Much of what has been said with regard to alcoholism finds ready application to the treatment of drug addictions. At the very beginning it must be realized that there is no specific remedy that will enable the patient to overcome his craving for a drag to which he has become habituated. There is no method of treatment that will infallibly and without serious and prolonged and determined effort on his part enable him to overcome his craving. The first and most important thing in any system of treatment is the patient's good will. If the patient is not ready to give up the drug, then nothing that a physician can do for him will make him do so, or will turn him against it; above all, nothing will make the process of cure so easy that there will be no trouble involved or only a passing period of struggle required to accomplish it. There have been many claims made in this matter. We have wanted such remedies and methods of treatment so much that it has been rather easy to persuade us sometimes that they have been discovered. It is like the question of specifics in medicine. For centuries men devoted themselves to trying to find a specific remedy for each disease. It was thought they must exist in nature. Now we know that they probably do not exist, though those who claim to discover them find an easy livelihood exploiting the credulity of those who still cherish the belief in them. Scientific students of medicine have practically given over the search for them in order to devote themselves to strengthen the patient to resist the disease rather than spend more time trying to find something to give him that cures it.

Treating the Patient rather than the Habit.—This principle holds with special force with regard to drug addictions. We do not treat the patient's habit, but we treat the patient. He must be braced up, must be made to understand that if he wants to quit the habit, no matter how slavishly he is addicted to it, he can do so. He must be told of men who had habits like his, often of longer duration and to a greater degree, yet gave them up when firmly resolved and properly stimulated. It is not hard to find such examples, since medical and even ordinary literature abound with them and every physician's experience furnishes him with instances. The first and {708} most absolutely necessary preliminary of the treatment is to lift up the patient in his own eyes and make him understand that, low as he has sunk, his case is not hopeless, that his degradation is not at all uncommon nor so rare as he might think, and that men and women have succeeded in lifting themselves out of conditions worse than his. The psychotherapeutist must, above all, not be of those who insist that human nature is degenerating and that people are much weaker physically and morally than they used to be, though of course he must be thoroughly aware that drug habits are more frequent than they were and are quite alarmingly on the increase. This is not due to any deterioration in human nature, however, but mainly to the excitement of modern life and its inevitable reaction, the strenuousness with which men now take existence and the consequent craving for artificial relief from over-activity, and then, above all, the facility with which the habit-forming drugs can be obtained.

Prophylaxis.—This last point accounts for the frequency of drug habits in our time more than anything else. Men have always been ready to do something for the sake of novelty and excitement. Everyone is curious to experience for himself the effects produced by drugs that can make people such slaves to them. We hear too often of the intense pleasure that the drug habituÉ gets from his use of drugs. The curiosity thus aroused constitutes the suggestion that has led many to try the effect, confident that he or she would be able to resist any craving just before it became seriously tyrannous. Psychiatrists agree that one of the worst elements in modern social conditions is the impression generally maintained that there is such intense pleasure in the taking of drugs. A clear statement of the reality of the case is eminently desirable. It is not positive pleasure that the drug habituÉ has, but mere negative pleasure, as a rule. His "dope" does not so much add to his good feeling as take away the bad feelings that he has because of depression or ennui at the beginning and later because of the craving for the drug.

Physicians to whom many drug habituÉs have told their experience frankly are not at all inclined to think that the usually accepted opinion of pleasure in drug taking is true. It is not that it is heaven to have the drug so much as it is hell to be without it. The patient's system has learned to crave it so much because of the surcease of painful consciousness of self it gives and this it is that compels these unfortunates to go back to ever-increasing doses. The pleasant side is a very dubious affair at all times, accompanies only the earliest steps of the formation of the habit at most, and usually whatever agreeable feelings there are are accompanied by such a nightmare of solicitude and anxiety as a background that the pleasure is more poignant than agreeable. As a prophylactic against the formation of drug habits this aspect of the experience of drug habituÉs deserves to be emphasized and knowledge of it widely diffused. Of course, the morphin fiend brightens up after his dose of morphin, his eye lightens, his expression becomes happy, and his nerves get steadier, but that is only because the depression in which he was sunk before has now been stimulated away, the struggle with his worst feelings is over and the consequent reaction has developed. Of course, the cocain-taker is pitiably helpless and downcast without his "dope," but it is only by contrast with this previous state that his succeeding condition can be said to be pleasant or agreeable, even to himself.{709}

