Chapter X · GENERAL SURVEY OF THE SITUATION AND THE NEED OF THE HOUR

From the foregoing it is easy to see that the sooner the established facts of the fundamental physical basis and reactions of the addiction-states become matters of medical, sociological, administrative, and lay knowledge, the earlier there will be a rational and practical consideration of the use as well as of the abuse of narcotic drugs, and a beginning of solution of the narcotic drug problem.

Lack of knowledge of the fundamental and constant physical reactions and phenomena, and of the characteristic clinical manifestations of this disease, and of the physical suffering of drug deprivation is in a very large measure responsible for failure in its therapeutic handling in the past, and indirectly responsible for whatever is unjust and misdirected in the framing of the various laws, and also for a great part of whatever incompetency and lack of wisdom has appeared in their administration.

Lack of knowledge of the disease facts of narcotic addiction is also responsible for the practical absence of widespread provision for humane and intelligent handling, for much of the jeopardy and fear on the part of the medical practitioner towards these cases, and for the existence of conditions resulting in the rapid growth and increase of the worst evils of the present situation.

The worst evils of the narcotic drug situation are not, as is widely taught, rooted in the inherent depravity and moral weakness of those addicted. They find their origin in opportunity, created by ignorance, neglect and fear, for commercial and other exploitation of the physical suffering resulting from denial of narcotic drug to one addicted. The many widely advertised drug cures derive their prosperity from the desperate desire of the narcotic addict to be cured of the condition which may at any time cause him intense physical suffering. The worst evil of the narcotic situation in the past few years, and especially since the enforcement of restrictive legislation, without provision for complete investigation of the whole situation, for education, and adequate treatment of disease aspects, is the rapid growth and spread of criminal and underworld and illicit traffic in narcotic drugs. This exists to its present extent because conditions have been created which make smuggling and street peddling and criminal and illicit traffic tremendously profitable, and it would not exist to its present extent otherwise. It is simply and plainly the exploitation of human suffering by the supplying to desperate and diseased individuals, at any price which may be demanded, one of the necessities of their immediate existence.

Such exploitation would become unprofitable on any large scale if the disease created by continued administration of opiates were recognized as it exists and its physical demands comprehended and provided for in more legitimate and less objectionable ways.

One of the most important and immediately available of these ways is the honest practitioner of medicine. If the average practitioner of medicine were made familiar with the physical facts of addiction-disease, and its phenomena and reactions, and were encouraged by both legal and medical authoritative support to admit addiction-disease patients to his practice, to be cared for just as other patients to the best of his honest therapeutic ability and judgment—if he were taught to regard them as sick people whom he could help—if he were relieved of uncertainty as to the meaning and possible interpretation of laws and regulations, and as to the possible action or lack of action and attitude of his medical brethren and medical organizations towards him—the best available, honest, humane and intelligent machinery would be set in motion for the immediate care of the average honest sufferer from addiction-disease, and for the discouragement of underworld or underground exploitation. This has been demonstrated. It would react furthermore as a stimulus to the education of the physician, to familiarize himself with the scientific and medical facts of this disease.

Another immediate provision is the establishing under proper supervision and management, especially as to competent medical management, and without possibilities of humiliation and interference with self-support, of stations or clinics at which those who for financial or other reasons are unable to secure reputable and honest medical help, may obtain their necessary opiate at minimum expense and in physically necessary amounts to enable them to work and support themselves and families, without resorting to underworld associations and illicit commerce. Such clinics might be established in connection with the various hospitals on the same basis as their other medical and surgical clinics or dispensaries, and in connection with various health departments. In them the narcotic addict could not only be supplied with opiate medication, but taught the nature of his disease and the elements and principles of its control and be given such medication other than opiate for the relief of such associated or intercurrent conditions as might exist. Such clinics would have great educational value, as well as fulfilling a therapeutic need.

Pending further study and investigation and education into narcotic drug addiction-disease and the conditions surrounding it, and pending the widespread acceptance and recognition of practical and desirable procedures in the handling of the disease, and pending the provision of sufficient and scientifically adequate accommodations for the army of those who seek relief—legitimate supply of the drug of addiction under medically competent and intelligent direction fulfills a great economic and sociologic and medical need.

