical addict--- persons who have been introduced to drugs through treatment and who have continued using the drug after the termination of the treatment. While, like the other types, there is some basic emotional problem underlying their continued use of the drugs, the difference lies only in that they first encountered the drugs in the course of medical treatment.
The second group embraces those having psychoneurotic disorders who take the drugs for relief of anxiety or whatever symptoms they may have.
In the third and largest group are found the psychopaths. These make up the bulk of the addict population and generally are created by infectious contact with persons already drug-conditioned. They seek the drug for its euphoric value and for the Pleasure and relief they believe they secure from it.
Lastly is drug addiction with psychosis in which group are encountered those mentally ill.
(Further analysis will be found in Medical Aspects of Addiction, later in this Chapter.)
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WHAT THE PHYSICIAN SHOULD UNDERSTAND
Generally, a normal, healthy person receives no specific psychological sensation from an opiate and will regard it simply as something to relieve pain. When the pain is alleviated, therefore, no need exists for its further use. However, extended use could result in the euphorizing effects taking hold, creating an accidental or medical addict. It is for this reason that doctors avoid the use of addicting drugs where a substitute can accomplish the purpose.
However, where a serious flaw exists in an individual's personality such as a neurosis, nervous hypertension, psychological maladjustment, or a psychopathic disorder, the drug will have a stronger and more rapid effect with euphoria occurring much sooner.
Erich Hesse very lucidly describes the impact of the addicting drugs on these types of individuals. Hesse states,* "Their minds feel at ease. The victim experiences a sensation of happiness, of freedom from all troubles, which makes him forget all his worries and his mental restlessness, or at least makes these appear insignificant (Peters, Steil, Geilen). Such an experience may be a sufficient motive for weak characters to enjoy a second intoxication soon after the first one."
Sensory perception decreases during the intoxication. In the initial stage of the addiction, volitional processes are not so strongly impaired as to make a voluntary renunciation of morphine impossible. Peters describes two such cases. One of them was a man known for his weak will power, who used morphine daily for three weeks, and then made up his mind to give it up, which he did. The other was a member of a nursing order, whose nerves had been frayed by his exhausting duty day and night. At first he would only occasionally reach for the morphine syringe. Then be took the drug daily for eight consecutive days. His superiors learned about it, and forbade him the further use of morphine. He actually kept his promise to stay away from the drug, for several years, at least.
* Erich Hesse--- Narcotics and Drug Addiction.
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Voluntary escape from the clutches of the poison is no longer possible after real addiction has developed. In this stage the alkaloid is the only thing capable of keeping the addict in a bearable physical and mental condition. If the drug level in the blood and in the tissues is lowered, the abstinence phenomena will set in. The addict becomes irritable, moody, depressed, and once again will reach for the narcotic in order to escape from this unpleasant state. His affective and emotional life now undergoes a basic change. If he had been sociable, now be shuns company. Preoccupied with himself, he keeps to himself, avoids people, and becomes disinterested in his environment and the outer world. His mind is dominated by only one thought, the desire for morphine or other narcotic drug, whose toxin alone is capable of making his life bearable. His will power is limited and the autistic attitude of the addict projects it in the direction of the alkaloid exclusively.
There begins the transition to the marantic stage. Periods of moodiness, delusions, lack of self-confidence, negligence of duties, moral aberration, and finally acute psychoses may set in. Morality wanes. Unscrupulousness, carelessness, negligence, lying, forgery of prescriptions, embezzlement of money, burglary, and other criminal acts may now be expected from the addict. Frequently the desire to secure the drug is the motive behind the illicit acts. Such individuals, now turned completely asocial, are responsible for the most horrifying human tragedies within their spheres of activity. The final stage begins with the negligence of physical cleanliness, and it ends with complete physical decay, preceded by various somatic symptoms; paleness, strong perspiration upon the slightest stimulus, skin rashes, sexual disturbances with dysmenorrhea and amenorrhea or decrease of potency.
THE CHARACTER OF THE ADDICT PERSONALITY
Hesse, citing Bonhoeffer, points out that only 10-15 percent of all addicts are non-psychopaths. Thus in approximately 85-90 percent of the cases are found individuals suffering from psychoneuroses, character disorders, and other problems ranging through the whole series of psychiatric ailments. While there is
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no typical addict personality, it is safe to say that there are numerous addiction-prone people with personality disturbances who could easily succumb to the drug habit.
The fact that the overwhelming number of drug addicts suffer from a character disorder points up these salient facts. First of all, an individual far more threatening to society is created when psychopathic tendencies are blended with drug addiction. The innate viciousness of drug addiction with its iron grasp on such an individual predisposes a dangerous result. Too frequently, altruists gloss over and generalize by classifying all drug addicts as sick persons-persons whom treatment will cure and rehabilitate. Too frequently the impression is conveyed that the drug addict population consists of unfortunate people who fell into a bad habit that could have occurred to anyone.
Too infrequently are we told that the chances of a complete cure are not good, that those addicted a relatively short time represent most of those cured, and that relapse is frequent. Too infrequently are we advised that we are in the main not dealing with average citizens who have suddenly been smitten with drug addiction, but in fact with people who had unpleasant and troublesome tendencies before drug addiction was superimposed. And too infrequently are we informed that many cases warrant strong corrective action because of some basic disturbance which drugs have awakened, or simply because of prior antisocial behavior. A spot check of any police record bureau will disclose the fact that many addicts were criminal offenders, long before taking on the drug habit. Make no mistake about it-we're not dealing with something hospitalization alone will cure but a dreaded scourge that penetrates infinitely deeper and requires a much greater effort to uproot. And in too many cases, we are confronted with some inherently bad patients.
TREATMENT AND CONTROL
An old time narcotic agent once summed up the subject of treatment by describing it thus: "About ten days in the 'shot room' to get off the drugs, four to six months of work under healthy conditions, after which it becomes a mental problem which the patient, now discharged, must overcome for himself.
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There isn't a great deal to quarrel with in that succinct analysis. Actual withdrawal of drugs can be accomplished either abruptly or gradually. The abrupt method, sometimes referred to as the cold-turkey treatment, is still used on occasion, but it is generally not preferred by a majority of the medical authorities. The weakness of this method in addition to its inhumaneness is that a particular patient's condition might be such that immediate and complete withdrawal might kill him, and futhermore, rapid sudden withdrawals only serve to create added burdens of anxiety and hostility to the overtaxed emotional state of the addict. It is safe to say that few hospitals or physicians employ this method today.
The cornerstone of successful treatment must be laid in a drug-free environment. Anyone who believes that the ambulatory method of treatment will succeed only deludes himself, as it has been proved a failure. A wise judge or probation officer will never countenance that type of treatment. Hospitalization presents the best guarantee of securing the important factors of proper control, thorough observation and complete medical care. Upon leaving the hospital, the vitally important factor of care after discharge arises.
Control of the addict cannot be overemphasized. As Dr. Reichard* so aptly stated: "Control of the addict for a period of at least one year is imperative. Sometimes the period of control must be longer; for a few, such control must be life-long." Control does not mean confinement in an institution. That is necessary for some months at the beginning of treatment. Supervision in the community, with the ability on the part of someone with the proper training to return the patient to an institution for further intensive treatment when necessary, is a type of control that is greatly needed.
The development and utilization by communities of legal methods of restricting the personal liberty of the addict, analogous to those now functioning for psychotic persons, is highly desirable. Since most definitions of addiction include loss of self
* "Addiction: Some Theoretical Considerations as to its Nature, Cause, Prevention and Treatment" by J. D. Reichard, American Journal of Psychiatry, Vol. 103, No. 6, May, 1947.
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control, it seems unrealistic to expect an addict to exhibit enough control to remain voluntarily in a drug-free environment.
We should, by obtaining the cooperation of our colleagues in the legal profession and of our legislators, endeavor to work out a more adequate method of control. Control, particularly after discharge, is imperative.
Proper treatment dictates that the drugs be withdrawn humanely and gradually from the patient followed by rehabilitative and psychiatric treatment. Generally the best plan for withdrawal involves the substitution of Methadon for whatever drug the addict has been using, followed by a reduction of the dosage of Methadon over a period of approximately ten days.
After withdrawal has been accomplished, any chance of cure requires a prolonged period of institutional rehabilitation under closest surveillance. The individual should be enabled to engage in useful work each day and occupational therapy should be geared to bring out and implement any talents or skills which are present. It is important that all patients, including those with chronic diseases, be required to participate in some type of useful endeavor. Recreational facilities, such as movies, athletics, games, reading rooms, and music should also be provided.
Psychotherapy, of great importance in the effort to avoid relapse, must be adequate. The treatment parallels that given to non-addicted persons suffering from psychoneuroses and other character disorders with a view to obtaining as high a degree of mental and emotional stabilization as possible. Unfortunately, adequate personnel is lacking to care for all those who require psychotherapy.
NEED FOR AN INTELLIGENT PUBLIC ATTITUDE
After discharge from the hospital, the most precarious period commences, and it is for this reason an adequate program of follow-up treatment is needed. Unfortunately there is very little opportunity for the addict to obtain this care. Too many free mental health clinics are disinterested in drug addicts. It is clear that welfare groups, churches, hospitals, and local government agencies must take a more affirmative interest in the returning drug addict. Nobody suggests a parade with ticker tape for the
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returned addict, but no community can be excused for failure to be interested or for failure to help. For those who regard it from a dollars-and-cents viewpoint, remember that a cured addict no longer is a taxpayer's burden. When an addict is cured, the underworld has lost one of its best customers.
