Sleepless - Opiates And Narcotics
( Originally Published 1914 )
Drugs not a Cure. Insomnia cannot be cured by drugs. It can be cured only through the detection and eradication of its causes, by the utilisation of measures to develop strength, tone and vitality, and by the adoption and maintenance of a sane point of view which means in a great many instances strengthening the will power.
To compel sleep by opiates or sedatives is not to cure sleeplessness. It is idle to attempt to cure insomnia by the taking of drugs whose most striking effect is to produce it. Not only is it bound to fail, but nearly always it leads to the formation of a habit, the continuance of which is subversive of happiness and health and leads the patient into a slough of unhappiness and despondency.
When the brain has been overtaxed by engrossing work or when the nervous system has been shattered by severe shock, exhausted by terrible anxiety or worn by excitement or vigils, a judiciously selected sedative may bring repose to the body and refreshment to the brain and so break the wakeful habit and restore the sufferer's confidence. But this is not a cure of insomnia nor is it a license to take narcotics whenever one is wakeful. The physician who is most earnest in his efforts to overcome insomnia in others is the last person to minimise their value. But no word of warning can be too loud and no protest too emphatic against the general use of narcotics. All such drugs are injurious and health destroying and their repeated continuance and administration is both unscientific and dangerous.
In view of the fact that the truth of this statement is universally admitted, it is difficult to understand how some supposedly intelligent persons are willing to jeopardise their health and happiness by taking drugs on the slightest provocation. The administration of narcotics leaves the cause of the sleeplessness untouched. The system becomes accustomed to the drug and larger and larger doses are required to produce the desired effect. Even when this effect is produced, it is at the expense of impaired digestion, disordered circulation and deterioration of the blood. On the morale of drug-takers the effect is even more disastrous. The victim of insomnia who has had his suffering momentarily assuaged by some sleeping powder, is no longer willing thereafter to bear with equanimity or to tolerate with patience a privation of sleep which previously he bore philosophically. Why lie awake till dawn when the peace of oblivion may be had through the absorption of an allegedly harmless powder made agreeable to taste by the apothecary l Chiefly because each succeeding powder or potion diminishes the resistance and impairs the man-hood of the individual who takes it. We constantly hear it said that modern narcotics such as sulphonal, trional, medinal and veronal are harmless or practically harmless as compared with chloral, opium and their derivatives. This is not true. They are less harmful insofar as they induce habit less quickly, but the habit once formed is quite as pernicious and often more difficult to break. The most obstinate example of drug addiction coming under my observation was one of sulphonal habit. The patient, a young woman of high social position, has so far remained unmoved by the solicitations of her family, the appeals of her fiance and the commands of her physician. She displays a combination of indecision and obstinacy which is not uncommon in narcotic habitues. This, combined with impairment of the moral sense which shows itself chiefly in bearing false witness and making statements at variance with facts, puts her beyond a physician's reach until after she shall have been adjudged an incompetent. Indecision, impairment of memory, blunted moral sensibility in some form and bodily inertia are the customary results of sleep-medicine addiction. Many who point the finger of scorn at the drunkard, wrestling with an imperious and ofttimes inherited appetite, extend sympathy amounting to approbation to those who stultify their manhood by reaching out for the ever-ready tablet or powder that will give them temporary oblivion.
Drugs Other Than Opiates.—The drugs that are of most general use in the treatment of insomnia are chloral and its compounds, bromide, paraldehyde, sulphonal, veronal, trional, medinal, opium and its derivatives. Of these the first and last are the most dangerous.
The sleep that results from narcotics varies in depth and in capacity for refreshment, that is, in its after effects. The drug-induced sleep that most closely approximates the normal is that produced by chloral, or, as it is technically called, chloral hydrate. Next to opium and its derivatives it is the most dangerous of all narcotics. First, because it seriously disorders the heart and, second, because the formation of the chloral habit is very easy. The appetite for chloral demands to be sated as imperiously as the appetite for opium and cocaine. Even in the hands of a physician, the greatest care and discernment are needed and no one thinks of prescribing it without first ascertaining the condition of the heart. When no weakness of that organ exists, it may be taken in ten-grain doses when sleep is absolutely essential. Chloral; combined with other bodies, and derivatives of chloral such as chloralmide, chloralos, etc., have had a wide vogue. Chloralmide is less depressing to the heart and the circulation than chloral, but chloralos is more poisonous than chloral, though it depresses the circulation less.
Examination of the prescription book of any pharmacy will reveal the fact that the salts of bromide, bromide of soda and bromide of potassium are more widely used than any drug in the pharmacopeia. The bromides are sedatives of motion and sensation. They lessen irritability, whether it be of mind or body, and tend to soothe and assuage pain. The penalty that one pays for their use is very great. Taken for any considerable length of time, they destroy initiative, impair vitality, disturb the vegetative functions of the body and produce physical and mental inertia.
