Читать книгу Habits that Handicap: The Menace of Opium, Alcohol, and Tobacco, and the Remedy - Charles Barnes Towns - Страница 9

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The Internal Revenue Reports are the only index to the extent of the drug consumption in the United States. They show for years past an annual increase in the importation of opium and its derivatives and cocaine, and for last year a very marked increase over that of any preceding year. This is not due to the increase in population; our immigrants are not drug-takers. Among the thousands of drug-users that I have treated or known, I have never seen an Italian, a Hungarian, a Russian, or a Pole. Moreover, I have met with only four cases of drug-taking by Hebrews. Few Jews—except in the under-world—acquire the habit knowingly. It may become fastened upon them through the use of a medicine the danger of which they do not realize, but, once freed, they will not again come under its power. The practical sagacity of their race is their surest safeguard.

What is commonly spoken of as the “American type,” highly nervous, living under pressure, always going to the full limit, or beyond, is peculiarly liable to disorders that lead to the habitual use of drugs. We are all hypochondriacal by nature, prone to “take something” whenever we feel badly. Lack of opportunity alone, of knowledge of what to take and how to procure it, has saved many a person under severe physical or mental strain from recklessly resorting to drugs. Since the passage of the Pure Food and Drugs Act, which was intended to protect the public by requiring the express statement of any dangerous ingredients in a compound, the sale of preparations containing habit-forming drugs has preceptibly increased. It seems a just inference that the information given, instead of serving as a warning to the unwary, has been chiefly effective in pointing out a dangerous path to many who otherwise would not have known where to find it.

Women, it should be said, though constitutionally more liable than men to feel the need of medicines, form the lesser portion of the drug-taking class. In the beginning their addiction is due almost exclusively to a physician’s prescription, except in the under-world.

The habitual users of drugs in the United States come from every grade of society. Professional men of the highest responsibility and repute, laborers wearying of the dullness in a mining-camp, literary men, clergymen, newspaper men, wire-tappers, shoplifters, vagrants, and outcasts—all are among the number. Strangely assorted as they are, they become yet more strangely alike under the influence of the common habit. Shoplifting is not confined to the professional thief; it is noticeable in many a drug-user who has had every moral and worldly advantage.

The major part of the habit-forming drugs used in the United States is consumed by the under-world. It would be impossible to calculate the extent of their influence. Many a record of heinous crime tells of the stimulus of a drug. But when the school-children in some of our larger cities are found to be using cocaine, and able to buy it at will, the limit of tolerance has surely been reached.

THE DRUG-TAKING PHYSICIAN, NURSE, AND PHARMACIST

Among the widely varying classes of drug-users, three in particular are a source of the gravest danger: the drug-taking physician, nurse, and pharmacist. To realize this, one has merely to recall that the drug-taker is a confirmed evader of responsibility; and the physician, of all men, is in a responsible position. He must not forget or break his appointments; he must realize the effects of the medicines he is prescribing; if a surgeon, his work must never be below its best. But the proportion of physicians that I have treated, or consulted with, suggests one specially grave danger. It is a characteristic of the drug-taker, no matter who he is or how he acquired the habit, on the smallest excuse to advise others to take the drug whenever pain or fatigue gives the slightest occasion for it. While he grows callous to everything else, he has an abnormal sympathy with suffering. Thus it will readily be seen that there are few more dangerous members of society than the physician who is addicted to a drug.

The fact that there are not more drug-taking doctors speaks volumes for the high character of the profession. The physician has such drugs constantly at hand. The more a man knows of their insidious action and the more he handles them, the more cautious he feels himself to be, and the more confident that he can discontinue the use of them whenever he chooses. Any fear that the layman may have of them is due less to the dread of being personally overcome than to the mystery which surrounds them; but for the physician they have no such mystery. Furthermore, by the nature of his calling he is peculiarly exposed to the need of such drugs. He is often under excessive physical and nervous strain not only because he is unable to arrange his work so as to prevent periods of too great pressure upon his time and strength, but also because in a unique manner he puts his heart into it.