Favorable Suggestion.—One of the most helpful sources of favorable suggestion for these patients is to be found in the stories of cured drug habituÉs. These may be used tactfully to bring confidence to patients that they, too, can be broken of their habit if they are willing to take the pains to do so. De Quincey, taking his thousand drops of laudanum a day, represents one of the most encouraging examples of this since he succeeded eventually in breaking away from his habit. Coleridge succeeded, also, in breaking his habit more than once, but unfortunately returned again and again, and illustrates the danger of the almost inevitable tendency to relapse, if the patient permits himself to think that now that he has once conquered the habit he is too strong ever to let it get hold of him again. If he ventures to think complacently of his self-control and that consequently he may with impunity—always for some good reason—take a dose or two of his favorite drug in order to tide him over some crisis of mental worry or some spell of physical pain, relapse is certain. The tendency of patients to fool themselves in this way is too well known to need special emphasis, but it is as well to say that there is scarcely a single cured case that does not relapse. The relapse is due not so much to craving for the drug, as to the memory of its previous effects in relieving discomfort and the unfortunate confidence that the patient has developed that now, knowing the dangers, he will be able to resist the formation of the habit before it gets a strong hold of him.

It is curious how even highly intelligent patients will slip back into their old habits, sometimes deeper than before, on this reasoning, in spite of the lessons of experience, even their own as well as others. Like the drunkard, they persuade themselves that just this once will not count, and when it would have been comparatively easy for them to say no they yield once or twice and make self-denial for the future increasingly difficult. This is especially true if patients have the drug near them, so that it is not difficult for them to have recourse to it. Hence doctors and nurses are not hard to cure of such habits, as a rule, provided they are away from their professional duties, but they almost inevitably relapse when they go back to work. Every time the relapse is due to the fact that tired feelings, because of irregular hours or some physical pain, prompt them to seek relief and they yield to the temptation of taking the old drug, sure that they need it, only for the moment. They will all assert that they could just as well resist as not, that, indeed, had not the drug been so handy, they would not have taken it, and that if anyone had been near to help them by a word in the matter even then they would not have indulged in it.

If patients are to be kept from relapsing, all this must be set before them frankly. After they have been told once or perhaps twice or perhaps many times and yet relapse into their habits, they must simply be told it again a little more emphatically, more encouragingly, up to seventy times seven, if necessary. Patience is needed more than anything else in taking care of these cases. Over and over again their confidence in their power to overcome their habit, if they really wish to do so, must be reawakened. Without this confidence in themselves success is hopeless. It matters not how often they have relapsed, they can still break off the habit, and if they will not fool themselves into over-confidence in their power to keep away, they need never be slaves to the habit again. There will be quite as many disappointments in {710} treating drug addiction as in the treatment of alcoholism. Those who have most experience insist that there are even more, but there are some wonderfully encouraging examples of men and women who have broken from their habit, even after a number of bad relapses, and have for many years lived absolutely without any of their drug and, though still not over-confident in their power to resist if once they should yield (such confidence, it cannot be repeated too often, is always fatal), do actually keep away from the drug without any other bother than the necessity of living a regular hygienic life and exercising a little self-control.