The financial possibilities of commercial exploitation of the sufferings of addiction-disease, combined with general ignorance of the true nature of the addiction condition, are responsible for the tremendous increase of late of narcotic addiction, of non-medical or non-therapeutic origin, among the youth. In ignorance of actual physical results, not knowing nor ever having been told that they are contracting a disease of torturing manifestations, actuated by curiosity and search for adventure, in some cases stimulated by unfortunate spectacular publicity, the youths fell easy prey to the agents, male and female, of the drug trafficker. The trafficker’s intended consummation is reached when these youths finally become, to their surprise and consternation, through the development of addiction-disease and physical dependence upon narcotic drug, enforced and continued customers and in some cases, virtual slaves.

Those who are interested in prostitution and in so-called “white-slavery” would do well to turn their attention to the chains forged by the suffering, and the fear of suffering, experienced by those who have developed narcotic drug addiction-disease.

It is this class of youthful addicts that has so alarmingly increased since the enforcement of the various narcotic laws. I have previously called attention to this situation, and also to the fact that for this increase the laws themselves are not so much to be blamed as is the totally inadequate meeting of the clinical and therapeutic and educational needs of the narcotic drug situation. There has been practically no organized scientific, medical or public health activity, so far as I know, directed towards the clinical and laboratory investigation of this disease—towards a dispassionate review, analysis and testing out of the truths and errors of its literature—towards an investigation of the scientific and other qualifications and experience of those whose utterances or writings influence medical and lay opinion and action, towards the establishing of pathological and physical facts and reactions and of clinical symptomatology and phenomena as fundamental bases for its rational handling and therapeutics, and for practical education of the public as to its sufferings and dangers.

The neglect of this education is largely indirectly responsible for illicit traffic in narcotic drugs. Illicit and underground traffic exists because it is profitable. This is the direct and immediate reason for its existence. Every new addict made of an adventurous youth means a new customer for the smugglers and vendors. If that adventurous youth had been taught the facts of the physical hell of the “withdrawal signs” of opiate addiction-disease—if he knew the sufferings attendant upon body-need for opiate drug—if he knew that any red-blooded animal will develop this physical body need if opiate drug is administered for a sufficiently prolonged period—that no living being is immune to the development of this disease—if he thought of addiction as he thinks of tuberculosis, and as he is now being taught to regard venereal-disease, instead of it as being something vague and surrounded by a halo of adventure and experience, he would not fall an easy victim to the agents of the trafficker. In other words, the most potent activity in the arrest of development of even the vicious and criminal aspects of the narcotic addiction situation lies in education. Laws and their enforcement in the control of the incorrigible and vicious will always be a necessity, but laws and their administration alone are not sufficient for the control of the many-sided addiction situation. Even in the control of smuggling and illicit traffic we need the application of every available influence capable of exertion, not only upon its end results but upon the machinery of its origin and development. As so much of it originates and develops through ignorance, the method of its remedy lies in education, education as to the facts of narcotic drug addiction-disease.

It is ignorance also that has stamped the honest and innocent, worthy and intelligent, and often illustrious sufferer from narcotic addiction-disease with the attributes and characteristics of the inherently irresponsible or otherwise incapable of self-guidance and self-restraint. The ignorance of the facts of addiction-disease has taken from these people even their ordinary legal and public rights in any issue which involved the possible revelation of their addiction. It has placed them in a position where any procedure which might reveal their narcotic medication would expose them to public gaze as members of a popularly despised and unworthy class of individuals. Until very recently the testimony of a known narcotic addict has been almost as a rule of no value in a court of law. Irrespective of a life-time of honesty and accomplishment, the revelation of a minute might destroy the reputation and standing of many years. Whatever the injustices or grievances suffered by an addict, he could not hope to evoke the protection or rights accorded an ordinary individual under statute law without the practical certainty, if his addiction became revealed, of personal, social and economic detriment far in excess of the legal rights to which he was entitled. The continuation of whatever is spurious or unworthy in methods of handling, advertised or otherwise, lies partly in the fact that the former patient cannot afford, however great his physical or other damage, to make public the existence of addiction-disease by the instituting of a suit for malpractice or other civil or criminal procedure. This alone has been one of the factors in lack of progress and in the persistence of narrow vision or false conception. He is in effect, however high his personal, moral and other status, deprived of some of his constitutional rights, simply because he has developed addiction-disease.

