Discussion upon the Opium Habit. Reprinted from The R. I. Medical Science Monthly, September, 1893. Compliments of HERMAN CANEIELD, M. 1) Hopeworth Sanitarium, Bristol, R. I. R. I. Medical S cience Monthly, A Mont lily Review of Reform and Progress IN THE MecJicaP 3c'ence<^* THE Some of the Most Eminent Medical Scien- tists are found among its Contributors. $ 1 .50 a Year. Published, by the R. I. Medical Publishing Co., 271 Washington St., Providence, R. I. SOCIETY REPORTS. RHODE ISLAND MEDICAL SOCIETY. QUARTERLY MEETING, HELD IN TILLINGHAST PAR- LORS, PROVIDENCE, R. I., THURSDAY, SEPTEMBER 7, 1893. A PAPER on the *• Prevention of the Drug Habit,” prepared by l>r. Wallace W. Potter, of Spokane, Washington, for many years a member of the society, was read by Dr. George \V. Port er. Discussion by l)r. Horinan Canfield, of Hopeworth Sanitarium, Bristol. Tlie doctor stated that he had been connected with an institution, where, for a number of years, patients liad been treated attiicted with the drug habit. “The paper is certainly an able one, and the advice given by the doctor is certainly very timely; but I cannot agree with one idea set forth, that we are to lay all the blame upon the physician, although the physician is greatly to blame in many cases. “ As the doctor notes in his paper, there has been an increase in the drug habit during the past ten or fifteen years. The increase in this habit began in the more frequent use of the hypodermic syringe. It is a very pretty little tiling. Men and women go into the physician’s office, and they want one of these injections tried. Persons who have once taken the drug in this manner will never take it in any other. The effect of the hypodermic syringe is so immediate, so sure of relief, so satiafactory, that they never will have the patience to wait for the action of the drug taken otherwise. If you will not use it, they will find the means themselves. In the cities, especially, it is a means of getting on a “ morphine jag.” Ladies use it as they do champagne, and men use morphine with their whiskey. I do not think that the opprobrium should all be laid to the profession, although they are partially to blame. I think it is due to the great fascination for the use of the syringe. You may give a person a number of suppositories,telling him how to use them, and also fit him out with a bottle of Majandie’s solution; give him a syringe to go with it, instructing him that if the supposi- tories do not work to use the syringe. The patient will return with all his suppositories intact; the bottle used up and the syringe worn out. ‘‘The use of cocaine, I do not think has become so prevalent in the New England states as in the West. Patients use it to prolong and increase the effect of morphine. Some persons get pretty full on morphine and as its effect begins to pass off, they take cocaine, the effect is thus continued, and they keep it up, alternating mor, phine and cocaine. I think there is one thing that should be borne in mind by the physician no matter what the circumstances, never use the hypodermic method in incurable cases attended by great pain. If you cannot relieve them let them get somebody else, and let them assume the responsibility. As sure as they get one dose, they will surely want another, aud get an appetite for the drug. The physician should disseminate among his patients the great dan- ger of using the hypodermic syringe, telling them what the effect will be. I should make them understand that nobody under God’s heaven can resist it. When they once form the habit, they cannot rid themselves in any way whatsoever. You will then find the num- ber of habitual takers will be reduced. “I would state that no patient who has been using the hypoder- 2 mic syringe ever recovers from that use by biinseif. That is a broad statement. 1 have heard of many cases where the patients said they recovered. I have heard physicians who state the patients re- covered, but I have never seen a single instance of the recovery from tlie use of the hypodermic syringe of the patients by themselves. The patient is powerless to withstand the terrible pain he suffers, and he will resort to its use to alleviate his misery again and again. ** The first thing to do in treating a patient with this habit is to have some competent person with the patient all the time. Do not trust him one minute out of your sight, because the result will be, he will take It ifhe has to steal it from under God’s footstool. You ask him how much he is taking and he will answer 12 or 15 grains. You may make up your mind it is nearer 15 than 12. The first thing you do is to take away the hypodermic syringe and substitute 20 grains of morphia by mouth, if he is taking 10 grains bv syringe. Divide it into three doses, so that he need not suffer, and also give him 20 grains of bromide. This he takes three times a day. The patient will be very comfortable. You keep that up and increase the bromide 20 grains more, and continue to increase the bromide 20 grains daily until the effect is produced, which 1 am going to de- scribe. The object is to so saturate the nervous system witli the drug, both the morphia and the bromide, in order to prepare for the period when you take the morphia away. The patient becomes unsteady in his legs and very drowsy, and sleeps most of his time. In