Morphine Habit

Chronic Poisoning Or Morphinism

Opium, and its alkaloid morphine, are vicious habit-drugs, the habit being common among physicians, nurses, and druggists. The drug may be taken by hypodermatic injection, by mouth, or by the inhalation of opium fumes (opium smoking). The last method is said to be the least pernicious. When the devotee does not get his usual dose he is nervous, restless, irritable, and unable to concentrate his mind upon his work; when he gets his drug he experiences a return of his energy, feels comfortable, and is in better spirits. He soon then passes into a dreamy, imaginative state of mental and bodily satisfaction, i. e., wholly indifferent to outside influences, and forgets his responsibilities and his troubles; then comes sleep, usually of a stuporous kind, and on awaking there may be nausea, headache, languor, and nervousness.

The prolonged use frequently results in digestive, nervous, and mental troubles, viz., loss of appetite, nausea, and obstinate constipation; irritability of temper, loss of will-power and self-control, mental depression, and if the habit is a bad one, a tendency to moral depravity (develop low, vulgar tastes, are frightful liars, etc.); irregular heart tremors, anemia and wasting, sometimes an irregular temperature, polyuria, and perhaps albuminuria or glycosuria, and often sexual impotence and amenorrhea. The writer delivered a devotee of fourteen years' standing whose husband had been a habitue for over twenty years. The child was not well-nourished, but thrived on the breast. During her stay in the hospital the mother received her daily dosage. From an experience with 12,000 cases at the Tombs, New York, McGuire and Lichtenstein report a wonderful growth of hair in women habitues.

Treatment

1. Isolation from friends and hirelings.

2. Gradual withdrawal of the drug in from two or three days to a week. Accompanying the withdrawal there may be diarrhea, cramps in abdomen, back, and legs, intense restlessness, mental and physical suffering, and collapse. Valenti has shown that the withdrawal symptoms in dogs are arterial hypotension and arhythmia, and that the serum after withdrawal will produce the same condition in normal dogs. Talmey attributes some of the withdrawal symptoms to acidosis, and reports a case developing coma from this cause. Stokes finds a sympathicotonic state.

3. The substitution for a time of other drugs, of which great favorites are atropine, hyoscine, dionine, and codeine. Keeping the patient in a state of partial narcosis for several days tends to prevent the discomforts which cause the craving for morphine.

4. Nourishing food, to the extent of overfeeding.

5. Massage, baths, and general measures to improve the hygienic conditions of living.

6. Excessive and persistent purgation.

7. Removal of the original cause of the habit, as by operation on an ovary or other source of pain.

In morphinism there is no hereditary neuropathic tendency as there is in alcoholism, and the cause of the continuance of the morphine habit is the distress of the withdrawal symptoms. The morphinist will often desire to give up the drug, but never does so of his own free will, because he cannot stand the physical suffering. Yet morphine patients have a greater desire to reform than alcoholics have, and, when once reformed, are quite likely to remain so, unless the pain or worry, etc., which was the original cause of the habit, recurs. Often they go back to the drug for relief from suffering, rather than because of any special craving for it. Stomach symptoms must be especially guarded against, as they are always attributed to abstinence from the drug.

Without some systematic method of treatment it is one of the most difficult tasks to check a morphine habit, and the habitue will take paregoric, and even Sun Cholera Drops, for the morphine they contain.

The cutting off of the habitual dose because of some intercurrent illness, such as pneumonia, causes needless suffering and danger. Collapse for want of the drug has been reported in infants born of habitues.

The Lambert method, employed at Bellevue Hospital, consists of the administration of a specific remedy, of decreasing doses of the opiate, and of powerful cathartics. It is as follows:

1. The specific consists of a mixture of 15 per cent. tincture of belladonna, 2 parts, with 1 part each of the fluidextracts of xanthoxylum and hyoscyamus. It is administered every hour, beginning with 6 drops and increasing 2 drops per dose every six hours. It is continued until belladonna symptoms are noticed or there is a thick, green stool.

2. The opiate - after the first free catharsis give two-thirds the total habitual daily dose of morphine or opium in 3 divided doses at half-hour intervals. After the action of the second dose of the cathartic (about the eighteenth hour) give one-third the habitual daily dose. About the thirty-sixth hour, give one-sixth the habitual daily amount. If very nervous, give 5 grains (0.3 gm.) of codeine phosphate hypodermatically.