The great numbers of innocent and worthy unsuspected sufferers from this disease, who could not by any stretch of wildest imagination, be regarded as mentally or morally abnormal or subnormal have therefore been placed in a position where they could not afford to demand their rights or state their case. Their problems are only recently beginning to receive general consideration. Their cases have compelled us to revise our conception of the narcotic addict, and to question ourselves as to the necessity for their continued addiction over the years of their addiction. For their own good and that of society, what shall we do with them, and what can we do for them? In the present state of public opinion and public attitude towards narcotic addicts in general would it benefit either them or society to class them merely as “drug addicts” along with the drug-users of other types of individuals and other personal characteristics for administrative handling by detailed administrative supervision and control? Can the same administrative and other methods which admittedly must be employed to protect society from the manifestly unfit accomplish anything of good in the cases of these responsible and valuable citizens?

Until there is a truer understanding of addiction-disease, and a wider appreciation of the facts that the personal attributes of its victims differ as widely as those of cardiac or any other disease condition, and that merely because a man has contracted this disease is no reason for regarding him as in any way unworthy or unfit—will stringent and drastic forcible regulative measures directed against mere use of narcotics work out to the advancement or hindrance of ultimate solution and to the ultimate benefit or harm of society? These are the questions to be applied to all restrictive administrative activities. The problem of the care of the worthy and innocent addict in such a way as not to unnecessarily harm him nor deprive his family and society of his competent activity is just as important as the handling of the addict of the type of individual from whom society must be protected. The large numbers of worthy and valued citizens who are individually and personally social and economic assets and who are sufferers from addiction-disease constitute a very important consideration in the narcotic problem.

They certainly are not fit subjects for enforced custodial and correctional handling, and if such were forced upon them they would be seriously harmed, personally, socially, economically and physically. Very many of them our equals or betters, we have no right to subject them to associations and experiences which we ourselves would rebel against and be humiliated by simply because they have developed a disease condition from which no one of us is immune.

Where is the blame for their continued addiction? Certainly not because of lack of effort on their part. Addicted for years, they have tried one after another of the various and diverse treatments and so-called cures without success or benefit. Is the blame theirs for lack of success and cure, or has there been something wrong in our treatment and handling of them? Did we know enough about addiction-disease to treat them intelligently and to exercise upon their cases the same professional skill and technical ability that we have been educated and trained to apply to other diseases? In the light of present available clinical information and study, and in the light of recent and competent laboratory research, we are forced to admit that we have not treated our addiction sufferers with sympathetic understanding and clinical competency, and that the blame for past failure to control the narcotic drug problem rests largely upon the educational inadequacy of the past.

We are in a stage of transition in our concepts of, attitude towards, and handling of the narcotic addict. Serious consideration of drug addiction as a problem of clinical and internal medicine, and of experimental laboratory research is a comparatively new thing to a majority of the medical profession, and of course also to legislators and administrators. We should all remember that no matter how strong we are in our beliefs and theories, there are many others whose experiences and results have caused them to hold just as strongly to opposite theories and beliefs, and that we are all on trial for the validity and extent of practical application of our beliefs and theories.

