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The Treatment of Drug Addiction
The Treatment of Drug Addiction l\iARIE NYSWANDER, M.D.*
treatment of drug addiction has in recent years become a subject for profound professional controversy. Our knowledge of the physiology, psychodynamics and pharmacodynamics of addiction has· been greatly increased during the past three decades, but this scientific advance has had little effect on the actual treatment of addicts. The rules and regulations governing treatment stem from the medical thinking of the early 1920's when addiction was considered to be an evil and deteriorating illness. Reasons for the lag between present scientific knowledge and its practical application may lie in events long past: the divorcement of physicians and general hospitals from the ambulatory and hospital treatment of addicts, and the ensuing development of an ethical problem revolving around the maintenance of addicts on drugs. Although the New York Academy of Medicine's comprehensive reportt implies that it is neither immoral nor unethical for a physician to maintain addicts on drugs, the medical profession as a whole has not yet settled this primary question on which hinge research and community planning, as well as treatment of the illness. It is therefore not surprising that many physicians are apathetic about this medical entity or, even if interested, prefer not to treat cases of addiction. Among the questions commonly heard are: "My hands are tied, what can I do?" ... "How far can I go in helping such patients without jeopardizing my professional standing?" ... "Can an addict be trusted to follow through any treatment regimen?" A physician who accepts drug addicts as patients will soon note that they exhibit a wide variation in attitudes towards their illness from time to time. He may have a patient who feigns such illnesses as acute cholecystitis, coronary thrombosis, or nephritis in an effort to obtain r-rHE
* Senior Supervising Psychiatrist, New York Postgraduate Center for Psychotherapy; Medical Director, Narcotic Addiction Research Project; Consultant, New York City Department of Health. t Report on Addiction, The New York Academy of Medicine, Committee on Public Health, Subcommittee on Drug Addiction. Bull. New York Acad. Med. 31: 592-607, 1955. 815
816
M arie N yswander
drugs; or he may discover that his office or car has been rifled for the same purpose. Another addict may appear at the office \vith severe withdrawal symptoms and openly ask for relief, or he may say he is undergoing a self-imposed cure and needs only a little help in the form of morphine or methadone. The doctor will recognize that the employment of countless ruses are part of the addict's personality structure. But one of these same addicts may within a few years become truly discontented with his way of life and again consult the physician, this time seriously seeking a cure. He mayor may not succeed with professional help. But, at all events, the discontent shared by all addicts is a strong force acting in the physician's favor. It is therefore vitally important that a physician be able to assess correctly the addict's various attitudes toward his illness, so that he ,viII know when and ho,v to concentrate his efforts in treatment. The purpese of this discussion is to suggest what the physician can do, considering the diagnosis, legal restrictions, and the addict's usually limited financial resources. COPING WITH PATIENT'S DECEIT
The physician should be suspicious of any patient who is able to get to the office unaided yet complains of such severe pain that ambulation would appear to be impossible. 1~his suspicion is usually confirmed when the patient refuses to accept hospitalization or any non-narcotic prescription. It must be emphasized that the addict is a past-master at applying pressure and appealing to the physician's humanitarian impulse to relieve pain. The presence of tell-tale vein markings may well clinch the diagnosis. It is understandable that a physician resentful of spending time and effort on a patient who feigns illness should seriously consider ordering him out of his office. But a sympathetic attitude at this juncture may lay the groundworl( for a cure. A doctor working with addicts has had patients return up to four years after their initial visit, with a sincere desire to undertake a cure. Lying, \vhich is part and parcel of the addicts sociological problem, should not be taken by the physician as a personal affront. When addicts hold this attitude toward their illness, the physician can only wait until they are ready to seek-thus able to accept-his help. An addict who openly requests drugs is equally trying. It is unlikely that the physician can motivate any sudden change in a desperate person whose request he must refuse. The doctor feels both helpless and resentful, and in such situations is tempted to take out his frustration by turning harshly on the addict. But here again, a kindly approach and expression of regret at being
