Opium – Joy of Medicine

Dr  Ajit Kulkarni & Dr S S Vithal

1 Introduction
Opium is one of the chief remedies of materia medica for comatose conditions. It is one of the ancient remedies used since antiquity. It is a mysterious drug used in various medical faculties in various forms. A lot of fascinating stories have made Opium famous. Opium has been notoriously defamed as responsible for deaths. It has been a destroyer of individuals, families, states and empires. It is difficult to count how many wars have occurred on earth because of Opium. 

Such a wonderful drug, when potentised, has manifested its versatile nature and hence it assumes the position of a polycrest drug.

2. The history of opium
Opium is an extract of the exudate derived from seedpods of the Opium poppy, Papaver somniferum. The poppy plant was cultivated in the ancient civilizations of Persia, Egypt and Mesopotamia. Archaeological evidence and fossilized poppy seeds suggest that Neanderthal man may have used the Opium poppy over thirty thousand years ago. Less controversially, the first known written reference to the poppy appears in a Sumerian text dated around 4,000 BC. The flower was known as hul gil, plant of joy. Papaver somniferum is the only species of Papaver used to produce Opium. It is believed to have evolved through centuries of breeding and cultivation from a Mediterranean–growing wild strain, Papaver setigerum.

In some parts of the contemporary Middle East, chilled glasses of poppy tea are served to mourners at funerals to ease their grief.

Opium was variously called the Sacred Anchor of Life, Milk of Paradise, the Hand of God, and Destroyer of Grief. Medical pioneer Thomas Sydenham (1624 – 1689), sometimes known as ‘the English Hippocrates’ and ‘the Shakespeare of medicine,’ writes….“Among the remedies which it has pleased Almighty God to man to relieve his sufferings, none is so universal and so efficacious as Opium.”

Robert Burton (1577 – 1640), scholar, priest and author of Anatomy of Melancholy, commended laudanum – essentially Opium dissolved in wine–for those who were insomniacs …. “…..by reason of their continual cares, fears, sorrows, dry brains (which) is a symptom that much crucifies melancholy men……..”

By the nineteenth century, vials of laudanum and raw Opium were freely available at any English pharmacy or grocery store. One nineteenth – century author declared: “[Laudanum] Drops, you are darling! If I love nothing else, I love you.” Another user, the English gentlemen quoted in Jim Hogshire’s Opium for the Masses (1994), enthused that Opium felt akin to a gentle and constant orgasm.

Youngsters were introduced to the pleasure of opiates at their mothers’ breast. Harassed baby-minders – and overworked parents – found Opium – based preparations were a dependable way to keep their kids happy and docile. De Quincey states that Opium was his “Divine Poppy-juice, as indispensable as breathing.”

Opium induces gentle, subtle, dream-like hallucinations very different from the fierce and unpredictable weirdness of LSD. Charles Baudelaire (1821 – 1867) likens Opium to a woman friend, “an old and terrible friend, and alas! Like them all, full of caresses and deceptions.”

A complex chemical cocktail
Until the nineteenth century, the only opioids used medicinally or recreationally took the form of crude Opium. Opium is a complex chemical cocktail containing sugars, proteins, fats, water, meconic acid, plant, wax, latex, gums, ammonia, sulphuric and lactic acids, and numerous alkaloids, most notably morphine (10% – 15%), codeine (1%- 3%) noscapine (4% – 8%) papaverine (1% – 3%) and thebaine (1% – 2%). All of the latter, apart from thebaine, are used medicinally as analgesics. The opioid analgesics are of inestimable value because they reduce or abolish pain without causing loss of consciousness. They also relieve coughs, spasms, fevers and diarrhea.

Opium resin contains two groups of alkaloids: phenanthrenes (including morphine and codeine) and benzylisoquinolines (including papaverine). Morphine is by far the most prevalent and important alkaloid in opium. It binds to and activates μ-opioid receptors in the brain, spinal cord, stomach and intestine.

Morphine was first isolated from Opium in 1805 by a German pharmacist, Wilhelm Serturner (1783 – 1841). Serturner described it as the Principium Somniferum. He named it morphium – after Morpheus, the Greeek god of dreams. Today morphine is isolated from Opium in substantially larger quantities – over 1000 tons per year – although most commercial Opium is converted into codeine by methylation. On the illicit market, Opium gum is filtered into morphine base and then synthesized into heroin.

