In addition to the pleasure derived from the effects directly attributable to the pharmacologic action of the drugs, the use of drugs may have many other meanings to the addict. To the hostile, aggressive psychopath, abuse of drugs represents a means of expressing hostility against society; drugs may be attractive to individuals with sexual conflicts because of repression of sexual urges; and drugs enable passive, dependent individuals to indulge in a parasitic existence without psychogenic conflict. Finally, prolonged use of either analgesics or barbiturates leads to the development of a physiologic change (physical dependence). By analogy with the satisfaction of hunger and thirst by food and drink, relief of this artificial biologically determined need may be quite pleasurable and its satisfaction may become the paramount motivation of the addict's existence. ANALGESIC DRUGS In the United States, addicts ordinarily use the analgesic drugs hypodermicany. The intravenous route is generally preferred to the subcutaneous. Use of drugs orally or as a snuff now is rather uncommon, as is the smoking of opium. In the beginning of addiction, drugs are taken intermittently and not constantly. As the potential addict becomes more familiar with the effects of the drug the interval between injections is gradually shortened until the drug is being used several times daily. When the drug is first taken it induces a characteristic group of symptoms which include flushing (if the drug is injected intravenously), nausea and vomiting, itching, constriction of the pupils, and a peculiar semisomnolent condition (termed "being on the nod"), characterized by alternating periods of somnolence and wakefulness. The addict is readily awakened by a slight stimulation, answers questions readily and accurately and exhibits no great degree of ataxia. Characteristically, the opiate drugs do not induce deep sleep or coma unless enough of the drug has been taken to induce a degree of intoxication which is dangerous to life. As the addict shortens the interval between injections he finds that, in order to induce the effects regarded as pleasurable, he must increase the dose. This phenomenon is termed "tolerance" and becomes so highly developed during addiction to morphine that the amount of the drug the addict can take is limited only by the difficulty of dissolving and injecting the large amounts of solution required. Authentic cases are on record of tolerant addicts taking 5 gm. (78 grains) of morphine intravenously in 16 hours without inducing any untoward effects. ABSTINENCE FROM MORPHINE If morphine is suddenly and completely withdrawn from addicted persons, a characteristic stereotyped and self-limited illness ensues. This is evidence of the altered physiologic state termed "physical dependence." About 8 to 14 hours after the last dose of morphine is given, the addict usually falls into a restless, tossing sleep ("yen sleep") which may last for several hours. About the 16th to the 18th hour of withdrawal and after the patient has awakened, slight lacrimation, rhinorrhea, perspiration, and yawning appear. Restlessness and nervous ness ensue and become progressively worse as the hours go by. Twenty-four hours after the last dose of the drug is administered most patients are acutely miserable, complain of chilly sensations and of cramps in the muscles of the back and extremities. Lacrimation, rhinorrhea, perspiration, and yawning become more marked. Recurring waves of goose-flesh and dilatation of the pupils appear. Mild hypertension, hyperpnea, fever, leukocytosis, and hyperglycemia are present. Patients become increasingly restless and continually move from one part of the bed to the other. They twitch their arms, legs, and feet almost constantly. This twitching of the legs has given rise to the term "kicking the habit." Patients usually cover themselves with blankets even in the hottest weather, curl into a ball and present an appearance of abject misery. They may become so uncomfortable that they leave their beds and lie on a hard concrete floor in an attempt to obtain some ease from the muscular cramping and aching. They are nauseated, gag, retch, vomit, have diarrhea and may lose from 5 to 15 pounds in 24 hours. All of these symptoms increase in intensity until the 36th to 48th hour after the last dose of morphine is given. The peak intensity of abstinence symptoms from morphine is maintained from the 48th to the 72d hour of abstinence, after which it begins to decline. Five to seven days after the last dose of morphine is given, practically all acute symptoms have disappeared and the only complaints remaining are nervousness, insomnia, and weakness. These gradually decline over a course of 3 to 4 months, but minor physiologic aberrations may persist for as long as 6 months. The symptoms and course of abstinence from analgesics other than morphine are qualitatively similar to those of abstinence from morphine, but differ in intensity and time course. Abstinence symptoms from heroin, Dilaudid, dihydrocodeinone, desomorphine, and ketobemidone (a derivative of Demerol) come on very rapidly, reach peak intensity in 8 to 12 hours after the last dose of the drug is administered and decline rapidly. The intensity of abstinence symptoms from these drugs is equal to, and usually greater than, the intensity of abstinence symptoms from morphine. Abstinence symptoms from drugs of the methadone group appear quite slowly and, though quite definite, are mild, and few signs of disturbed autonomic function are present. Abstinence symptoms from methadone, however, decline quite slowly and leave the patient weaker than does abstinence