Trickle-Down Addiction

by Patrick Dowd

Between 1999 and 2010, sales of opioid analgesics like Vicodin, Percocet, and OxyContin, quadrupled in the United States [1]. Overdose deaths have increased proportionately during the same timespan, with more Americans dying from prescription opioid overdoses than from heroin and cocaine overdoses combined [2]. Still, the distinction between prescription and illicit drugs continues to carry a tremendous amount of social and legal significance in America, and Americans facing countless varieties of pains and ailments continue to look to their physicians for legal and accessible relief. A brief look at the history of medicinally prescribed opiates shows a frightening trajectory in which drugs are considered only as threatening as the population using them, and a period of over-prescription to a single class can quickly turn into a substance abuse problem among the general population.

In the mid-to-late 19th century, the average opiate or morphine addict was white, often southern, middle or upper class, and female. For decades, the general public found this population so non-threatening and the problem so benign that they accepted opium addiction as a fact of life. Physicians were undoubtedly implicated in the widespread opium consumption within this population, as they prescribed opium in lenient quantities for menstrual pains, indigestion, constipation, nervous debility, uterine and ovarian complications, and any number of other ailments of varying severity. While opium was commonly prescribed for medicinal purposes even in colonial America, several epidemics between 1830 and 1860 likely increased the number of addicts significantly. We can observe a large spike in the volume of crude opium imports in the 1840s, and it is likely that cholera and dysentery epidemics played a role in this increase in demand as doctors scrambled to treat the pain of those who were afflicted. However, opium imports did not slow down with the passing of these epidemics, as the Civil War and popularization of hypodermic medication also increased the volume of opium entering the United States.

One of the reasons most commonly given for the over-prescription of opiates in the 19th century is ignorance on the part of physicians. Historian David Courtwright writes, “Not only was the graduate of a typical proprietary school ill-informed about the danger of repeated administration of opiates, but his general lack of diagnostic skills tempted him to fall back on blind, symptomatic treatment” (Courtwright 50). Prescription opiates were an effective and dependable tool for physicians during an era that lacked surefire cures, and physicians used them to bolster their own credibility and necessity. Additionally, ignorance about women’s health in general also perpetuated physicians’ dependence on opiates as a cure. There was a perception that white, upper class women were incapable of managing pain, and that doctors should use any means necessary to relieve discomfort. In 1895, Dr. R.V. Pierce wrote of opium, “This divine drug overshadows all other anodynes… You can easily educate her to become an opium-eater, and nothing short of this should be aimed at by the medical attendant”[3]. With such misinformation circulating at the nation’s highest medical institutions, it is clear that many physicians were blissfully unaware of the nefarious problem that they were in the midst of creating.

The other most commonly cited reason for the epidemic of opiate prescription was greed. There is evidence that many physicians saw an opportunity to secure long-term, paying customers with a reliable reason to seek a doctor’s services on a consistent basis. What went unspoken rather than unnoticed was that this security was based largely on dependence that could not be instantly reversed once the prescriptions stopped. A survey of 10,000 prescriptions filled by thirty-five Boston drugstores in 1888 revealed that 1,481 of them contained opiates. However, among prescriptions refilled three or more times by a patient, 78 percent contained opiates [4]. The customer-controlled climate of American medicine would have proved frightening to any physician who was reluctant or unwilling to prescribe opiates to those who demanded them. It was not uncommon for patients to consult many doctors and pharmacists to find one who was willing to prescribe the desired elixir in the desired quantity. Even those without personal family physicians could go to the local pharmacist, and “if a pharmacist didn’t like that, habituees could go to competing shops ‘in the outskirts of our large cities’ that specialized in low-priced laudanum” [5]. Opium was ubiquitous and astonishingly unregulated. In short, physicians did not see refusal to prescribe opiates as a service to the patient’s health, but rather a death sentence to their own practice.