Regular use leads to physical tolerance and dependence. Various degrees of psychological addiction can occur. These mechanisms result from changes in nervous system receptors in response to the drug. The brain creates new receptors for opioids. These receptors are “pseudo” receptors and do not work. When the opioids are out of the body, the brain has the same amount of endogenous opioid (endorphins) to fill these receptors, but less of the functional receptors and more non-functional ones. Abstaining from the drug for a time allows the brain to replace the pseudo receptors with functioning ones.

Hahnemann has given one statement about Opium, “It is much more difficult to estimate the action of Opium than of almost any other drug.”

3. Opium poisoning
The symptoms manifest themselves in three stages.

Stage of excitement or euphoria: During this stage, the symptoms are: increased sense of well-being, mental activity, freedom from anxiety, loquacity, restlessness or even hallucinations, flushing of the face and increased action of the heart. This stage is of a short duration and may be absent if a large dose is taken. In children convulsions are a marked feature in the first stage. In adults a widely excited and even a maniacal condition may be seen in this stage.

Stage of sopor: The nerve centers are depressed during this stage, which sometimes comes on quite suddenly. The symptoms are headache, nausea, vomiting, giddiness, lethargic condition, drowsiness and an uncontrollable desire to sleep, from which the patient may be roused by external stimuli. The pupils are contracted, the face and lips cyanosed and an itching sensation is felt all over the skin. The pulse and respiration are still normal.

Stage of narcosis: The patient now passes into deep coma from which he cannot be roused. There is a marked insensibility to pain. During this stage the muscles are relaxed and the reflexes are lost. All the secretions are almost completely suspended, except that of the skin, which feels cold and clammy. The face is pale; the lips are livid, lower jaw drops. The pupils are contracted to pin points due to depression of supranuclear inhibition of papillary constrictor tone and are insensible to light, terminally they may dilate when asphyxia intervenes. The conjunctivae are injected. Blood pressure begins to fall and the pulse is slow, small and compressible. The respirations are slow, labored, stertorous and the rate may be 2-4 per min.

At this stage, recovery may take place by prompt and proper treatment, otherwise in the case of fatal termination lividity of the surface increases. The pulse becomes slower, more irregular and imperceptible. As the respiratory center becomes insensitive, Chyne – stokes breathing follows before respiratory failure and death occurring from asphyxia. The heart may continue to beat for a short time after respiration has stopped. Convulsive twitching in groups of the muscles is observed and the pupils become widely dilated towards the end. Sometimes, death occurs from failure of heart. The odour of Opium may be present in the breath throughout the illness. This is sometimes masked by injudicious administration of alcohol by relatives.

4. The essence of Opium
Life is neither individual nor collective. Life is one individual whole. Unity is the nature of life. Cherishing fragmentation of dividing life into individual and collective, the inner and the outer, the physical and the physiological results in dichotomies, the bonds get loosened and the overall outcome is that of chaos.

Our study of materia medica has a similar theme. Each drug is an individual whole. All the components- the action, the mentals, the physicals, the particulars, the concomitants, the behaviour – have no isolated existence of autonomy. They are bound by one unifying force. If we can’t recognize this force, we will be lost in the jungle of symptoms and the likely outcome will be that we may become wild animals.

The action of a remedy at various levels yields innumerable symptomatology of diverse and heterogeneous type. Although apparently it gives the picture of chaos, there lies in the data an organizing, unifying principle, which connects the components. To understand this principle, this thread that connects together all the components should be recognized to know the essence.

Out of the mess of symptoms, the design with clarity has to be developed so that it can become an easy tool of application. For that sake, an order has to be developed through appropriate connectedness with the help of relevant faculties like psychology, psychiatry, physiology, pathology, bio-chemistry, repertory, language etc. etc.

Such a design will make the readers appreciate the data in a far better way.

4. a. Monogram
The concept of monogram relates to the very core of a remedy. Each word in the bracket  is like a genetic code. The fundamental characters run through and through and when combined together, they make the organizational whole, making the totality more meaningful and pragmatic. 

Insensible. Torpid. Adynamia. Heavy. Paralytic. Epileptic
Tremulous.  Senile.  Dropsical.  Atonic.  Dry.  Sweaty.  Thrombotic.  Deep.

1. Insensibility :Insensibility is the central feature of Opium.
Opium is one of the most complicated substances of our materia medica. It contains about 18 alkaloids of which the Apomorphine, Morphine, Heroin and Codeine are well known. Besides mucilage, albumen, fat, sugar, and salts of ammonia, calcium and magnesia, it contains “17 or 18 alkaloids and two neutral substances, as well as  meconic acid” (Brunton).