The Treatment of Dr1lg Addiction
817
unable to comply with the addict's request may lead to an opportunity to suggest a return visit if and when the patient wants help in withdrawal. In this way, a constructive plan is proffered as an alternative to his present dilemma. WITHDRAWAL TREATMENT
Contrary to current opinion, my experience indicates that withdrawal treatment must be individualized for each patient.! A prime consideration is whether to conduct ,vithdrawal at the patient's home, in a general hospital, in the Public Health Service Hospital at Lexington, I{entucky, or in a private, psychoanalytically oriented mental hospital. Home Treatment
Treatment at home is, of course, the least expensive and least timeconsuming. Success of this method depends on the patient's motivation, and to a large extent, on the constant attendance of reliable person, or member of the family, throughout the withdrawal period. This attendant must expect anguished pleas, threats and bribes when the addict's discomfort becomes acute, and must be strong enough to withhold any drugs not prescribed by the physician. U.S.P.H.S. Hospital
The D.S. Public Health Service Hospital at Lexington is available, upon request, for the withdrawal and rehabilitation of the addict. This treatment is available regardless of cost. Since the treatment regimen includes a four-month rehabilitation period, an employed addict would have to give up his job. The prison atmosphere and regulations deter most middle-class patients from applying for admission. Private Sanitoria
Private p~ychoanalytically oriented hospitals may involve a stay of many months and a good deal of expense. A daily session with a psychoanalyst and the privilege of leaving the grounds during the day give the addict an optimal psychiatric environment and are among the advantages of this type of institution. Patient's Self-Evaluation
The patient's wishes must, of course, be taken into consideration. If he says, "Doc, all I need is to get off the drugs. I tried it at home and it didn't work. Can you send me some place?" chances are that he knows what is right for him. At any rate, this is the kind of help he is motivated to receive. On the other hand, a patient may say, "Something is wrong. I'm not satisfied with my life and I'm scared of people. I don't think my main
818
M arie N yswander
problem is drugs," chances are that he is right too. Under psychoanalytically oriented therapY, 2 within a comparatively short time he may resolve to go off drugs and carry out his purpose without jeopardizing either his job or his therapy. To hospitalize such a person, thus removing him from the impact of daily encounters, may tend to reinforce his already strong tendency to retreat from life situations. Withdrawal of drugs in these cases may be accomplished at home after psychotherapy has been instituted. Medically Addicted Addicts
It is not uncommon to find addiction among persons treated with narcotic drugs over a long period of time for relief of such chronic conditions as colitis, chronic pancreatitis, migraine headache and neurodermatitis. This group, frequently made up of middle-class patients, includes a large number of physicians and nurses. In the past they have undergone voluntary hospitalization numerous times; an exacerbation of their illness has usually occurred during each attempted withdrawal. Many attending physicians, concluding that withdrawal is impossible, have therefore recommended continued addiction. Incidentally, it is interesting to note that these patients who receive drugs legally continue to be relatively useful and law-abiding citizens. The chronically ill not only can be withdrawn from drugs but feel immeasurably better for it. To prepare this type of patient, it is necessary that he-and the physician as well-realize that both the body and the Unconscious will put up a struggle. Certainly, when the going is rough, the chronic illness will be used as a "good" reason for remaining on drugs. But the patient who has been warned that this inevitable conflict may result in an exaggerated outbreak of his physical illness during withdrawal will not be unduly alarmed when it occurs. And the physician, similarly prepared, will not meet the emergency by restoring narcotics. Usually there is only one such attack, subsiding perhaps within 24 hours. Contraindications to Withdrawal Treatment
Cardiac conditions, acute infectious diseases, or necessary surgery take precedence over withdrawal procedures. In these cases, the patient should be stabilized on a comfortable dosage of the narcotic he has been taking, while the medical condition is treated. Usually morphine 8 to 16 mg. (7-8 to ~ grain) or its equivalent four times a day will keep most addicts in drug balance during the time necessary for treatment. s For cardiac patients, the withdrawal period should be extended. Whereas ten days suffice for the average uncomplicated withdrawal, cardiac cases require approximately one month.
