With the Author s Covfpliments. CLINICAL NOTES ON OPIUM ADDICTION. byS J. B. MATTISON, M:b„ Brooklyn, N. Y. CLINICAL NOTES ON OPIUM ADDICTION. Ay J. B. MATTISON, M.D., Brooklyn, N. Y. A Paper read before the Kings County Medical Society, January i6th, 1883. CINCINNATI. THE CINCINNATI LANCET PRESS PRINT. 1883. CLINICAL NOTES ON OPIUM ADDICTION. By J. B. Mattison, M.D., Brooklyn^ That the continued use of opium, in any form, from whatever cause, will, in time, beget a well marked functional disorder, is a fact which no properly informed physician can fail to accept; and that this disorder, under ordinary professional regime, is one difficult, and often impossible, to treat with success, is another fact which any one who has had experience in this direction, will, very likely, not dispute. Under special supervision, however, this diffi- culty disappears, and, granting cases suitable for treatment, the disease proves promptly and easily curable, as the following notes will tend to attest. A. B.; physician; set 27; length of addiction one year ; amount 5 grs. morphia, hypodermically, daily; cause, experimental medication—for details see Med. and Surg. Reporter, January 20, 1883 ; effects, generally deterioration, mind and body. Treatment begun and the morphia with- drawn in five days, with so little discomfort that, on the evening of the fifth day, after taking his final dose of of a grain, patient attended and enjoyed a theatrical performance. Moderate restlessness within twenty-four hours. Thirty hours after abandonment, was suddenly seized with a severe attack of frontal neuralgia, which was met by an injection of £ gr. morphia. Prompt and permanent relief with eight hours sleep resulted. Thirty-six hours later, sharp bout of lumbar pain. One half gr. morphia in- jected in painful part and again complete relief and several hours sleep. No further disturbance. Stomach and bowels quiet. Patient made a rapid recovery, and was dismissed, cured in seventeen days, having been able to sleep unaided each night for a week before leaving. Later tidings.—“My present physical status is in every way satisfactory. I have gained six pounds since leaving, sleep well at night, and have enormous appetite”. C. D.; physician ; aet 47; length of addiction three years; maximum taking, 15 grs. morphia subcutaneously, daily; on admission, 8 grs. per diem ; cause,headache ; effects, debility, anorexia, irritable temper—in fine, decided departure from his normal condition—body and mind. Sedative treatment for seven days, when the morphia was abandoned, the final dose being of a grain. Painless restlessness followed in 14 hours. Thirty hours after abandonment severe attack of neuralgia involving right eye and temple. One grain of morphia injected which gave prompt relief and several hours sleep. Twenty-four hours later, another, but less severe neuralgic attack, which was relieved by a full dose gii fl’d ext. Jamaica dogwood. No further trouble of this kind. Bowels and stomach undis- turbed. Patient complained most of debilty. Strength, sleep, and appetite rapidly returned, and he left for home, recovered, on the 19th day 4 of his treatment, sleep having been free from hypnotic for the previous week. Latest tidings from him.—“I am well. My strength has almost entirely returned, and I enjoy my food better than I have for three years. My feelings are natural and not blunted as they were when I used morphine. I can truthfully say that I am better than I was at any time during the last three years. I feel like a man and not as a slave—thanks to you for the happy results attained.” E. F.; gentleman ; set 27; three years’addiction; maximum taking 30 grs. morphia hypodermically, daily; cause, intercostal neuralgia; effects, debili- ty, emaciation, insomnia, capricious appetite, alvine torpor and partial impotence. Had been under sanitarium treatment for nearly six months, with no other result than reduction of his daily allowance to 6 grains. Sedative treatment was begun the third day after his admission, the morphia reduced at once to 4 grains, and entirely withdrawn in seven days. The results were restlessness and occasion- al attacks of gastric cramp. No disturbance of stomach or bowels. The reflex irritation rapidly subsided, and patient convalesced so speedily that on the evening of the fifth day after abandon- ment, he was able to attend an operatic performance, and was dismissed, cured, on the twenty-first day of his treatment. G. H.; physician ; set. 42; ten years addiction ; daily taking, 18 grs. morphia, hypodermically; cause, peritonitis; effects, bowel torpor—for years no evacuation without enemas; vesical and sexual debility, anorexia, indigestion, hemorrhoids— the hemorrhage sometimes profuse, mental depression, muscular weakness and emaciation ; in general, a wreck-like state of mind and body. On admission, was pallid and weak. Tonic regime, exclusively—strychnine, iron, and digita- lis, with generous diet for ten days. Morphia then reduced to six grains without discomfort. Sedative treatment secured desired effect, and entire opiate withdrawal in eight days. During afternoon of last day’s habituation—the final dose being one-third of a grain—had severe headache, of limited duration, relieved by hot sitz bath and cold to the head. Moderate restlessness followed, subsiding in 48 hours. No other symptom of note. No vomiting; no diarrhoea. Patient made an astonishingly rapid recovery, and was dismissed, cured, on thirty-first day of his special treatment. 