FACILITIES FOR TREATMENT
A word about the facilities for treatment. With the exception of the hospital for teen-age addicts opened in 1952 in New York City and the clinics established at Chicago, Illinois, very little, if anything, has been done below the Federal level. The great majority of State and local governments continue refusing to assume any responsibility for the cure of drug addiction. Care for the insane? Yes. Tuberculars? Yes. Sex offenders? Yes. Epilepsy? Yes. Drug addicts? No! A truly indefensible situation!
Facilities at the two United States Public Health Service Hospitals-one located at Lexington, Kentucky, and the other at Fort Worth, Texas-permit patients to remain under treatment for the necessary length of time. The larger hospital at Lexington, opened in 1935, was the first of its kind in the world and unique in the combined program of research and treatment. Subsequently, the additional hospital in Fort Worth was constructed in 1938. Thus today there are approximately 2,200 beds for the treatment of narcotic addicts in these Federal hospitals.
Every year approximately 3,000 men and women receive treatment at the hospital at Lexington. Staffed by over 500 medical and other hospital personnel, it is located on 1,250 acres of Kentucky blue-grass farm land where the farm, dairy, and building maintenance, in addition to the furniture factory and garment shop, offer splendid occupational training opportunities. For physical recreation a baseball diamond, gymnasium, tennis courts, and bowling alleys are provided. Weekly motion pictures and stage shows are shown in the auditorium, and there are regular school classes, an excellent library, and a music department with a band and orchestra. Church services are conducted each week in the hospital chapel by Protestant, Catholic, and Jewish Chaplains.
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Admission to the hospital is limited to those men and women who have become addicted to narcotic drugs as defined by Federal law which reads as follows:
The term addict means any person who habitually uses any habit-forming narcotic drugs so as to endanger the public morals, health, safety, or welfare, or who is or has been so far addicted to the use of such habit-forming narcotic drugs as to have lost the power of self-control with reference to his addiction,
The term habit-forming narcotic drug or narcotic means opium and coca leaves and the several alkaloids derived therefrom, the best known of these alkaloids being morphia, heroin, and codeine, obtained from opium, and cocaine derived from the coca plant; all compounds, salts, preparations, or other derivatives obtained either from the raw material or from the various alkaloids; Indian hemp and its various derivatives, compounds, and preparations, and peyote in its various forms; isonipecaine and its derivatives, compounds, salts, and preparations; opiates (as defined in Section 3228(f) of Title 26).
BASIC PRINCIPLES FOR THE PHYSICIAN
In discussing the individual physician's role in connection with the problem of drug addiction, three principles should be expressed at the outset:
1. The physician should familiarize himself thoroughly with the Federal laws and regulations as well as State laws and regulations, remembering that the laws of each State vary, as do Federal and State enactments.
2. Ambulatory treatment of drug addiction should not be tried.
Institutional treatment is always required.
3. An addict should never be given drugs for self-administration.
A previous chapter has discussed the physician's legal obligations.
"WHAT TO DO WITH A DRUG ADDICT"
An excellent statement* has been prepared by the Committee on Drug Addiction and Narcotics of the National Research
* Journal of the American Medical Association, July 26, 1952, page 1220.
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Council,* assisted by Dr. Harris Isbell, Director, National Institute of Mental Health, Addiction Research Center, United States Public Health Service Hospital, Lexington, Kentucky, and it contains some pertinent advice concerning treatment, some excerpts from which are here presented.
Diagnosis of Addiction
Most frequently, addicts who appear in a physician's office are transients who are unknown to the physician. Such persons are likely to appear when circuses and carnivals are present in a community. Less commonly, addicts may be nontransient persons who are fairly well known to the physician. Frequently, nontransient addicts are neurotic persons or are patients who are known to have been chronic alcoholics. It is not unusual for the nontransient addict to be a physician. In recent years, it has not been unusual in certain areas for an adolescent boy or girl to be brought to the physician by relatives or by representatives of social organizations for advice relative to the treatment of addiction.
Most frequently, the diagnosis of addiction is made at the onset of the interview by the patient's statement that he is addicted to and needs drugs. The addict may attempt to conceal his addiction and may present a glib story of some physical illness; most frequently mentioned are atypical angina pectoris, kidney colic, migraine, or hemorrhoids. Generally, the story culminates with the suggestion that other physicians have found that the only adequate remedy is a prescription for narcotic drugs. Frequently, addicts of this type may appear armed with a formula which they state was given to them by another physician and which they have found very effective for the relief of their alleged symptoms. The formula will usually contain morphine, laudanum, or cocaine. If refused morphine, many addicts will ask for either methadone or meperidine. They will state that these drugs are not opiates but are synthetic drugs and are nonaddicting, All too frequently, uninformed physicians will be taken in by this story and will prescribe the synthetic analgesics. It is not unusual for addicts to attempt to obtain narcotics on the basis of some mild, chronic, nonfatal disease, such as asthma, arthritis, or chronic osteomyelitis, for which narcotics are not usually required or given. They will state that these diseases cause them terrible pain, that physicians
* See Appendix II for the composition, purposes and functioning of this Committee.
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in another town have been prescribing narcotics, and that their own physician is away and they need drugs only until be returns. Occasionally, transient addicts may appear who are suffering with serious physical diseases, such as advanced cardiovascular diseases or emphysema. These cases present particularly difficult problems and treatment since the stress of abrupt withdrawal might prove fatal.
Nontransient addicts who are well known to the physician sometimes attempt to develop stories similar to those used by the transient, veteran, criminal type of addict. Nontransient addicts, however, are more likely to be sincere than the transient addict. Many such patients truly desire to be cured of their addiction and should be given an possible help. All too frequently, a nontransient addict will be a physician or a nurse. In such cases, the most likely drug of addiction is now meperidine largely because of the widespread belief among the medical profession that this substance is not addicting.
The presenting situation may also be that of an adolescent girl or boy who is brought to the physician by his parents or by other responsible persons. Generally, such adolescents will admit the use of drugs and present no particular problem in diagnosis. In such cases, the physician should exercise a certain degree of care, since because of the widespread publicity concerning addiction in adolescents, many parents may wrongly attribute normal or abnormal adolescent behavior to drug addiction.
When the history leads one to suspect addiction, a complete physical examination is of the utmost importance. A transient addict is frequently surprised when the physician indicates a desire to perform a complete physical examination and may refuse the examination and immediately leave the office. It is important to realize that there are no pathognomonic physical signs of addiction. The opiate drugs do not cause drunkenness as do the barbiturates and alcohol, so mental confusion, emotional instability, nystagmus, and ataxia are not to be expected. Since complete or partial tolerance to many of the effects of morphine develops during the course of addiction, doctors must not expect that addicts presenting themselves in their offices will show the same effects as might be expected in persons not addicted, namely, constriction of the pupils and sedative effects. An addict may or may not show pupillary constriction depending on how recently he has received a dose of morphine. Superficially, tolerant addicts will appear to be physically and mentally normal unless they have been without drugs for some time and signs of abstinence have appeared.
The most important findings are the presence of old and recent
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needlemarks. These needlemarks should be sought over the veins in the antecubital spaces, the deltoid region, the abdomen, the anterior surface of the thighs, and along the veins of the legs and hands. Multiple abscesses or old abscess scars are also suggestive. Miosis is not a completely reliable sign since partial tolerance to pupillary constriction caused by morphine develops during addiction. Addicts who are using either meperidine or methadone are likely to have induration and inflammation of large areas of the skin, particularly over the deltoid region and the anterior surface of the thighs. Presence of long scars or tattooing over superficial veins is extremely suggestive, particularly if fresh needlemarks are present. One important feature may be that no physical findings are present which satisfactorily explain the serious symptoms detailed by the patient when the history was taken.
Occasionally, persons who are suspected of taking cocaine or marihuana are brought to the physician for an opinion. Neither cocaine nor marihuana produces physical dependence. Since such patients are usually brought to the physician long after the drug effects have worn off, findings are generally scanty. The signs of cocaine intoxication, however, include mydriasis, sweating, tachycardia, increase in blood pressure, increase of deep tendon reflexes, nervousness, tremor, an unblinking stare, and auditory and visual hallucinations. Intoxication with marihuana is characterized by injection of the conjunctivae, a sleepy appearance, excessive giggling, silly behavior, absence of marked ataxia, and a strong odor on the breath resembling that of cubeb cigarettes.
There are no laboratory procedures generally available to the average physician which are helpful in the diagnosis of addiction. Reliable tests for the presence of morphine and cocaine in the urine have been developed, but these methods are quite complex and are not suitable for use in the ordinary laboratory. There are no methods available for the detection of morphine in blood and no laboratory procedures which are sufficiently specific for the detection of synthetic analgesics and marihuana in either blood or urine. Furthermore, if such procedures were available, a positive test of the presence of drugs in the urine would mean only that the person had recently taken or been given a dose of a drug and would not necessarily mean that he was addicted to that drug.