The Treatnzent of Drug Addiction
819
Methods of Drug Withdrawal
The three methods of drug withdrawal are: (1) Abrupt withdrawal of all narcotics, known as "cold turkey"; (2) abrupt withdrawal with substitution of a drug such as apomorphine or insulin; and (3) gradual withdrawal with use of morphine or methadone as a substitute drug. 1. Abrupt Withdrawal. "Cold turkey" is generally considered to be inhumane and, particularly in older people, it may give rise to serious complications such as pneumonia or acute cardiac disturbances where none were known to exist previously. This form of treatment still obtains today in prisons, except for a few modern ones. However, the physician may have requests for this method-from addicts well motivated toward withdrawal, from addicts to whom this is an oft-repeated experience, and from patients currently in psychotherapy. In each case their expressed wish is to "get it over quicker." The method depends essentially on "bolstering" the patient by checking daily on his progress, manifesting constant interest and encouragement. These patients are usually withdrawn from drugs at home, and, if employed, they can return to their jobs after taking a few days' sick leave. The family member or friend who is put in charge should preferably be agreed on by both patient and physician. The three should then discuss together the treatment routine. An adequate amount of barbiturates must be provided to insure sleep at night. Hot tub baths several times daily will reduce the muscular pains to a minimum, after which the patient may be able to take fluid or solid nourishment. It must be emphasized that even the best-intentioned patient may attempt to conceal several doses of narcotics at home. He should be urged to turn over all drugs and syringes to the person in charge. The physician may allow him limited amounts between the forty-eighth and seventy-second hours after institution of treatment, for relief of severe symptoms. For an employed addict, the withdrawal regimen is usually started on a rrhursday evening, when he stops taking drugs. His symptoms on the following day will not prevent his working, but by the weekend he is very likely to have major withdrawal symptoms including nausea, vomiting, diarrhea and muscular cramps. Although he may still feel weak on Monday and Tuesday, the worst will be over. A moderately addicted person should be able to return to work toward the end of this week or, at the latest, by the following Monday. In some instances hospitalization may be needed to complete the "cold turkey" method of withdrawal. Recently I treated a patient who had gradually reduced his daily drug intake to ~ teaspoonful of tincture of opium. Since he was unable to effect a complete withdrawal, he
820
M arie N YS1Dandcr
requested hospitalization over a weekend. During this short stay when he could not obtain any narcotic, he was able to free himself of the drug habit completely. 2. Abrupt Withdrawal with Substitute 'llherapy. Some physicians believe the success of \vithdrawal treatment depends greatly on use of such drugs as ACTH, hyoscine, apomorphine, insulin and calcium gluconate, and on such procedures as prolonged narcosis or electroshock. In Great Britain, physicians have a high regard for apomorphine in drug withdrawal. The new tranquilizing drugs have also been suggested as an effective means of reducing the discomfort of withdrawal symptoms. 4 In the substitute therapy method, narcotics are abruptly cut off and supportive treatment with one of the aforementioned drugs is immediately instituted. Extensive experimentation at the Public Health Service Hospital at Lexington has thus far shown that none of these drugs provides consistently predictable results in reducing withdrawal discomfort. In fact, symptoms seem to be aggravated by many of these drugs rather than relieved. s It has been my experience that a number of addicts have been helped by chlorpromazine and meprobamate. The chief advantage of these drugs is that they induce a semisomnambulant state during the painful days of withdrawal. 3. Gradual Withdrawal with Use of 1J([ orphine or Methadone. Either morphine or methadone can be substituted during withdrawal of a patient who has been taking any narcotic of equal or greater strength. It would, of course, be unwise to substitute these drugs in withdrawing a person habituated to a less addicting drug such as codeine or Demero!. This method consists in giving the addict either morphine or methadone and slowly reducing the dosage until he is entirely off drugs. The maximum initial dose for any addict is either 1() mg. (74:' grain) of morphine or 10 mg. of methadone four times daily. In morphine withdrawal, dosages are reduced to 8 mg. (% grain) of morphine and then G5 mg. (1 grain) of codeine is substituted. '"fhe number of daily dosages is then reduced to two and eventually terminated. In methadone withdrawal, the patient is kept on 5 to 10 mg. of methadone four times daily for several days. rrhe shots are progressively reduced during the next few days and then stopped altogether. The major difference between withdrawal results of the t\VO drugs is that morphine produces severe withdrawal symptoms within 24 to 72 hours, whereas methadone produces milder symptoms which occur four to seven days after the drug has been discontinued entirely. However, methadone may leave a patient with a considerbale state of weakness extending for as long as a month after all drugs have been discontinued. ])etails of this treatment may be found in references 1 and 6.
