Mon. Jul 4th, 2022

America’s opioid epidemic began more than a century ago – with the civil war

An estimated two million people abused opiates during the war, after using drugs disseminated by healthcare providers, doctors and nurses to stem pain.


Five Union army officers in a field outside Fairfax, Virginia in June 1863.
 Five Union army officers in a field outside Fairfax, Virginia, in June 1863. Photograph: Alexander Gardner/Getty Images

For many Americans, it was the prescription of a well-meaning physician that sent them down the dark road.

Aggressive marketing and over-prescribing of painkillers touched off a scourge of opiate addiction and Congress, pushed by the destruction it had wrought, introduced a new law to reform painkiller prescribing.

It was 1915 and Congress was considering what would become the first law to criminalize drug use, the Harrison Narcotic Act. By this time, addiction had already touched middle-class housewives, immigrants, veterans and even physicians hoping to soothe their own aches and pains. Between the 1870s and 1880s, America’s per capita consumption of opiates had tripled.

More than a century later, Americans are fighting some of the same demons.“I freely admit that I did not expect another wave of medical opiate addiction in my lifetime,” said David Courtwright, a professor of history at the University of North Florida, and an expert on the history of drug use in the US.

“It’s similar in the sense that millions of Americans who are suffering from chronic painful conditions have become addicted to opium-based medicines or their synthetic equivalents,” said Courtwright. “But there’s also a difference,” he said. “Medicine today is very sophisticated, pharmaceutical marketing is very sophisticated … There’s nothing like Purdue Pharma in the late 19th century,” Courtwright said.

Courtwright was referring to the maker of Oxycontin. Purdue received Food and Drug Administration approval of Oxycontin in 1995, a move which many believe kicked off the wave of opioid abuse gripping America in the 21st century.

Since 1999, more than half a million Americans have died of drug overdoses. Recent data shows the trend accelerated in 2016, when 63,600 people were killed by overdoses and the rate of Americans dying increased by 21%.

Declaring America’s overdose epidemic a public health crisis, Donald Trump told a White House audience in October: “Nobody has seen anything like what is going on now.” But experts dispute that characterization.

“I think we see history repeat itself,” said Anna Lembke, an addiction expert and behavioral scientist at Stanford University. “Increased opioid use during the civil war was first and foremost disseminated by healthcare providers, nurses and doctors, who were trying to stem the pain of wounded soldiers. That gave way to a pandemic of opioid addiction.”


A pharmacist counts pain medication at a South Portland Pharmacy on 19 February 2014.
 A pharmacist counts pain medication at a South Portland Pharmacy on 19 February 2014. Photograph: Portland Press Herald/Getty Images

Richard Heimer, a professor of epidemiology and pharmacology at the Yale University School, said there were an estimated two million people who abused opiates. “It did come to be called, immediately after the civil war, morphonism or soldier’s disease,” he said.

However, Courtwright warns veterans were not the only people afflicted by addiction in the late 19th century.

“No precise estimate exists for the number of addicted veterans; we can be sure, however, they comprised a minority of overall opiate addicts,” he wrote in the Civil War Veteran: A Historical Reader. With easy access to morphine and syringes, physicians used; white gamblers and sex workers often smoked opium; and respectable white women used laudanum for menstrual cramps.

“There was a massive opioid epidemic after the civil war,” said Robert Heimer, a professor of epidemiology and pharmacology at Yale University School of Public Health. “Except is wasn’t a black market – it was a perfectly legal market filled with patent medicines that contained not just cocaine and opiates, morphine mostly, but also alcohol.”

Laudanum, Heimer said, “was commonly taken as a relief of colds, coughs, and in stronger form was particularly good for lung diseases such as tuberculosis, which was common at the time, in addition to being widely used in combat situations to facilitate amputations”.

Where Purdue Pharma marketed Oxycontin to doctors as a “continuous around-the-clock analgesic” formulation of semi-synthetic oxycodone great for chronic pain, Mrs Winslow’s Soothing Syrup marketed morphine and alcohol to parents as a “perfectly harmless and pleasant” way to produce “quiet sleep, by relieving the child from pain”.

History, Courtwright said, offers some “grounds for optimism”. Beginning in the 1890s, physicians began to criticize colleagues who reached for the prescription pad when patients had aches and pains; pharmacists refused to sell heroin or cocaine (then both legal); and in 1906 muckraking journalists and campaigners successfully argued for reforms to end the sale of patent medicines.

By 1915, Courtwright argues in the New England Journal of Medicine, “the Harrison Act closed the barn door after the horse was back in”. Problematically, the Harrison Act also became the first law to criminalize drug use and opiate maintenance therapies, such as methadone and buprenorphine.

That stigma stuck. Despite double blind clinical trials showing the efficacy of methadone, abstinence-based 12-step programs are still much more common in the US, and politicians have so far failed to find the courage to fund such evidence-based treatments.

Waves of addiction have also hit the US since 19th century – adulterated alcohol killed thousands during the 1920s Prohibition era; barbiturates and amphetamines were abused in the 1930s and 1940s; heroin addiction claimed lives in the 1960s; valium addiction in the 1970s.

“The problems of globalization and loss of prestigious jobs have damaged community wellbeing in areas that were previously spared from the kind of malaise that led to large-scale opioids use in the inner cities in the 60s and 70s,” said Heimer. “The lessons are that community disadvantage and community alienation sets the stage for youthful experimentation to turn into tragedy.”



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