A definitive diagnosis of addiction to morphine or similar drugs depends upon the demonstration of the characteristic signs of abstinence following complete and abrupt withdrawal of drugs. In order to
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prove the presence of physical dependence, the addict must be isolated in an environment so well controlled that there is no possibility of any narcotic drugs, other than those prescribed, being obtained by the addict. If such an environment is available, isolation of the addict and withholding of all narcotics will prove the presence or absence of dependence on these drugs. The detection of physical dependence requires familiarity with the signs of abstinence from morphine.
If morphine is abruptly withdrawn from a patient who has been receiving as much as 0.26 to 0.39 gm. (4 to 6 grains) daily for a period of 30 days or more, few signs are observed during the first 16 hours of abstinence. The patient is likely to go into a restless tossing sleep which may last for several hours. About 14 to 18 hours after the last dose of the drug was given, the addict will begin to yawn; rhinorrhea, perspiration, and lacrimation will appear. These mild signs increase in intensity during the first 24 hours of abstinence; thereafter, they become constant. Dilatation of the pupils then appears and, on close observation, recurring waves of gooseflesh will be seen. About 36 hours after the last dose of morphine was given, uncontrollable twitching of the muscles occurs. The patient will become extremely restless, will move from side to side in bed, and tremor of the face and tongue will be evident. The patient will complain of severe cramps in his legs, abdomen, and back; be will be unable to eat or to sleep for any period of time and vomiting and diarrhea frequently occur. Rectal temperature rises about 2 F, respiratory rate is usually elevated to 20 to 30 per minute and is increased in depth. Systolic blood pressure is usually elevated about 15 mm. of mercury, and patients mill lose 5 to 15 pounds of weight during the second 24 hours of abstinence. A reduction in eosinpohils per cubic millimeter of blood closely parallels the intensity of abstinence symptoms, and, at the peak intensity of the withdrawal illness, the eosinophil count will be nearly zero. This constellation of signs and symptoms constitutes as clear-cut and well delineated a syndrome as is ever seen in clinical medicine. Once it has been observed, it scarcely can be mistaken for any other condition. Acute signs and symptoms reach maximum intensity 48 hours after the last dose of morphine has been given and will remain intense until 72 hours have passed. Thereafter, they gradually subside and, after 50 to 10 days, completely disappear, although the addict may still be weak and sleeping poorly.
It is necessary to remember that the intensity of the abstinence syndrome varies from person to person and is, within limits, dependent on the dose that the addict has been receiving. Not all patients will
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exhibit all the signs of abstinence listed above. Severe grades of abstinence symptoms are practically always seen in addicts who have been receiving as much as 60 to 90 gm. (I to 1.5 grains) of morphine four or more times daily. The intensity of abstinence symptoms becomes milder as the average daily dose declines. Since most adolescent addicts actually have been receiving only small amounts of opiates, the effects of abstinence are usually quite mild in juvenile addicts and very close examination may be required to detect the minor signs which are present.
Symptoms of abstinence from other opiates and the synthetic analgesics differ from morphine chiefly in intensity and duration. Effects of abstinence from heroin, dihydromorphinone, and metopon appear very rapidly, reach maximum intensity in 12 hours or less, are somewhat more severe than those from morphine, and subside more rapidly. Abstinence symptoms from codeine appear slowly and are more prolonged than those from morphine. Abstinence symptoms from dibydrocodeinone and eucodal are less intense than those from morphine, but more intense than those from codeine. The symptoms from Dromoran are quite similar in course and intensity to those from morphine.
Effects of abstinence from meperidine appear rapidly and are detectable two to three hours after the last dose of meperidine has been administered. Abstinence from meperidine has an effect somewhat similar to that of abstinence from morphine, but restlessness is even greater, and uncontrollable twitching and jerking of the muscles is extreme. The course of abstinence from meperidine is quite short and symptoms usually disappear two to three days following withdrawal.
Signs of abstinence from methadone come on slowly and are usually not detectable until the third or fourth day after the last dose of the drug has been given. Autonomic signs, such as sweating and mydriasis, are not very prominent. For this reason, the detection of abstinence symptoms is more difficult. The course of abstinence from methadone, however, is quite prolonged. Because of this, withdrawal of methadone is regarded by many addicts as being more uncomfortable than abstinence from morphine.
Frequently, because of the lack of suitable facilities, it may not be possible to isolate the addict and prove the presence of addiction by allowing the signs of abstinence to appear. It is almost useless to attempt to carry out diagnostic withdrawal in a general hospital, or even in mental hospitals, since addicts frequently manage to smuggle drugs into these environments. Diagnostic withdrawal may also be impossible
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because of the addict's refusal to undergo the procedure and, in certain cases, it may be unwise if the patient has some serious physical disease.
Where adequate isolation for diagnostic withdrawal is not possible, the diagnosis of addiction can be established only tentatively.
A new drug, N-allylnormorphine, which is a very effective antidote for morphine, has recently been shown to precipitate signs of abstinence in addicted persons within 15 minutes following its administration. This agent, therefore, may provide a means of quickly establishing the presence and degree of physical dependence on opiate drugs, but sufficient information on the safety and reliability of the procedure is not available at this time to permit a recommendation for general use of N-allylnormorphine as a diagnostic agent in suspected addiction.
Reporting of Addicts
The physician is under no legal obligation to report cases of addiction to Federal officials. The Bureau of Narcotics, however, welcomes voluntary reporting of addicts by physicians.
Disposition of the Addict
Once a tentative diagnosis of addiction has been made, the physician would be well advised to seek consultation for confirmation. The problem then becomes one of advising the addict in accordance with the two cardinal principles of treatment set forth above-institutional treatment is necessary, and drugs must not be given to the addict for self-administration. The addict must be advised to seek admission to an institution for treatment. If be will not accept this advice, the physician may ethically refuse to take any further action. If the patient indicates willingness to undergo institutional treatment, steps should be taken immediately to obtain admission to the nearest and most available institution. Frequently, this can be accomplished immediately by telephoning the institution selected. The physician should refuse to administer any narcotics unless the patient shows the utmost diligence in obtaining entrance into an institution. Such excuses as time for arranging business and personal affairs or preference for one institution over another should not be accepted as reasons for the administration of narcotics; nor should the presence of signs of abstinence be a valid reason for immediate administration of narcotics unless the patient has such serious physical disease that stress of abstinence might prove fatal.
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The physician must be prepared to resist the demands of addicts for narcotics and must exercise great care and judgment in determining whether physical disease which requires the immediate administration of opiates is present. If a physician yields to the importunities of an addict and gives him morphine for mild asthma, his waiting room will soon be cluttered with other addicts, all of them complaining that they have asthma or some similar condition. Such a situation can lead only to embarrassment to the physician and, perhaps, to difficulties with the authorities.
When the patient has agreed to go to an institution and has presented satisfactory evidence that he has taken steps to obtain admission (mere statement of the addict is not sufficient evidence of this), the problem is then reduced to the immediate management of the patient. The second principle, drugs should not be given to the addict for self-administration, applies here. it may be possible to place the patient in a general hospital where narcotics can be administered under direct supervision while final arrangements for entrance to the specialized institution are being made. The physician, in any event, should not give the addict a prescription for narcotics but should administer personally such drugs as are appropriate for immediate need only. It may be emphasized that it is always wise to seek consultation with another physician relative to the diagnosis of addiction and/or the presence of serious physical disease. A special record of narcotics administered should be kept, and, as has been previously mentioned, temporary administration of drugs should not be extended beyond the minimum time absolutely necessary for arrangements for admission to an institution to be completed. When the addict leaves his home community, he should be accompanied to the institution, whenever possible, by some responsible person, preferably a physician or a nurse.
No absolute rule can be laid down for the amount of narcotics to be given during the time arrangements for admission to a proper institution are being made. However, no amount of narcotic should be used in excess of that necessary for the immediate need of the patient. Either morphine or methadone may be used since these two drugs will adequately control abstinence from any of the other narcotics. It is advisable to limit the initial dose to 16 mg. (1/4 grain) of morphine or 10 mg. (1/6 grain) of methadone. It practically never should be necessary to exceed as a single dose 60 mg. (1 grain) of morphine or 30 mg. (1/2 grain) of methadone. Even in patients with very severe heart disease, there is little danger of abstinence from morphine causing
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death if the above dosage schedule is followed. The type of drug given and the dose should be unknown to the addict and all possible precautions should be taken to prevent the addict from obtaining narcotics from other sources.
The Adolescent Addict with or without Demonstrable
Dependence on Narcotic Drugs
Despite their ages, adolescent addicts must be separated from their usual environments. Institutional treatment for adolescents with demonstrable dependence is just as necessary as for adult addicts and the same procedures should be followed. Adolescents without physical dependence might possibly be sent to a camp, farm, or some other environment where rehabilitative treatment may be attained rather than sent to institutions where contact with older, more hardened addicts is unavoidable.
Patients with Incurable, Fatal, Painful Diseases
Persons in this class are usually patients who are dying with advanced carcinoma, tuberculosis, or some other chronic disease. The problem in such instances is completely different from those described above. The physician is properly concerned, primarily, with relieving suffering and, only secondarily, with the addiction. Federal and State narcotic laws were not designed to prevent narcotics from being prescribed in such cases. Proper, ethical medical practice, however, demands that certain principles be followed.
