One hundred and thirty people die from an opioid overdose every day in the United States. Lawmakers and public health officials work hard to get people who struggle with opioid addiction into treatment programs and to prevent people from beginning to abuse opioid drugs in the first place.
Heroin and fentanyl are two of the most abused and dangerous opioids, currently leading the epidemic in the country. But where did these drugs come from?
We will cover the history of opiates and the history of opioid addiction below.
The Opioid Addiction and Overdose Epidemic Has a Long History
Many people point to loosened prescribing practices in the late 1990s as the root cause of opioid addiction and overdose. For many, this is where the history of the opioid epidemic starts. Pharmaceutical companies developed new prescription painkillers like OxyContin, Percocet, and Dilaudid. They allegedly convinced doctors to prescribe narcotic painkillers to more people with less severe types of pain.
Due to the opioid abuse epidemic in the 1970s, doctors had spent decades tightly guarding opioid prescriptions and only giving these drugs to people with severe or chronic pain problems. In the 1990s, more doctors started exploring the possibility of prescribing smaller doses of allegedly less addictive types of opioid drugs to treat pain that was expected to go away in a few months, like pain from an injury or after surgery. This is the beginning of the history of the opioid crisis in the United States.
Unfortunately, greater access to prescription narcotics led to higher rates of abuse around the nation.
Opiate drugs have almost always been both a boon and a detriment. In the thousands of years since people first harvested opium from poppies, scientists have learned a few things about how to safely prescribe these drugs and how to safely overcome addiction to these chemicals.
These higher rates of abuse have also brought about more drug overdoses, firmly rooting the United States in a public health emergency that has been fighting for years now.
The National Institute on Drug Abuse (NIDA) says increased drug availability is linked to use and overdose. It cites data that shows during the 20-year period from 1991 to 2011, U.S. pharmacies nearly tripled the rate of opioid prescriptions dispensed. The number went from 76 million prescriptions to 219 million in that time. NIDA also writes, “In parallel with this increase, there was also a near tripling of opioid-related deaths over the same time period.”
In 2017, nearly 58 opioid prescriptions were written for every 100 people in the U.S., according to the CDC. It also notes that more than 17% of Americans had at least one opioid prescription filled that year.
According to data in a 2013 report from the U.S. Centers for Disease Control and Prevention (CDC), drug overdose deaths have increased five-fold since 1980. The report says 2009 is the year where drug overdose deaths outnumbered motor vehicle crash fatalities in the United States. It also reports that opioid analgesics have been increasingly involved in drug overdose death over the past decade.
Prescription Drug Monitoring Put Into Place
Overprescribing has been identified as a contributing factor to opioid-related overdoses. The CDC’s report said oversight to curb improper prescribing practices has been lacking.
In recent years, guidance for prescribing opioid medications was put into place due to the history of opioid addiction in the U.S. All U.S. states also have a prescription drug monitoring program (PDMP). According to this report from the CDC, U.S. counties with a higher opioid supply and higher prescribing rates include those that have:
- Smaller cities or larger towns
- More white residents
- More primary care physicians and dentists per capita
- Higher numbers of people who have no insurance or a job
- Have more residents with diabetes, arthritis, or a disability
These programs monitor opioid prescriptions and medical professionals’ prescribing practices to track which medications are going where in each state. PDMPs are also designed to protect patients who may not be aware their doctor gave them too much of an opioid medication.
The CDC says that although results have been mixed so far, PDMPs are promising tools to fight unscrupulous prescribing practices.
Ancient Civilizations and the Opium Poppy
Opium is a naturally occurring chemical found in certain types of poppies that forms the basis for synthetic opiates like oxycodone, hydrocodone, heroin, fentanyl, and morphine.
The first recorded uses of opium go back to ancient Mesopotamia, a civilization dating back to about 3400 BC, centered on the Tigris and Euphrates rivers in the Middle East. Even in that era of human civilization, opium was used as a painkiller and sleep aid, but it was also well-known to be a substance of abuse. The Sumerians, a civilization in the same area during the same time, referred to the milky white sap of the poppy as the joy plant.