In drug addictions as in alcoholisms, the question of sanitarium treatment comes up in every case. Much more rarely than in the case of the alcohol habit is it necessary to send a drug habituÉ to a sanitarium. Here once more, however, the patient's circumstances and the possibility of diversion of mind with reasonable freedom from temptations to take the drug and from ready access to it, are the most important considerations. If a patient really wants to break off the use of a drug, it can be done gently and without much bother in the course of three or four weeks. I have seen cocain fiends who have tried many remedies and many physicians completely cured in five or six weeks without serious trouble. The important thing is perseverance in the effort and in the treatment and the definite persuasion of the patient that it is not only perfectly possible to get rid of the habit, but that it is even easy with good will on his part. If certain other milder stimulants are supplied for a time so that all the symptoms due to the physiological effects of the excessive use of the drug are minimized, the physical trial need not be severe. The patient's mind, however, must be occupied. Time must not be allowed to hang heavy on his hands and all physical symptoms must be treated promptly. Drug addictions are indeed more curable than alcoholism and the danger of relapse is not quite so imminent. The social temptations do not exist for drug habituÉs as they do for alcoholics. As I have said, however, in the cases of nurses and physicians almost a corresponding state of affairs obtains and in them the danger of relapse is great.

Early Treatment.—It is quite as important for drug victims as it is for alcoholics that the case should be taken under treatment early. Every physician knows how curiously easy it is for some people, indeed for most people, to acquire a drug habit. I have seen one of the solidest men I ever knew, with plenty of character that had been tried by many a crisis in life, recommended cocain for a toothache when he was past fifty years of age and in the course of ten days acquire a thorough beginning of the cocain habit, so that he was taking several grains a day. He had no idea that he was unconsciously slipping into a drug habit. When the druggist refused any longer to supply the cocain solution without a prescription he was quite indignant. It was not until he had forty-eight hours of nervous symptoms and craving that he realized that he had created a need for stimulation of his nervous system by the mere taking of cocain by application on his gums. This habit was broken up at once and there has never been any tendency to its recurrence. He had his warning, fortunately, without evil effects.

If the cocain habit can be formed as unconsciously as this, there should be little difficulty in treating it. It is not a profound change in the organism, but only a habit. It is not the habit itself that is hard to break, but the effects {711} upon the nervous system of the patient are such as to create a series of symptoms that can only be soothed by the drug. It is these symptoms of depression, irritation, sleeplessness, lack of appetite, constipation and the rest that it is the physician's duty to treat in order to help the patient. The patient breaks the habit by his will-power when properly persuaded and when it is made clear to him that it is neither so difficult as he thought, nor is he so likely to fail in the matter as he has imagined, and as has perhaps been suggested to him even by physicians. The mental treatment consists in making him realize that he can do it and that if he wants to get rid of his habit he must do it for himself. With this must come the assurance that every annoying symptom will be met, that he need not recur to his favorite drug for this purpose, that his appetite will be gradually restored and that, though perhaps for a week he will have considerable inconvenience to bear, after that it will be plain sailing. Usually three days can be set as the term at which his craving ceases to be so disturbing as to make the possibility of his relapsing into the habit a positive danger. As in alcoholic and sex habits, the patient to be helped in breaking the habit should be seen once a day at least, usually oftener. If he can be made to understand that whenever the old tendency seems about to get the upper hand is the time to see his physician, and if something physical as well as moral is done for him, the breaking of the habit is comparatively simple.

This method of treatment looks too simple to be quite credible to those who have so often tried and failed in the cure of drug habits. It is not the doctor, however, who fails, but the patient. We cannot put new wills into a patient, but we can so brace up even an old and tottering will as to make it possible for the worst victims of drug habits to reform. The doctor, too, easily becomes discouraged. He has not confidence enough in his own methods to make assurance doubly sure for the patient as to his cure. This is what many of the pretended specific purveyors of drug habit cures have as their principal stock in trade. They assure patients with absolute confidence, while the physician only too often says the same thing, but half-heartedly. A half-hearted physician makes a hesitant patient, and success is then very dubious from the beginning. Every patient can be cured. They may relapse, but then they can be cured again. This is the essence of the psychotherapy of drug habits, but it is also the only successful element in any treatment of the drug habit that is really effective. Specifics come and go. Sure cures cease to have their effect. The only really effective element in any cure is the absolute trust of the patient.

