Morphinism and its Treatment

Kai Tiaki : the journal of the nurses of New Zealand, Volume XVII, Issue 4, 1 October 1924, Page 169

Morphinism and its Treatment

The following article, by Harry Campbell, M.D., F.R.C.P., Physician to the West End Hospital for Diseases of the Nervous System, which appeared m a recent number of the "Medical Press/ is quoted almost m full: — Most opiate addicts possess the neurotic temperament. They are curiously elated and exhilarated by their first experience of an opiate, and being weak-willed and unstable, they develop the opiate habit with fatal facility. Such patients are correspondingly difficult to cure. The more stable type of addict generally acquires the habit through having been given the drug for the relief of inveterate pain, and not, as may be the case with the unstable type, from the example of others. The four chief derivatives of opium are morphine, heroine, dionine, and codeine. The latter two are far less powerful than the former, and the taking of them never develops into a drug habit. Dionine is about twice as powerful as codeine. The confirmed opiate addict is generally sallow and emaciated, restless, irritable, depressed, weak-willed, and untruthful. Acidosis and constipation are common. Pruritis is often complained of. In spite of the stringent laws regulating the sale of narcotics, the opiate addict manages, by hook or by crook, to get all of the coveted drug he wants. His imperative craving allows nothing to stand between him and its satisfaction. One feels that such persistent effort as these patients display, if employed m the service of some legitimate pursuit, might carry a person of quite ordinary ability a long way. The modern addict introduces his drug — morphine or heroine — hypodermically. The prick of the needle becomes associated m the patient's mind with the pleasant relief which speedily follows upon it, so that he comes actually to crave for the prick as well as for the effect of the drug. Not only does he crave for the "feel" of the needle, but he is able to recognise the feel of the injected morph-

ine, and he can tell at once if the injection is devoid of the drug. It is more difficult for him to detect its absence if strychnine has been added to the solution, but this drug sometimes gives rise to painful swellings at the site of the injection. It is because the patient craves for the feel of the needle, and the rapid relief associated with it, that he does not take kindly to the oral method of administration when this is resorted to during the treatment 'by gradual withdrawal. Symptoms on Sudden Withdrawal of Drug. When the opiate is suddenly withdrawn the patient experiences symptoms such as the following, and somewhat m the order given : A feeling of apprehension, yawning, sneezing, running of the eyes and nose, cold sweats, nausea, vomiting, purging, tremors, twitchings, and shooting pains, especially m the legs. He sinks into the lowest depth of misery and may actually collapse and die. (It is noteworthy that pronounced physical symptoms do not occur m chronic cocaine poisoning.) These symptoms increase m severity from 36 hours to five days, the average length being from two to three days. Thereafter they gradually subside, though it may be some days before the periodic outbursts of craving and the distressing pains disappear; while to the end of life the chance administration of the drug tends to revive the craving m all its pristine intensity. It is comparatively rare to effect more than a temporary cure. Methods of Treatment. It is useless to attempt to cure the opiate addict unless he is genuinely anxious to be cured. His genuine co-operation is essential to success. To put a patient under lock and key for a term against his will simply means that he will revert to his habit directly he is released. It is needless to emphasise the importance of the personality and experience on the part of the doctor and, m institutional cases, the nurse m the treatment of these cases,

not only because the skilful handling of them can only come with experience, but also because the opiate addict is hypercritical — quick to take the measure of doctor and nurse — and he soon loses confidence m them if he detects the slightest sign of inexperience. Infinite tact, a fund of common sense, and enthusiasm is necessary. The patient must be made to feel lie has friend and stand-by m those who are helping him through the difficult ordeal confronting him. He must have perfect confidence m them. Treatment consists m withdrawing the drug either gradually or abruptly. Abrupt withdrawal necessitates the confinement of the patient m a home or institution of some kind. Treatment m the patient's own home is rarely advisable. Confinement is also desirable m the case of most of the patients treated by the era dual method. Only those of the more stable type, whose general health is fairly good, and who are not associating with other opiate addicts, are suitable for ambulatory treatment. When this method is adopted the patient is not to be given a prescription for his narcotic. It 'is to be administered by the doctor himself on the occasions of the patient's visits, and the precise quantity which the patient is to take should be doled out to him at each visit. It is rarely necessary to conceal the amount from the patient. The knowledge of the progress he is making m the direction of diminution tends to stimulate him to fresh endeavour. It is of little use attempting the treatment of opiate addicts belonging to the highly neurotic, irresponsible, degenerate, borderland class, or such as have grown grey m the vice. "Whether a gradual or a rapid withdrawal of the narcotic is decided upon, the patient should be put through a preliminary course of treatment with the two-fold object of improving his general condition — which is often desperately bad — and the reduction of the daily dose of narcotic to the minimum quantity consistent with moderate comfort, for it has to be remembered that the patient generally takes an amount considerably m excess of this.

