The harm produced by Addiction to Analgesic Drugs
Characteristics of Addiction to Analgesics
The Cause of Addiction
Diagnosis of Opiate Addiction
Treatment of Drug Addiction
Rehabilitative Therapy
Prevention of Drug Addiction
Author: Victor H. Vogel, Harris Isbell
Pages: 31 to 40
Creation Date: 1950/01/01
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[1] * 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 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.
Superior figures in the text indicate reference to the "Bibliographic Notes" at the end of this article. (See page 40.)
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.[2] , [3] 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 impor- tant 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-II]); 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.
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. They do not cause the addict to indulge in crimes of violence or crimes of a sexual nature.[4] In fact, because of the soothing qualities of these drugs, they tend to decrease propensities to violent anti-social acts. 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 alcohol, 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[5] 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".
Thus the damage produced by narcotic drugs is traceable to the lessened social productivity and parasitic existence which addicts lead. In countries where addiction to opiates is culturally unacceptable the damage caused by the drugs is increased by social factors. In such situations, the unfortunates who are addicted to drugs must depend chiefly upon the illegitimate traffic in drugs for their supplies. Due to the high prices of illegitimate drugs, most addicts must engage in illegal pursuits in order to obtain sufficient funds to support their addictions, and must, therefore, associate with persons of low moral character. They are frequently arrested and sentenced to terms in jails and penitentiaries. All these factors tend to increase the unfavourable character changes and moral deterioration produced by the drug and convert people who might have been fairly useful citizens into outcasts, idlers and dependants.
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.[6] 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 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.[7] 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[13] 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.[8] Repeated administration of morphine strengthens the physiological counter responses and diminishes the effect of the drug. Wikler[9] 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 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 Wilkler[9] 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.[10] 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 18 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 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.[3] 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 dihydrocodeinone 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.[11] Abstinence from methadone comes on rather slowly, is mild in intensity, and subsides quite slowly.[12] 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.7,9 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[13] 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 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 Wikler and Frank[14] 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.[8] 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 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.
In order to produce addiction a drug must have effects which certain persons regard as pleasurable. Kolb[5] 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, ease, 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.
This is a crude outfit used by a North American addict for injecting morphine. It consists of an eye-dropper, a hypodermic needle and a spoon with a bent handle. The spoon is used for dissolving the drug and heating the solution over the flames of a match
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 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[15] 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. 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. This particular group of persons, which accounts for only 12 per cent of addicts in the United States, is responsible in great part for the public attitude regarding addiction. Since such individuals are basically criminals, the public has come to believe that all addicts are criminals and that the use of drugs leads to crime. Actually, it is likely that narcotic drugs inhibit the aggressive impulses of persons of this class and so reduces their propensities toward major criminal actions. As Kolb[4] said, morphine changes the potential murderer into a mere thief.
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 borderline class incude 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, 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. In many instances the exchange of the original addiction, particularly in the case of alcohol and the barbiturates, for addiction to an opiate, represents a change for the better in the sense that the person has exchanged a greater for a lesser evil.
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[14] 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 simulanteously 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 he 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 he develops some illness and is uncomfortable, he remembers the relief which morphine gave when he was ill from lack of the drug and feels that he must have some of his magical "cure-all" to alleviate the manifestations of his present illness.
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.
Abscess scars on the arm and forearm of an addict. The abcesses are caused by self-injection of unsterile solution of impure drugs
Picture shows tattooing which occurs over the veins as a result of repeatedly injecting opiates intravenously
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 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 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 subse- quent 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 tong 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 substitued for morphine without signs of abstinence appearing[12] 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.[16]
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 drags prolongs emotional dependence on drug therapy and one may succeed in transferring the addiction to barbiturates 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 how 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 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.
Occupational therapy. This man has been withdrawn from drugs and is learning the trade of shoe repairman as part of his treatment at the U. S. Public Health Service Hospital, Lexington, Kentucky
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 therapeutic sessions. Many patients seem to benefit from participation in the activities of the groups known as Alcoholics Anonymous and Addicts Anonymous.
Prior to discharge from an institution the patient should make a plan. If possible, he should have a definite place to go, job, and friends to whom he can turn. He should remain under some type of supervision for several years. In planning and conducting this phase of treatment, the resources of a good social service department are invaluable.
There are two basic approaches to the prevention of drug addiction: (1) mental hygiene programmes administered by public health authorities which have as their object the development of people so emotionally sound and well integrated that they will have no need for drugs, and (2) legislation designed to prevent narcotic drugs from going into channels where they will be easily available to addicts.
The first line of approach, although offering the greatest promise, is just getting under way and the results cannot yet be evaluated. The second approach, that of the enactment of legal controls, is known to be effective when well enforced. 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 that many of these people were actually sick individuals 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 re garded as a considerable gain just as a long 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.
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