In January 1889, The British Journal of Psychiatry published a letter said to have been written by a “young lady laudanum-drinker” to her doctor. The writer tells of taking laudanum, a tincture of opium, to cure her insomnia, then of her resulting torpor, desperation for more doses and (horrifying, by Victorian standards) indifference to housework. Finally, she describes quitting (“I don’t like owning to bodily suffering, but will not deny that I suffered”) before chastising the doctor and his colleagues for allowing this to happen.
“You doctors know all the harm those drugs do, as well as the ‘victims’ of them, and yet you do precious little to prevent it,” she wrote.
It’s a letter that could have been written about the opioid epidemic of today. Driven by a massive overprescription of opioid painkillers that is only now being reined in, the opioid epidemic claims 91 American lives each day, according to the Centers for Disease Control and Prevention (CDC). It’s the deadliest drug epidemic in history, thanks to the potency and the type of drugs involved. But the epidemic today parallels the laudanum and morphine overuse outbreak of the late 1800s in many important ways, even sharing some of the same causes and racial disparities — and perhaps offering lessons on how to rein in addiction.
Opioids are any drug that acts on the opioid receptors in the brain, spinal cord and digestive tract. Natural opioids, like morphine or heroin, come from the gum of the poppy (Papaver somniferum). There are also synthetic opioids, molecules assembled in laboratories, like the powerful drug fentanyl.
Opioids relieve pain while creating a pleasant sense of euphoria. Unfortunately, they also bind to opioid receptors in the brain stem that help coordinate breathing.
“Opioids are very dangerous because they operate on the part of your brain that tells you to breathe,” said Jonathan Caulkins, a drug policy researcher at Carnegie Mellon University’s Heinz College in Pittsburgh. “And if they tell you to turn off that part of your brain, you die.”
The only treatment for an opioid overdose is a medication called naloxone, also known by the brand name Narcan, which blocks the binding of opioid drugs to opioid receptors in the brain stem, reversing the respiratory depression.
The deadly action and ubiquity of these drugs have created an epidemic of opioid deaths. According to the CDC, 64,070 Americans died of drug overdose in 2016. Heroin was responsible for 15,446 of those deaths, while synthetic opioids like fentanyl claimed 20,145 lives. Other natural and semisynthetic opioids killed 14,427. A recent report issued by the Substance Abuse and Mental Health Services Administration (SAMHSA) found that in 2016, 11.8 million Americans misused opioids, including both street drugs like heroin and prescription drugs, such as hydromorphone (brand name Dilaudid), oxycodone (brand names OxyContin, Percocet and Percodan) and morphine.
The root of this epidemic rests in the overprescription of opioid pain medications. According to the CDC, prescriptions for opioid painkillers quadrupled in the United States between 1999 and 2014, despite no increase in reported prevalence of pain. Between 2010 and 2012, there were up to 81.2 opioid prescriptions issued per every 100 people in the United States, according to a July 2017 report in the CDC publication Mortality and Morbidity Weekly.
The problem was more severe in some states than in others. In 2012, Californians had an opioid prescription rate of less than 64 prescriptions per 100 people. That same year, Tennessee’s rate was a whopping 136.1 prescriptions for every 100 people. In Alabama, there were 143.8 prescriptions per 100 people in the population.
The rate of new prescriptions has declined from its peak, to an average of 66.5 prescriptions per 100 people nationally, as of 2016. The tightening of the prescription pill supply, however, has sent some addicts into the arms of street dealers selling heroin, according to Caulkins. Prescription pills provided an on-ramp to heroin addiction for many people who would never have imagined they’d end up sticking needles in their veins, Caulkins told Live Science.
“Once you become dependent on pills, then you might do something you wouldn’t do otherwise,” he said.
Making matters worse, many opioid prescriptions were for chronic pain, even though research suggests that opioids aren’t a very effective treatment for long-term pain. Some studies even suggest that using opioids for long periods of time can increase pain by altering the activity of glial cells in the nervous system.
The ease of swapping and trading prescription pills has also hit young people hard. In a 2017 study presented at the annual American Academy of Pediatrics conference in Chicago, doctors found that 135 individuals under age 21 test positive for opioid use or dependency in emergency rooms across the country every day. That was up from 88 youths a day in 2008, the researchers reported.
“We thought that we would probably see a handful of kids,” study author Veerajalandhar Allareddy, the director of pediatric intensive care at the University of Iowa Stead Family Children’s Hospital, told Live Science. “But to have these kind of numbers is very surprising.”
Eighty-eight of the youth who tested positive for dependence were between ages 18 and 21, and 8 percent were between 16 and 17, Allareddy said. The vast majority, 92 percent, had no additional health conditions, indicating that they weren’t using opioids as medications and were thus abusing the drugs. The late teen years are one of the most vulnerable times for falling into substance abuse, Allareddy said.