The introduction of legislation regulating the sale and use of opiates in the United States did not coincide with the statistical peak in opiate use, which occurred sometime during the mid-1890s. It also did not target the demographics that were most likely to succumb to addiction, which were women under the direct care of a physician. Instead, it coincided with an increasingly racialized national dialogue about drug use in immigrants and African Americans. Largely unsubstantiated claims that a large percentage of Blacks were using cocaine, and even more unsubstantiated claims that this increased the likelihood that they would rape and assault white women, ran rampant among laypeople and legislators alike. One historian wrote, “Making a connection between sexuality, drug abuse, and women became an important way to generate public revulsion of drug use by a population of users that was increasingly minority, poor, and urban” (Fahey and Miller eds. 782). Additionally, discrimination against East Asian immigrants led to a panic over opium smokers, whereas those who consumed opium by different means were seen as a different, more acceptable breed.

It was in this environment that the Harrison Narcotics Act, introduced in 1914, passed through Congress. Taken at face value, the Harrison Act did not appear to be a prohibition act at all, but rather a way for the distribution of opiates to become more organized and sufficiently registered. Congressmen claimed that it would have no implications in allowing a physician, pharmacist, or dentist to provide suitable pain medications to their patients. In reality, the 1906 Pure Food and Drug Act had already made significant strides in limiting the sale of prescription drugs to patients, and it could be argued that the Harrison Act aimed to target those who were already using, ushering in an era of criminalized addiction. In United States v. Doremus, the Supreme Court ruled that physicians could no longer prescribe opiates purely for the purpose of maintaining an addicts addiction, and some physicians were jailed for violating this law. As a result, physicians quickly slowed the rate and ease at which they were supplying opiates to patients. If the Harrison Act aimed to add transparency and documentation to the prescription of opiates, it may have had the opposite effect. Opiate use became increasingly confined to the underworld, with wealthy addicts able to afford to legitimately maintain their addiction in the medical sphere or afford treatment for their addictions, while the poor sought new illicit means of securing drugs.

It is my fear that physicians in the 21st century have fallen into the same trap of over-prescription of opioids that characterized the unregulated drug market in America before the 1906 Pure Food and Drug Act. The parallels do not end at the sheer volume at which the drugs are being prescribed or the eclectic categories of illness which they are being used to treat. Just like in the 19th century, the problem began with those who could afford to seek medical care for non-emergency conditions like chronic pain, and has proceeded to trickle down to poorer individuals as time went on. Almost 25% of pregnant women on Medicaid filled prescriptions for opioid painkillers during their pregnancy [6]. This is compared to an estimated 14.4% of pregnant women overall [7]. Additionally, legislation and media coverage has continued the tendency of focusing more on poor, minority drug users, with urban crack cocaine abuse in the 1980s sparking far more public fear and punitive backlash than opiate abuse among a whiter population.

As history shows, the problem cannot be put to rest simply by reducing the number of prescriptions that physicians give out to patients. The problem lies in the fact that even once changes are made to the leniency with which physicians dole out opioids, the lasting effects that even a short period of over-prescription can have are devastating and often concentrated within specific groups. While OxyContin abuse has fallen over the last several years, heroin abuse has made a significant resurgence. Prescription opiate addicts face obstacles in the price of maintaining their addiction compounded with the reality of building up tolerance, and heroin is seen as a cheaper and more effective alternative. The increase in heroin use has also coincided with an abuse-deterrent formation that was added to OxyContin. In 2010, the CDC recorded 2,789 fatal heroin overdoses, which was roughly a 50% increase over the largely consistent levels observed in the early 2000s [8].

An element of this narrative that is easy to forget is that Americans are in pain, and they will continue to seek relief from those that they trust. Physicians are put in a difficult position in which they are sometimes forced to choose between permitting pain and possibly inflicting harm, and until there are alternatives with comparable effects, opiate use and abuse is likely to thrive.

Books Cited

Courtwright, David T. Dark Paradise: A History of Opiate Addiction in America. Harvard University Press, 2009.

Fayhey, David M., and Miller, Jon S eds. Alcohol and Drugs in North American: A Historical Encyclopedia. ABC-CLIO, 2013.

Further Reading
Conrad, Peter. Deviance and Medicalization: From Badness to Sickness. Temple University Press, 2010.

Kandall, Stephen R. “Substance and Shadow: A History of Women and Addiction in the United States—1850 to the Present.” (1996).

Musto, David F. “The American disease: Origins of Narcotic Control (expanded edition).” NY: Oxford (1987).