by Bruce Dunlavy)
My blog home page and index of other posts may be found here.)

[A second post on this topic may be found here.]

By now, just about everyone knows that the United States is in the midst of an epidemic of addiction to heroin and other opioids (opium-derived or opium-like drugs). What was once a scourge of urban slums has invaded suburbs, small towns, and rural areas. Heroin – the drug that was once associated with frightening criminals, sleazy low-lifes, and decadent jazz musicians – is now more widely used by middle-aged white consumers than the urban poor.

Last year, Peter Shumlin, the governor of Vermont, devoted almost his entire State-of-the-State Address to the issue of how heroin is ravaging the State.  That’s Vermont, with a total population of 626,000 and only three towns with more than 10,000 people. Hardly the place one would expect a heroin crisis. There are opioid problems in many other rural regions, as well, especially northern Appalachia, and in small towns all across the country.  Nationwide, the number of overdose deaths from opioids doubled between 2008 and 2013. In Ohio and in Kentucky, it tripled.

The people dying from overdoses of opioids are not members of the groups traditionally associated with such drugs, either. The highest rate of overdose death is among those aged 45 to 54, and the victims are usually white men. In Lucas County, Ohio, where Toledo is located, the local department of health reports that 85 percent of heroin deaths occur among white males.

If there’s an upside to this, it’s that once heroin addiction became a problem in places other than inner cities and among people other than urban African-Americans, it gained more attention.  Addicts gained more sympathy, and the “disease model” of addiction replaced the “moral weakness” model. It is generally recognized now that opioid addiction is a disease that can be treated, and that if it is not treated it is usually a fatal disease. Its victims end up killing themselves without intending to.

So, what’s the story here? How did this come about? For some perspective, let us take a look back to when opium addiction was even more widespread than it is now. In the last third of the Nineteenth Century, nearly one in 400 Americans was addicted to some form of opiate. Although the problem had been around for a long time, that epidemic began in the aftermath of the Civil War, when wounded veterans were given opium to relieve severe pain.

The problem was exacerbated by other factors. Not the least of these was that the practice of medicine as a rigorous, scientific process was in its infancy. The idea that disease could be caused by bacteria or viruses was still not widely accepted. There were no Federal laws effectively regulating drug usage, and worthless/dangerous “patent medicines” were widely consumed by an unsophisticated public. Although opium use had been common in the USA for at least a century, immigrant laborers from East Asia (particularly China) and later the annexation of the Philippines as a prize of the Spanish-American War brought a culture of casual opium use, and its analgesic, sedative, and narcotic effects were quickly noticed more and more.

Patented drugs derived from opium soon followed. Laudanum, a suspension of opium in alcohol, was used for everything from relieving menstrual cramps to calming fussy babies. A stronger opium derivative, morphine, had been isolated from opium poppies just after 1800, and by 1827 the pharmaceutical company Merck had put it on the broad market. The invention in the 1850s of the hypodermic needle syringe provided a quick and powerful way to administer morphine, and by the end of the century its use had become a noticeable problem.

In the late 1890s, the German drug company Bayer began marketing a more powerful form of morphine, diacetylmorphine. This drug was advertised as a non-addictive alternative to morphine –not addictive at all – and was presented as a “cure” for morphine addiction as well as a replacement for morphine. Bayer saw it as a wonder drug that could conquer the effects of many illnesses and gave it a trade name to suggest its power: Heroin (likely to be pronounced with the emphasis on the second syllable). Heroin was sold unrestricted and without a prescription.

Officially, the Harrison Narcotics Act of 1914  was not a prohibition law. It merely placed registration, record-keeping, and tax requirements on the distribution of opiates, and restricted their use to the practice of medicine. However, it was indeed designed to ban narcotic drugs, partly as a moralistic precursor to alcohol Prohibition, partly as an international effort to control trafficking and resultant conflicts, and partly in reaction to racist fears of crazed African-American, Asian-American, and Hispanic “drug fiends” taking advantage of white women.
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The Harrison Act was a failure in terms of limiting the use of narcotics. Illegal distribution and resultant addiction flourished, and a whole new criminal enterprise was created in which traffickers made even more money. The drug dealers’ business became more lucrative because their income was derived not from the drugs themselves, but from the illegality of the drugs.

The current heroin/opioid problem is a direct result of the over-prescribing of heroin-like drugs for pain relief. As was the case with heroin, each new opioid is presented as a solution to the problems created by those before. Under Federal law your doctor can prescribe you heroin by its chemical name, diacetylmorphine or diamorphine (oddly, the same laws prohibit your doctor from prescribing you marijuana). Such use was intended to be restricted to treatment for extreme suffering in terminally ill patients.

However, opioid medications such as hydrocodone (used in Vicodin) are widely prescribed. They are routinely handed out for relatively minor pain, even though they have the addictive strength of heroin or morphine. Drugs that were developed to ease excruciating end-of-life suffering are commonly prescribed to teenagers after wisdom-teeth removal. Shorter-term prescriptions alone are unlikely to end the problem; six percent of patients who are prescribed opioids for one day are still using them a year later.

The drug companies continue to create new drugs or new formulations to fix the problems of the old drugs and old formulations. Oxycodone, for example, was replaced by Oxycontin, which is the same drug in a timed-release form.  Since the drug is fed into the body over a longer period of time, more of it can be packed into a single dose. The idea was to limit the number of pills physicians would prescribe and thus the amount available for abuse by the patient or others.

Of course, what too often happens is that the patient develops a dependence, runs out of the drug and cannot get any more prescriptions for it. Upon searching for the drug on the street, the patient finds it too expensive – more expensive, in fact, than heroin, to which the patient then turns to feed that dependence.

The transformation of heroin addiction from a reviled perception of weakness and immorality to a treatable disease is a result of the broadening of the addicted population. Treatment centers taking a “disease-based” approach to addiction are showing not just more compassion, but also more success. One of the symptoms of the disease of addiction is periodic relapsing. Treatment programs based on a “criminal model” of addiction thus expel from treatment those who exhibit symptoms of their disease.

There is some movement toward the first necessary step – cutting down on the over-prescribing of opioid medications. Physicians for Responsible Opioid Prescribing (PROP) is a leader in this effort. Earlier this month, National Public Radio’s program “Here and Now” produced a four-part series on the heroin epidemic and its consequences. Once we get a handle on the way opioids are developed, prescribed, and distributed, we will be counting fewer dead victims of this terrible disease.

[A second post on this topic may be found here.]