Through trade, cultivation of the opium poppy spread to other ancient cultures, including the Persians, Egyptians, and Greeks. During the reign of Pharaoh Tutankhamen, from 1333 BC to 1324 BC, opium abuse was widely popular among the upper classes. Homer refers to the drug’s healing powers in The Odyssey.
Opium use was well documented as a leisure or recreational activity, a drug treating sleep and pain problems, even in children, and a dangerous substance of abuse. The drug was also employed as an early form of anesthesia in ancient surgeries.
China and East Asian countries were introduced to opium first through the Silk Road, around the sixth or seventh century CE. While the British East India Company reintroduced the drug as an addictive, recreational substance later, its first introduction started some opium production in this area of the world. Afghanistan, Pakistan, northern India, Myanmar, and Thailand still produce much of the world’s supply of opium.
By the 18th century, the British Empire had conquered India as well as some of the Middle East and Southeast Asia. This gave the country, primarily through the East India Company, access to opium production.
The corporation smuggled opium into China from where it was manufactured in India, leading to rampant problems with addiction throughout the Chinese Empire. The epidemic nearly toppled the Chinese government and led to huge profits for Britain in the form of silk, porcelain, and tea. The increased trade led to even more opium production in China itself, which the Qing Dynasty attempted to squash by outlawing opium dens and use of the drug altogether.
After the Qing Dynasty attempted to stop China’s struggle with opium addiction, Britain tried to keep illegal opium trafficking routes open, leading to the First and Second Opium Wars. China lost both of these conflicts, leading to the British forcing the Chinese to keep several ports open to trade with Europeans and the concession of Hong Kong to British rule.
As several Chinese workers emigrated to the United States in the 19th century to find work, primarily in railroad construction and the Gold Rush, they brought the habit of smoking opium with them. This led to the rise of opium dens across California. This habit transferred to many Americans, but it was not the only source of opiate abuse in the U.S.
Opiate Use Rates in the United States
Currently, Americans abuse most of the world’s supply of synthetic opiates, called opioids. The numbers vary based on which opioid is being measured. Statistics show that Americans consume about:
- 57.3 percent of morphine in the world, as of 2013
- 81 percent of oxycodone in the world, as of 2008
- 99 percent of hydrocodone in the world, also in 2008
- 29.3 percent of the global supply of fentanyl, in 2015
- 30 percent of the global opiate supply in general
While prescriptions for many new opioid drugs, like codeine, hydrocodone, and oxycodone, have decreased since 2014 due to dramatic changes in prescribing practices, regulation, and laws, people in the U.S. are more likely to be exposed to potentially addictive prescription narcotics compared to those in many other countries.
Heroin purity is variable across the world, but the U.S. gets much of the world’s purest heroin. Since 2000, the price of very pure heroin in the country has fallen. This correspondence with the current rise in opioid prescriptions has led to a severe problem with heroin addiction and overdose. But why is heroin such a widely abused synthetic opiate across the nation?
Morphine is still a prescription opioid painkiller, but it was the first opioid drug synthesized from opium in 1803. This synthetic narcotic was intended to take the opium poppy’s pain-killing properties and isolate them, reducing the risk of addiction.
The drug became popular among doctors during the U.S. Civil War. Prescribing morphine to soldiers with severe wounds and chronic pain led to the young country’s first opioid addiction epidemic. An estimated 400,000 soldiers abused the substance, and many died of overdoses as a result.
Since morphine was found to be so dangerous, chemists began the search for a useful drug that could treat pain like morphine, but that was potentially less addictive. In 1874, researchers at pharmaceutical giant Bayer synthesized heroin and believed that its faster action on the brain would be less addictive than morphine. If the drug hit the brain quickly and was then metabolized out quickly, it could treat surges of pain without leading to substance abuse, according to theories.