An even greater danger, in some respects, is the drug-taking professional nurse. Whatever has been said of physicians both in the way of extenuation and of warning may be repeated of nurses. They have the same exposure to the habit, and, once addicted, are likely to exhibit signs of irresponsibility. They are more dangerous in that their opportunity for mischief is greater, since they are closer to the patient and able to thwart the doctor’s orders with perfect freedom. “I have had several nurses on this drug case,” a doctor once said to me, “and I find that they have all smuggled morphine to my patient.” This was, no doubt, an exceptional case, but the fact remains that nurses, because of their close alliance with druggists and doctors, find it comparatively easy to purchase drugs and hypodermics at any drug store without causing the slightest suspicion or reproof. Nor should one censure them too severely for clandestine compliance with the demands of a patient. It should not be overlooked that the nurse, in being paid by the patient and not by the doctor, is ordinarily subjected to great pressure when the patient clamors for morphine. In such circumstances the protection of a physician’s monopoly of the drug would be most welcome. But how much worse is the pressure when the well-intentioned nurse also is a drug-taker! The morphinist has an abnormal sympathy with those who have undergone or are undergoing experiences similar to his own, and there is no stronger bond than that which unites two morphine victims. As a matter of the most elementary precaution for all concerned, no nurse should under any conditions be allowed to buy habit-forming drugs.

Another kind of drug-taker against whom physicians’ distribution would be a safeguard, and the only safeguard that can be devised, is the pharmacist. The contingency of a drug-taking pharmacist, perhaps more than anything else, will bring sharply home to the average man the menace of morphine when used by a professional person. By reason of closer and more personal observation one may feel rashly confident of his ability to detect when a doctor or a nurse is “queer,” but generally the patron of a drug store has no such opportunity for observation. Addiction to a drug incapacitates the pharmacist for filling prescriptions. Often the slightest deviation from a precise formula in either quantity or ingredient is of the gravest consequence, and hence the utmost care should be used to insure the scrupulousness of one on whom such responsibility rests. As long as he is accountable to no one, or even accountable to the Government only on a business basis, there can be no safety for the public. If he may sell to any purchaser other than a physician, he may always supply his own wants. But if he has to account to a physician for the entire amount of habit-forming drugs that he distributes, any leakage may quickly be detected by the man who more than any one else can be relied upon to stop such a leakage promptly and sternly. A pharmacist should be allowed to dispense habit-forming drugs only on a physician’s prescription.

The physician should be limited as to his authority not only for prescribing such drugs, but, as the Boylan Act provided, there must be a careful accounting on his part for all such drugs administered or given away. In other words, he must account for all such drugs which he buys for office use, and he cannot prescribe such drugs except under certain definite limitations.

METHODS OF TREATMENT: “THE HOME CURE”

For many years only two methods of dealing with the drug habit were known. They continue to be the only ones in general use to-day. They are the “home cure” and the sanatorium method. Neither is in any proper sense a treatment or anything more than a process of substitution and deprivation.

In many of the periodicals and daily papers are carefully worded advertisements setting forth that a man may be cured of a drug habit quickly, secretly, painlessly, and inexpensively. These are written by people who thoroughly understand the mental and physical condition of the drug-taker. In almost all cases he wishes to be freed from the habit, but at the same time to avoid the disgrace of being classed with “drug-fiends”; he is unwilling that even his family or his intimates should know of his condition. He has an exaggerated sensitiveness to pain, upon which also the advertisement relies. Furthermore, attention is directed to the fact that the patient may take the alleged remedy without spending much more money than he has been spending for the drug itself, naturally a powerful appeal to a man of limited means. Moreover, the people who take these “cures” are generally those who are unable to consider the expense of leaving home. That the advertisement is very alluring to the average drug-taker is shown by the fact that in my entire practice I have encountered few patients who have not at some time or other taken a home cure.

A minister wrote to me the other day begging me to cure a fellow-minister of the cure habit. His friend had had occasional attacks of renal colic, and a physician had eased their acuteness with a hypodermic. The patient of course knew what he was taking, and since he was forced to consider the cost of the physician’s visits for the mere administration of the hypodermic, he naturally procured his own outfit, and in a short time was using it regularly upon himself. When he found that he could not leave off the practice he entered into correspondence with a succession of “home-cure” advertisers, whose clever use of the word “privacy” offered a hope that his condition might be concealed from his congregation. For ten years he had been undergoing the cures, and during all this time had been forced to take a regular dosage of the so-called remedies.