Each new theory or belief that is brought forward should be taken simply for record and investigation. Much that we believe to-day we know to-morrow to be based upon misinterpretation and lack of complete information. Much that we believed in the past to apply to and solve conditions, we found later to have been merely based upon observations of distracting incidentals or non-basic aspects and phases. What we need is competent, disinterested, and honest effort to get together and evaluate all available material of whatever sort and from whatever source. If it were possible of accomplishment, it would be of advantage to get together in open and frequent discussion the various workers in the field. We are all partly wrong and partly right. There is no one of us who cannot learn from any one of the others. The real end of effort should be, not to prove one or another of us right, but to take each from the other whatever is of value and all to contribute in true scientific spirit of broad tolerance towards the ideas of others and of willingness to correct or modify ideas and theories of our own, searching for no panaceas or specifics, medical, legislative or administrative, simply hunting for truth wherever we may find it and applying it intelligently to meet the needs of the individual.

There is too much work to be done, and the situation is too urgent for remedy, to permit of longer delay in scientific approach. Under present conditions, no man’s announcement of theory or of remedy is to be taken as ultimate authority, but simply as his opinion based on his personal deductions, and his personal experience, to be evaluated in accordance with the extent and variety of his personal experience in the light of his individual ability and training.

Education and training are the best hopes we have as a foundation for the alleviation of present conditions and the prevention of their further spread. Lack of appreciation of and of ability to recognize and meet varied and various clinical and other indications for treatment and handling under widely different circumstances and in widely differing individuals means failure in a majority of cases, and throws a burden upon society and a complexity of problems upon municipal, state and federal authorities which they are unable to meet. Each class of workers should be working in its own field in co-operation with those working in other fields, none trying to dominate the rest, but each giving to the others credit for honest effort and appreciation of difficulties to be made easier if possible.

All possible forces should be encouraged to the work of study and investigation and education. A campaign of medical and lay investigation and education will require a much shorter time than a continuous trying out of various panaceas, medical, legislative or administrative. Also, it will bring far more satisfactory and earlier results. The narcotic wards of our great charity hospitals should be made use of for honest unbiased and trained clinical and laboratory study. The narcotic addict himself should be given a much wider hearing than he has in the past received. The mass of honest and intelligent narcotic addicts should be encouraged to tell their stories and their experiences, and should receive a fair and unbiased hearing as to the reactions upon them of various measures proposed. We, doctors, legislators, administrators are in truth as much on trial with the narcotic addict and with society for our understanding and handling of the narcotic addict and his problems as the addict is for his condition.

The remedy is plain, and the necessity for immediate activity is obvious. Education—scientific medical and lay, administrative and public health education is the lacking element or factor in the solution of the many sided narcotic drug problem. Appreciation of addiction-disease and what it may mean in the individual should be as widespread and as comprehensive as possible and at the earliest possible moment.

Without a basis of generally recognized and widely appreciated fundamental facts, there can be no competent treatment, legislation, administration or judicial decision. There can be no competent evaluation of the merits and defects of various measures promulgated, medical, legislative or administrative. There can be no competent selection of those in whose hands shall lie the handling of a tremendous problem, a problem of disease, of sociology, of economics, of public health and welfare. There can be no competent evaluation of the remedies advanced, nor of the qualifications and true authority of those who recommend them. Under such conditions various measures or procedures in their adoption or discarding or application must depend more upon the publicity and other influence of their proponents than upon their intrinsic values.

There are always some things about any condition which either are or are not, some things which are physically determinable. The basic facts of addiction-disease are now physically determinable. There are many material and obvious and easily demonstrable physical facts of greatest value to the medical profession and to the laity, facts which are still but little appreciated, and not widely known.

These facts in addiction-disease could be easily investigated. The various conflicting statements of different schools of thought or of observers working from different angles should be investigated, evaluated and correlated—taking from each whatever is useful, determining its true sphere of application and making it available to all. Every possible interest or worker should be encouraged, and every source of information sought out, not least among them the honest and intelligent sufferer from addiction-disease of many years duration whose knowledge of the facts of his condition, and efforts to control it, and search for and trial of remedy and remedies for it, and the experiences and problems, social, economic and personal, which its possession has forced upon him would constitute a touchstone of greatest value for the determination of validity of promulgated measures and procedures.

