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essentially similar to the familiar toxema of chronic alcoholism and starvation, commonly called "delirium tremens" on account of the delirium present as the prominent symptoms in that condition. In both these toxemas, renewed doses of the poison that has produced the condition indirectly immediately covers up the symptoms by renewed depression of the sensory paths of the automatic reflexes. Immediate and absolute withdrawal of the drug has been routine practice at Bellevue Hospital, Metropolitan Hospital, and Riverside Hospital of the Health Department of the City of New York; at Kings County Hospital, Brooklyn, and at the United States Penitentiary, Atlanta, Ga., in all their cases during the past several years. In all these 25,000 cases of immediate withdrawal of the drug, there have been no deaths resulting, nor any suffering permitted that cannot be easily controlled. Of course, those patients suffering from complicating disease of heart, lungs, or kidneys received a more gradual method of withdrawal, but were nevertheless subjected to withdrawal from their addiction.

Gradual withdrawal methods have been used at the New York City Prison in some 12,000 cases, partly to avoid criticism on the part of the friends of the prisoners having access to them during treatment. Here it has been found necessary to extend the withdrawal period to not more than 2 or 3 weeks.

Personal observation of their condition under treatment, and interviews with the addicts during and after their having been taken off the drug, both at Riverside Hospital and at the penitentiary, gave convincing evidence that the method of immediate and complete withdrawal of the drug is the method that is preferable, by far, in all cases not complicated with organic disease. Both from the medical point of view and that of the more intelligent addicts, the best results are attained in the shortest possible time by this method. Many of them preferred it because thus their durance was not long protracted. The immediate improvement in mind and body, when thoroughly detoxinated, is quite remarkable. Many who had experienced various methods of withdrawal, previously, some as many as seven times in different institutions, including every well-known method that is practiced, volunteered this testimonial of the "cold turkey." Those who were less ingenuous, and said they preferred the gradual withdrawal method, when pressed for reasons, replied, "If we can't get any more of the dope, we want to get what we can while it is going." Many of the prisoners of lower grade mentality, belonging in the group of correctional class mental defectives, were frank to say "they would go back on the drug, when released from confinement, if they could get it." The higher grade types, however, were glad of their release from the slavery to the drug, expressing their firm determination of staying off for good, but were yet conscious of their own weakness of will, fearing they might relapse in spite of their resolution, if projected among their former associations. One of the prisoners in the penitentiary, doing time for an offense against the Government in time of war-a person who has never been a drug addict and is possessed of a mentality superior to that of the ordinary prisoner— having been closely associated in the prison hospital with those other prisoners then undergoing treatment for withdrawal from narcotic drugs, had been a close and sympathetic observer of, and was intimately conversant with all their sufferings and complaints. This prisoner proved on careful inquiry to be a valuable witness, bringing to the subject evidence that cannot be impugned, gained at firsthand and without previous bias or prejudice of any sort. He said:

"I have been in the hospital about 8 monuths, and in the prison for a year. During that time, I have observed under treatment between 50 and 75 cases of narcotic drug addiction. I had no idea what a terrible affliction drug addiction is, until I saw its victims here. They represent the very lowest level of humanity; often very young men-mere boys, from 20 to 22 years old-already wrecked. Such men as Victor Hugo speaks of in Les Miserables: 'men who are old, without ever having been young; possessing all the ignorance of youth, without any of its innocence.'

"All these cases have been treated by immediate withdrawal of the drug, except those whose physical condition (diseased) required more gradual methods. Generally speaking, from my own observation and from what the men tell me, they do not suffer. They say they have felt altogether better, when they had been gotten off the drug. It seems to revive and stimulate their willpower, which had been put in abeyance by the drug. I am gratified with the results of the treatment. Never has it failed in a single case to break off the habit, and in no single instance have I seen a bad result from the treatment. The men also express their gratification over the relief it affords them. The craving

seems to be due, in part, to uncertainty; as soon as the habitué realizes here that there is no chance of his getting any 'dope,' he feels better in his mind, and his will is strengthened to stay off.