Physicians prescribing narcotics for such patients should personally be attending the patient. A diagnosis of a painful, incurable disease should be confirmed by consultation with another physician. An means of relieving pain other than prescription of narcotics should be exhausted, Such measures include the use of drugs other than narcotics, physical therapy, and surgical procedures designed to relieve pain. When administration of narcotics becomes necessary, the physician should initially use drugs of lesser potency, such as codeine. When use of more potent narcotics is required, they should be given in the smallest possible dose and the interval of administration should be as long as possible. Precautions should be taken to ensure that the amounts of narcotics prescribed are no greater than those actually required for the particular patient so that there will be no surplus for diversion to illicit use. Whenever possible, the drugs should be given orally rather than hypodermically. Drugs should not be given directly to the patient for self-administration. The status of the patient and his
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disease should be reviewed periodically to make certain that the diagnosis is correct and that definitive, curative therapy is not possible.
Cocaine and Marihuana Addicts
Since physical dependence on these drugs does not develop and there is no withdrawal illness, the patient should simply be advised to seek treatment in a properly staffed institution. Hospitalization until admission to an institution can be obtained but is not necessary or advisable.
Choice of Institution
The choice of an institution depends upon the type of case, the financial situation of the patient, and other factors. Many private sanatoriums in the United States make a specialty of the treatment of narcotic drug addiction. Advice concerning these institutions can be obtained from local medical societies, the American Hospital Association, The American Psychiatric Association, or the American Medical Association. Alternatively, the physician may investigate the possibilities of having the patient admitted to a public, local, or State institution. Information concerning such institutions can be obtained by contacting local or State health departments. Lack of suitable local facilities remains one of the difficulties in the treatment of addiction. Physicians should support the establishment of such facilities in States in which no provision for addicts has yet been made.
Where local facilities are not available, addicts can be referred to the two federal hospitals maintained by the U. S. Public Health Service at Lexington, Kentucky, and Forth Worth, Texas. Persons addicted to opiates, synthetic analgesics, cocaine, and marihuana are eligible for admission to these institutions. Patients who are addicted to alcohol, barbiturates, or bromides are not eligible for admission to these federal hospitals unless they are also addicted to morphine, synthetic analgesics, marihuana, or cocaine. If the patient is indigent, treatment is available without charge. If the patient has funds, he is required to pay $5.00 daily for his treatment. Addicts entering these institutions are asked to remain at least 135 days before being discharged. Ordinarily, there is no waiting list for male patients and admission can be arranged readily by writing or telephoning the Medical Officer in Charge of either hospital. Only the institution in Lexington has facilities for female patients, consequently, women usually must wait for a short time before they can be admitted.
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The Need for Compulsion
Unfortunately, many addicts will not go to an institution or remain there until treatment is completed unless compelled to do so by legal means. There is a great need for legislation in most of the States which would make it possible to commit addicts to institutions where they would be forced to remain until maximum benefit of treatment had been obtained. The Federal Bureau of Narcotics has drafted a text of such a proposed law and will distribute copies to interested persons on request. Legislation has also been proposed which would make it possible for the two U. S. Public Health Service Hospitals that treat addicts to accept and hold addicts committed under State laws. Passage of such laws deserves the support of all physicians.
Treatment Following Discharge from Institution
The follow-up treatment after the patient has been discharged from an institution is usually the weakest link in the overall treatment of addiction, and it is in this particular phase of the problem that the ordinary physician can make the greatest contribution. The physician should do what he can to assist the addict to find a job following discharge from an institution. He can attempt to make arrangements, utilizing such social agencies as are available, to separate the addict from the environment which played a role in engendering the addiction. He should encourage the former addict to participate in the activities of community groups, such as churches and clubs. The physician can advise the relatives of a former addict respecting environmental and familial factors which may be contributing to the patient's difficulties. He can also administer such forms of psychotherapy as he is qualified to carry out. When suitable facilities are available, intensive psychotherapy by a qualified psychiatrist is of great value provided the patient is willing to accept such treatment. The addict should remain under close supervision for at least two years following discharge from an institution. Although the tendency to relapse is very great in addiction, the physician should maintain an optimistic attitude even in the face of repeated recurrence and should continually encourage and support the addict.
Management of Disease in Former Addicts
When a person who formerly has been addicted to morphine becomes afflicted with a disease for which narcotics are usually prescribed (this situation usually develops when a surgical operation
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becomes necessary), he should be handled just as if he had never been addicted. Since the former addict has been withdrawn from narcotics and has lost his tolerance to them, narcotics should be prescribed in the same doses and at the same intervals as is customary with persons who have never been addicted. Larger doses are not required. Narcotics should never be given to the former addict for self-administration, and use of narcotics should be discontinued as soon as possible. The addict should then be supervised closely for a month or so in order to avert relapse to uncontrolled use of drugs.
Management of Addicts Who Have Relapsed
The management of patients who have relapsed to abusive use of narcotic drugs should follow the same lines as detailed above. The only difference is that the period of supervision following discharge from an institution should be extended.
CAN THE ADDICT BE CURED? YES AND NO, DEPENDING ON INDIVIDUAL circumstances. Young people and those addicted a short time are the best prospects. There is at Lexington the finest hospital of its kind in the world. Many experts will cite an over-all rate of 25 percent cures; cynics off the record will claim that it actually is no more than 2 percent. At the best, there are harsh statistics. The bright side, however, is the Lexington story. From 1935 to 1952, 18,000 addicts were admitted for treatment. Of these, 64 percent never returned for treatment, 21 percent returned a second time, 6 percent a third time, and 9 percent four or more times. These figures should give everyone confidence that the U. S. Public Health Service Hospitals can secure good results in one of medicine's most tremendously difficult tasks. The hospitals and their great staffs have proved that the addict can be rehabilitated. Complete and unselfish support by the general public will certainly increase the number of addicts who can be made into useful members of society. That support is merited.
One final word. Those who fight drug addiction are fighting uphill with the odds very much against them. There is no sure cure, no complete knowledge, and the chances of winning are definitely not too good. It may very well be the beginning of the end--- a short and horrible existence. The best cure for addiction? Never let it happen!
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MEDICAL ASPECTS OF ADDICTION TO ANALGESIC
The following discussion has been extracted from an article by Dr. Victor H. Vogel and Dr. Harris Isbell of the United States Public Health Service Hospital at Lexington, Kentucky, on this subject published in the United Nations Bulletin on Narcotics, Vol. II, No. 4, October, 1950.
Before discussing a subject it is necessary to define it. In the past the most widely used definition of addiction has been that formulated by pharmacologists which states that addiction is a condition brought about by the repeated administration of a drug such that its use becomes necessary and cessation of it causes mental and physical disturbances. The symptoms which appear following withdrawal of morphine indicate the development of a state called "dependence" on the drug. Dependence may be emotional, physical, or both. However satisfactory this definition may be to pharmacologists, who are concerned only with the effects of drugs, it is not acceptable to persons who actually have to handle the human beings who are addicted. The pharmacological definition of addiction puts the cart before the horse because one has to take morphine for at least two or three weeks before any dependence is developed. Moreover, if dependence were the only important factor in addiction the solution of the problem would be very easy. One simply would permit addicts to have drugs so that their dependence would be continuously satisfied. It should also be noted that this definition makes coffee, tea and tobacco addicting substances because emotional dependence on these substances is just as marked as it is on cocaine or marihuana which are regarded as addicting drugs by practically all societies.
Any definition which makes dependence the central feature of the definition is undesirable because of the public's reaction to the term addiction. Laymen and even physicians believe that the use of an "addicting" drug is an extremely bad thing. Contrariwise, the habitual use of a "non-addicting" drug is not nearly so reprehensible and is not a matter of public concern. Actually, we are concerned about addiction and attempts to regulate the use of addicting drugs, not because individuals who use the drugs become dependent upon them, but, because the effects of the drug are harmful both to the individual and to society. The harm which the use of various drugs may cause arises in a number of ways. It may be due to a decrease in the potential
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social productivity of the addict as occurs during addiction to morphine and similar drugs, to the precipitation of undesirable and dangerous behaviour (even of temporary insanity) as may occur with the abuse of cocaine and marihuana, or to the mental confusion and impairment of motor function which are prominent features of addiction to either alcohol or the barbiturates. Dependence is important in addiction but it is important chiefly because it tends to make the addiction continuous rather than periodic and so increases the amount of harm which the addiction produces.
In recent years a number of psychiatrically oriented workers in the United States have formulated a definition which makes loss of self-control with reference to the use of the drug and harm to the individual or to society the essential features. This point of view was accepted in part by the Drug Addiction Committee of the National Research Council who, after long discussion, recently adopted the following definition: "Addiction is a state of periodic or chronic intoxication which is detrimental to the individual and to society which is produced by the repeated administration of a drug. Its characteristics are a compulsion to continue taking the drug and to increase the dose with the development of psychic and, sometimes, physical dependence on the drug's effects. Finally, the development of means to continue administration of the drug becomes an important motive in the addict's existence." One should note that the leading sentence of this definition makes "detriment to the individual and to society" necessary to the definition of addiction and that the development of physical dependence is not a necessary characteristic of the term.