The Treatment of Drug Addiction
821
Necessity for a Strict Routine
A strict routine, both at home and in a hospital, is the basis of all methods presented for treating addicts during the various stages of withdrawal. In home treatment, the routine (worked out with the patient) includes hot tub baths, administration of tranquilizers if indicated, eating and taking fluids, the physician's phone call (or visit when possible), administration of sleeping pills, and a definite time for "lights out." The physician must impress upon all concerned that this routine is essential to success, and that one of the purposes of his daily phone call is to check on its enforcement. A definite routine serves to allay the patient's anxiety, and its very completeness tends to assure him that the physician has found the plan "workable." It follows that, by adhering strictly to the routine, the desired result will be achieved. PSYCHIATRIC TREATMENT
A variety of personality types are found in addicts to drugs; there is no single type of "addict personality." The very presence of addiction presupposes the creation ofa new biological need; thus similar attitudes towards drugs, as well as similar emotional reactions, are common to all addicts. Many persons are quite able to handle the problem of addiction without insight into their psychic make-up. Considering the fact that few addicts are solvent, and that psychiatric treatment is relatively difficult to obtain, it must be assumed that the majority of addicts who have gone off drugs have done so without benefit of psychiatry. Yet the process might have been greatly facilitated with such therapy, and the physician should certainly suggest it. Addicts who complain of certain deeply disturbing problems other than their drug habit have, without exception, proved amenable to psychotherapy.2 Preliminary findings seem to indicate that male addicts show considerably more progress when treated by male therapists. The reason undoubtedly lies in the average addict's peculiarly close relationship to his mother, and the actual or relative absence of the father in the family constellation. 7 All medically addicted persons should receive psychotherapy to help resolve their problems regarding pain. It is necessary for them to understand the emotional uses and the importance that pain and sickness have assumed in their lives. Pain and associated panic usher in the need for narcotics. Psychotherapy dramatically reduces the frequency and intensity of the painful attacks associated with their illness; removing the necessity for strong analgesics. SUMMARY
1"'reatment plans have been presented "\\Thich cover practical problems arising in cases of narcotic addiction. A flexible individualized approach
M arie N yswander
822
to each patient has been recommended, and detailed suggestions given for gaining the addict's trust and cooperation from the initial interview through to the period of withdravval treatment. Methods of withdrawal have been discussed. It has been suggested that there is a Jag between the treatment methods of addiction and current scientific knowledge of the illness. This disparity is felt to be due to the historical removal of the drug addict from the physician and the general hospitals. Suggestion is made for clarification by the medical profession as to ,vhether or not the maintenance of addicts on drugs is contraindicated either medically or ethically. REFERENCES 1. Nyswander, M.: The Drug Addict as a Patient. New York, Gl'une & Stratton, 1956. 2. N yswander, M. et al.: The Treatment of Drug Addicts as Voluntary Outpatients. J. Orthopsychiat. To be published. 3. Wikler, A.: Drug Addiction. In Tice's Practice of Medicine. Hagerstown, Md., W. F. Prior Co., 1953. 4. Friedgood, C. E. and Ripstein, C. B.: Use of Chlorpromazine in the Withdrawal of Addicting Drugs. New England J. Med. 252: 230-233, 1955. 5. Maurer, D. W. and VogeI, V. H.: Narcotics and Narcotic Addiction, Springfield, Ill., C. C Thomas, 1954. 6. Nyswander, M.: Withdrawal Treatment of Drug Addiction. New England J. Med. 242: 128-130, 1950. 7. Chein, I. and Rosenfeld, E.: Juvenile Narcotic Use. Law and Conteluporary Problems 22: (1): 52-68, 1957.