6 Later, per letter, he says: “Do you ask ‘does the old enemy ever assert power, and tempt me to the hypodermic?’ Most gladly can I answer, no. There is not the least physical desire for morphia!” Still further testimony to his radical recovery is his present active pursuit of his calling. The therapeutics of these cases included bromide of sodium, hot baths, electricity—both galvanic and faradic current, atropia, strychnia, hyoscyamia, quinia, chloral, coca, cannabis indica, Jamaica dogwood, varied tonics, full feeding, and cheerful surroundings. To note these in detail requires some prelimin- ary reference to the morbid condition they are > intended to relieve. The symptomatology of opium abandonment, in our opinion, relates to an exalted activity of the spinal cord manifested in varied reflex irritations. To this are attribut- able the aches, pains, vomiting, purging, collapse and horrible discomfort, in general, which follow entire and abrupt withdrawal of a long accustom- ed opiate. If this be correct, it is also correct to assert that any drug able to control this over- action must prove potent for good in treatment. Such we have in bromides. Their power to subdue reflex irritation is known to all, and in no disorder is this more happily proven than in the one to which we refer. A special and original application of this power is what we term preliminary sedation, which consists in the giving of the bromide for a time prior to entire opiate withdrawal—mean- while gradually reducing the accustomed narcotic —so that at the time of maximum spinal irritation we have maximum bromide sedation, and the one counteracts and controls the other. We use, exclusively, bromide of sodium. It has two leading advantages. Saving bromide of lithium, it contains the largest proportion of bromine, which is the active factor, and it is less unpleasant than any other, never, in our experi- ence, causing gastric trouble. Minor points in its favor are, lessened tendency to digestive and muscular impairment, and cutaneous irritation. We use it in full doses—60 grains, increased to ioo orjj20&'—in eight ounces of water, twice, daily, at twelve hour intervals, and continue it from five to ten days, or even longer—average time 8 one week—the extent of its giving, both amount and duration, depending entirely on the peculari- ties of each case, before and during treatment. Hot baths, no0 to II2°, are the most efficient agent at command to relieve and remove the peculiar restlessness which is an invariable sequel of opiate abandonment. They are given often as required, ten to twenty minutes duration. Their efficacy is sometimes enhanced by a short douche or shower. Electricity is used as a tonic and sedative. The galvanic current we often employ from the outset, and, after abandonment, find it useful as a general restorative and remover of local pains. For the muscular debility following withdrawal, nothing, in our experience, equals general faradi- zation—io to 20 minute seances daily. The sense of exhilirating comfort resulting is often very decided. Occasionally it is used twice, daily, and, very exceptionally, it is not at all acceptable. Atropia is used in initial doses of gr., hypo- dermically ter did—or its equivalent by the mouth—and pushed until it produces systemic effects—dry throat and disturbed vision. This has never required a dose exceeding of a grain. Strychnia is given in subcutaneous doses of of a gr., thrice daily, and continued, in some form, throughout treatment. Hyoscyamia, in our experience, has proven itself the nearest approach to morphia of any alkaloid yet presented. We use Merck’s amorphous, in the dose of £ gr. hypodermically, and have knowm it, repeatedly, to produce steady sleep of several hours’ duration. Quinia is used for a two-fold purpose—tonic and sedative. As the former, in two grain doses, three or four times daily, throughout treatment. As a sedative, in 20 gr. doses, given a few hours in advance of the restlessness following withdraw- al, and repeated at 12 or 24 hour intervals, as required. Thermometric observation proves its power to control the rise in temperature noted after opiate abandonment. Subsequently, it is sometimes given as a soporific, and its efficacy, in this respect is, to us, beyond dispute. During the first three or four days after opiate discontinuance, chloral fails of its usual effect and we never employ it. We have not noted the excitement, stated by Levenstein, but, simply, that it does not induce sleep. Subsequently, as a hypnotic, it answers every purpose, and is given—usually combined with a bromide or hyos: cyomus—as long as may be required. We use Squibb’s make, in decided doses, our experience being that a single full dose is preferable to one