Under the terms of this definition, many drugs would be considered addicting. They include opium and some of its derivatives (morphine, heroin, dihydromorphinone [dilaudid], codeine, methyldihydromorphinone [metopon], dihydrocodeinone and eucodal); the synthetic drugs with morphine-like actions (meperidine [demerol or dolantin] and its derivatives, methadone [amidone, dolophine, "10820," physepteone] and all derivatives of methadone including isomethadone and heptazone [CB-11]); cocaine; hashish in any form; barbiturates; bromides; alcohol; peyote (mescaline); and amphetamine. Coffee, tobacco, and tea cause little harm and are culturally acceptable in most societies and are not regarded as addicting substances. In this article we will be concerned only with the medical aspects of addiction to the analgesic, or pain-relieving drugs.
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The Harm Produced by Addiction to Analgesic Drugs
Many of the popular notions concerning the damage caused by addiction to analgesic drugs are completely erroneous. These drugs do not make individuals who use them into supermen. . . . Moreover, individuals who are tolerant to opiates show no outward evidence of intoxication and are very difficult to differentiate from persons who are not taking drugs. Individuals who are addicted to these drugs maintain good muscular co-ordination and, if sufficiently strongly motivated, can continue to work, although the amount of work produced is definitely impaired by addiction. It is perfectly correct to state that the physical effects of addiction to a narcotic drug are much less damaging than are the effects of addiction to barbiturates or coca leaves. What then is the damage which these drugs produce and why are we concerned with them? The harm caused by addiction to analgesic drugs has been best described by Kolb who said "When taken in large doses they (the opiates) sap the physical and mental energy; lethargy is produced, ambition is lessened and the pleasurable feeling already described--- that all is well-makes the addict contented. These various facts cause him to pay less attention to work than formerly; consequently they tend to become idlers by these means alone . . .
"The dreamy satisfaction and the pleasurable physical thrill produced by opium in many addicts in their earlier experiences with it are of themselves forms of dissipation which tend to cause moral deterioration.". . .
Characteristics of Addiction to Analgesics
Addiction to opium and similar drugs is usually described as embracing three intimately related but distinct phenomena-. (1) tolerance, (2) physical dependence, and (3) habituation. It is wise to keep in mind that these terms are descriptive and do not constitute a definition of addiction.
Tolerance is defined as a diminishing effect in repetition of the same dose of the drug over a period of time or, conversely, a necessity to increase the dose to obtain an effect equivalent to the original dose. Physical dependence refers to an altered physiological state brought about by the repeated administration of the drug which necessitates the continued use of the drug to prevent the occurrence of the characteristic illness which is termed an abstinence syndrome. Habituation refers to emotional and psychological dependence on the drug-substitution of the drug for other types of adaptive behaviour. Habituation
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is closely related to the euphoric effect of the drug; that is, the relief of pain or emotional discomfort.
The mechanism of the development of tolerance to the analgesic drugs is unknown. The older theories of the mechanism have been reviewed by Eddy. Most of them are unsatisfactory. Marme believed that morphine was oxidized in the body to a substance called oxydimorphine and that oxydimorphine had effects which opposed the actions of morphine. Other investigators have been unable to confirm Marme's theory. Gioffredi thought that prolonged administration of morphine caused the production of a substance which was a specific antitoxin for morphine but, in carefully controlled experiments, Du Mez and Kolb were unable to find any evidence of the presence of any antimorphine substance in the serum of monkeys who were tolerant to morphine. Other investigators have felt that increased destruction and excretion of morphine by the body might account for tolerance. This is quite unlikely since tolerance develops to some effects of morphine at varying rates and on the other hand tolerance to certain effects never develops. Since morphine simultaneously stimulates and depresses different parts of the nervous system of animals, and since the stimulant effects outlast the depressant effects, Tatum, Seevers and Collins postulated that, as addiction proceeds, there is an increment of stimulant effects which oppose the depressant action of morphine thus bringing about tolerance. Amsler stated that morphine produced a persistent change in the cells of the body which rendered the cells more sensitive to the stimulant effects of morphine and more resistant to the depressant effects of the drug. Cloetta and others have postulated that there is some increase in resistance of the reactive cells to morphine but do not explain how this increased resistance is brought about. The hypothesis which is most widely held at present states that administration of morphine brings into play certain physiological responses which oppose some of the actions of morphine. Repeated administration of morphine strengthens the physiological counter responses and diminishes the effect of the drug. Wikler believes that these enhanced physiological responses are actually conditioned reflexes.
Physical dependence is one of the most striking characteristics of addiction to analgesic drugs and its importance in the total picture of addiction has both been over-emphasized and minimized. Pharmacologists are prone to regard physical dependence as the primary and only distinguishing characteristic of an addicting drug. The reasons for rejecting this view have been stated above. Other individuals have
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denied the existence of physical dependence and have attributed withdrawal phenomena to anxiety or malingering. This latter view is certainly not tenable because physical dependence has been produced in dogs, monkeys and chimpanzees, and Wikler has shown that physical dependence can be observed in the paralysed extremities of dogs whose spinal cord has been severed as well as in dogs from whom all of the cerebral cortex (the part of the brain involved in thinking and emotions) has been removed.
The course of abstinence from morphine has been described in great detail by Himmelsbach. If morphine is abruptly withdrawn from an individual who has been taking as much as 0.26 to 0.39 grammes daily for a period of 30 days or more, few signs are seen in the first 8 to 16 hours of abstinence. The patient is likely to go into a restless, tossing sleep which lasts several hours. About 12 to IS hours after the last dose of the drug has been given, the patient begins to yawn, his nose begins to run, he starts to sweat and large tears form and run down his face. These signs increase in intensity and, during the second 24 hours of abstinence, the pupils of the eyes become widely dilated, the patients complain of "hot and cold" flashes and, on careful observation, one can see recurrent waves of gooseflesh on the skin. The gooseflesh resembles the skin of a plucked turkey and accounts for the origin of the term "cold turkey" which is used by the addicts in the United States to describe abrupt and complete withdrawal from drugs.
Thirty-six hours after the last dose of morphine has been given, uncontrollable twitching of the muscles begins. This twitching and jerking accounts for the term "kicking their habit." Severe muscular cramps develop in the legs, abdomen and back. Anorexia and insomnia become prominent. Vomiting and diarrhoea are frequently seen. The patient has a mild fever, the respiratory rate rises to 25 or 30 per minute and becomes irregular and sighing in character, and the blood pressure is slightly elevated. The addict is unable to eat and will probably lose five or six pounds during the second and third days of abstinence. The acute signs and symptoms reach their height 48 hours after the last dose of morphine was taken and remain at the peak until the 72nd hour of abstinence. Thereafter, all signs gradually subside and after 5 to 10 days the addict, though weak and shaky, is almost well. Difficulties in sleeping and small changes in pulse rate, temperature, and in the blood can be detected as long as three to four months after withdrawal. Thereafter, the physical state of the addict
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becomes completely normal unless he is suffering from some other disease.
The intensity of the withdrawal sickness is more dependent on the dose of morphine the addict has been receiving than any single factor. Mild grades of abstinence can be detected in former morphine addicts after the administration of as little as 20 mgm. of morphine four times daily for 30 days. Grades of abstinence which are as intense as any which can be developed with any drug for any period of time can be produced by the administration of 60 to 90 mgm. of morphine four times daily for 30 days. The picture of abstinence from opium (either smoked or eaten), heroin, dihydromorphinone and metopon is qualitatively similar to that of abstinence from morphine and the intensity is just as great. Abstinence from opium develops at about the same rate as abstinence from morphine, whereas, abstinence from the other drugs mentioned above comes on more rapidly than does abstinence from morphine and subsides somewhat more quickly. Abstinence from codeine, though quite definite, is less intense than abstinence from morphine, comes on more slowly and subsides more slowly. Abstinence from dibydrocodeinone is somewhat more intense than abstinence from codeine but less intense than abstinence from morphine. Abstinence from meperidine (demerol or dolantin) is milder than abstinence from morphine but comes on more rapidly and subsides more quickly than abstinence from morphine. Abstinence from methadone comes on rather slowly, is mild in intensity, and subsides quite slowly. Abstinence from methadone is qualitatively different from abstinence from morphine in that few of the signs which indicate involvement of the autonomic nervous system (yawning, running nose, tearing, dilatation of the pupils, and vomiting) are seen.