fact until you are satisfied that he is well under its influence, you keep this up until you withdraw the morphia altogether. After he has been under this treatment four or five days, which will vary in different cases, until he is completely saturated and under the effects of the bromide, then it is time to stop the morphia. Com- mence then to give one-quarter of a grain of sparteine three times a day. The heart is the only thing you must watch all this time. 3 There is another drug you can use in the place of sparteine and that is digitalis. I prefer to save the digitalis for an emergency. If you use sparteine you should be very careful and particular to give enough to keep the heart going full and strong. You should go on with the sparteine and increase the dose of bromide until the pa- tient is in a favorable condition. In the meantime he is perfectly happy and contented. Now when you have him in that condition put him to bed. lie won’t object to that, because he is rather dull. You put him to bed and in the evening give him a drachm of canna- bis iudica. Be sure you have a good preparation of the drug. There is no drug so uncertain as cannabis indica. This is your sheet anchor. He may sleep quietly, but the main point is to see that he has no shock. Keep up the cannabis indica, so as to get him to sleeping quietly, which he will do in a few hours. I should have said when you give him the cannabis indica you stop the morphine entirely. Drop it off in one dose. At the same time give your sparteine and reduce the bromide twenty grains each day. In some cases this is not required until after the effects of the cannabis have worn off. As a rule, you had better hold on to the bromide for fear some of the pains may return. In two or three days the patient will have become quite himself. He has no pain and that is the main point the physician is after. You now add to the sparteine 1-25 of a grain of strychnia every four hours, grad- ually lessening the doses until he is thoroughly cured. If at any time there are symptoms of collapse, as there are very likely to be during the twenty-four hours after the complete withdrawal .give 1-60 grs. atropia hypodermically, and surround your patient with hot water bags—dry heat in any form is the best remedy for the collapse and pain of this period, 1-100 grs. of nitro-glycerin also answers well, and as last resort a hypodermic of morphia will set everything all right. After the patient is up he will be subject to periods of in- 4 tense depression, when the temptation to return to the drug will be well nigh unconquerable. A mixture offl.ext.coca 5 i,capsicum m x and nux vomica m x, repeated as often as required will remedy this. Diarrhea* is favorable unless it becomes profuse, when the usual remedies are used, with rectal injection of laudunum as last resort. Vomiting is best relieved by small blister over the stomach, in- tense localized pain is also dissipated hy the blister. After the withdrawal sleep is the most important matter demand- ing your attention. The cannabis indica will answer for a lew days, then resort to paraldehyd, chloralamid, sulphonal, trional, etc. A good meal before retiring or during the night of some easily di- gested food will greatly aid in this matter. Often the coca mixture will answer alone. This treatment in my hands has been very successful and as fur as I have noticed without danger.” 5 Dr. Win. «J. McCaw continued the discussion, in which he ad- vocated some legislative action lor the stopping of advertisements of so-called cure-alls. It is fair to suppose, and it is so considered, that these preparations do contain those drugs, which ure deleteri- ous. If it is necessary that a patient should have the drugs,the pre- scribing and administering of them should be in the hands of the physician. It is not right to leave it iu the hands of every person. And after the drug has been prescribed and the patient desires the prescription re-filled, the physician should determine that fact and the druggist should not re-lill it. Dr. McCaw related a case of the drug habit that he had treated successfully, and at the end of 25 days the patient was well. Dr. •!. Frederick Haller, iu discussing the paper, said that much credit was due Dr. Canfield in particular, for having delighted 6 the society with a discussion that was both practical and revealed much original work. He would assert, that while some authors had used some of the remedies mentioned by Dr. Canfield spora- dically for the cure of the opium habit,no one had,to his knowledge, used them in the same systematic manner Dr. Canfield had. The only question about using so much bromide might be, the produc- tion of bromism. Opium had been used as far back as the earliest history and Islam asserts that the Hindoos had used it for centuries. In the last decenniums America and England have learned to use it from the Chinese. England brings into China over seven million kgrm. of the drug annually. Foremost among American writers on this subject is Alf. Galkins, of Philadelphia, who published “ Opium and the Opium Appetite,” in 1871. The first sensation upon taking opium is a feeling of warmth and happiness, all sensations are pleasant, imagination is heightened, all sorrows disappear, every- thing both past and present appears in the brightest light, all desires seem easy to satisfy and no obstacles obstruct the progress.