1045 Park Avenue New York 28, N. Y.
treatment of drug addiction has in recent years become a subject for profound professional controversy. Our knowledge of the physiology, psychodynamics and pharmacodynamics of addiction has· been greatly increased during the past three decades, but this scientific advance has had little effect on the actual treatment of addicts. The rules and regulations governing treatment stem from the medical thinking of the early 1920's when addiction was considered to be an evil and deteriorating illness. Reasons for the lag between present scientific knowledge and its practical application may lie in events long past: the divorcement of physicians and general hospitals from the ambulatory and hospital treatment of addicts, and the ensuing development of an ethical problem revolving around the maintenance of addicts on drugs. Although the New York Academy of Medicine's comprehensive reportt implies that it is neither immoral nor unethical for a physician to maintain addicts on drugs, the medical profession as a whole has not yet settled this primary question on which hinge research and community planning, as well as treatment of the illness. It is therefore not surprising that many physicians are apathetic about this medical entity or, even if interested, prefer not to treat cases of addiction. Among the questions commonly heard are: "My hands are tied, what can I do?" ... "How far can I go in helping such patients without jeopardizing my professional standing?" ... "Can an addict be trusted to follow through any treatment regimen?" A physician who accepts drug addicts as patients will soon note that they exhibit a wide variation in attitudes towards their illness from time to time. He may have a patient who feigns such illnesses as acute cholecystitis, coronary thrombosis, or nephritis in an effort to obtain r-rHE
* Senior Supervising Psychiatrist, New York Postgraduate Center for Psychotherapy; Medical Director, Narcotic Addiction Research Project; Consultant, New York City Department of Health. t Report on Addiction, The New York Academy of Medicine, Committee on Public Health, Subcommittee on Drug Addiction. Bull. New York Acad. Med. 31: 592-607, 1955. 815
816
M arie N yswander
drugs; or he may discover that his office or car has been rifled for the same purpose. Another addict may appear at the office \vith severe withdrawal symptoms and openly ask for relief, or he may say he is undergoing a self-imposed cure and needs only a little help in the form of morphine or methadone. The doctor will recognize that the employment of countless ruses are part of the addict's personality structure. But one of these same addicts may within a few years become truly discontented with his way of life and again consult the physician, this time seriously seeking a cure. He mayor may not succeed with professional help. But, at all events, the discontent shared by all addicts is a strong force acting in the physician's favor. It is therefore vitally important that a physician be able to assess correctly the addict's various attitudes toward his illness, so that he ,viII know when and ho,v to concentrate his efforts in treatment. The purpese of this discussion is to suggest what the physician can do, considering the diagnosis, legal restrictions, and the addict's usually limited financial resources. COPING WITH PATIENT'S DECEIT
The physician should be suspicious of any patient who is able to get to the office unaided yet complains of such severe pain that ambulation would appear to be impossible. 1~his suspicion is usually confirmed when the patient refuses to accept hospitalization or any non-narcotic prescription. It must be emphasized that the addict is a past-master at applying pressure and appealing to the physician's humanitarian impulse to relieve pain. The presence of tell-tale vein markings may well clinch the diagnosis. It is understandable that a physician resentful of spending time and effort on a patient who feigns illness should seriously consider ordering him out of his office. But a sympathetic attitude at this juncture may lay the groundworl( for a cure. A doctor working with addicts has had patients return up to four years after their initial visit, with a sincere desire to undertake a cure. Lying, \vhich is part and parcel of the addicts sociological problem, should not be taken by the physician as a personal affront. When addicts hold this attitude toward their illness, the physician can only wait until they are ready to seek-thus able to accept-his help. An addict who openly requests drugs is equally trying. It is unlikely that the physician can motivate any sudden change in a desperate person whose request he must refuse. The doctor feels both helpless and resentful, and in such situations is tempted to take out his frustration by turning harshly on the addict. But here again, a kindly approach and expression of regret at being
The Treatment of Dr1lg Addiction