The mechanism of physical dependence, like that of tolerance, is still unknown. It is certainly not due to anatomical alterations in the cells. Many of the theories which have been proposed to explain the manifestations of physical dependence are identical with those advanced as explanations of tolerance. These include the oxydimorphine, antitoxic and pathobiotic hypotheses. Theories which are based on changes in the way in which the body handles water, theories involving reversible coagulation of the proteins of the cell, and theories involving the replacement of a cell constituent have all been shown to be without basis. The excitation theory of Tatum, Seevers and Collins has had considerable vogue. According to this hypothesis, withdrawal signs are due to the stimulant actions of morphine outlasting the depressant actions. There are however a number of objections to
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the theory of Tatum, Seevers and Collins. Signs of abstinence from morphine in all species of animals are different from the signs produced by the stimulant actions of the drug. For example, these authors state that constriction of the pupil and slowing of the pulse are the result of stimulant actions. During withdrawal, instead of pupillary constriction and slowing of the pulse, dilatation of the pupils and increase in the pulse rate occur. Convulsions, which are one of the most striking stimulant actions of morphine in the dog, are not a feature of abstinence in this species. The stimulant actions of codeine are greater in proportion to its depressant actions than are those of morphine. One would therefore expect, on the basis of the theory of Tatum, Seevers and Collins, that dependence on codeine would be more severe than on morphine. The reverse is the case. The results of Wilder and Frank on the reflexes in the paralysed hindlimbs of addicted chronic spinal dogs also do not support the views of Tatum and Seevers. The hypothesis, which is currently favoured by most authorities, states that signs of abstinence represent a release of the enhanced physiological mechanisms which oppose the actions of morphine from the brake imposed by the continuing presence of morphine in the body. This particular idea appears to fit the known facts better than any other hypothesis yet advanced. Many of the signs of abstinence from morphine are qualitatively the opposites of many of the acute effects of morphine. Morphine depresses body temperature and during abstinence one sees fever. Morphine constricts the pupils and during abstinence one sees mydriasis. Himmelsbach suggested that the homeostatic responses which oppose the actions of morphine are mediated largely by the hypothalamus (the portion of the brain which is largely concerned with the regulations of temperature, blood pressure, etc.) via the autonomic nervous system. While this may be true, the experiments of Wikler show that other parts of the nervous system are also involved.
Habituation has been described by Himmelsbach as the psychical phenomena of adaptation and mental conditioning to the repetition of an effect. In more simple language, this means that the addict comes to use the drug as the answer to all of life's stresses. Rather than taking positive and definite actions about his difficulties, the addict temporarily defers the need for a solution of the problems by taking a dose of his favourite opiate. The directly pleasurable effects of the opiates are strongly reinforced in individuals who have been addicted by the relief which the drug affords from the symptoms of abstinence. Having once experienced the relief of abstinence by morphine, the
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addict comes to think of the drug as possessing magical qualities. He refers to it as "God's own medicine" and comes to believe that it is a cure" for all mental and physical ailments.
The Cause of Addiction
In order to produce addiction a drug must have effects which certain persons regard as pleasurable. Kolb distinguishes two types of pleasure following the use of morphine. Negative pleasure refers to relief of either physical pain or psychic tension while positive pleasure refers to elevation of the individual above his usual emotional plane. The pleasure which morphine induces in susceptible individuals is one of the most subtle and enjoyable sensations known to man. As mentioned above, the drug does not increase the efficiency of the individual, does not make him more courageous, and does not permit him to engage in long continued effort. Actually, morphine produces a sensation of pleasant relaxation, case, and warmth. It resembles the feeling one gains after working in the garden or completing some other pleasant task. In this state, all worries vanish and the individual can sit and dream deferring all decisions until tomorrow. One should keep in mind that in taking drugs to induce this state, the addict is seeking the same thing we all desire--- peace and comfort. He is merely going about attaining this universal human desire in a way which provides only temporary peace and which is in itself pathological. If the drug is taken intravenously, a pleasant tingling spreads
through the entire body. This sensation is most marked in the abdominal region and has been compared by some addicts to the sensation of a sexual orgasm. Intravenous injection appears to be especially attractive to individuals with psychopathic personalities.
The meaning which the effects of morphine have for a given individual is dependent upon his personality characteristics. Psychically normal individuals do not have psychic tension, are already at ease, and are not impressed by the effects of the drug. To put it differently, they cannot be, or feel no need to be, raised above their usual emotional plane. If such persons are suffering from physical pain, the relief of the pain by morphine may be very impressive and may be interpreted as pleasure. Psychically normal individuals, however, feel no need for the drug once the physical disease which was responsible for their pain has disappeared. Individuals who are fundamentally
emotionally immature childlike persons that have never made a proper adaptation to the problems of living are, however, greatly pleased by the effects of the drug. They find that morphine gives them a sense of
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relief comparable to the solution of a difficult problem or the shaking off of a heavy responsibility. Many of them feel that their efficiency is increased and that they can meet better adjusted people on equal terms. For a time, morphine seems to be the answer to their difficulties, but as they develop tolerance they find that they must take more and more to induce the desired effects. Finally, the drug will not produce the desired sensations at all, and the addict finds himself taking it to prevent the discomfort of withdrawal.
It follows, from what was said above, that the effects of morphine are much more pleasurable to individuals who have some type of psychic maladjustment than it is to psychically normal individuals. The types of individuals who are especially prone to addiction have been well described by Kolb and Felix who list four general personality patterns.
The first personality group consists of cases who, during the course of a physical illness, received drugs over an extended period of time, and, following relief of their ailment, continued to use the drug. These persons are frequently termed "accidental" or "medical" addicts. Such persons are regarded by some authors as constituting a special group of addicts who differ from persons who began the use of drugs as a result of thrill and pleasure seeking and association with persons who were already addicted. In our experience, all "medical" addicts have some fundamental emotional problem which causes them to continue the use of drugs beyond the period of medical need. There is, then, no basic difference between "medical" and "non-medical" addicts except in the mode of their original contact with drugs. In persons with stable personalities, social pressures, conscience, and a well balanced make-up negate the pleasure produced by drugs sufficiently to prevent their continued use.
The second group consists of persons with all types of psychoneurotic disorders. Included in this classification are people who have a great deal of anxiety, are nervous, tense, and frightened or worried by minor matters; people who feel compelled to do things in a certain way and who become very uncomfortable if their routines are upset; and individuals who have strange inexplicable types of paralyses or losses of sensation in their extremities (hysterical persons). Individuals of this class begin the use of morphine because it relieves their anxiety and takes away whatever symptoms they may have. Even in the beginning, the drug is used to induce "negative" pleasure. Such persons do not ordinarily increase the dosage of narcotics as rapidly as do psychopaths and may remain on low dosages of morphine for years.
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These people usually have no criminal records prior to addiction, and their illegitimate activities after addiction usually are of a minor kind which are generally traceable to their great need for drugs. They are certainly deserving of pity and need treatment more than punishment.
The third group consists of psychopathic persons who ordinarily become addicted through contact and association with persons who already are using drugs. They are generally emotionally undeveloped, aggressive and hostile persons who take drugs for the pleasure arising from the relief of the tension arising from their unconscious aggressive drives. In many of these people, the use of morphine represents a means of expressing hostility and resentment against society. Many of these individuals are basically amoral and addiction is merely an incident in their criminal careers....
The fourth, and smallest group, is made up of individuals who are insane (psychotic) and who are also drug addicts. The mental illness in many of the persons in this classification is mild in degree and some of these persons seem to be able to make a better adjustment while taking drugs. It is often difficult to determine whether these individuals are actually insane while they are actively using morphine since signs of the psychosis do not become apparent until the drug is withdrawn.
Many addicts are difficult to classify exactly as to personality type. Many of them exhibit much of the overt behaviour pattern of the psychopath but, when studied more carefully, are found to possess psychoneurotic characteristics as well. Kolb originally described such persons as suffering from a vague, poorly crystallized personality defect which he termed a psychopathic diathesis. They are now classified under the terms of behaviour or character disorders. Types of individuals who fall into this bordedline class include persons who unconsciously wish to be sheltered and protected, shy, withdrawn individuals who feel the world is against them, and people who seem to have never grown up. Most of the persons in this group make a marginal adjustment to life before becoming acquainted with narcotics. Once they begin the use of drugs they lose part of their normal adaptive patterns of adjustment and become parasites on society. This regression of personality and loss of social adaptation represents the greatest danger in drug addiction.
The mode of contact with a drug determines to a great extent whether an individual with a susceptible personality will become addicted. If contact with a drug results from legitimate medical administration during the course of illness, addiction seldom occurs. In fact,
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less than 5 per cent of addicts become addicted by this means. Contact with the drug through addict friends as a result of curiosity, association, thrill and pleasure seeking is a much more potent cause of addiction. This fact explains why so many individuals who have personality characteristics similar to those of addicts never become addicted. They do not have addict acquaintances.
Abuse of all types of drugs is based on the same personality factors, so that addiction to one drug predisposes to addiction to another. Thus an individual who abuses alcohol and receives morphine for the relief of symptoms of alcoholic debauches is very likely to change his addiction to morphine. Persons who smoke marihuana are frequently thrown into close contact with narcotic drug addicts and, as a result of the association, change from marihuana to heroin or morphine....
Addiction to opiate drugs is continuous and not intermittent as is frequently the case with alcohol, cocaine and barbiturates. This is usually interpreted as indicating that the addict fears the abstinence symptoms and continues to take the drug to avoid the pain of withdrawal. Wikler believes that, in addition to the avoidance of pain, the relief of abstinence symptoms by morphine represents the satisfaction of a biologically determined need which is similar to the relief of other biologically determined needs such as hunger or thirst and is therefore Pleasurable in a positive sense. This idea implies that addicts enjoy being dependent upon drugs so that they can experience the pleasure of the relief of the abstinence symptoms by morphine. It is possible that both mechanisms operate simultaneously in the same individual.
