The opioid crisis is not new. People in Italy were growing opium poppies 7,500 years ago. Opium is mentioned in the writings of both Egypt and Sumeria. It was well known to both Hippocrates and Galen of Greece. Its uses may have been lost in Europe after the fall of Rome, but it was described in detail by the Islamic physician Avicenna about 1000 A.D. Paracelsus may have reintroduced the use of opium to Europe about 1500. Sydenham developed laudanum, a liquid tincture of alcohol and opium in 1669.
The modern era of narcotics began in 1804 when Friedrich Serturner isolated morphine from opium. The invention of the hypodermic syringe and needle allowed more accurate dosing .
The first American opioid crisis came in the aftermath of the American Civil War. The rifled musket and the Minie ball inflicted terrible injuries on soldiers of both sides. Aseptic surgical technique had not yet been developed. Infections were more likely than not. Wounds to the extremities required amputation. Anesthesia was frequently not available, so surgeons usually had to value speed over meticulousness. Phantom limb pain was common.
The wounded veterans often had chronic pain and became addicted to narcotics, often injected morphine. No drugs were controlled then, so they were freely available at the pharmacy. By 1900 there were perhaps 300,000 opiate addicts in the United States. The total population was 75 million, compared to 330 million today.
Many were addicted to “patent medicines,” like Coca Cola and Dr. Pepper, which did not have to list their ingredients. Surveys taken in the late 19th century showed that two-thirds of those addicted to medicinal opiates were female. The passage of the Pure Food and Drug Act in 1906 changed all of this. Patent medicines that contained morphine and cocaine became much less popular. Many, like Coca Cola, removed the psychoactive ingredients. Others disappeared from the market.
Despite the decrease in narcotic usage over the previous eight years, the Harrison Narcotics Act was passed in 1914. This established the current system of controlled substance regulation.
The current crisis began as an academic exercise. In the 1970s, pain management became a component in Anesthesiology departments at university medical schools across the country and the world. At the time, chronic narcotic prescriptions were reserved for the terminally ill, usually cancer patients. Patients with lower back pain usually received anti-depressants after an initial narcotic regimen. Physicians who wrote too many narcotic prescriptions were often disciplined by their state medical boards.
The new pain management specialists advanced the theory that pain had been under-treated for a century. That early treatment of pain would reduce chronic pain. They based this view on rat studies and the cardiac surgery experience. Rats continue breathing even if given large doses of narcotics. Anesthesia for cardiac surgery had come to rely on high doses of narcotics to blunt the “stress response.” They told the Joint Commission on the Accreditation of Hospitals that pain should be seen as the “5th vital sign.” In 2003, the Joint Commission concurred. The new standards required pain scales and threatened physicians who did not provide sufficient treatment with disciplinary procedures.
Unfortunately, this all proved incorrect. Unlike rats, humans will quit breathing when given narcotics. Cardiac patients are ventilated until the narcotics wear off. Worse, there is now much evidence that chronic use of narcotics reduces the pain threshold. It’s not just a question of tolerance, people who have received narcotics feel more pain with time.
What is to be done? I don’t even pretend to know. But the first thing to do is to stop telling the people that their suffering can be permanently relieved with narcotics.
Julian Mardock is a native Texan and retired physician.