In his "Drugs and the Drug Habit" (Methuen, London) Dr. Harrington Sainsbury, Senior Physician to the Royal Free Hospital of London, has emphasized all these points that can only be touched on very briefly here. He has called particular attention to the fact that the victim of one drug habit is rather prone to acquire another if by any chance he should once begin to take another habit-forming drug. The original drug habit has broken down the will. It is not so much the craving for a particular drug as the lack of will power that proves unfortunate for the patient. He suggests "incidentally, if this explanation hold good, it proves the solidarity of the will that it works as a whole and not by compartments." He has dwelt on recoveries from the most discouraging depths and insists "we must teach that {712} no one is ever so enslaved by a habit as to be incapable of relief—this alone is right teaching, justifiable moreover by records well substantiated of recoveries from desperate plights."

Heredity and Unfavorable Suggestion.—As to the suggestion, sometimes encountered, of the influence of heredity and its all-powerful effect in making it practically impossible for the son of a man who has taken drugs to keep from doing the same thing, we must recall very emphatically here the principles discussed elsewhere. So far as concerns heredity, opium and the other drugs are exactly in the same position as alcohol in their effect upon the human race. Instead of being justified in saying that by heredity individuals of succeeding generations are rendered more susceptible to them, just the opposite is true and, if anything, an immunity is produced. This is not only racial and general but is personal and actual. In recent years we have come to realize that individuals born of tuberculous parents who care for themselves properly are much better able to resist the invasion of the tubercle bacilli than those who come from stocks that were never affected by the disease. They are the patients who, in spite of the fact that their disease reaches an advanced stage, sometimes live on for years with proper care. Just this is true for drug addictions so far as we know anything about it. The whole subject is as yet obscure, but heredity rather favors than hurts the patient in these cases.

Hereditary Resistance.—Instead of being discouraged by the fact that his father took a drug to excess and that therefore he is weaker against this than other people, a man should rather be encouraged by the thought that a certain amount of resistance to the craving has probably been acquired by the particular line of cells through which his personality is manifested. Dr. Archdall Reid has said that "the facts concerning opium are very similar" (to those that concern alcohol). Then he continues:

That narcotic has been used extensively in India for several centuries. It was introduced by the English into China about two centuries ago. Quite recently the Chinese have taken it to Burma, to various Polynesian Islands, and to Australia. There is no evidence that the use of opium has caused any race to deteriorate. Indeed it happens that the finest races in India are most addicted to its use. According to the evidence given before the late Royal Commission on Opium, the natives of India never or very rarely take it to excess. When first introduced into China it was the cause of a large mortality; but to-day most Chinamen, especially in the littoral provinces, take it in great moderation. On the other hand. Burmans, Polynesians and Australian natives take opium in such excess and perish of it in such numbers that their European governors are obliged to forbid the drug to them, though the use of it is permitted to foreign immigrants to their countries. In exactly the same way alcohol is forbidden to Australians and Red Indians in places where it is permitted to white men.

After-Cures.—I have said so much about the after-cure of alcoholism that applies directly to drug addictions also, that it does not seem necessary to repeat it here. Patients must be warned that if they become overtired, if they lose sleep, if they are subject to much excitement, if they put themselves in conditions of anxiety and worry, if any form of recurrent pain develops—headache, toothache, stomach-ache—they are likely to be tempted to take up their old habit. If they are in a position where they can easily get the drug it is almost inevitable that something will happen to make them feel that {713} they are justified in taking one or two doses and from this to the reestablishment of the habit is only a small step. Often these patients need a change of occupation. Some of them are over-occupied, some of them have not enough to do. In either case it is the doctor's duty to know enough about his patient to be able to give directions. We do not treat a drug addiction with the hope of curing it, but we treat a patient suffering from a particular drug habit and we try so to modify that patient's life that after we have succeeded in getting him away from his habit, which is never difficult, he will not relapse into it. The after-cure is the more important of the two.