3. The cathartic - at the outset give 5 compound cathartic pills and 5 grains (0.3 gm.) of blue mass, followed in six hours by a saline. At the tenth hour after the first dose of opiate repeat the pills and blue mass, and six hours later the saline. Ten hours later repeat again, followed by the saline if necessary. When a thick, bilious, green stool appears, give 2 ounces of castor oil to clean out the intestines. If the patient is weak, give strychnine or digitalis.

The Stokes method is based on the idea that there is a sympathicotonic state induced by the withdrawal. He gives enough morphine to prevent withdrawal symptoms, and injects a mixture of pilocarpine and physostigmine salts every two or three hours. Petty's method includes large doses of strychnine. It would seem that to obtain a cure as much depends upon the physician in charge as upon any method.

The morphine habitue is prone to be an abominable liar, and five minutes after taking the dose will state emphatically that he has not taken the drug for weeks. Tablet triturates found in the possession of a suspect may be tested as follows: Dissolve one in 0.5 c.c. (8 minims) of water, and add 2 drops of the tincture of ferric chloride: a blue or bluish-green color indicates morphine. Sometimes needle punctures in the arms or legs will confirm the diagnosis, or a state of dopiness with contracted pupils, or a test with a dose of morphine to see if it gives great satisfaction. A peculiar blue coloration of the skin in the region of the needle punctures has been described as "pigment atrophy." The author has seen some striking cases.

Therapeutics

Morphine or opium is used extensively to allay severe pain, and to overcome restlessness and nervousness or anxiety associated with sickness; in other words, to promote ease of mind or body. Some of its more special uses are:

1. To check vomiting.

2. To stop intestinal peristalsis, as after rectal or abdominal operations, and in peritonitis; and to check excessive peristalsis, as in intractable diarrhea, e. g., that of tuberculosis. Paregoric, or the pills of lead acetate and opium, each 1 grain (0.06 gm.), or of camphor and opium, are preferred, but hypodermics of morphine are also effective. In the presence of acute abdominal pain one should avoid opiates if possible until the diagnosis is determined.

3. To quiet a nervous heart, or rest a diseased heart, by promoting general rest and quiet.

4. To lessen pain.

5. To relieve the pain and gastric upset in migrainal vomiting attacks.

6. To relieve the pain and anxiety of angina pectoris.

7. To check cough. It should be avoided in chronic cough because of habit formation.

8. To lessen worry and restlessness in acute conditions, such as hemoptysis, or in incurable diseases, such as cancer.

9. To compel quiet and sleep, as in delirium or mania, or in spite of powerful factors which tend to keep the patient awake, such as pain.

10. As a preliminary to general anesthesia, to quiet the mind and promote the anesthesia. It is frequently given with hyoscine (scopolamine). Its tendency to produce nausea and vomiting, dilatation of the stomach, and depression of the respiration, and its interference with pupil reactions are drawbacks to its use.

11. To induce sweating at the onset of a cold, in the form of Dover's or Tully's powder. It is not a good diaphoretic.

12. In diabetes - opium, morphine, and codeine have a special power to bring about a reduction in the sugar excretion; and von Noorden attributes this to the quiet of the body and the sleep induced by their use. From the author's experience this explanation of the action seems inadequate. Klercker was able to prevent alimentary hyperglycemia following large amounts of glucose, an effect that may be due to retardation in the stomach and consequent retardation of absorption.

13. In acute paroxysmal edema of the lungs it is specific (Stengel), but not in any other form of pulmonary edema.

Contraindications Or Cautions

It should not be used in - (a) Conditions with much depression of the respiration, as in edema of lungs (except the acute paroxysmal type), Cheyne-Stokes breathing, and some cases of pneumonia; (b) acute dilatation (paralysis) of stomach or bowels. It should be employed cautiously in - (a) nephritis, especially if there is any uremic tendency; and (b) infancy and old age. The work of Macht would suggest that a better preparation for general use is narcophin.

Atropine is frequently given with morphine in hypodermatic use. It tends to supplement the good effect on pain and to lessen the nausea; but its most important effects are to counteract the depression of respiration and perhaps the vagus stimulation.

Scopalamine-Morphine Anesthesia

See Belladonna Group.