—(Tide- man, Freiher v. Bibra, Alf. Calkins.) Later, comes a feeling of lassitude and inability to act, disturbed sleep, bodily pain, loss of appetite, indigestion, loss of flesh; the facial expression is blank, the face pale, or grey as ashes and pinched; the eyes lie deep in their sockets, glassy and expression- less; the mental faculties become dulled and the desire to meet other people is gone; inability to work or think is common. Some- times the mental faculties and the physical strength are momenta- rily abnormally brilliant and increased. The central nervous system, however, suffers the most from the use of opium or morphine, and after that the spine. Both are at first stimulated, but later, more or less paralyzed (Bernatzik <6 Vogl). Bushheim states, that the higher the individual stand* in mental development, the more Revere and rapid the eflects, and the lower the individual stand* mentally, the slower and less noticeable are the eflects. Myosin follows usually from changes in the brain (Rump/). The respiration always becomes slow, from the paral- yzing effect of the drug upon its centres, and death from opium or morphine is usually looked upon as coming from this source.— (Witkowsky). The circulatory apparatus is more or less distuihed, partly from its influence on the nerves, partly on the muscle*. The depression or lassitude following large doses probably comes from lessened blood pressure. The congestion of various organs particularly of the head, roseola and other skin diseases, are very likely attributable to this.—( PreisendArfer). The constipation present is due to disturbances of the splanchnic nerves, says Xothnagel. Probably also to disturbances of the sensory intestinal nerves and by lessening secretion and the stopping of peristalsis. The secretions are usually diminished; the bronchial mucous membrane is dry, as is the mouth ami nasal cavities. The secretion of bile and gall, as well as milk (in women), is also diminished (Rutherford). In the brain the secretions are diminished; sugar and albumen is found there in abundance.— (Kckhard). Osmosis and ejrosmosis is also interfered with, owing to inability of nerves and muscles to act. Marme, Polstorf and Schutsenberger claim that the drug is changed in the system into oxydimorjihine or orymorjthine and as such, and in form of other alkaloids, it is partly eliminated and partly accumulated in the system. The treatment of the opium habit as indicated by Dr. Canfield is certainly original ami admirable; it may, however, not be amiss to 7 8 speak of the “cures” established for the opium habit, etc. by Keeley and others. Aside from being a clever and bold way to make money out of these unfortunate people addicted to this habit, these “cures” amount to nothing. During last summer I had excellent opportunities to study the modus operundi at these so-called “ cures,” dictated partly by curiosity and partly by scientific interest for anything that can help us over ‘ a rough stone in our road.’ They begin treatment with hypodermic injections four t. daily of a fluid which the G/temisches-technisches Repertorium, of Berlin, 1893, has analyzed and found to be : 0.75 grm. bi-chloride of gold. 0.4 grm. chloride of ammonia. 0.065 grm. strychnine. 30.00 grm. fl. extr. of coca (in tonic only.) 30.00 grm. glycerine. 30.00 grm. distilled water. Some “ cures ” use atropine in addition to the above. After a while, apo-morphine is mixed with the hypodermic injec- tion (the green liquid), in smaller or full doses to nauseate patient and make him vomit (the spiritus or drug). The physician in charge must be clever to give the apo-morphine injection either immediately before or after a drink or dose, preferably before. The tonic (generally called “ dope ”), contains the same medicine as the injection, and is, besides, made up of fl. extract of coca in full doses (and a tablespoonful of coca between times is given when patient craves opium;. The principal ingredients in the “dope” are, however, fl. extract cascara sagrada, enough to keep just short of diarrhoea, with tr. of rhubarb U. S. P.; also tr. of gentian and cinchona, U. S. P. Tr. of gentian and cinchona are given in one-half teaspoonful doses every two hours. If patient is extremely nervous, 10 grains of assafcetida are given three to four times daily, and if absolutely necessary, bromide and quinine; bromide is not otherwise used. For weak heart, digitalis is used. As a matter ot course, appetite and strength increase under this treatment, and the patients are kept on a most substantial diet. The craving for the drug becomes less as the system is toned up, particularly the nervous system, with strychnim ammonia and assafietida directly, and through corrected digestion anil a nourishing diet indirectly. Four to six weeks are generally considered long enough for a cure. The patient so treated can, however, as has been demonstrated repeatedly, begin the use of the drug again if he so desires, or if he is induced to do so, and there is nothing in the treatment to hinder him or to render him free from its alluring temptations. There is great danger, however, in those afflicted with heart disease, disease of the blood vessels or of serious disturbances in the central or special nervous centres from