817
unable to comply with the addict's request may lead to an opportunity to suggest a return visit if and when the patient wants help in withdrawal. In this way, a constructive plan is proffered as an alternative to his present dilemma. WITHDRAWAL TREATMENT
Contrary to current opinion, my experience indicates that withdrawal treatment must be individualized for each patient.! A prime consideration is whether to conduct ,vithdrawal at the patient's home, in a general hospital, in the Public Health Service Hospital at Lexington, I{entucky, or in a private, psychoanalytically oriented mental hospital. Home Treatment
Treatment at home is, of course, the least expensive and least timeconsuming. Success of this method depends on the patient's motivation, and to a large extent, on the constant attendance of reliable person, or member of the family, throughout the withdrawal period. This attendant must expect anguished pleas, threats and bribes when the addict's discomfort becomes acute, and must be strong enough to withhold any drugs not prescribed by the physician. U.S.P.H.S. Hospital
The D.S. Public Health Service Hospital at Lexington is available, upon request, for the withdrawal and rehabilitation of the addict. This treatment is available regardless of cost. Since the treatment regimen includes a four-month rehabilitation period, an employed addict would have to give up his job. The prison atmosphere and regulations deter most middle-class patients from applying for admission. Private Sanitoria
Private p~ychoanalytically oriented hospitals may involve a stay of many months and a good deal of expense. A daily session with a psychoanalyst and the privilege of leaving the grounds during the day give the addict an optimal psychiatric environment and are among the advantages of this type of institution. Patient's Self-Evaluation
The patient's wishes must, of course, be taken into consideration. If he says, "Doc, all I need is to get off the drugs. I tried it at home and it didn't work. Can you send me some place?" chances are that he knows what is right for him. At any rate, this is the kind of help he is motivated to receive. On the other hand, a patient may say, "Something is wrong. I'm not satisfied with my life and I'm scared of people. I don't think my main
818
M arie N yswander
problem is drugs," chances are that he is right too. Under psychoanalytically oriented therapY, 2 within a comparatively short time he may resolve to go off drugs and carry out his purpose without jeopardizing either his job or his therapy. To hospitalize such a person, thus removing him from the impact of daily encounters, may tend to reinforce his already strong tendency to retreat from life situations. Withdrawal of drugs in these cases may be accomplished at home after psychotherapy has been instituted. Medically Addicted Addicts
It is not uncommon to find addiction among persons treated with narcotic drugs over a long period of time for relief of such chronic conditions as colitis, chronic pancreatitis, migraine headache and neurodermatitis. This group, frequently made up of middle-class patients, includes a large number of physicians and nurses. In the past they have undergone voluntary hospitalization numerous times; an exacerbation of their illness has usually occurred during each attempted withdrawal. Many attending physicians, concluding that withdrawal is impossible, have therefore recommended continued addiction. Incidentally, it is interesting to note that these patients who receive drugs legally continue to be relatively useful and law-abiding citizens. The chronically ill not only can be withdrawn from drugs but feel immeasurably better for it. To prepare this type of patient, it is necessary that he-and the physician as well-realize that both the body and the Unconscious will put up a struggle. Certainly, when the going is rough, the chronic illness will be used as a "good" reason for remaining on drugs. But the patient who has been warned that this inevitable conflict may result in an exaggerated outbreak of his physical illness during withdrawal will not be unduly alarmed when it occurs. And the physician, similarly prepared, will not meet the emergency by restoring narcotics. Usually there is only one such attack, subsiding perhaps within 24 hours. Contraindications to Withdrawal Treatment
Cardiac conditions, acute infectious diseases, or necessary surgery take precedence over withdrawal procedures. In these cases, the patient should be stabilized on a comfortable dosage of the narcotic he has been taking, while the medical condition is treated. Usually morphine 8 to 16 mg. (7-8 to ~ grain) or its equivalent four times a day will keep most addicts in drug balance during the time necessary for treatment. s For cardiac patients, the withdrawal period should be extended. Whereas ten days suffice for the average uncomplicated withdrawal, cardiac cases require approximately one month.