small and frequently repeated. When unaccept- able to the stomach it is often kindly received, per rectum, same dose as by mouth, in an ounce or half ounce of warm mucilage. Coc«*a, though far from being what some theoretical enthusiasts have claimed, is a stimulant of value and as such fills a place in treatment. We use Squibb’s extract, in half ounce doses, frequently repeated after the opiate withdrawal. Cannabis indica, in some respects, is an efficient substitute for opium. It relieves pain and brings sleep, though often causing a mild, harmless intoxication. After a trial of various prepara- 9 tions, foreign and domestic, we prefer the fluid extract made by Squibb. It must be given in large doses, the ordinary dose of the books being of no avail whatever. Jamaica dogwood is a somewhat uncertain ano- dyne and soporific, yet worthy of trial to relieve the neuralgic sequelae of opium addiction. We give it in full 3 ii doses. , Varied tonics include iron, arsenic, digitalis and cod liver oil. The first two if anemic. Digitalis after the sedative treatment, as a tonic and also diuretic, to eliminate the bromine. Cod liver oil is a particularly valuable roborant, possessed of special nutrient properties to repair the wear and tear of prolonged narcotic addiction. We prefer Molkr’s plain oil and Phillips’ emulsion. During the first two days of opium abstinence, patients are best restricted to a diet of milk and lime water, in small amounts, often repeated. After that full feeding is allowed and encouraged to the largest extent consistent with gastric com- fort. Cheerful surroundings are a valued adjunct in treatment. No restraint is imposed upon patients, and they are permitted to indulge in walks, rides, drives and amusements freely as possible. The practice of subjecting them to a rigorous search on admission, and regarding them as prisoners under strict surveillance during the period of active treatment, we do not approve. No one of a fine nature can rest under this constant sus- picion without a sense of resentment, which can- not be other than prejudicial to the cordial re- lation which should ever exist between physician and patient. We ask for and extend confidence, and believe we largely enhance a good result by so doing. Nor do we share in the opinion, largely held, that no reliance is to be placed on the word of opium habitues. While admitting that the greatest liar we ever knew belonged to this class, his admission affords no support whatever to the assertion that they all are liars. That the habit- ual use of opium, in many cases, does exert a baneful influence on the moral nature we are fully aware, but we also know that in the ranks of these unfortunates are those who would scorn to deceive, and whose statements are as worthy of credence as those upon whom has not fallen this blieht. Under the plan of treatment we pursue, the temptation to secret taking is small. Patients are allowed a sufficient amount of the accustomed opiate during the sedative regime to obviate any great discomfort. Besides, we have at command, infallible means for determining clandestine in- dulgence, both before and after the opiate with- drawal. Two pre-requisiles are essential—freedom from organic disease, and an earnest desire of the pa- tient to recover. Granting these, excess of tak- ing—time Or quantity—offers no bar to success. Before closing, we cannot refrain from inviting attention to this method of treatment as com- pared with that of peremptory abandonment or prolonged decrease, offering as it does, a more or less happy medium between these two ex- tremes. If our statement as to its merit be true —and we challenge proof to the contrary—then we make bold to assert that no physician is war- ranted, save under circumstances peculiar and beyond control, in subjecting his patient to the torturing ordeal of abrupt withdrawal. We are well aware that it has the sanction of men other- wise eminent in the profession ; but, we venture to suggest, with no lack of respect to these gentlemen that, like a somewhat famous nautical individual, “they mean well; but they don’t know. Theory is one thing—practice another, and we are quite certain, were they compelled to undergo the trial, there would be a rapid and radical change of opinion. We regard it as cruel, barbarous —utterly unworthy a healing art. Gradual decrease has its advocates, and some- times its advantages. It is the plan pursued by the charlatans, who find in the peculiar, secretive characters of this disorder a fertile field. It is a mistake to assert, as does Howe, that “tapering off will not effect a cure.” It often succeeds, but, oftener fails, unless under close and con- stant professional observation. Its great disad- vantage is, that prolonged decrease tries the pa- tience to such an extent that it is sooner or later abandoned, patient lacking both time and incli- nation for its continuance. Should any physician, having a personal or other interest in the topic to which this paper re- fers, be desirous of the name and address of the cases here cited, we are privileged to place them at his service.— The Proceedings.