The poisonous effects of Opium are absolute unconsciousness, complete muscular relaxation, pupils contracted to a pin-point aperture, turgid, bloated, stertorous breathing, pulse slow, asphyxia and death. All these poisonous effects are due to the depressive action, which culminates asity. At the physical level the insensibility is expressed as loss of reflexes. The reactive pattern is depressed to such an extent that we do not get the response even to intense input. Hence, painlessness is the characteristic of Opium. The depressive action of Opium results in nerves ‘at an end’

This is available at both mind and body level in Opium pathogenesis with dynamic doses. At mind level we get higher intellectual faculties being depressed, self-control and power of concentration is lessened, judgement is progressively affected. This leads to poor perception, consequently confusion of mind and fanciful ideas. The senses are perverted including the moral sense, which is expressed at the dispositional level as a ‘knave’ person (unprincipled, crafty man, a rogue, a scoundrel), keeping insensibility to the feelings of others. Insensibility revokes the reality, the sufferings and goes to the extreme polarity of paradise. (It is interesting to note that, at different points in the body, we manufacture endorphins, natural opiates which intervene to calm fear, pain, and cough, among other things). This state is characterized by a well- feeling even in grave conditions. A person is unable to understand or appreciate his sufferings. He looses the mental grasp of anything and says that nothing ails him. He wants nothing, he is placid and in his own dreamy state as if of “nirvana”.

It is interesting to note that Opium has indifference to both joy and suffering; this indifference is not associated with melancholy (like Natrums) but it is an ‘exhalted’ state. It is similar to ‘Anhalonium Levii’ but unlike it. Anhalonium has colourful, brilliant visions, beautiful and varied kaleidoscopic changes and a sensation of increased physical ability. These are however absent in Opium. It is similar also to Cann-i which has fantastic visions; however, time sense is more disordered in Cann-i.

Opium has been reputed as a remedy for ‘deep unconsciousness’ where there is no response to superficial or deep reflexes. The unconsciousness may come on due to fright or head injury or even metabolic failure. During the convulsions the pupils are non-reacting to light. Want of susceptibility to remedy even though indicated is due to the insensibility that results in lack of reaction or adynamia. Here it must be competed with Carb-v, Psor, Zinc, Sulph, etc. Opium is, however, more acute in its manifestations. 

2. Torpid: The depressive action of Opium results in sluggishness both at mind and body level. The mind loses its perceptive filter capacity. The comprehension is affected, there is loss of will power and the person loses the go.

At the physical level the torpidity is expressed as lack of vital reaction, insensibility of the nervous system, painlessness and soporous condition. Opium lessens the voluntary movements.
This torpidity is exhibited at the level of various systems: sluggishness of the intestines; paralytic atony of bowels; obstipation; no desire to go to stool; senile. At urinary system there is feeble stream and slow to start. Loss of power or sensibility of bladder. Paralytic atony of bladder; retention of urine; after laparotomy or confinement. At the genital level there is suppressed menses especially from fright, also suppression of lochia. Uterine inertia with cessation of labour pains with coma is the characteristic feature.

Opium checks all secretions except that of skin. Torpidity results in general relaxation of the system expressed also at prolapse of uterus, ptosis and paralysis, hemias (more inguinal), hoarseness, slow pulse, heavy, stupid sleep and fever associated with sleepiness. In short, torpidity runs through and through and is manifested at mental and physical planes. 

3. Paralytic: The depressive action of Opium on the nervous system causes paresis and paralysis. Opium has paralysis of painless or painful type; of brain, tongue, bowels, bladder, larynx, limbs, etc.; from fright; from lead poisoning; head injury after; apoplexy; senile; alcoholic.

In paralysis Opium should be compared with Caust, Alum, Plb, Gels and Zinc. 

4. Adynamia: The torpidity, general depressive action of Opium results in the state of lack of vital reaction. This want of susceptibility gives a poor or no response to even well indicated remedies. Adynamia indicates the grave condition. The system has lost its power of resistance and the vitality needs to be aroused as a dire necessity. Opium is helpful in acute manifestations chiefly but it has the usefulness also in chronic ones. To illustrate if a patient has become unconscious due to CVS, thromboembolic phenomena, or septicaemia, and he is not responding to the indicated remedies, Opium should be given to arouse the vitality of a person and then again the indicated remedy should be prescribed. 