Before the passage of the Pure Food and Drugs Act the ingredients of such remedies were not stated. The patient seems never to have suspected the truth—that the bottle contained the very drug he had been taking, its presence disguised by added medicines. In certain instances the makers boldly advertised that a trial bottle would be sufficient to prove clearly that the taker could not get along without using his drug. Now that the law compels a list of dangerous drugs on the label, the cures proceed admittedly by a reductive principle. The patient graduates from a number one bottle to a number two, containing less opium, and so on, until finally he is supposed to be cured. The proprietors of these cures make a great deal of capital out of the fact that the reduction is so gradual that the taker experiences no discomfort. This consideration is highly effective, for while it irresistibly appeals to the morbidly sensitive morphinist, it also makes him comprehend, as time goes on, why the process of cure is so slow. It is hardly necessary to state that the final stage is almost never reached.

Almost without exception, the basis of restoration to health is the perfect elimination of the effects of the drug. It should go without saying that it is impossible to eliminate the effects of opium with opium or to find any substitute for opium that is not itself opium. At the International Opium Conference in China I exhibited seventy-six opium-cures which I had had analyzed and found to contain opium; and as a consequence of the Pure Food and Drugs Act all the American “cures” announced on their labels that they also contained it. Thus it is easy to see why the sale of these cures had always greatly increased wherever the rigid enforcement of anti-opium enactments had closed up the customary sources of habit-forming drugs.

Up to the passage of the act, however, the presence of opium in the American cures was concealed, and their formulas were kept secret; and hence all of them, by the very nature of the case, were put forth either by irresponsible persons or by persons outside the pale of the profession; for one of the pledges given by a physician is that he will not patronize or employ any secret treatment, and that he will give to the profession whatever he finds to be of benefit to his fellow-men.

In very rare cases these home cures have been able to relieve a man of strong will power, with the added assistance of a regimen for building up his bodily tone. But these cases have been so infrequent as to be virtually negligible, for to administer the treatment successfully demands from the patient the exercise of precisely that power of self-control the loss of which drove him to the cure in the first place. If there ever was any curative property in one of these so-called cures, a man could not be benefited unless he were under constant supervision. A treatment of this sort must, except in case of a miracle, be administered by another and under continuous medical surveillance. A man addicted to a drug, be he physician or longshoreman, in a short time becomes utterly unable to deal justly with himself, for it is the nature of the drug to destroy his sense of responsibility.

THE SANATORIUM TREATMENT

Besides the home cure there was, and is, the sanatorium treatment. Unlike the former, this was first established and carried on by trustworthy medical men, who depended for their support upon the patients of reputable doctors. A physician who had a morphine patient was obliged to send him to a sanatorium because there was nothing else to be done with him; elsewhere no course of treatment under constant surveillance could be given. It afforded the only opportunity of carrying the patient through the long period of gradual reduction which was then the only known treatment. Thus there was nothing optional about the matter; the physician could not recommend a home cure, and the only means of approximating systematic treatment was the sanatorium. Furthermore, those relatives and friends who knew of the patient’s condition were anxious that he should go to one, since they realized the increasing awkwardness of keeping him at home. In many cases, indeed, they even went so far as to resort to means of commitment, if they failed to get his voluntary coöperation. It is due to the ease with which this type of patient can be committed that the State of Connecticut, for instance, abounds in sanatoriums. In that State, when a patient has entered one of them, he can often be detained there virtually at the pleasure of his relatives and friends.

