What Have We Learned From Our 100-Year History of Opiate Addiction?
“A similar thing happened just over 100 years ago, and it’s as though we completely forgot about it,” says David Sack, MD, chief medical officer at Elements Behavioral Health.
In the period between 1701 and 1914, tinctures of opium and its derivatives were widely prescribed by doctors and sold over the counter as a painkiller treatment and remedy for a range of ills, from migraines to toothaches, as well as more severe pain, such as the agony suffered by wounded soldiers.
Opium and Its Derivatives: A Long History of Drug Epidemics in the United States
When did our use of opium-derived drugs begin? According to a historical timeline of opium/opiate use through the ages, we have been harvesting opium from poppy seeds since 4500 BC, when the ancient Sumerians recorded their use of a juice made from poppy seeds that could dull pain and bring euphoria. The Sumerians referred to the poppy as “the plant of joy,” but the ancient Greeks are credited with naming the poppy seed juice opium.
Opium continued to be popular for both medicinal and recreational purposes through history, but opiate derivatives entered the picture in the 16th century, when an alchemist-toxicologist named Paracelsus created a tincture of opium, an opiate-alcohol formula he called laudanum, which was just tasty enough to be taken orally. In the 17th century, a physician named Thomas Sydenham further refined the recipe for laudanum tincture — a 10% solution of opium powder in alcohol — using sherry wine and other flavorings, which he marketed as an affordable cure-all. By the 18th century, Sydenham’s palatable version of laudanum was being sold widely as an over-the-counter syrup in pubs, grocers, barber shops, tobacconists and chemists (pharmacies).
Overuse of Opiate Tinctures Reached Epidemic Proportions
Laudanum became a favorite household remedy in pre-Civil War America (1789-1850). It continued to be affordable and accessible to people at all levels of society through the 19th century, when Victorians were advised that it could be used to treat “melancholy,” aches and pains, sleeplessness, cough, gout, rheumatism, diarrhea, “women’s troubles” and to soothe a colicky baby. Rich and poor alike got hooked on laudanum as both a painkiller and a sedative, including several famous artists, writers and poets, who described it in their works as both a virtue and a vice.
Morphine, another opiate tincture derived from the opium of the poppy plant, was developed in the early 1800s as a painkiller and sleep medication. Named for Morpheus, the Greek god of dreams, morphine was commercially marketed by Merck in 1827 and, though it was a prescription drug available only through a doctor, it was soon being used as widely as laudanum — more so after the hypodermic needle was invented in the mid-1800s.
A Cure Worse Than the Sickness
Morphine was used by doctors as a purported cure for opium addiction, and also in tandem with laudanum as a painkiller during the American Civil War. As a result, many soldiers developed opiate addiction during the war, including John Pemberton, a pharmacist who later formulated Coca Cola as a potential cure for his own morphine habit. In 1886, Pemberton combined carbonated water and a cocaine tincture made from the coca leaf, and began marketing Coca Cola as a tonic health drink and cure for morphine addiction (the cocaine in the drink led to further problems, but that is another story.)
By the 1890s, opiate tinctures were being sold in the U.S. through the Sears Roebuck catalogue, increasing the number of Americans consuming them. And, although Bayer Labs commercialized a non-addictive painkiller called aspirin in 1899, opiates continued to be wildly popular.
By 1900, the medical community decided that opiates needed to be better regulated, so bottle labels soon included the word “poison” with warnings that high doses could be toxic. Further, while some tinctures and syrups didn’t require a prescription, the potions had to be purchased through registered chemists (pharmacies). Nonetheless, opiate addiction reached epidemic proportions in this era, with stories from users reporting that habitual use of laudanum and morphine led to agonizing withdrawal symptoms, including depression, restlessness, listlessness and the sweats.
“The typical opiate addict in 1913 was not some poor person on the street,” says Dr. Sack. “She was a middle-class 30-plus-year-old housewife who had been prescribed morphine for chronic headaches or menstrual cramps who then became addicted to it. This incidental exposure to an addictive drug for pain led to the morphine epidemic,” says Dr. Sack.
During World War I, morphine was again used as the painkiller of choice by those wounded in battle. By the end of WWI, hundreds of soldiers had full-blown morphine addiction, known as “soldier’s sickness.” The medical community realized that morphine was even more addictive than pure opium, especially when it was injected. In search of non-addictive alternatives to morphine, chemist C.R. Alder Wright synthesized heroin from morphine. Later marketed by Bayer as a non-addictive pain alternative to morphine, heroin turned out to be just as addictive, leading to additional problems.
The opium and opiate drug epidemics in the United States continued unabated until the Opium Exclusion Act of 1909, followed by the Harrison Narcotics Tax Act of 1914, which restricted the manufacture and distribution of all opium derivatives in the U.S., including the morphine and laudanum, as well as coca derivatives. Heroin was later outlawed with the Heroin Act of 1924.
Parallel History: Today’s Opioid Epidemic Echoes the Opiate Epidemic in 19th-Century America
Perhaps because of the opiate epidemic that peaked in the U.S. in the 19th century, medical approaches to pain management changed. Doctors in later years took a more cautious approach to prescribing pain medications that fell into the opiate or opioid category, because these narcotics were so addictive. However, attitudes shifted in the 1990s.