The Treatnzent of Drug Addiction
819
Methods of Drug Withdrawal
The three methods of drug withdrawal are: (1) Abrupt withdrawal of all narcotics, known as "cold turkey"; (2) abrupt withdrawal with substitution of a drug such as apomorphine or insulin; and (3) gradual withdrawal with use of morphine or methadone as a substitute drug. 1. Abrupt Withdrawal. "Cold turkey" is generally considered to be inhumane and, particularly in older people, it may give rise to serious complications such as pneumonia or acute cardiac disturbances where none were known to exist previously. This form of treatment still obtains today in prisons, except for a few modern ones. However, the physician may have requests for this method-from addicts well motivated toward withdrawal, from addicts to whom this is an oft-repeated experience, and from patients currently in psychotherapy. In each case their expressed wish is to "get it over quicker." The method depends essentially on "bolstering" the patient by checking daily on his progress, manifesting constant interest and encouragement. These patients are usually withdrawn from drugs at home, and, if employed, they can return to their jobs after taking a few days' sick leave. The family member or friend who is put in charge should preferably be agreed on by both patient and physician. The three should then discuss together the treatment routine. An adequate amount of barbiturates must be provided to insure sleep at night. Hot tub baths several times daily will reduce the muscular pains to a minimum, after which the patient may be able to take fluid or solid nourishment. It must be emphasized that even the best-intentioned patient may attempt to conceal several doses of narcotics at home. He should be urged to turn over all drugs and syringes to the person in charge. The physician may allow him limited amounts between the forty-eighth and seventy-second hours after institution of treatment, for relief of severe symptoms. For an employed addict, the withdrawal regimen is usually started on a rrhursday evening, when he stops taking drugs. His symptoms on the following day will not prevent his working, but by the weekend he is very likely to have major withdrawal symptoms including nausea, vomiting, diarrhea and muscular cramps. Although he may still feel weak on Monday and Tuesday, the worst will be over. A moderately addicted person should be able to return to work toward the end of this week or, at the latest, by the following Monday. In some instances hospitalization may be needed to complete the "cold turkey" method of withdrawal. Recently I treated a patient who had gradually reduced his daily drug intake to ~ teaspoonful of tincture of opium. Since he was unable to effect a complete withdrawal, he
820
M arie N YS1Dandcr
requested hospitalization over a weekend. During this short stay when he could not obtain any narcotic, he was able to free himself of the drug habit completely. 2. Abrupt Withdrawal with Substitute 'llherapy. Some physicians believe the success of \vithdrawal treatment depends greatly on use of such drugs as ACTH, hyoscine, apomorphine, insulin and calcium gluconate, and on such procedures as prolonged narcosis or electroshock. In Great Britain, physicians have a high regard for apomorphine in drug withdrawal. The new tranquilizing drugs have also been suggested as an effective means of reducing the discomfort of withdrawal symptoms. 4 In the substitute therapy method, narcotics are abruptly cut off and supportive treatment with one of the aforementioned drugs is immediately instituted. Extensive experimentation at the Public Health Service Hospital at Lexington has thus far shown that none of these drugs provides consistently predictable results in reducing withdrawal discomfort. In fact, symptoms seem to be aggravated by many of these drugs rather than relieved. s It has been my experience that a number of addicts have been helped by chlorpromazine and meprobamate. The chief advantage of these drugs is that they induce a semisomnambulant state during the painful days of withdrawal. 3. Gradual Withdrawal with Use of 1J([ orphine or Methadone. Either morphine or methadone can be substituted during withdrawal of a patient who has been taking any narcotic of equal or greater strength. It would, of course, be unwise to substitute these drugs in withdrawing a person habituated to a less addicting drug such as codeine or Demero!. This method consists in giving the addict either morphine or methadone and slowly reducing the dosage until he is entirely off drugs. The maximum initial dose for any addict is either 1() mg. (74:' grain) of morphine or 10 mg. of methadone four times daily. In morphine withdrawal, dosages are reduced to 8 mg. (% grain) of morphine and then G5 mg. (1 grain) of codeine is substituted. '"fhe number of daily dosages is then reduced to two and eventually terminated. In methadone withdrawal, the patient is kept on 5 to 10 mg. of methadone four times daily for several days. rrhe shots are progressively reduced during the next few days and then stopped altogether. The major difference between withdrawal results of the t\VO drugs is that morphine produces severe withdrawal symptoms within 24 to 72 hours, whereas methadone produces milder symptoms which occur four to seven days after the drug has been discontinued entirely. However, methadone may leave a patient with a considerbale state of weakness extending for as long as a month after all drugs have been discontinued. ])etails of this treatment may be found in references 1 and 6.