The method of treatment at most of the sanatoriums is like the home cure, except that it is under surveillance; that is, it is merely one of gradual reduction accompanied by an upbuilding of bodily tone. The morphine-taker with means and time at his disposal will stay in a sanatorium as long as he can be made comfortable. This shows that whatever reduction he has undergone is extremely slight; for gradual reduction, when it is carried to any extent, sets up a highly nervous state, together with insomnia and physical disturbance. The patient, as is often said, has an exaggerated dread of discomfort, and will not, if he can help it, endure it at all. Unless he is committed, he transfers himself to another sanatorium the moment he ceases to be made comfortable. I had one patient whose life had been a continuous round of sanatoriums. He would stay in one place until the point was reached where discomfort was in sight, and then remove to another, remaining there for a similar period, and then to another, and so on, until he had finished a long round of sanatoriums to his taste in America and Europe. Then he would begin all over again.

A patient of mine who had visited eight different sanatoriums in the vicinity of New York told me that in America the sanatorium treatment of neurological patients was divided into three great schools: the “forget-it” system, the “don’t-worry” system, and the “brace-up” system. Any nervous invalid who has stayed much at sanatoriums will appreciate the humor of this classification.

The gravest aspect of these long stays at a sanatorium is the unavoidable colonization. Picture to yourself a group of from half a dozen to fifty morphine patients, eating together, walking together, sitting on the veranda together, day in and day out. In this group are represented many different temperaments and many different stations of life, from the gambler to the clergyman. All the more on this account is there a general and eager discussion of previous history and present situation. For where the alcoholic is quite indifferent, the morphine victim has an insatiable interest in symptoms. He has also an excessive sympathy with all who have been through the same mill with himself. Thus, in a matter where individual and isolated treatment is imperative, most sanatoriums deal with patients collectively. Furthermore, these are peculiarly a class of unfortunates who ought never to become acquainted. Whatever moral restraint the habit has left in a man is completely relaxed when he hears constant bragging of trickery and evasion and has learned to envy the cleverness and resource so exhibited. The self-respect and pride which must be the main factors in his restoration are sometimes fatally weakened. Colonization should be restricted to the hopeless cases, and to them only because it is unhappily necessary.

FAILURE OF THE REDUCTION METHOD

All this, moreover, is never, or almost never, to any purpose. As the uncomfortable patient will move if possible, it is naturally the business of the sanatorium to keep him from being uncomfortable. The method of reduction, therefore, is rarely carried out to the point where it would do any good, even if good were thus possible. But it is not possible. In the first place, lessening the dose is of little avail; there is as much suffering in the final deprivation of a customary quarter of a grain as of twenty grains. In the second place, it cannot be ascertained by gradual reduction whether there is any disability which makes morphine necessary, since no intelligent diagnosis can be made so long as a patient is under the influence of the smallest quantity of the drug. Obviously, the first step in taking up a case should be to discover whether any such disability is present, and, if so, whether it is one that can be corrected; otherwise it may be a waste of time to try to correct it. The true physical condition of the patient, which should be considered before a long course of treatment is undertaken, can seldom be discovered by the reduction method.

The best doctors have always felt that they could not afford to lend their names to any institutions or sanatoriums except those which restricted themselves to mental cases. Yet these home cures and sanatoriums, unscientific and ineffective as they were, have offered to the victims of the drug habit the only hope they could find. The investigations begun by Mr. Taft in the Philippines extended over considerable time and cost two hundred and fifty thousand dollars, but, although furthered in every way by the whole world, they failed to discover a definite treatment for the drug habit. It was generally believed by physicians that there was no hope for the victims of it.

COST OF THE DRUG HABIT

It may be noted that I have not dwelt upon the expense of the habit. This consideration may be omitted from the case. To the average victim, the cost of his drugs, no matter what he may have to pay for them, seems moderate. He is buying something which he deems a vital necessity, and which, moreover, he places, if a choice be required, before food, drink, family, sleep, pleasures, tobacco—every necessity or indulgence of the ordinary man.

The real cost is not to the drug-taker, but to the world. If a human life be considered merely as a thing of economic value, an estimate may perhaps be made of the total loss due to the habit.

But the loss should not be reckoned in any such way. It should rather be reckoned by the great amount of moral usefulness and good that might be rendered to the world if these unfortunates could be freed from their slavery, and by the actual harm being done by them, especially by those that are now loosely classed as criminals and degenerates.

The retrieving of much of the waste of humanity may be accomplished by adequate treatment of the drug habit.