Preliminary Treatment. By means of suitable deiting, the relief of acidosis and constipation, the employment of massage and hot baths, the administration of tonics (notably strychnine), bromides, mixed glands, and the like, and by regulating the times at which the narcotic is given, it may be possible not only to effect a considerable improvement m health, but speedily to reduce the habitual daily amount of narcotic to onehalf, if not to one-third, without the occurrence of serious withdrawal symptoms. Any local disease, especially such as is likely to cause pain — for example, bad teeth, or sinus disease — should be treated before the process of complete withdrawal is begun, inasmuch as pains are apt to be lighted up m weak spots when the narcotic is withheld, and this may necessitate a return to it at a critical period of the treatment. Gradual Withdrawal. After the preliminary treatment just outlined has been carried out, gradual withdrawal may be begun. The treatment consists m fortifying the patients' general health and treating symptoms as they arise, while steadily reducing the daily dose of the accustomed narcotic and substituting for it an equivalent of dionine or codeine. After a time an attempt is cautiously made to substitute the oral for the hypodermic method of medication, gradually increasing the proportion of the dose thus given by mouth. It is not possible to say beforehand how rapidly the reduction can be effected. It sometimes happens that a patient who has been taking large daily doses can be reduced more rapidly than one who has been taking quite moderate doses. The greatest difficulty is experienced over the reduction of the last daily grain. Even when the patient has for some days been taking only a fraction of a grain each day he may dread the further reduction of this small amount. If dionine or codeine is added to the injection mixture m gradually increasing doses, while the morphine (or heroine) is being decreased, by the time the latter is omitted altogether patient will not be able to detect its absence by the "feel" of the needle.

When the hypodermic method is entirely abandoned for the oral method, it may be advisable temporarily to increase the daily allowance of narcotic. It is better to give the daily quantity m a few doses administered at long intervals, rather than m small doses at short intervals. One should be reserved for the night to promote sleep, and one for the morning — the time above all others when the patient craves for the drug; without it he may be incapable of getting up. Acidosis and constipation are best combated by bi-carbonate of soda (3|-31) and cascara. Strychnine is a useful tonic. Bromides help to quiet nervousness. For the relief of the distressing pains mygrone ?s useful. One of the most troublesome symptoms calling for treatment is sleeplessness. Among the most effective hynoiics are dial ciba, mcdinal, veronal, sulphonal, luminal sodium, paraldehyde, chloral and chloretone, to be given m certain prescribed doses. Rapid Withdrawal. This method necessitates confinement. In the milder cases rapid withdrawal may be effected without recourse to hyoscine. We will suppose the daily allowance of the drug to have been reduced to one grain of morphine. The patient is given a warm bath at bedtime, followed by a brisk laxative and the usual dose of morphine. A saline purge is administered m the morning, and half -an-h our later 20 grains of sodium bromide with 15 grains of sulphonal. No further morphine is given.

Directly urgent withdrawal symptoms appear the patient is immersed m a hot bath and a bag of ice applied to the head, or he may be given a hot pack, followed after sloAvly cooling down by salt masage. This treatment is repeated, if necessary, several times during the 24 hours, the patient being encouraged meanwhile to drink as much hot water as possible, and to take an abundance of nutritious food. Bromides and hypnotics are administered according to circumstances. Unsteadiness of the heart may be relieved by hyperdermic injections of digitalis. This active treatment is continued for 48-60 hours, but hypnotics and bromides need to be given some days longer as well as drugs for the relief of leg pains. The craving for the customary narcotic may be relieved by the administration of dionine and codeine, preferably the former. If these drugs alone are ineffective, a small dose of heroine may be given m addition. Another method of rapid withdrawal is carried out with the help of hyoscine, and consists m the production of mild hyoscine delirium (twilight sleep) for 36--48 hours, and the administration of piloearpine to promote elimination. Mild hyoscine intoxication may continue for some days after the last dose of the drug. During this time there is no craving, but withdrawal pains are apt to supervene and the patient needs to be kept under treatment for some time longer. Bromide of sodium may be needful to allay nervousness, hypnotics to promote sleep, and mygrone to relieve the painful limbs. — "The Nursing Mirror."