Opioid Medications in America: From the Past to the Present
In 2017, the U.S. Department of Health and Human Services (HHS) declared a public health emergency and subsequently announced a five-point strategy to combat what we now refer to as "the opioid epidemic."
Opioids are a class of drugs used to treat pain. Common types are oxycodone (OxyContin), hydrocodone (Vicodin), morphine and methadone.
According to HHS data for 2019, more than 10 million people misused prescribed opioids, and 1.6 million had an opioid medication use disorder. Additionally, 1.6 million people misused prescription pain relievers for the first time, and 70,630 deaths were linked to drug overdoses.
Death, however, is not the only symptom of opioid abuse. In patients with noncancer pain, for example, studies have identified links between opioid use and sexual dysfunction, particularly in men who received higher mean doses of morphine for pain when compared to women. Opioids can cause severe dizziness, nausea, respiratory depression, constipation, vomiting and, of course, physical dependence. As is the case with many substances, our tolerance for opioids increases the more we use them, which leads many people who abuse opioids to find more effective, and dangerous, methods of injection.
The Centers for Disease Control and Prevention (CDC) states the opioid crisis began in the 1990s when pharmaceutical companies assured lawmakers their pain relief medications weren't addictive, and promoted their availability to patients and doctors for prescription use. While this would be a logical point to identify as the inciting incident for our modern-day opioid crisis, this time frame ignores the 200 years of American history preceding it.
The syringe and the Civil War
We can trace the use of opium back nearly 8,000 years to the writings found on clay tablets from Mesopotamia, the Sumerian civilization located in what is now Iraq. Researchers also point to examples of opium use in ancient Egypt, Greece, Rome, India, China and Europe.
The prescription, use and misuse of opium is not a modern issue. The primary difference is that now it has crept into suburban communities cleverly designed as easy-to-swallow pills rather than the mainstay product in some off-path, smoke-hazed drug den.
"Opium does three things really, really well," said Emily Einstein, Ph.D., chief of the science policy branch at the National Institute on Drug Abuse. "It relieves pain, suppresses coughs and treats diarrhea supereffectively. These are three profound symptoms of a lot of human diseases. Unfortunately, it also comes along with really strong properties that lead to addiction."
Historical evidence indicates opium was used to treat pain, but the real inception of opium into the medical realm was with the invention of the syringe and hypodermic needle, Einstein explained. Alexander Wood, a doctor from Scotland, is credited with inventing the hypodermic syringe in 1853, basing his creation on an earlier invention of the hollow needle by Irish doctor Francis Rynd in 1844.
"That coincided, tragically, with the Civil War," Einstein said. "It was a time in history where so many people were injured or needed amputations or surgeries, and suddenly, here was this 'miracle drug' that relieved pain incredibly effectively. So it became more and more common in medical practice. But because it had such potent addictive properties, veterans were becoming addicted to it even as it shifted into mainstream medicine."
Over the course of the following centuries, primarily in the late 1800s, many upper-class women became addicted to opioids because society considered them the "weaker sex," Einstein added. When they complained to doctors about issues such as menstrual cramps, doctors prescribed opioids as an effective painkiller.
Once practitioners realized how addictive morphine was, medical experts began looking for alternatives. Drug companies started marketing heroin as a way to avoid morphine addiction, and laudanum—a mixture of opium and high-proof alcohol—was given to children to help ease the pain of teething or to help with diarrhea. Unsurprisingly, these choices did not prove to be the best alternatives.
The early discourse and legislation surrounding drugs and prohibition were deeply involved in racist beliefs. Einstein pointed out that xenophobia, or fear and hatred of foreigners, was a major driving force behind the outlawing of opium because at the time many people associated the drug with Chinese immigrants. Conversely, this may begin to offer an explanation as to why these drugs were never completely outlawed. The wrong section of the community may have been targeted. Look at the majority of people who overdose on opioids today: about 70 percent are non-Hispanic white Americans.
The War on Drugs was officially announced by President Richard Nixon on June 18, 1971. He declared drug abuse to be "public enemy number one" and pledged to increase federal funding to reduce the illegal drug trade in the United States. There was a heavy focus on the distribution of crack cocaine and marijuana, but given that 80 percent of the people who used crack cocaine were Black, the campaign disproportionately affected minority communities. Meanwhile, the mainstream medical community continued to supply white people with opioids that were, for all intents and purposes, perfectly legal.
Enter fentanyl
Another factor leading to the current opioid crisis is the growing prevalence of fentanyl, a synthetic opioid that's about 50 to 100 times stronger than morphine. Pharmaceutical-grade fentanyl was developed for pain management in cancer patients, but our current supply in the U.S. is mostly illegal.
The city of New Haven, Connecticut, saw a record high in 2020 with more than 140 recorded drug overdose deaths. Records show that 94 percent of these overdose deaths involved opioids and 84 percent of those included fentanyl.
"People were overdosing and the ambulance would come to pick them up, administer naloxone [and] get them to the hospital, " said Virginia Allread, M.P.H., who works in the Rutgers University School of Nursing and co-authored a study titled "A Population Health Approach to America's Opioid Epidemic." "But then the word got out that this heroin was so good, people were OD'ing on it, so it actually attracted more business."
The study's main focus is on the philosophy of gradualism, which acknowledges that human change happens by degrees. In other words, quitting a drug cold turkey may not be the best approach. For example, someone who injects drugs but wants to quit might begin by injecting less often, then transition to snorting, then to oral ingestion and then, eventually, to not using.
Pharmaceutical-grade fentanyl was developed for pain management in cancer patients, but our current supply in the U.S. is mostly illegal.
Allread also took into consideration "deaths of despair," a term coined by Princeton economists Anne Case and Angus Deaton, who sought to analyze why American life expectancies have fallen in recent years. Case and Deaton identified the main causes as drug overdoses, suicide and alcoholic liver disease.
"We've got so much going on," Allread explained. "We've got such high rates of depression that people are seeking out drugs to self-treat. Possibly, some people are suicidal. They have a death wish. We've got a couple of epidemics going on at the same time."
There aren't any clear-cut answers to solving the opioid crisis. While Allread and her co-author Susan Salmond's gradualism approach incorporates empathy and human psychology, it remains controversial. We aren't conditioned to think it's OK to supply someone who abuses drugs with more drugs, even if the end goal is to help them gradually ease themselves off the substance altogether. Instead, we've routinely asked people to quit cold turkey, suffer through withdrawal and join a program such as Alcoholics Anonymous or Narcotics Anonymous to stay on track with their sobriety.
Einstein noted new, emerging technologies—particularly, virtual reality (VR)—that are playing a part in helping people recover from opioid dependency. However, these technologies don't fully address the true heart of the issue.
Remember, doctors gave laudanum to kids and police sent nonviolent Black and Latino drug users to prison more often than their white counterparts—in many cases, only for possession. These strategies failed to decrease opioid addiction in the United States. The business of prescribing opioid medication to white people continued unabated.
Perhaps by acknowledging the long history of opioids and the mistakes that have been made during the 50-year-old (and counting) War on Drugs, there can be some reassessment and better alignment of the focus on opioids, and a better understanding of how these powerful "wonder drugs" can help, and hurt, people.
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