from morphine. Abstinence symptoms from isomethadone come on at about the same rate as do abstinence symptons from morphine, are less severe and decline at about the same rate. Abstinence symptoms from meperidine (Demerol) come on and decline rather rapidly, and are less severe than with abstinence from morphine. Abstinence symptoms from codeine are slow to appear, and are even milder than abstinence symptoms from meperdine. BARBITURATES Although addicts will ingest any type of barbiturate, they usually prefer pentobarbital, secobarbital, and amobarbital, in the order named. The less potent, more slowing-acting drugs, such as phenobarbital and barbital, are seldom used. Generally, barbiturates are taken orally, but, occasionally, some morphine addicts will dissolve the contents of the capsules and inject them intravenously. If the barbiturate is injected into the perivenous tissue, large abscesses are formed. The drugs may be used for a single night's debauch, a spree of a few days' duration, or they may be taken continually for periods of months or even years. In chronic cases, the amounts used vary over a wide range, but most habitues usually consume 0.5 to 3.0 gm. of barbiturates daily. Concomitant use of the barbiturates and alcohol is quite common, as is the combined use of morphine and barbiturates. Frequently, barbiturate addicts also take large amounts of benzedrine in an attempt to counteract the depressant effect of the barbiturates. The symptoms and signs of chronic barbiturate intoxication are predominantly those of cortical depression and of cerebellar dysfunction. They may be divided into mental and neurological types. The mental symptoms include difficulty in thinking, inability to perform simple calculations and psychometric tests, confusion, somnolence, defective judgment, and increased emotional instability. The neurological signs include nystagmus on lateral gaze, ataxia in gait and station, adiadokokinesis, choreiform movements, dysarthria, and tremors. The superficial reflexes may be absent, but the deep reflexes, the corneal reflex, and the pupillary reflexes are seldom altered unless a severe acute intoxication is superimposed upon the chronic intoxication already present. The pulse, blood pressure, and respiratory rate are not significantly changed. Body temperature may be slightly depressed. The effects of the same dose of barbiturates vary greatly in the same individual from day to day. This variation in effect is partly related to variations in food intake. The effect of a barbiturate is much greater if the drug is ingested while the stomache is empty. Cumulative effects appear even though a drug whose actions are regarded as very short (secobarbital) is used. Tolerance definitely occurs but is never as complete as is tolerance to opiates. WITHDRAWAL SYMPTOMS Despite the widespread opinion that barbiturates are not addicting, abstinence from barbiturates is much more dangerous to life than is abstinence from morphine. During the first 12 to 16 hours of withdrawal from barbiturates the patient appears to improve. As the signs of intoxication diminish, the patient becomes apprehensive, nervous, and extremely weak. Difficulty in making cardiovascular adjustments to standing appears, fasciculations of various muscles are seen, a coarse tremor of the hands and face becomes evident, the reflexes become hyperactive, and slight tactile or auditory stimuli may cause excessive muscular responses. Patients are unable to sleep, are nauseated, have abdominal cramps, and frequently vomit. Systolic blood pressure is elevated, the pulse rate is increased, and there may be slight fever. Patients may lose as much as 12 pounds of weight in the first 36 hours of abstinence. The nonprotein nitrogen content of the blood usually is elevated 45 to 80 milligrams percent, but no clinical evidence of kidney damage is detectable. Symptoms as described above may be regarded as prodromal. Between the 16th hour and the 5th day of withdrawal, but usually about the 30th hour, patients may have one or more convulsions which are typically grand mal in type. After the convulsion is over, patients generally regain consciousness within a few moments. They may be slightly confused for an hour or so, but prolonged stupor, such as is seen following grand mal convulsions due to idiopathic epilepsy, seldom occurs. Patients usually have no more than three major convulsions, but numerous minor episodes characterized by clonic twitching without loss of consciousness, or by writhing, athetoid movements of the extremities may occur before, between, or after the major convulsion. Addict's outfit for injecting drugs. The outfit favored by addicts for injecting drugs consists of an ordinary eyedropper and a hypodermic needle. A piece of cigarette or tissue paper is wrapped around the end of the dropper, thus making a tight seal with the needle. A spoon is used to dissolve the drug and the handle of the spoon is bent in such a way that the spoon can be placed on a table without tilting and spilling the solution. A piece of cloth or handkerchief is tied around the arm for a tourniquet. After the drug has been dissolved, the solution is drawn into the eyedropper through a small wisp of cotton which acts as a filter Whether or not convulsions occur, the patient may develop a psychosis which usually appears between the third and seventh day of abstinence. The onset of the psychosis often is heralded by insomnia of 24 to 48 hours' duration, after which patients begin to experience hallucinations, both visual and auditory. Hallucinations are likely to begin and be worse at night. Patients are usually disoriented in time