5. Epileptic: The convulsions are the toxicological effects during the phase of stimulation. The causes are: after violent anger or rage; after fright; insult; puerperium; after cholera; from suppressed urine; when labour pains are ceased; apoplectic; brain diseases.

The aura begins with congestive headache and convulsions are worse during and after deep sleep, glares of light, heat; of room or bath, from approach of strangers (children). During convulsions – stertorous breathing; coldness of limbs; froth at mouth; eyes half open; pupils dilated and insensible to light; face dark red and hot. Throws limbs about or stretches arms at right angle to the body; stupor between spasms. The attacks are followed by relaxation of muscles and deep sleep.

Opium can be tried in cases of mental retardation with epilepsy. Indolence, stupidity, rashness, recklessness and boldness characterize the Opium children. Such children are nervous, irritable and there is a tendency to start even at the least noise. These are the dreamy children who are deceptive in nature and are liars. Opium should be compared with Bufo, Tarent-h., and Tub.  Opium should be tried in spastic children. 

6. Tremulous: Trembling characterizes Opium. Fright, anger or rage cause tremors. Twitching, jerking during sleep. Twitching of limbs; after fright. Jerks as if flexers are overacting. Shuffling and trembling gait. One or other arm moves convulsively to and fro. Trembling, twitching of facial muscles.

Opium is one of the chief remedies for a patient who has developed trembling after fright. 

7. Dropsical: Opium poisoning has produced anasarca. Opium has oedema of lower limbs especially feet, and of lower eye lids. Oedema: uremia; diabetes mellitus; strokes; of face (red, bloated, swollen, dark suffused, hot). 

8. Dry: Internal dryness typifies Opium paresis and paralyses are the results of the dryness of the nerves. We get the dryness of mouth (with consequent intense thirst); of eyes (red, burning, hot and dry); of throat (with inability to swallow); of rectum (resulting in obstinate constipation with stools-dry, hard, round, black-balls); cough dry and racking; suppressed discharges (except sweat); dryness of emotions; indifference to pleasure and sufferings. 

9. Senile: The metabolic processes in old age are characterized by torpidity, low susceptibility and degeneration. Opium has all these characters in its pathogenesis. It has at the physical level senile vertigo with lightness of head; senile painless ulcers; slow circulation; tremors; various degenerative disorders of spinal cord; constipation; C.O.P.D.; occulo-motor paralysis; cardiac diseases; various digestive and kidney disorders; dryness of the mucous membranes and of the skin; nutrition impairment; etc. 

10. Atonic: The system under Opium develops ‘atony’ under its depressive and torpid action expressed at bowel and bladder in the form of constipation and retention of urine; prolapse of rectum, uterus; abortions; ptosis etc. The causes usually are fright, anger, insult etc. There is inhibition of reflexes. At mind level we get indifference, dullness. Want of susceptibility to remedies and insensibility are the furtherance of atonic state. 

11. Sweaty: In Opium all secretions are checked except sweat. This produces internal dryness. The characteristics of sweat are: hot sweat over whole body except lower limbs, cold perspiration over whole body especially on head and forehead, and fever is > without perspiration; Sweat without >. Skin is usually hot, damp and sweating. 

12. Thrombotic:The reputation of Opium in unconscious, comatose state has brought to the fore the pathological condition of thromboembolic phenomenon. Under eyes we get ‘embolism of central artery’. Paralytic effects consequent to cerebral thrombosis come within the range of Opium. 

13. Heavy: The word ‘heaviness’ aptly describes the mental and physical characters. The mind is heavy, unable to comprehend. This leads to irresolution, confusion of mind; finally we get idiocy of mind. Indifference to mind, dullness are also found in Opium. Torpidity at physical level explains heaviness at physical level. 

14. Deep: Opium is a deep-acting, polychrest remedy of wide range. Its toxic effects are devastating. Opium penetrates deep in the vital economy and causes a severe depressive action over the system. The ‘insensibility’ and ‘wants nothing’, ‘I am fine’, a ‘paradise’ state even with grave illness is actually indicative of deep magnitude of illness. One will naturally expect the warning signals through psycho-neuro-immunology in terms of pains through prostaglandin synthesis or of anxiety and conscientiousness through psychogenic defenses. But warning signals are absent and the system manifests the deceptiveness. This is reflective of syphilitic dominance.