Unfortunately, the opposite was found to be true very soon after heroin was introduced to the United States. Because opiates can suppress coughing, create a calm relaxation, ease sleep, and ease pain, heroin was quickly put into cough syrups, early anxiolytics, and drugs to treat sleep disorders. Since many of these substances were available in the 19th century without a prescription, heroin addiction spread rapidly across the country.
The steep rise in heroin abuse and addiction led to some of the first drug control laws in the U.S.
President Theodore Roosevelt appointed Dr. Hamilton Wright as the first Opium Commissioner position in the nation.
Wright becomes the first person in the U.S. to claim that the nation consumes most of the world’s opiates.
The Harrison Narcotics Act was passed, which banned heroin from any prescription or over-the-counter medication. The act also restricts the sale of opium and cocaine.
A social movement among doctors leads to restrictions within the profession against prescribing heroin, although there are no boards or local laws that require this.
Heroin abuse still ravages communities across the country, leading to the Anti-Heroin Act, which entirely bans the import or sale of the opioid.
With less heroin available in drug stores or through prescriptions, the epidemic slowed down. There were still reports of heroin, morphine, and opium abuse across the country, but medical practitioners turned toward other substances or approaches to pain management. Different types of anesthesia and painkillers were developed, including novocaine and related drugs around World War II.
However, heroin abuse rose again during the 1950s and 1960s. The return of this opioid, and its quick spread to other countries like Britain, led to the development of epidemiology, the study of addiction in populations and subgroups as a “socially infectious condition.”
During the same period, addiction also became better understood in the modern psychiatric community as a behavioral or mental condition, leading to improvements in treatment approaches that became prevalent in the 1970s.
Substance abuse of all kinds rose dramatically in the 1970s — not just abuse of heroin, but also abuse of marijuana, LSD, and cocaine. This led President Gerald Ford to create a task force to study the issue and recommend solutions.
The Release of Major Prescription Painkillers
During the 1970s, pharmaceutical companies released Percocet and Vicodin, with the active ingredients of oxycodone and hydrocodone, respectively.
As the task force created recommendations, methadone clinics became prominent treatment centers for people struggling with heroin addiction. The Controlled Substances Act (CSA) went into effect, and doctors were much less likely to prescribe new narcotic painkillers for fear of contributing to the opioid abuse epidemic.
Methadone to Treat Heroin Addiction
Methadone is a long-acting, full opioid agonist that can be abused, but it was one of the country’s first approaches to medication-assisted treatment.
The drug was synthesized in 1937 in Germany. After World War II, the medication became widely popular as other anesthetics were less available due to rationing and shortage.
It was introduced to the U.S. in 1947 as a pain reliever for several ailments, but prescription use did not take off until 1964 when methadone’s use in withdrawal management was proven.
By 1971, methadone use to manage heroin withdrawal became popular. Clinics expanded across the country to help those suffering from heroin addiction to overcome the problem with therapy and a slow tapering approach using methadone.
Birth of the Modern Epidemic
While doctors were cautious with opioid prescriptions throughout the 1970s and 1980s, other medical researchers began to argue for a broader application of these medications in pain treatment.
One notorious 11-line letter published in 1980 in the New England Journal of Medicine began the pushback on opioid prescriptions, arguing that only about one percent of patients treated with these medications suffered from addiction or patterns of abuse later. At the time, opioid drugs were primarily used in the treatment of chronic pain, so most of the subjects had to receive prescription painkillers long term or even for the rest of their lives.
In 1996, Purdue Pharmaceuticals started testing OxyContin, a high-dose, long-acting oxycodone painkiller. This is considered the beginning of the modern opioid addiction and overdose epidemic.
In the next few years, Purdue pushed doctors to prescribe OxyContin to manage pain from injuries or surgeries rather than just to treat chronic pain. Between 1995 and 1996, prescriptions for all narcotic painkillers rose by eight million, almost quadruple the rates of the previous decade. After Purdue’s promotional video for OxyContin came out in 1998, prescriptions for opioid painkillers, especially OxyContin, rose by 11 million.
