Opioid Abuse in the USA: Part I

By Emily Duchenne - Geography Student @ Brasenose College, Oxford

The opioid epidemic across the US has been described as a “uniquely American problem”, taking the lives of almost 400,000 people from 1998 to 2017. The term opioid refers to all compounds that bind to the opiate receptors on nerve cells, with natural compounds such as heroin and morphine known as opiates. Opiates have been used for millennia due to its analgesic (painkilling) qualities, with heroin being cultivated from poppy seeds over five-thousand years ago in Mesopotamia, yet today’s long-term administration of an opioid for the treatment of chronic non-cancer pain continues to be controversial due to concerns related to effectiveness, safety, and abuse liability through addiction. The confluence of pharmaceutical lobbyist agendas, a culture of overmedicalisation, failure to recognise the epidemic due to racialised and classist stereotypes of drug users, all reflect the importance of what Arjun Appadurai (1986) terms ‘the social life of things’, where opioids have become loaded with histories and contemporary investments that sit in contrast to their innocuous pill form. In this essay, I will consider the history of America’s experiences with opioids, contrasting with today’s epidemic in Part II to analyse whether there are similarities or differences to be learnt from.

America’s history with opioids over the 19th and 20th centuries is one of infatuation followed by revolt. Following scientific developments in Europe during the 19th century, the extraction and administration of the active ingredient morphine to relieve patients of severe pain not only presented opioid use as a breakthrough for successful treatment, but recognised pain as a debilitating and destructive condition. In the American context, morphine appeared a godsend for soldiers severely injured during the Civil War in the 1850s; however, the liberal use of the drug to sooth patients meant many soldiers came home from field hospitals addicted to the analgesia experience. Throughout the 19th century, the overzealousness of doctors who prescribed opiates to upper-middle-class women for everything from menstrual cramps to hysteria resulted in a “tally of wrecked middle-class families and lives”.

The synthesisation of the more powerful heroin towards the end of the century entrenched opioids as part of the pharmacist’s counter, marketed as a cough suppressant and even an aid to help infants cope with teething. By 1895, morphine and opium powders had led to an epidemic that affected roughly 1 in 200 Americans, with the typical opiate addict being an upper-class or middle-class white woman. Due to the demographic, however, the situation was treated more as a scandal than a crime, and it was not until advances in medicine, public health, and sanitation, as well as the debut of pain relievers such as aspirin in 1899, did doctors begin to slow and reverse the overuse of opiates. Conceptualising pain as a medical condition became criticised, with doctors who reached for the hypodermic needle to administer morphine as a quick solution deemed lazy, unintelligent, and often reckless.

As middle- and upper-class opioid addiction began to wane, a new user who could be more readily demonised emerged as the face the addict in the early 20th century. Low-class white urban males and Chinese immigrants who engaged in opium smoking and smuggling encouraged a less-sympathetic approach to opioids, and the import of opium was banned in 1909 while possession was criminalised. The Harrison Narcotics Tax Act passed in 1914, further restricting the availability and consumption of opium, and so America increasingly associated opiates with the underbelly of society once the narrative had been shifted to a more unfavourable demographic.

As such, there remained cautiousness regarding opioids amongst American medical professionals throughout the 20th century, with a widely held perception that the long-term use of opioid therapy to treat chronic pain was contraindicated by the risk of addiction, increased disability and lack of efficacy over time. It took almost a century before pharmaceutical companies were able to broach the topic of opioid usage in medical fields again, with many of the same characteristics of overzealous prescribing, painting medicines as panacea to illness, and lax attention on the demographics most affected due to not fitting stereotypes of drug users. However, this time, a more insidiously commercial element played a significant role in the spread of opioid use and abuse.

Further reading:

  1. DeWeerdt, S., 2019. Tracing the US opioid crisis to its roots. Nature, 573(7773), pp.S10-S10.

  2. Manchikanti, L., Sanapati, J., Benyamin, R.M., Atluri, S., Kaye, A.D. and Hirsch, J.A., 2018. Reframing the prevention strategies of the opioid crisis: focusing on prescription opioids, fentanyl, and heroin epidemic. Pain physician, 21(4), pp.309-326.

  3. Louis Theroux, 2018. Dark States: Heroin Town. BBC. https://www.bbc.co.uk/programmes/b0991fsb