Abstinence (a490)

ABSTINENCE (withdrawal) from the use of narcotics that have become habitual often leads to the development of pathological phenomena connected with the fact that the biological regime of an organism accustomed to the use of large (often toxic) doses of poison is thrown out of balance by its absence. The phenomena of abstinence are especially sharply expressed in morphine addicts, the state of which after sudden and complete deprivation of morphine presents such a specific picture that one can speak of morphine abstinence as a completely independent symptom complex. The appearance of this symptom complex during morphine starvation is inevitable to a greater or lesser degree: cases of its development have even been described in newborn children of morphine-addicted mothers. Usually the matter begins with the fact that 5–6 hours after the last intake of morphine a feeling of being broken down, fatigue, and weakness appears, and then a state of tormenting anxiety and worry gradually develops, sometimes taking the form of sharply expressed fear. Simultaneously a series of convulsive symptoms appear: frequent yawning, sneezing, twitching in individual muscles, often accompanied by pulling pains, especially in the extremities, sometimes severe chills and general tremor. All this is accompanied by palpitations, a feeling of constriction in the chest and burning in the epigastric region, general increased pain sensitivity, paresthesias, and loss of appetite. The intake of a sufficient dose of morphine eliminates all these phenomena; in the case of continued abstinence they increase further. The pulse becomes frequent, often irregular, and in more severe cases weak; headaches, dizziness, nausea, vomiting, and bladder pain appear. Very constant is the symptom of persistent insomnia. Characteristic are also phenomena of increased activity of the secretory organs: increased salivation, lacrimation, and sweating, profuse diarrhea, frequent urination, etc. A tormenting sensation of lack of air is created by spasms of the diaphragm; in some, asthmatic attacks and attacks of convulsive cough develop. The patient's weight falls; urine sometimes (according to Vitke in 15%) contains protein; the pupils are dilated and give an excessively lively reaction. Oppenheim found paralysis of accommodation in all cases. The threatening significance is acquired by sudden attacks of cardiac weakness that sometimes develop, leading to severe collapses: the pulse becomes irregular and slow, breathing is impeded, the patient loses consciousness, and in case of slowing down with help death may occur. Delirious states are observed very rarely, extremely similar to the picture of delirium tremens and lasting from several hours to several days. Kraepelin, however, thinks that these states, if one does not count unstable cloudings of consciousness of hysterical type, occur only in patients who used another narcotic (alcohol) simultaneously with morphine. The duration of the phenomena of abstinence in morphine addicts is extremely varied: in mild cases, reaching their greatest strength on the second day, they quickly then weaken, but often weeks pass before the patient obtains at least a relatively tolerable condition. The onset of sleep and appetite is an objective sign of the beginning of improvement, followed by improved nutrition and weight gain. A very important circumstance must be considered that all phenomena of morphine abstinence can be eliminated by giving the patient a sufficient dose of morphine. It is precisely for this reason that it is difficult to conduct withdrawal from it outside the conditions of a forced regime of a psychiatric hospital. Physiologically, the phenomena of morphine abstinence are easiest to explain by the fact that in habitual morphine addicts the poison enters into a more or less stable chemical compound with vital components of the body's cells (according to Loofs with lecithin), becoming, thus, a necessary component of them: the cessation of its supply leads to chemical hunger of tissues and their subsequent breakdown with the release of a number of poisonous substances (Macht attributes the phenomena of abstinence to the action of oxidation products of morphine, Loofs considers them the result of poisoning with choline released during the breakdown of lecithin, etc.). Only when a new, morphine-free equilibrium is established in the chemical economy of the organism do the phenomena of abstinence disappear. In addition to morphine and its derivatives, chronic use of some other narcotics (alcohol, chloral hydrate, etc.) also leads to chemical habituation and, consequently, to the sequential development of abstinence phenomena, although much lighter than in morphine addicts; cases of delirium tremens developing as a result of sudden cessation of drunkenness (after imprisonment, placement in a hospital, etc.) can serve as an example. It is interesting to note that cocaine addicts in the majority give only very insignificant phenomena of abstinence. The concept of abstinence is also applied to socially organized forms of refusal to use narcotic substances, primarily alcohol (see Abstinence).