Origins of an Epidemic

The views expressed in this piece are my own and it should be noted that this is a piece of opinion. In order to better understand how the opioid epidemic got to where it is today a lot can be learned from the drugs past. All opioids are derived (or synthetically created) from Opium. People have been using opium for centuries. Since ancient times not much changed until the early 1800s when German pharmacist Friedrich Sertürner isolated morphine from opium. Hailed as a miracle drug; morphine was used to treat everything from pain, anxiety and respiratory problems to constipation and feminine cramps. By the mid-1850’s morphine had made its way to the US. The drugs addictive properties went unnoticed and it grew in popularity until sometime post-1865, after the Civil War. Our country’s first Opioid Crisis was recognized when tens of thousands of soldiers came home addicts.

Recreational use of morphine was on the rise and with the growing number of addicts Bayer Pharmaceutical Company set out to find a new, less addictive, morphine. Near the end of the 19th Century, Bayer scientists settled on heroin (the drug was discovered sometime earlier, however, Bayer led in its commercialization). Which, interestingly, is an acetylated form of morphine one and a half to two times more potent than morphine itself.

In 1908, recognizing a problem, and riding a populist wave fresh off being elected to his second term as president Teddy Roosevelt appointed Hamilton Wright, to be the countries first Opium Commissioner. I hope to find more information on Dr. Wright and what he accomplished, unfortunately, it’s proving difficult to track down information. From what I can tell he’s basically the original Nancy Reagan, a cheerleader in opposition to using. I imagine Dr. Wright played some role in Congress passing the Opium Exclusion Act in 1909. Making it illegal to import opium for the purpose of smoking. The countries first major drug policy followed the Harrison Narcotics Tax Act of 1914 which required physician and pharmacist registration for the distribution of opioids and put a tax on them. The first major steps in the regulation of this drug classification and the government profiting from their distribution. *It’s worth noting the government did, however, begin taxing opium in 1890.

Despite the government’s efforts, by the 1920s the number of opiate-addicted Americans had reached an all-time high. To combat this, the government passed the Heroin Act in 1924 banning the substance nationwide and doctors began only prescribing opioids to the dying with acute pain rather chronic issues. After a few years, the country returned to normalcy and life went about its merry way without much change for the next 60 years outside of two exceptions. Spoiler alert: war tends to lead to addiction. The first one began after World War II and the second began during the latter part of the Vietnam War. Both drug crises lasted roughly ten years.

It’s my opinion that we started to see a shift by the medical field regarding the perception of pain management in the 1980s. Here are some of what I attribute to this changing of beliefs: The American Pain Society begin advocating for more readily available, non addictive, pain relief; Percocet and Vicodin became approved by the FDA; The Joint Commission on Accreditation of Healthcare Organizations begin developing a performance monitoring system, The Indicator Measurement System, for healthcare providers; and the Wong-Baker Faces Pain Rating Scale (WBFPRS) and was developed in 1983. Have you ever been to the doctor and wondered where in the hell the smiley faces of pain came from? It’s called the Wong-Baker Faces Pain Rating Scale. These events set the stage for the adaptation of pain as the fifth vital sign in medicine.

As I’ve mentioned, up to this point in American medicine opioids, Oxycodone included, were prescribed only for the acute pain of terminal patients.  Purdue Pharma combined oxycodone with a time-release ingredient, making OxyContin the only opiate that offered multiple hours of pain relief. In 1995 the FDA approved the drug. The love child of capitalism and Purdue Pharma, America’s current opioid epidemic was born in 1995. Purdue spent two hundred seven million dollars on OxyContin marketing in 1998. This is the year shit hit the proverbial fan. Patrick Radden Keefe of the New Yorker, in his October 30, 2017 article “Empire of Pain”, had this to say about the sales campaign:

A major thrust of the sales campaign was that OxyContin should be prescribed not merely for the kind of severe short-term pain associated with surgery or cancer but also for less acute, longer-lasting pain: arthritis, back pain, sports injuries, fibromyalgia. The number of conditions that OxyContin could treat seemed almost unlimited. According to internal documents, Purdue officials discovered that many doctors wrongly assumed that oxycodone was less potent than morphine—a misconception that the company exploited.

Patrick Radden Keefe

And the rest, as they say, is history. From 1997 to 2002 the following opioids saw the following increases: morphine prescriptions by 73%, Hydromorphone by 96%, Fentanyl by 226%, and Oxycodone by 402%. To recap: our species utilized the natural forms of opium relatively unchanged for thousands of years until 1806 when German chemist Friedrich Wilhelm Adam Sertürner isolated morphine (named after Morpheus, the god of dreams). Following the conclusion of the Civil War in 1865, there were all sorts of newfound junkies running around and the problem of opioid addiction grew too large to continue turning a blind eye towards. In the early 1900’s Bayer began producing heroin as a safe alternative to morphine (truth’s stranger than fiction, I know). Uncle Sam took an interest over the early part of the 20th century and present-day drug policy was enacted. Over the next 60 years there were two significant spikes in opiate use, both corresponding with times of war, but for the most part, everything was hunky dory for over half a century. In the 80s opinions begin changing in regard to pain management, creating the perfect storm for Purdue Pharma’s miracle drug Oxycontin.

Sources/Additional Readings

Opium: Origin and History

Michaels House: History of Oxycontin

The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy

The fifth vital sign: A complex story of politics and patient care

From Teddy Roosevelt to Trump: How drug companies triggered an opioid crisis a century ago

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