The tendency to relapse is also a striking characteristic of addiction to narcotic drugs. According to most authorities, the tendency to relapse is due to the fact that once drugs are withdrawn the same personality characteristics which predisposed the individual to addiction are still present. The proneness to addiction caused by these personality traits is greatly reinforced by the phenomenon of habituation, or emotional dependence. As Kolb says, the addict is so conditioned that be thinks of taking a dose of morphine when he is exhilarated or depressed. If an individual who has been an addict meets a friend on the street he is pleased and this leads to the idea of a "shot" to celebrate the event. If he becomes depressed or upset by any matter, no matter how minor, he is inclined to take the drug so that he can forget the problem or defer its solution until the following day. If be develops some illness and is uncomfortable, he remembers the relief which morphine gave when he was ill from lack of the drug and feels
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that he must have some of his magical "Cure-all" to alleviate the manifestations of his present illness.
Diagnosis of Opiate Addiction
The appearance and behaviour of addicts who have developed a high degree of tolerance to morphine may be indistinguishable from the appearance and behaviour of individuals who are not taking drugs. Morphine does not produce staggering, slurring of speech or as great a degree of impairment of intellectual functioning as does alcohol or the barbiturates so that, so far as can be ascertained by casual examination, the addict may appear to be completely normal. The presence of numerous abscess scars in the skin and the finding of needle marks, particularly in the form of tattooing over the veins, are very suggestive. Emaciation arises only when the addict is in poor financial circumstances and spends all his available income for drugs rather than for food. Frequently it is necessary to isolate a person suspected of being an addict and allow him no drugs in order to determine whether he is actually physically dependent on drugs. If the characteristic signs of abstinence appear, the question is immediately settled. Tests are available for the detection of morphine and other drugs in the urine, but these tests are difficult to carry out and are not available to most physicians.
The appearance and behaviour of individuals who are addicted to methadone is identical with that of individuals who are addicted to morphine. Marked induration and inflammation of the skin over the sites where the drug is usually injected is a characteristic finding in addiction to methadone. Individuals who are taking large amounts of meperidine (demerol) may exhibit marked dilatation of the pupils, inco-ordination, uncontrollable muscle twitching and even convulsions. In the amounts taken by addicts, chronic intoxication with meperidine is even more undesirable than is addiction to morphine.
Treatment of Drug Addiction
Treatment of drug addiction can be divided into two phases; withdrawal of drugs, and rehabilitative therapy. Withdrawal is necessary and is the first step in treatment but is much less important than rehabilitative therapy and is the only part of the treatment of drug addiction which is easily accomplished.
Withdrawal of drugs from narcotic addicts on an outpatient or office basis should not be undertaken as it almost surely will fail. Withdrawal in any environment except that of a well managed institution
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under the control of persons trained in the treatment of addiction is difficult to accomplish. Withdrawal should be carried on in the quickest, smoothest and most humane manner possible so as to establish good rapport between the patient and the physician on which to base subsequent psychotherapy and rehabilitation. Abrupt and complete withdrawal of narcotic drugs carries a certain degree of danger and is unnecessarily cruel. This type of treatment tends to foster an attitude of resentment and hostility in the addict which greatly hampers efforts for his continued treatment. A withdrawal which is conducted too slowly tends to keep the addict mildly uncomfortable for long periods of time. He is, therefore, likely to become discouraged and to discontinue treatment. Simple reduction of the dosage of drugs over a period of 7 to 14 days represents a good method of denarcotizing the addict. Recently it has been found that methadone can be substituted for morphine without sips of abstinence appearing and that the symptoms which do appear during reduction of methadone are milder than those accompanying reduction of morphine. This latter method of withdrawal has, therefore, become quite popular.
Many physicians who do not have a complete understanding of the problem of drug addiction have devised various schemes of withdrawing drugs. About ten new methods are advocated each year and frequently these are spoken of as "cures." This fixation on withdrawal therapy is probably traceable to the idea that addiction is merely a matter of physical dependence and all that one has to do is to withdraw the drug. Many of these methods have been based on erroneous theories of addiction, are illogical and more dangerous than abrupt withdrawal of morphine. We are referring here to treatments which involve intensive purgation, inductions of convulsions by electric shock, raising huge blisters on the skin and injecting the blister fluid into the addicts, the use of scopolamine or hyoscine which makes the patient psychotic, the use of atropine, the use of insulin and of heavy sedation with barbiturates. As Kolb has pointed out, abstinence from morphine is a self-limited illness, and any withdrawal method which involves taking away the addict's drug will succeed unless the patient is killed in the process.
Adjunctive treatment during withdrawal includes the use of small doses of sedative drugs. It is important not to use large amounts of these agents since excessive sedation seems to accentuate the development of emotional upsets during withdrawal. Furthermore, the use of sedative drugs prolongs emotional dependence on drug therapy and one may succeed in transferring the addiction to barbiturates
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which is a far more damaging and serious matter than is addiction to morphine. Hydrotherapy in the form of continuous warm tepid baths is helpful in relieving excessive nervousness. Maintenance of a sufficient fluid intake is very important and a light ample diet should be supplied.
Emotional reactions to withdrawal are frequently much more difficult to handle than are the physical symptoms. Excessive anxiety, hysterical reactions, and attempts at malingering frequently occur. These must be handled by appropriate psychotherapeutic techniques as they arise. Generally, simple reassurance will suffice. Individuals undergoing withdrawal of drugs seldom become psychotic.
It has recently been both reported and denied that the operation Of prefrontal lobotomy prevents the appearance of abstinence signs following withdrawal of drugs from addicted individuals. This operation consists of severing the frontal lobes from the other parts of the brain. It is difficult to understand bow this operation would prevent the appearance of withdrawal signs since Wikler has shown that severe abstinence occurs in dogs from whom all the cerebral cortex has been removed. In any event, the operation produces considerable intellectual impairment and personality change and would not be justified merely on the basis of preventing signs of abstinence. Its use in addiction should probably be limited to the treatment of individuals with intractable pain. Whether the operation will so alter the personality of the addict that he will not relapse to the use of drugs has not been determined.
Whenever possible, any physical disease which the addict may have should be removed by appropriate therapeutic procedures after withdrawal has been completed. In cases of addiction associated with chronic diseases which are not completely curable, the treatment should be designed to produce the maximum possible degree of improvement and to teach the individual to manage his disease without resort to narcotics. In cases in which intractable pain plays a part in causing the addiction, appropriate surgical procedures designed to relieve the pain should be considered.
Time is an extremely important factor in handling drug addicts. Time is necessary not only to allow the altered physiology of the addict to return to normal (this requires about three to six months) but also time is necessary to break up his established habit patterns of using drugs as the answer to all his problems. The addict must
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learn to work, play, and sleep without drugs. Since time is such an important factor, some kind of coercion is frequently necessary. Many addicts may begin treatment with the best intentions in the world, but after a few days their basic personality difficulties assert themselves and they discontinue treatment. Coercion may take the form of pressure from friends, relatives or law enforcement officers. Frequently these measures fail and some type of legal action becomes necessary.
An adequate programme of occupational therapy is extremely important. Occupational therapy should not be a matter of weaving rugs, but should be so designed as to permit every patient who is capable of it an opportunity to perform at least eight hours of useful productive work daily. Whenever possible, the types of occupations available should maintain and add to any skills which the addict may possess so that following discharge he will be well prepared to take a useful place in society. Individuals with physical handicaps should not be allowed to vegetate on infirmary wards but should do as much work as the limits imposed by their disabilities will permit.
Whenever possible, addicts should receive psychotherapy designed to remove or lessen their personality problems. The first decision is whether psychotherapy should be offered at all. The emotional development of many addicts was arrested at a very early stage and such individuals are very resistant to psychotherapy of any type. About all that can be done in such cases is to provide a short period of institutional supervision followed by a long period of supervision of the patient by his family, friends, minister, or probation officer following discharge from the institution. Other individuals who reached a greater level of emotional maturity prior to addiction should be offered intensive psychotherapy. Psychotherapy is an individual matter which is dependent not only upon personality characteristics of the patient but on the training, orientation, and skill of the person who administers the treatment. It is in no wise different from psychotherapy administered to non-addicts and complete description is beyond the bounds of this article. There are, unfortunately, not enough psychiatrists to administer psychotherapy to all addicts who need and will accept it. This deficiency in therapeutic facilities perhaps can be partially bridged by organizing group therepeutic sessions....
Prior to discharge from an institution the patient should make a plan. If possible, he should have a definite place to go, a job, and friends to whom he can turn. He should remain under some type of
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supervision for several years. In planning and conducting this phase of treatment, the resources of a good social service department are invaluable.
Prevention of Drug Addiction
.... Prior to the passage of the Harrison Narcotic Act in 1914, it was estimated that there were from 150,000 to 200,000 narcotic addicts, mostly women, in the United States. By 1948, the number of addicts in the United States had been reduced to approximately 48,000, mostly men. The Geneva Convention of the League of Nations had also operated to reduce world-wide production and refining of opium and therefore addiction. Further progress in the control of production and distribution of narcotics under the aegis of the United Nations is to be expected.
Although legal control of narcotics represents an effective means of reducing addiction, these laws can hardly be regarded as completely just unless some provision is made for the addict who is the person chiefly affected by the passage of such laws. Since many addicts are not criminals, they should not be incarcerated in ordinary penal institutions merely because they are addicted. Special institutions which view addiction as a medical problem should be provided for the care of such persons. Addicts who are basically criminals should, however, not be treated in hospitals but should be sent to the usual penal institutions.