“The opioid epidemic we’re having today is a direct result of changes in doctors’ prescribing habits starting in the 1990s,” says Dr. Sack. “The medical community had seen that in the ‘70s and ‘80s, certain forms of pain weren’t being treated very well, particularly chronic pain that was associated with cancer. So as a profession, the medical community began to question whether our fear of these drugs was excessive and inappropriate — that we were using opiate and opioid pain medications too infrequently. There was a concern that many people whose pain could be safely and well-controlled were not getting those medicines.”
An active effort was made to retrain doctors to consistently ask their patients about pain and to more aggressively treat pain by prescribing opioid pain medications like hydrocodone, oxycodone and others. Once doctors started doing that, notes Dr. Sack, they saw positive outcomes. People whose pain had not been well-controlled by other forms of pain treatment like NSAIDs or Tylenol got more relief, and their last months or years were happier.
Since the outcome of this new approach was a success, there was an active effort to promote the assessment of pain as part of the core medical evaluation in hospitals, clinics and doctor’s offices to identify people who were in pain and, therefore, who might need acute or chronic pain management services. Because of this shift in prescribing practices, many more people were exposed to addictive narcotics from the 1990s onward.
“The reality of drug abuse and dependency is that the proportion of people who use a drug is directly related to how available it is,” says Dr. Sack. “When you make these addictive drugs more available, more people become addicted. What’s happening with opiates and opioids today is exactly what happened with them 100 years ago — many more people have incidental exposure to these drugs and, as a result, many more people are becoming addicted.”
New Efforts to Regulate Opioids to Prevent Addiction
The situation today is that the prescribing of opioid medications has swung too far in the other direction — from an overcautious approach to an unguarded one. The overprescribing of opioid painkillers has led to an upsurge in trips to the emergency room due to drug toxicity (1,000 opioid-related ER visits per day) and a spike in opioid drug overdose deaths — more than 50,000 people died of an opioid-related drug overdose in 2015. As of 2016, drug overdose is the leading cause of death for Americans under 50.
The CDC. In response to the opioid addiction crisis, the Centers for Disease Control and Prevention (CDC) launched research studies and gathered statistics, which revealed that the dangers of opioids and opiates often outweigh the benefits — long-term use of opioid painkillers doesn’t necessarily produce superior effects to less risky pain management measures.
Recommendations for doctors. In an effort to prevent widespread addiction to these narcotics, the agency issued its CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. The CDC guidelines recommend that doctors keep opioid dose levels as low as possible and, since addiction can take hold within just a few days of taking a narcotic medication, opioid/opiate prescriptions should be limited to seven days or less. After the prescription runs out, doctors are advised to follow up with their patients to monitor their pain and recommend a transition to non-addictive medications and/or non-medicine pain management approaches such as relaxation techniques and physical therapy, among others. The CDC also recommends that people be advised to properly dispose of unused opioid prescriptions since these can fall into the wrong hands if left in the home.
Retail pharmacy chains. Following the CDC’s distribution of its guidelines, CVS, one of the largest retail pharmacy chains in the U.S., announced that it was instating new pharmacy measures to help prevent opioid addiction. That is, for patients who are new to pain therapy, CVS will limit opioid prescriptions to seven days for certain conditions. Further, CVS will limit the daily dosage of pain pills based on their strength and will also require the use of immediate-release formulations, found to be less addictive, before extended-release opioids.
Support for state-funded addiction treatment centers. Because many U.S. states have reported that they don’t have enough affordable treatment centers to accommodate the thousands of people who require opioid or opiate addiction treatment, the federal government has announced that it will be distributing grants to states that need funding for more treatment programs that specialize in treating these types of addictions.
“At Elements we have learned that to help people overcome an opioid or opiate addiction, we need to use a treatment model where the kind of treatment that we offer is individualized to the kinds of problems that people come in with,” says Dr. Sack. “We have moved away from a one-size-fits-all strategy so that people who previously failed a treatment program, perhaps one based on 12-step facilitation or another approach, won’t simply be repeating that approach. We want them to succeed, so we are looking beyond their initial treatment to create an individualized plan with a new approach and more therapy options so they are more likely to achieve recovery.”
This Isn't the First US Opiate-Addiction Crisis. Stephen Mihm. Bloomberg View, July 2017.
Heroin Addiction's Fraught History. P Nash Jenkins. The Atlantic, February 2014.
The Lure of Laudanum, the Victorians' Favorite Drug. Claire Cock-Starkey. Mental Floss, November 2016.
Laudanum Use in the 19th Century. Caroline Clemmons Blog, February 2011.
Poetry, Pain, and Opium in Victorian England. Stephanie Cowell. Wonders and Marvels, February 2013.
Opioid epidemic shares chilling similarities with the past. Mike Stobbe, AP Medical Writer. ABC News, October 2017. http://abcnews.go.com/Health/wireStory/opioid-epidemic-shares-chilling-similarities-past-50782023