"Never in a single instance have I heard a man complain of his having been cut off the drug completely, that is, after 2 or 3 days to a week. I have sympathized with these poor fellows, and they have given me their confidence. If there had been any complaints, I would have heard them; but not one complaint about the treatment have I heard in the hospital. Dr. Weaver is as kind and sympathetic, as humane as any doctor could be, and I thoroughly approve the methods used and the results obtained by him, which I regard as the best that could be done for these men. Once they are off the drug, they are in a different state of mind. If sound and well physically, I believe that is the way to do it. I know the method is a most humane way to deal with them.

"In my own town I have known narcotic practitioners to try to taper them off, but I have never known a case to be cured by tapering off. It is a false confidence inspired by the doctor, who yields to the infirmity of an addict, listens to his importunity, and gives him the drug he craves. For he thus shares his infirmity with him, and the responsibility for his unfortunate condition.

"I do not see that any good results can be attained by catering to the thing that has caused the evil. You remember how, when Paul was at Ephesus, the silversmiths caused a riot among the people because they wished to perpetuate worship of the silver shrines of Diana, because, they said, 'Ye know that by this business we have our wealth.' So these doctors who cater to the addicts defend the business because their professional income is dependent on and wrapped up in it. That is the only excuse for them. It is there is no reason in it.

"To break them off the drug habit is practically useless, unless it can be made permanent. If some of these men go back to it, after leaving here cured, that is because their treatment has not been completed. The hospital has done its part, having put the men on their feet physically. To save them from their vicious circle, however, something ought to be done on the outside to guard them from their old surroundings, when they leave here cured.”

The first comprehensive series of facts, having real scientific value, that has yet been compiled anywhere in the world, is embraced in the published statistics gathered from analytic study of the nearly 8,000 cases of addiction registered and cared for during about 10 months by the department of health of the city of New York. These cases were subjected to most careful observation and study by specialists qualified to make scientific analyses and arrive at sound conclusions from them. Except from equally careful and extensive clinical study by the scientific method, which has not been duplicated and which is not likely to be, the conclusions deduced from this source cannot be safely challenged. From these statistics it was shown that:

While some 5 percent claimed that an illness was their excuse for addiction, 69 percent frankly blamed their "bad associations" for their plight. (Making due allowance for the addict's unreliability of statement, especially when opportunity offers to blame another than himself, we may revise downward the 5 percent. while there can be no reason to assume that the 69 percent were lying, particularly since their testimony was voluntary and likewise self-derogatory.) Seventy percent were under 30 years of age.

Twenty-six percent were employed in the business of transportation. Less than 4 percent were suffering from a disease or painful malady which would justify their addiction. (Corroboration of this figure is found in the statement by Dr. Weaver of the United States penitentiary, who found "not more than 3 percent of addicts received having some organic disease, such as chronic Bright's disease, heart lesions with broken compensation, or advanced tuberculosis necessitating a more gradual withdrawal of the drug.")

Only 1,580 out of 2,800 received at the clinic were willing to accept treatment for withdrawal of the drug of addicition, so long as they could secure a supply of the drug from street peddlers or from a "script doctor." These were given hospital care, withdrawn from the drug by the scopolamin method, and kept for 6 weeks under careful reconstruction training afterward, until able to be discharged in good physical condition, and able to do an honest day's work. Within 3 months it was found that a large proportion of them had already relapsed to their old habits and associates, notwithstanding every effort made to assist them with moral support and friendly solicitude by every agency possible. Peddlers from their own underworld, well known to them, were ready at the dock to meet every boat returning from the island hospital, eager to supply them with the drug once more, even gratuitously, so anxious were they to rebuild their clientele.