The wards of the great charity hospitals, the institutions of science and medical experiment and research, the Departments of Health, and the Public Health Services are in existence and are equipped for the early determination of clinical, and laboratory facts, and for their dissemination. These are the things towards which their activities are directed in other diseases and conditions affecting public welfare and public health. It would take a very short time to determine the physical facts of addiction-disease—to establish finally and conclusively its clinical symptomatology and constant reactions and phenomena for authoritative and educational dissemination. Every one of us who has written in description or exposition of his study and observations, together with what we have written and taught, should be made the subject of critical and unbiased investigation, and whatever of truth we have stated should be made the possession of all. The experimental development of addiction-disease in dogs and other experimental laboratory animals, the symptoms and phenomena observed in them recorded by instruments such as the sphygmomanometer and the sphygmograph and paralleling similar records and observations upon the addicted human, the reactions of the serum of these animals injected into the non-addicted of their species are not to be lightly ignored, and should be matters of common scientific knowledge. The manifestations of addiction-disease in the new-born developed in the infant’s body prenatally long before vice or habit or appetite can be possibly considered as causative factors, demand more than casual consideration and have a significance much deeper than as occasional curiosities.

An educational campaign as to the facts of addiction would save many an innocent person from the contraction of the disease, and many a present sufferer from unintelligent handling. Authoritative bodies with sufficient power and independence might easily institute unbiased review of what is written, and trial and proving out of what is stated by various writers, and give out their findings for the guidance of future work and action. Hospitals and public institutions for the handling of narcotic addicts may be erected. Without comprehension of addiction-disease and full and complete familiarity with its manifestations, the possession of those who work in them, will they accomplish anything of good?

The deduction from the testimony of the Whitney Investigation and from other sources leads to the conclusion that one of the reasons why the narcotic addict does not go to many of our present institutions is that he is more afraid of them, and anticipates more suffering in them than he cares to face in view of the fact that neither from previous personal experience or from repute he has little hope of being discharged from them in a condition of physical competency with his addiction mechanism arrested. He sees no use in going through them only to come out in a condition where he will have to revert to his opiate to enable him to endure and work. This is not an all-inclusive statement. It expresses, however, the frequent response of the addict seeking advice when asked why he does not go to the municipal institutions for treatment. Again then the work of those in the institutions will be the determinating factor in their success or failure, and their education is the dominant element required for success. Some interesting observations upon this point will be found in the Yearly Report for the Department of Correction of New York City, 1915.

Of public clinics the same thing may be said. Whether they react to the benefit of the addict and of the community, or to the harm of the addict and community will depend upon their intelligent understanding and competent management.

Hospitals and clinics might be made into sorely needed educational centers for the training of doctors and nurses to go out and take up the work of the care of the addict—either private or institutional.

Education is the great need of the hour. Until it is accomplished all else will fail. Until we all know what we are dealing with, how can we hope to successfully handle it? It is to be hoped that the time is not far distant when in every medical school and hospital will be taught in principle and practice, in class-room and clinic all that is known or will be known of the pathology, symptomatology, physical phenomena and rational therapeutics of narcotic addiction-disease. It is to be hoped that in school and college, in pulpit and press, the facts of addiction will be presented in their practical existence, stripped of spectacularity; a calm, cold presentation of basic facts. There is no subject upon which philanthropy can better expend its forces than to this end of education as to addiction-disease and humane help to its sufferer.

In the past the problem of control of addiction has been “What shall be done with or what shall be done to the narcotic addict to make him stop using drugs?” It is now gradually coming to be realized that the true problem is “What can be done for the narcotic addict to relieve him of the physical necessity of using drugs?” and “What can be done to so educate the public as to the facts of addiction, so that this disease will claim as few victims as possible?”

In this change of attitude lies the hope for the future. Some of the narcotic addicts will have to be done with or done to. They are the inherently irresponsible, vicious or defective. They demand care and restraint irrespective of their addiction. The mass of addicts, however, need something done for them. They are clinical problems of internal medicine, victims of a definite disease, characteristic in its symptomatology, reactions and phenomena, a disease which will before long come to be known as clinically and therapeutically controllable and arrestable.