The study of Opium through above characters i.e. through monogram renders in a nut-shell the essence of this important drug.

5. Evolution of Opium
a. Foetal state

• Mother had experienced a state of fright during gestational period.
• Mother addicted to opiates, heroine, morphine etc.
• H/o Mother had taken sedatives during pregnancy.
• Mother suffered from constipation during gestational period.
• Lively and violent foetal movements.
• Difficult labor: mother in a shock stage and has received inj. morphine and birth of a child has occurred.

b. Neonatal state:

• Asphyxia neonatorum with consequent effects at mind and body level. The child is unconscious, pin pointed pupils, convulsions, cold perspiration.
• Retention of urine soon after birth.
• Constipated bowels; no urging for days.
• Birth trauma – Caput medusae. Head injury.

c. Child:

• Delayed milestones. Mentally retarded. Imbecile.
• The child is born emaciated, non – fleshy, puny, not putting on weight; remains thin and undernourished; failure to thrive.
• Nursing mother if in a state of fright, child suffers from convulsions.
• Somnambulism.

Behaviour:

• Non-demanding with tendency to lie. Indifferent to immediate surrounding, appears apathetic. No sense of responsibility as his normal faculties of mind are not developed. Confusion of mind. If asked to perform two tasks, he creates confusion.

• Lack of maturity results in impulsive, audacious behaviour; boldness or recklessness. Dreamy. Doesn’t understand the ground reality.
• The child is absent minded with abstraction of mind. He appears cheerful and innocent, hence pampered. No responsibilities to be shouldered hence his capacities have not developed. Procrastination and avoidance of task – the usual features.

• Kleptomania. Active, sharp or weak memory. Deceptive. Temper tantrum.

d. Adolescence:   

• Opium adolescents retain some characters of childhood. His mental age is disproportionate to his physical one.
• Untruthful, unsympathetic, immature, amoral, liar, witty, humorous, shameless, perverted sexual behaviour, lascivious, dramatic, quarrelsome.
• Low comprehension, dull. Neither he performs at school nor he is helpful at home. Hence the utility part is very little. But retains his sensitivity of mind: to insult, to indignation, to mortification, to fright. He also develops jealousy with siblings.
• There is often an unpredictable response e.g. one expects rage but instead, quiet disposition is observed. At times expects too much love, and when offered behaves indifferently. At times very demanding or opposite. Kleptomaniac. Memory is deceptive. Will show no pains after trauma.

e. Adult Life:
Opium assumes the group of dull, indolent, imbecile and also manipulative remedies. ‘To lie’ is common with Opium. He knows well how to deceive others. Apparently he gives a feeling of innocence and dullness. He uses these two weapons to go in for winning through deception. Lack of intelligence keeps Opium in problem as he can’t utilize his brain for the sake of bread and butter. He resorts to deceptive methods.

Constipation is a strong feature that runs chronically in Opium adult life. He resorts to laxatives and makes his intestines idler.

Opium retains the timidity in adult life. He doesn’t take any risk or enterprise. Flight response is common. Dependency is marked. He can’t discharge a responsible work as he has less capacity and maturity. Opium has also abundance of ideas and clear mind. This should be understood as the flip-flop side of a polychrest remedy like Opium. Opium sits at home, does nothing and hence a “bucket” for the family members.

f. Old age:
Already depressive phase of senility adds to the Opium state. The senile period is characterized by depressive phase at all levels. The mind loses its go. The patient may suffer from psychiatric illnesses like depression, imbecility, schizophrenia etc. or he may have organic brain diseases, chronic respiratory diseases of obstruction, paralysis of single organs or side; cerebro-vascular strokes etc.

The end of Opium is usually in an unconscious state! ‘Demands nothing’ as a strong, peculiar feature is exhibited at the end of life. The unconscious state demands nothing, insensibility is a strong feature and the patient dies in a calm, placid stage. The plant of joy ‘Opium’ has its say at the last and euthanasia, as the result is the confirmation of Opium essence.

6. Conclusion
Opium has been presented from the standpoint of history, poisoning, essence and evolution. A deep-acting, multi-miasmatic remedy of wide range, Opium represents the ‘non-suffering’ part of the suffering humanity in its unique way, masking the true portrait of the sickness and camouflaging the physician

Dr. Ajit Kulkarni M.D.(Hom.)
Email : dr_ajitkulkarni@rediffmail.com