The products of the chemical laboratory, popularly spoken of as coal tar distillations of which the drugs cited ending in "al" are types, enjoy a fictitious reputation for being practically harmless. These sleeping tablets are so innocuous looking and their effect is so pleasant and efficient that it is difficult to convince the sufferer from insomnia that danger lurks in their habitual use. But every physician who has had experience in the treatment of so-called nervous diseases can testify that cases of chronic poisoning from one or all of these drugs is frequent and that disturbances of nutrition and serious ill-health often result from their indiscriminate use. I am sure that if it were generally known that such drugs as veronal, trional, medinal and sulphonal had the capacity to cause serious ill-health, which I know from experience they have, those who are tempted to take them just because they fear an hour or two of discomfort while awaiting sleep would think twice before doing so.
The ideal narcotic is one that produces sleep of sufficient duration to refresh under all conditions and without ill effects or disagreeable after effects. It need scarcely be said that there is none. Some narcotics are less harmful than others and among these is paraldehyde. Were it not for its disgusting taste and vile, persistent odour it might have more usefulness than it has. I have never seen paraldehyde taking degenerate into a habit. The aroma of it is such that no one can take it without advertising the fact. In states of apprehension, mental perturbation, anxiety and depression a tea-spoonful or two taken in sugar water is sufficient to produce sleep. There is no narcotic that I recommend to patients with more satisfaction than this, for I am reasonably sure that they will not take it except as a last resort.
Opiates, etc.—By far the most important of the narcotics is opium. Sleeplessness is founded so frequently in pain and discomfort that all that is required is cessation of them and sleep will follow. In the true sense of the term opium is not a narcotic at all. On the contrary, it often produces wakefulness, but by virtue of its unique capacity to assuage pain it is more widely used in combating sleeplessness than all the narcotics combined. For upward of two thousand years surcease of pain has been brought about by opium and its derivatives. Its usefulness to the human race is immeasurable. It is regrettable that one cannot say this without pointing out and emphasising the great danger of its slightest abuse. Probably no one is so ignorant of the capacities of opium as not to realise this. But only the physician and those who are so unfortunate as to have fallen into the bondage of opium can realise how terrible such servitude may be. It is unfortunate for mankind that De Quincey and Coleridge took opium but more unfortunate that they told about it, or let it become known. Not a few even in my own experience have found it easy to convince themselves that their mental faculties would be stimulated and their endurance enhanced by such indulgence. In the same way I have known the cocaine habit to develop in ambitious youths while Dr. Doyle was still administering the drug to Mr. Holmes to whet his sensibilities and to stimulate his capacity to draw logical conclusions. It is doubtful if the working capacity of the human machinery can be enhanced in any way temporarily by narcotic or stimulant, and for each loan that it accepts, or has thrust upon it, usurious interest has to be paid. This interest is invariably taken from the bank of health.
There are many drugs that contribute to sleep by relieving pain, discomfort and distress. Such are phenacetin, acetanilid, aspirin, valerian, etc. Five to ten grains of phenacetin, or ten to fifteen grains of aspirin will frequently transform a night made hideous by headache and insomnia into one of comparative comfort.
From earliest times alcohol has been used to facilitate sleep. That it produces drowsiness in some, wakefulness in others is well known. It is at best but a temporary care-killer and save when taken in small quantities, highly injurious to the human race. Those who have observed the effect of its use and abuse are unanimous in the belief that the health and morals of all nations would improve if it were banished from the world. Its use to combat insomnia is fraught with danger.
Where insomnia is casual there are simple sedatives which will relieve. It is not an admission of cowardice to take one of them, no more than putting an extra log on a fire is an admission on the part of the one who wants to be warm and comfortable, that he is a weakling. Nor is such indulgence injurious to the health or well-being. On the contrary, it may be and often is beneficial. It is when the physiological function of sleep is fundamentally disturbed and the attempt is made to restore it by drugs that the mischief begins.
When the time comes when disease is no longer treated by drugs, save such drugs as have specific action: quinine in malaria, iron in anemia, arsenic in psoriasis, the millennium will be at hand. Drugs and chronic disease should be divorced forever. The use of drugs should be confined to the relief of conditions that are for the time intolerable, such as alkali to relieve the discomfort of a sour stomach, a laxative to stimulate the expulsive power of the large intestines, an analgesic to relieve pain. If there is a diseased state underlying these conditions it is to be combated by the administration of a specific or by the utilisation of such measures as contribute to the restoration of diseased tissues,—rest, exercise, occupation, recreation, fresh air, sunlight, food, water, heat, electricity, massage, suggestion, discipline and surgical aid.