In the United States, the addict was at first neglected following enactment of the Harrison Narcotic Act and was sent to penal institutions along with criminals. The realization ... led to the establishment of two hospitals, one at Lexington, Kentucky, and the other at Fort Worth, Texas, which specialize in the care of narcotic addicts. The Lexington Hospital has been in operation since 1935 and the results obtained in treating addicts at this institution show that the effort has been well worthwhile. Of 11,041 addicts admitted between May 1, 1935 and January 1, 1949, 6,788 or 61.4 per cent have been admitted to the institution only once. Stated in another way, the known relapse rate is only 39.6 per cent. Although this rate indicates that the treatment of drug addiction is still far from completely satisfactory, it also shows that the treatment of drug addicts is far from the hopeless proposition which so many persons have thought it to be. Many addicts, who do relapse, remain abstinent for many years before returning to the use of drugs and such period of abstinence should be regarded as a considerable gain just as a long
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remission is counted a gain in other chronic relapsing diseases such as tuberculosis or arthritis.
The treatment of drug addicts also contributes to the prevention of addiction. Since addiction spreads from person to person like an infectious disease, isolation of the addict from susceptible individuals during his treatment prevents the spread of addiction. Cure of an addict, like cure of a tuberculous patient, removes an infectious focus.
Continuing improvement in the results of the treatment of drug addicts is dependent more upon advances in our knowledge of mental disease than it is upon any other factor. The intensification of research in this field gives us every reason to hope that new knowledge, which will lead to great improvement in the results of the treatment of addiction, will soon be uncovered.
DECEPTIONS BY ADDICTS TO OBTAIN NARCOTICS
FROM PHYSICIANS AND DRUGGISTS
Curtailment of illicit supplies of narcotics has placed great pressure on legal stocks. The Bureau of Narcotics with the assistance of the local police and the medical and pharmaceutical associations had diligently pursued a campaign for the safeguarding of narcotic stocks. The holding of large drug stocks in exposed places has been discouraged, and safeguarding by electrical alarm systems has been recommended wherever substantial supplies are stored. The result has been that, while burglaries, robberies, and larcenies of drug stock occur in considerable numbers, the proceeds from individual thefts are usually small.
The narcotic addict already skilled in confidence games and similar dissimulations in evading the law has had to intensify and improve on many time-honored dodges for obtaining illicit drugs.
The schemes are sometimes of a rather elaborate confidence type. In one case addicts secured a series of narcotic prescriptions from a physician for a non-existent female patient and went so far as to have the doctor reserve hospital facilities for a proposed operation on the supposed patient. Some devices are much more simple. A successful modus operandi is for the addict or confederate, usually a woman, to walk into a drugstore---
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generally when the proprietor or clerk is alone--- and make a purchase of a personal appliance, asking permission to use the prescription room. After this customer has left the store the narcotic cabinet is found to have been pilfered.
The relative scarcity of narcotics has resulted in a great deal of pressure on physicians by addicts in order to obtain narcotic supplies. Simulating illness with a plausible story, these addicts are sometimes able to deceive inexperienced medical men into furnishing narcotics or prescriptions calling for them. Living in a world of deception, the addict often develops unusual acting ability. He becomes a specialist in whatever disease be decides to suffer from, reads everything about his "ailment" in the medical journals, learns every symptom, knows precisely when to twinge with pain at the doctor's touch.
Some addicts go to almost unbelievable lengths to carry out their deceptions. One had been operated upon years ago for a kidney ailment. In his efforts to obtain narcotics from a physician he would claim severe pain from a kidney stone. Whenever the physician insisted upon taking an X-ray, the addict would conceal in his hand an ordinary small stone. After being prepared for the X-ray, be would then secrete the stone in a pocket of the scar tissue on his back, in the exact position of a kidney stone, thus disclosing a stone in the X-ray. On his last attempt the stone fell out and was retrieved by the technician, resulting in his prosecution and conviction to a term of a year and a day for obtaining narcotics by fraud. Some inflict wounds on themselves to simulate postoperative scars. Others use some material which will produce a real coughing fit.
There have also been several instances of vicious assaults by criminal addicts on physicians and druggists in attempts to secure narcotics; one addict attacked a seventy-two-year-old physician and his elderly housekeeper with a knife.
Doctors who leave medical bags or kits in parked automobiles really are inviting predatory addicts to break into the vehicles for the narcotics that may be found in the bags. In these cases the addicts will often wantonly throw away or dispose of valuable medical instruments.
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In Celina, Texas, a burglar entered the storage room of a drug store before closing time and hid in the rafters until the store was locked. He then removed the narcotics from a wooden cabinet and left the store.
In Dallas, Texas, a burglar gained entrance to a drug store by sawing boards which covered the skylight and he then used an explosive on the safe in which the narcotics were kept, damaging the safe beyond repair. In Central City, Kentucky, a pharmacy was burglarized twice in five weeks for narcotics. The drugs were stored in an unlocked cabinet.
TWO addicts, brothers, staged an armed robbery of a drug store in Memphis, Tennessee, to obtain a supply of narcotic drugs. Due to the fast thinking of the pharmacists on duty in the store, other drugs were given to the robbers in place of narcotics, and they failed to get any narcotic drugs other than a small amount of Empirin with codeine. The robbers were both under the influence of narcotics at the time of the holdup.
In Houston, Texas, in August 1952, a druggist who was fed up with burglars, shot to death an ex-convict who was trying to force open the door of his pharmacy. The store had been burglarized at least eight times in the past few years. When the druggist heard someone trying to force the door open, he went out and fired a shotgun and a pistol. The burglar, a narcotic addict, was dead on arrival at a Houston hospital..
In a daylight robbery early on Sunday afternoon, September 14, 1952, at Seattle, Washington, a big stock of narcotic drugs was taken from the largest exclusive prescription pharmacy in the city. At gun point, the pharmacist and a porter were directed to lie face down on the prescription room floor. A second robber forced 'a customer to he on the floor beside the other men, and the hands of all three were tied behind them. The robbers then asked where the narcotics were stored and when told where the stock was kept they asked where the rest of the stock was. The pharmacist replied that it was upstairs in the safe but that be did not know how to open it, an explanation which was accepted for some unknown reason.
The door of a midwest drug store opened one day in January a few years ago, and the proprietor saw a middle aged woman somewhat shabbily dressed, approaching the counter. The thin worn cloth coat certainly didn't provide much protection from the sub-zero weather the area was undergoing, but what particularly aroused the pharmacist's pity was the cumbersome and uncomfortable neck
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brace the woman was wearing. A fractured vertebrae, she said as she laid her torn gloves on the glass counter together with a prescription for some morphine sulphate tablets. It was particularly cruel because the injury had forced her to discontinue working and she just didn't know how she could make ends meet. The druggist felt a twinge of conscience for accepting the price of the tablets as he punched the register and watched the woman leave the store and start down the street. Unconsciously his eyes followed her, and to his complete amazement, he saw her enter an automobile, and sliding behind the wheel, whip off the brace and toss it into the back seat. As she drove off, the surprised druggist noted the license number and immediately advised the Federal Bureau of Narcotics.
A brief investigation was quickly made, and the woman arrested. Of course she was a drug addict. She had to have drugs, and the neck brace had surely deceived a lot of people--- several doctors and druggists. So well taken in were some of them that they even refused to accept payment for their services.
The old man was sitting on a park bench staring into space. Dirty, disheveled, unshaven, and worse yet, broke. His main concern was tonight's lodging. just then he noticed a rather attractive young lady approaching and much to his surprise, as she drew abreast of him, she spoke. Would he like to earn five dollars? It was very easy and it would not take long. Ten minutes later the two of them were sitting in a doctor's office. Poor father was suffering severe pains from cancer of the rectum, and a prescription for morphine was necessary. And since it was so difficult for him to get to the doctor, would it be all right if the young lady simply picked up the prescriptions in the future. Assured that it was, they departed.
A year later the doctor encountered the young lady on the street. "How is your Dad these days?" "Still in great pain" was the response. "Well you better bring him in and let me look him over next week," said the doctor.
This presented quite a quandary for the young lady for she had not the slightest idea of the whereabouts of her alleged father. But she needed drugs badly. Down town she went, searched around, hired another old bum, visited the doctor, who after a short chat, issued another prescription and continued to issue them as previously.
And he might be issuing them today if our young lady drug addict had not been arrested for forging a prescription in another city. The doctor was a mighty surprised individual when Federal agents unveiled the whole story for him.
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The man handed the Minnesota doctor the certificate from the Mayo Clinik and the doctor noted that it was signed by the chief surgeon. That was good enough for him and within a matter of minutes, the patient was departing with a prescription for narcotics nestling in his pocket. Of course the doctor had made no physical examination. A great many doctors saw this certificate, and many of the drug stores in the area were divested of their narcotics supply before agents of the Federal Bureau of Narcotics caught up with a couple of drug addicts who were using the counterfeit certificate to satisfy their craving for drugs. The incredible fact, however, is that not one doctor noticed that the word clinic had been misspelled.
The reason for setting forth these cases is to show to what length addicts will go to procure drugs to satisfy their craving and also to show how physicians and druggists may be deluded into helping them.
Addicts are both ingenious and crafty, and it has been the aim of this chapter to attempt to supply information which will. assist physicians and druggists in dealing with this type of individual.