A Tipping Point
By 2010, state laws, federal regulations, and doctors’ prescribing practices all caught up to the problem of prescription opioids. However, heroin abuse began to rise that year, which doctors have less direct control over.
The National Institute on Drug Abuse (NIDA) and other medical organizations tie the tighter control of oxycodone and hydrocodone to the switch from prescription opioids to heroin abuse, but the link is still primarily correlation, not causation. NIDA notes:
- Between 21 and 29 percent of people who receive opioid painkiller prescriptions misuse these drugs.
- Between eight and 12 percent of people with opioid painkiller prescriptions develop an addiction to the substance.
- Approximately four to six percent of people who develop an addiction to prescription painkillers transition to heroin abuse.
- About 80 percent of people who report abusing heroin stated that they started abusing prescription opioid drugs first.
Prescription narcotics are still involved in high rates of opioid abuse and overdose, but according to the U.S. Centers for Disease Control and Prevention (CDC), heroin and fentanyl are the two most abused and the two deadliest substances associated with the current problem.
Fentanyl: The Leading Cause of Opioid Overdose Death
Fentanyl was developed as a potent prescription painkiller, used only in people with chronic pain who developed a tolerance to other opioid painkillers. This medication is 100 times more potent than morphine and about 80 times more potent than heroin.
Prescription versions include Duragesic, Sublimaze, and Actiq.
Since 2014, illicit fentanyl production has been on the rise. The drug is found in several illegal substances, most often mixed into or sold instead of heroin.
Between 2014 and 2015, there was a 194 percent increase in the rate of fentanyl found by law enforcement or involved in opioid overdoses. The drug’s rising presence in the country was associated with a 73 percent increase in opioid overdose deaths in that same time. By 2017, 59 percent of opioid overdose deaths involved fentanyl compared to 14.3 percent in 2010.
Fentanyl is more likely to be produced by clandestine laboratories in China and Mexico, according to the U.S. Drug Enforcement Administration (DEA), and then shipped to the U.S. Very few reports of fentanyl abuse involve prescription diversion or theft.
Many people who take drugs cut with fentanyl or take fentanyl, thinking it’s heroin or cocaine, often do not know it until it is too late. They usually will suffer permanent injury or death as a result of the drug being added to heroin, cocaine, and even marijuana. It can be in any street drug, including designer drugs like MDMA and ecstasy. Users are taking a risk every time they use these drugs. There are strips available to test a substance for fentanyl.
According to a National Public Radio (NPR) report, how likely fentanyl will show up in cocaine depends on where someone lives as well as what’s making the rounds at the time. Still, it’s unclear if the rise in cocaine and synthetic opioid-related deaths resulted from people using drugs cut with fentanyl or if they used more than one substance and that one of those substances was tainted with the potent opioid. Polysubstance use is common on the recreational drug scene. More research is needed on how tainted drugs land in recreational users’ hands, NPR says.
Evidence-Based Opioid Addiction Treatment
Medical science has many approaches to opioid addiction treatment.
The first step is to be assessed by a doctor and get help from a detox program that offers medication-assisted treatment (MAT). The three drugs available in MAT for opioid detox are:
- Buprenorphine, a partial opioid agonist, approved by the U.S. Food and Drug Administration (FDA) in 2002
- Methadone, which is still used in managing long-term, high-volume heroin abuse
- Naltrexone, a drug that reduces cravings and helps to reduce the risk of relapse after detox
Unlike some other approaches to addiction treatment, withdrawal from opioids using MAT can take months, so you will enter rehabilitation for behavioral therapy as you are slowly tapering from opioid dependence using buprenorphine or methadone.
You will continue therapy after your body has stopped relying on opioid drugs to feel normal. Then, when rehabilitation is complete, you will have an aftercare plan, which may include mutual support groups, regular doctors’ visits, and a strong support network.
Opiate abuse has a long history in the United States, but there are many evidence-based ways to treat this issue.