The Treatment of Drug Addiction
821
Necessity for a Strict Routine
A strict routine, both at home and in a hospital, is the basis of all methods presented for treating addicts during the various stages of withdrawal. In home treatment, the routine (worked out with the patient) includes hot tub baths, administration of tranquilizers if indicated, eating and taking fluids, the physician's phone call (or visit when possible), administration of sleeping pills, and a definite time for "lights out." The physician must impress upon all concerned that this routine is essential to success, and that one of the purposes of his daily phone call is to check on its enforcement. A definite routine serves to allay the patient's anxiety, and its very completeness tends to assure him that the physician has found the plan "workable." It follows that, by adhering strictly to the routine, the desired result will be achieved. PSYCHIATRIC TREATMENT
A variety of personality types are found in addicts to drugs; there is no single type of "addict personality." The very presence of addiction presupposes the creation ofa new biological need; thus similar attitudes towards drugs, as well as similar emotional reactions, are common to all addicts. Many persons are quite able to handle the problem of addiction without insight into their psychic make-up. Considering the fact that few addicts are solvent, and that psychiatric treatment is relatively difficult to obtain, it must be assumed that the majority of addicts who have gone off drugs have done so without benefit of psychiatry. Yet the process might have been greatly facilitated with such therapy, and the physician should certainly suggest it. Addicts who complain of certain deeply disturbing problems other than their drug habit have, without exception, proved amenable to psychotherapy.2 Preliminary findings seem to indicate that male addicts show considerably more progress when treated by male therapists. The reason undoubtedly lies in the average addict's peculiarly close relationship to his mother, and the actual or relative absence of the father in the family constellation. 7 All medically addicted persons should receive psychotherapy to help resolve their problems regarding pain. It is necessary for them to understand the emotional uses and the importance that pain and sickness have assumed in their lives. Pain and associated panic usher in the need for narcotics. Psychotherapy dramatically reduces the frequency and intensity of the painful attacks associated with their illness; removing the necessity for strong analgesics. SUMMARY
1"'reatment plans have been presented "\\Thich cover practical problems arising in cases of narcotic addiction. A flexible individualized approach
M arie N yswander
822
to each patient has been recommended, and detailed suggestions given for gaining the addict's trust and cooperation from the initial interview through to the period of withdravval treatment. Methods of withdrawal have been discussed. It has been suggested that there is a Jag between the treatment methods of addiction and current scientific knowledge of the illness. This disparity is felt to be due to the historical removal of the drug addict from the physician and the general hospitals. Suggestion is made for clarification by the medical profession as to ,vhether or not the maintenance of addicts on drugs is contraindicated either medically or ethically. REFERENCES 1. Nyswander, M.: The Drug Addict as a Patient. New York, Gl'une & Stratton, 1956. 2. N yswander, M. et al.: The Treatment of Drug Addicts as Voluntary Outpatients. J. Orthopsychiat. To be published. 3. Wikler, A.: Drug Addiction. In Tice's Practice of Medicine. Hagerstown, Md., W. F. Prior Co., 1953. 4. Friedgood, C. E. and Ripstein, C. B.: Use of Chlorpromazine in the Withdrawal of Addicting Drugs. New England J. Med. 252: 230-233, 1955. 5. Maurer, D. W. and VogeI, V. H.: Narcotics and Narcotic Addiction, Springfield, Ill., C. C Thomas, 1954. 6. Nyswander, M.: Withdrawal Treatment of Drug Addiction. New England J. Med. 242: 128-130, 1950. 7. Chein, I. and Rosenfeld, E.: Juvenile Narcotic Use. Law and Conteluporary Problems 22: (1): 52-68, 1957.
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