and place but not in person. The barbiturate withdrawal psychosis may mimic almost any of the major psychiatric entities and may be confused with schizophrenia. The resemblance of the barbiturate withdrawal psychosis to alcoholic delirium tremens is quite striking. Even if untreated, patients usually recover from the psychosis within 2 weeks of its onset. Some patients recover in 3 or 4 days and some may require 2 or 3 months. Improvement generally begins with a return of the ability to sleep. The hallucinations become less vivid and finally fade, but the patient may, for a few days, believe that the hallucinations were real. After recovery, most patients usually recall part of the hallucinations they experienced during the psychosis. Recovery from chronic barbiturate intoxication and from the barbiturate withdrawal symptoms appears to be complete. No permanent anatomic damage remains so far as can be determined by clinical and psychologic technics. The barbiturate abstinence syndrome varies considerably from patient to patient. Some patients have convulsions but excape the psychosis; other patients may not have convulsions but develop a psychosis; and other patients may escape both. TREATMENT The treatment of any type of drug addiction is primarily a psychiatric problem and favorable results cannot be expected unless treatment is continued for a period of several months. Attempts to treat drug addiction in the home or office practically always fail, and institutional treatment usually is required. Patients seeking treatment for addiction should, therefore, be referred to one of the private institutions devoted to care of drug addiction or to the United States Public Health Service hospitals at Lexington, Ky., or at Fort Worth, Tex. These two Government institutions can accept persons addicted to opiates, cocaine, or marihuana, but cannot admit individuals addicted only to barbiturates, benzedrine, alcohol, or bromides. Information concerning admission to these hospitals may be obtained by writing to the medical officer in charge of either hospital. Treatment can be divided into two phases: (1) withdrawal of drugs, and (2) rehabilitative and psychiatric treatment. The best plan for withdrawing morphine or similar drugs from addicted persons involves substitution of methadone for whatever drug the patient has been taking, followed by reduction of the dosage of methadone over a period of about 10 days (except in cases complicated by severe organic disease). This treatment is based on the fact that, although methadone will prevent the appearance of abstinence symptoms from any of the known analgesic drugs, abstinence symptoms from methadone are milder than abstinence symptoms from any of these other drugs. One milligram of methadone can be substituted satisfactorily for 4 milligrams of morphine; 2 milligrams of heroin; 1 milligram of dilaudid; or 20 to 30 milligrams of either meperidine or codeine. When this system is used, the only adjunctive therapy required is the administration of small amounts of sedative drugs during the last half of withdrawal. WITHDRAWAL OF BARBITURATES Barbiturates should be withdrawn from barbiturate addicts very slowly and cautiously. On admission, it is best to give the patient 0.2 to 0.4 gram of pentobarbital or an equivalent amount of any other barbiturate every 6 hours. The dosage should be adjusted to a level which will maintain a mild degree of intoxication. After the proper dosage has been determined, it should be maintained for a day or two and then reduction of the barbiturates started. Dosage should not be reduced more than 0.1 gram daily at any one time. The total withdrawal period should extend over a period of 3 to 4 weeks and, occasionally, reduction should be stopped for a day or two to permit the patient to stabilize at his new level. If the patient is exceedingly nervous, apprehensive, and weak, or if paroxysmal slow activity appears in the electroencephalogram, the reduction should be stopped until these signs have cleared. Patients undergoing withdrawal from barbiturates must be kept under close observation. The bed should be provided with sideboards so that if convulsions occur patients will not fall to the floor. Patients should not attempt to walk, bathe, or go to the bathroom unattended. The diet should be light or soft throughout most of the period of withdrawal. REHABILITATIVE TREATMENT After withdrawal has been completed, the patient should receive treatment for any organic disease which he may have. If the patient has a disease which is not curable, such as asthma or rheumatoid arthritis, the treatment should be designed not only to produce the greatest possible physical improvement but also to teach the patient how to live with his chronic disease without depending on narcotics or barbiturates. In cases of addiction associated with intractable pain, appropriate surgical procedures sympathectomy, rhizotomy, chordotomy, lobotomy should be carried out so that the patient's need for pain-relieving drugs will be abolished. All patients should be provided with the opportunity to engage in 8 hours of productive and useful work daily. Occupational therapy should not be a matter of weaving rugs but should maintain and add to any skills which the patient possesses. Patients with chronic diseases should not be allowed to vegetate on infirmary wards but should, within the limits of their imposed diseases, be given some type of useful activity to pursue and, if possible, should be trained in some occupation which they can carry on despite their infirmity. Provisions also should be made for various types of recreationathletics, movies, music, and books. |