Epidemics of opioid use are old news in the United States, but an epidemic that kills over 200,000 Americans is not. A multiplicity of intertwined factors have brought us to this place. From 30,000 feet, it is the story of good intentions gone bad, a drug industry gone rogue, and government watch dog agencies gone to sleep. At ground level, it is the story of physicians unfamiliar with addictive drugs and drug addiction, new long-acting opioids deceptively marketed, cheap black tar heroin, encouragement to use opioids for chronic noncancer pain by professional organizations with conflicts of interest and without science, a culture intolerant to pain and tolerant to drug use, and the greedy response of the pharmaceutical industry and drug cartels to an expanding market opportunity. These factors are among those that have joined to form a tsunami of addiction and deaths that keeps on coming. A better understanding of them could speed the end of the present cycle of opioid abuse, perhaps prevent others, and inform future decisions about pain management.
Introduction
The current American epidemic of opioid-related deaths began in the 1990s and has resulted in over 200,000 deaths.1 The average American does not know who to blame (Figure 1).2 The only systematic review on causation suggests that the factors are multiple, intertwined, and frequently changing (Table 1).3 That review determined that physician behavior is clearly one of them. This paper reviews backstories on some factors that help inform our response as physicians.
America’s Long Tarantella with Opioids
Extracts of the poppy plant have been used for medicinal purposes since the Sumerians named it the “joy plant” 5000 years ago. By the time of the American Revolution, an alcohol-based tincture of 10% powdered opium called “laudanum” was widely prescribed in the United States and many became addicted. Morphine was isolated from opium about 50 years before it caused “Soldier’s Disease,” an epidemic of addiction during the Civil War.4Bayer Pharmaceuticals marketed heroin in 1874 as an analgesic and claimed it was less addictive than other opioids, claims made about the new opioids to follow. During this period, opium, heroin, and cocaine were used in over-the-counter patent medicines and sold over the counter in “emergency kits” equipped with hypodermic syringes and needles (Table 2). By 1925, there were an estimated 200,000 heroin addicts in the United States.
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-Richard D. deShazo, MD, McKenzie Johnson, BS, Ike Eriator, MD, Kathryn Rodenmeyer, BA
This article originally appeared in the June issue of The American Journal of Medicine.