SOLUTION OF PROBLEM

Any solution of this vexing problem must necessarily resolve itself into some plan for abolishing the total supply of drug that may be available to the addict from any and all sources. There are two main sources of supply, viz., the peddlers, most of whom are themselves addicts; and the trafficking doctor, the narcotic practitioner, the “script doctor" who prescribes or dispenses the drug to them for self-administration. The peddler, who deals largely in smuggled drugs, constitutes a comparatively simple police problem, easily solved by thoroughgoing enforcement of existing laws. The doctor is more difficult of apprehension, for he hides behind the cloth of a reputable profession, and pretends that he is treating a “disease" when he is really selling his professional privilege in a sordid market for a very large return in money. One man, now serving his term in the penitentiary, wrote from 100 to 2,600 prescriptions each week for about 10 months, and a total of more than 23,500 in that time, at about $3 each! Many of these "scripts" call for as much as 500 grains of morphine or heroin at one time, and these doctors do not hesitate to give addicts several "scripts" at one time, or even send them in the mails to a distant city. One "respectable addict,” meaning a person who was willing to pay a large fee, has testified that she paid 1 doctor $1,000 monthly for a period of 13 months, "to keep her in good health." It has been estimated that 90 percent of opium imported into the United States is used for other than proper medicinal purposes. Much of this is ostensibly exported, but is in reality merely transferred by connivance to the underworld traffic, appearing in the hands of the peddlers as "smuggled goods," and sold at fancy prices according to the necessities of the fraternity at the time.

The remedy consists in abolishing the addicts' drug supply first by prohibiting the prescribing or dispensing of these drugs to them by physicians, under severe penalty for such violation, and secondly through vigorous enforcement of both Federal and State laws dealing with narcotic abuse.

AMBULATORY TREATMENT

The so-called reductive dosage ambulatory treatment of addicts, defined by the United States Bureau of Internal Revenue as the "prescribing or dispensing of a narcotic drug to an addict, for self-administration at his convenience," has been uniformly condemned as a method of treatment by every competent medical authority, and is definitely prohibited by law in Massachusetts, Rhode Island, and Pennsylvania, as well as by implication, certainly, in the Harrison law and the court decisions that have been rendered to date relating to it. A recent ruling by the United States Commissioner of Internal Revenue stated that:

"This office has never approved the so-called reductive ambulatory treatment of addicts, for the reason that where narcotics are furnished to an addict who controls the dosage himself, he will not be benefited or cured.

"It is well recognized by medical authorities that the treatment of addicts, with a view to curing their addiction, which makes no provision for confining them while the drug is being withdrawn, is a failure, except in a relatively small number of cases where the addict is possessed of a much greater degree of willpower than is possessed by the ordinary addict. If a physician, pursuant to the socalled reductive dosage ambulatory treatment, furnishes drugs to an addict who is financially unable to enter an institution for the cure, and whom the local State or other officials are unable to put in a place of confinement where he may be cured without expense to himself, such physician will be held strictly accountable, and his furnishing of narcotics to an addict for an extended period will be regarded ipso facto as showing lack of good faith in the treatment of an addict and that he had been merely satisfying the cravings of an addict."

The conclusion, therefore, seems ineluctable that a physician who supplies narcotic drugs to an addict, knowing him to be an addict, or who connives with or condones such an act, is either grossly ignorant, or deliberately convicts himself as one of those who would exploit the miserable creatures of the addict world for sordid gain. It may be that he is himself addicted to the drug and has thus become a victim of its power to produce such profound moral perversion. For such there can be but one verdict. Suspend or revoke his license to practice medicine, by all means. Let him suffer the penalty of the law, and may God have mercy on his soul!

Present Status of Narcotic Addiction

With Particular Reference to Medical Indications and Comparative Addiction Liability of the Newer and Older Analgesic Drugs

VICTOR H. VOGEL, M.D.

HARRIS ISBELL, M.D.
and

KENNETH W. CHAPMAN, M.D.

Lexington, Ky.

U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

PUBLIC HEALTH SERVICE

Reprinted from The Journal of the American Medical Association
December 4, 1948, Vol. 138, pp. 1019-1026

COPYRIGHT, 1948, BY

AMERICAN MEDICAL ASSOCIATION
535 NORTH DEARBORN STREET

CHICAGO 10, ILL.

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