A country divided by ideology over slavery and the federal government’s role in prohibiting it led to America’s Civil War of 1861-1865 and a devastating loss of 625,000-750,000 lives. Long after rain washed away the blood of thousands of fallen soldiers at Gettysburg, Shiloh, Chancellorsville, Antietam and dozens of other battlefields, the nation was left with maimed veterans suffering from horrific injuries, amputations and chronic pain. Although the Civil War sparked an opioid epidemic rivaling the one America is currently experiencing, the use of morphine to treat sick and wounded soldiers harkens back to the American Revolution. As Alexander Hamilton lay dying from fatal wounds incurred in his duel with Aaron Burr, his doctor prescribed laudanum, a tincture of opium (codeine and morphine) mixed with alcohol.
The 19th Century Opioid Epidemic
The Union Army alone issued nearly 10 million opium pills to its soldiers in addition to 2.8 million ounces of opium powders and tinctures. The hypodermic syringe was introduced in the U.S. five years prior to the onset of the Civil War, in 1856. Thousands of Civil War soldiers wounded during combat or fallen ill in camps, were prescribed opium or morphine for the first time in field hospitals during the war. Many soldiers returned home from the war with gruesome amputations and narcotic addictions. One Union soldier who endured brutality at the infamous prison camp Andersonville wrote about opioid withdrawal symptoms when he tried to quit cold turkey. “No tongue or pen will ever describe … the depths of horror in which my life was plunged at this time; the days of humiliation and anguish, nights of terror and agony, through which I dragged my wretched being.” This soldier’s description is akin to the agonizing symptoms associated with what’s known today as acute withdrawal, which is often followed by post-acute withdrawal syndrome. It wasn’t only soldiers who became addicted to opioids. Heartbroken families turned to drugs to cope with the devastating loss of husbands, sons, brothers and fathers, especially hitting southerners hard after defeat and the loss of wealth after the fall of the Confederacy. In his book Dark Paradise: A History of Opiate Addiction in America, author David T. Courtwright wrote, “Even if a disabled soldier survived the war without becoming addicted, there was a good chance he would later meet up with a hypodermic-wielding physician.” Although morphine was not a cure, it was found to be an effective method for dulling all types of pain. In its most potent form, laudanum was widely used to treat lung diseases such as tuberculosis and in the Civil War to facilitate amputations. In its milder form, it was commonly prescribed for insomnia, colds and coughs in infants and adults. Alarmingly, laudanum was responsible for 236 infant deaths in a four-year time period in the late 1800s. From the 1840s to 1890s, opiate usage in the U.S. rose by 538%. During the 1890s, the Sears & Roebuck catalog offered a syringe and a small amount of cocaine for $1.50. By 1895, the wide use of morphine and opium powders led to about one in every 200 Americans getting addicted to opioids, which equates to an estimated 344,500 people. It is estimated 60% of those addicted were women.
America’s War on Drugs
Most people associate America’s war on drugs with modern times, but it began in the late 19th to early 20th century. By the late 1890s, most medical school curriculums included education about the dangers of opiates. Bayer introduced heroin in 1898 to treat respiratory illness and it was often available without a prescription, which led to another upsurge in addiction. The following year they introduced aspirin commercially and many doctors realized it was the safer option for common aches and pains. In 1909, a bill passed Congress to ban the import of opium, which by now was burgeoning due to the proliferation of opium smoking dens in most major cities and Western towns. The shift from a painkiller narcotic to a recreational drug played a part in changing the nation’s view on opioids. The Harrison Narcotics Tax Act of 1914, which went into effect in March 1915, was enacted to more strictly regulate the distribution of cocaine and opium-based drugs. According to Courtwright, the use of opioids had already been declining for about 20 years. And by 1920, the U.S. had succeeded in reducing the number of Americans addicted to opioids to less than two in every 1,000 people.
The Current Opioid Epidemic
The onset of the current opioid epidemic is blamed in part on Purdue Pharma launching aggressive targeted marketing campaigns starting in 1995, stating OxyContin (oxycodone) was not addictive. Increased prescription of opioid medications led to widespread misuse of both prescription and non-prescription opioids before evidence showed these medications were highly addictive. The number of prescription opioids (e.g., oxycodone and hydrocodone) sold to pharmacies, hospitals and doctors’ offices nearly quadrupled from 1999 to 2010. By 2016, opioid overdoses reached a new high of more than 42,249 deaths, with an estimated 40% involving a prescription opioid. Of 948,000 people who used heroin in 2016, 170,000 were first time users and the drug was linked to 15,469 overdose deaths. On a positive note, misuse of all prescription opioids has been declining in 12th graders, with a 2017 prevalence of 4.2% versus 9.5% in 2004. Unlike the early 19th century, today we are armed with sophisticated medicine, technology and science, robust clinical research, the knowledge addiction is a chronic disease and lessons from the past. Preventing overdose deaths, access to addiction treatment and preventing new addictions are only parts of the equation. While it’s essential to punish drug dealers, history tells us ostracizing and punishing users is not the solution. And it’s also unfair to cut off all prescription opioids from people suffering from severe, debilitating chronic pain syndromes. Developing less addictive, efficacious alternatives could help, but solutions to this problem need to address all of the contributing factors.