sudden death, either by rupturing a blood vessel (usually in the brain), while vomiting, or from the over dose of atropine, etc. 9 Or. T. I*. Bancroft, superintendent of the hospital at Concord, New Hampshire, being present, was invited by the President to make a few remarks. “It is by accident that I happen to be with you to-day. I was in Providence, and one of your members very kindly iuvited me to your meeting. I did not expect to hear a paper upon this subject, and I have been very much intersted in this discussion, because my practice in Concord has brought a number of cases to my notice. As has been said, when the hypodermic syringe was first used, it was used principally by the physician. At that time tlie influence of the physician was more than now. Now everybody knows about the hypodermic needle, and everyone knows where to get morphine, and how to use it, and in a large 10 measure it becomes a habit, but nevertheless, I think that a physi- cian has a distinct duty to the public to perform. It has been said here, it should never be given in chronic and painful disorders. I do not see how we can help it. The patient has hut little time to live and I think it would he cruel to withhold it. The people who more frequently develop the habit are those with a neurotic temper- ament, and I think we should be very careful about ever using or giving it to them. «• I was interested, too, in regard to the treatment, and what has been said to-day, because in Concord, New Hampshire, we have had two of the recent “ cures ” established. I have had an oppor- tunity to see the cases which have come from these institutions,and it has led me to feel that we, as physicians, ought to know about the treatment. I hardly think their treatment is a cure. Except so far as the persons so treated have a strong will power to do better, they may have an influence in controlling that habit, but I see no other cure whatever. “ In regard to the use of this drug you are all familiar. The tak- ing of opium has become very prevalent, particularly the habit of smoking. That of course is in large cities, and particularly where the Chinese dwell. On the Pacific coast opium smoking is very preva- lent. The Chinese habit is extending to the American people, largely among women, and even to people who ought to know better. It is a very dangerous and insiduous habit. I have had a very peculiar case, but it happens to be the only one that I have ever seen. A young woman who began the habit of smoking and gave it up from lack of funds and was using the ‘liquid of the ashes of opium’ which had been smoked once. There is a name for it and she informed me that it was a prevalent habit among the Chinese who cannot afford to get the drug. They take the ashes and put so much ashes in a bottle, shake it up and drink the contents. It is a 11 vile mixture, but yet, she said she got sufficient effects of opium lrom that mixture to produce the characteristic ettects of the drug. In her case we succeeded in getting full control. But in six months’ time, after she left us, I was sent to see her in Boston. I found her in a miserable condition, thoroughly back to her old condition. The effect of the opium habit on the mind is getting to be recog- nized as a very peculiar condition. You know that there isastrange condition of the mind following the alcohol habit. We have now a condition of the mind following the opium habit. The person gets suspicious, and is given to falsifying. He has no regard for the truth. PersonB who were known for their veracity and truth are given to exaggerate, and state what they do and what they have ac- complished in life, not to accomplish any specified purpose, but simply for the sake of telling large stories. I have a man whose chronic case will never be any better. His mind Is undoubtedly damaged in that peculiar way. L think the medico-legal aspect will assume more prominence, because the habit is becoming very ex- tended thoroughout tbe country. I have been very much interested in your proceedings, and thank you very much for giving me an opportunity to speak on this im- portant subject. Dr. C. II. Leonard inquired how they were to discriminate be- tween persons coining to their offices and asking for the syringe, which was duly replied to hy Dr. Canfield. Dr. Noyes, the President, suggested that opium habitues will very quickly find an excuse for asking for this particular drug or suggest that that might be just what would relieve them. Ten years have been spent in developing a system whereby the withdrawal of narcotic drugs can be accomplished with a minimum of pain and shock to the unfortunate patient, who, in the majority of cases, through no fault of his own is bound hand and foot, unable to free him- self from an enslaving habit without assistance. This is now continually accomplished at Hope- worth, where the patient is surrounded with all the comforts of home and has the constant attendance of merciful and sympathetic physicians and nurses, who, while steadfast in their purpose, regard the habitue not as a criminal or one deserving pain, but the unfortunate victim of a burden of misery such as is experienced in no other form of human suffering. Absolute privacy can be maintained if the patient so desires. Hkrman CANFIELD, M. D., Wm C. Canfield, M. I)., Physicians in Charge.