Flashbacks to laudanum
In many ways, this story has played out before. In the 1700s and 1800s in Europe and North America, the laudanum tincture became a go-to treatment for all sorts of conditions. As with chronic pain today, doctors had few other options for dealing with many patient complaints, so they prescribed laudanum for problems ranging from cough to epilepsy to insomnia to “hysteria,” according to a 1979 article in the British Journal of Addiction.
Laudanum did have some real benefits: Like other opioids, it is constipating, so it was prescribed for the frequent outbreaks of diarrheal disease that haunted communities before the availability of clean, treated water. It also reduced coughing and helped relieve pain. [The 27 Oddest Medical Case Reports]
But laudanum’s overuse had deadly effects. Dosing fussy infants with homespun medicines made with opium became so common in England in the 1800s that the Registrar-General Reports, which recorded annual population statistics, had to add new age categories to its “narcotic deaths” section, according to 2015 article in the Journal of Human Lactation. Between 1863 and 1867, that section recorded 236 deaths in infants younger than a year, a number that may have been underreported. Many other infants suffered. In 1816, Edinburgh physician Marshal Hall wrote about seeing a 6-month-old infant whose mother had dosed him with laudanum nightly.
“The infant is thin, emaciated, sickly, and puny, and is said to be less in bulk than on the day of its birth,” Hall wrote. “He is apt to be very restless and cross, frequently cries for a long time together unappeased, and sometimes appears to be affected with griping [abdominal pain].”
Statistics on laudanum addiction in the 19th century are hard to come by. According to “Heroin: Its History, Pharmacology and Treatment” (Hazeldon, 2011), the number of opioid addicts per capita in the late 1800s was three times that of the mid-1990s in the United States, which would put the epidemic on a similar footing to today.
Some research suggests the opioid epidemic of the late 1800s had similar dynamics to the crisis of today. According to the book “Heroin,” between half and two-thirds of addicts in the late 1800s were female. Today, women are also more likely to use prescription opioids than men, according to the CDC. And a report released Sept. 26 by the firm QuintilesIMS found that women between ages 40 and 59 received twice as many opioid pills after surgery than men in the same age group. This age group has the highest opioid death rate among women, according to the report. (Though men do have higher overall opioid overdose rates in general.)
Today, opioid addiction hits white Americans harder than black Americans. A 2015 analysis by the Henry J. Kaiser Family Foundation of CDC data found that 10 times more white, non-Hispanic Americans died of opioid overdose that year than either black non-Hispanic or Hispanic Americans. Research has found that black patients are less likely than white patients to be prescribed opioid painkillers for tooth, back or abdominal pain in emergency rooms. All of these conditions rely on the patient’s description of the pain for a diagnosis, so the findings could indicate a subtle bias against black patients. An earlier study, published in 2008 in the journal JAMA, found disparities in emergency-room care in all types of pain, with 40 percent of white patients complaining of pain receiving an opioid prescription in 2005, compared with 32 percent for all other races.
Diseases of despair
Likewise, the morphine and laudanum epidemic of the late 1800s was apparently more severe among white Americans than black Americans, and for similar reasons. According to a 1983 paper published in the University of North Florida’s journal History Faculty Publications, the post-Civil War South saw an epidemic of morphine and other opioid abuse among whites. Black Southerners made up a tiny proportion of addicts seen in clinics in the South, wrote historian David Courtwright. The main reason, he wrote, was likely that blacks had less access to doctors than whites: They were poor, they were discriminated against, and few had the opportunity to become doctors themselves.
A possible second reason for the racial disparity also parallels today’s epidemic. The post-Civil War South was a region in defeat, which had suffered high casualties in the conflict. Many people became hooked on morphine while trying to cope with war injuries, Courtwright wrote. An opium dealer in 1877 wrote that once-wealthy Southerners were turning to opium to “drown their sorrows.” Newly freed black Southerners, on the other hand, had nothing to mourn.
“Confederate defeat was, for most of them, an occasion of rejoicing rather than profound depression,” Courtwright wrote.
Similarly, many experts today attribute some of the opioid epidemic to despair. The states with the highest rates of prescriptions and overdose deaths also tend to be the states where the economy is struggling and the loss of stable working-class jobs has hit hard. According to a 2015 report by Princeton researchers Anne Case and Angus Deaton, disparities in death rates between college-educated and high-school-educated middle-age white Americans tell the tale: While deaths from overdose, suicide and alcohol in this 50-to-54 age group have risen 44 percent since 1998 among men with college educations, they’ve skyrocketed 130 percent in white men with only a high-school education or less. For women with a college education, the death rate from these causes in middle age is up 70 percent, but for women with a high-school degree or less, they’re up 381 percent. Case and Deaton call these deaths the result of “diseases of despair.”
End of an epidemic
The epidemic of laudanum and morphine use in the post-Civil War era came to an end, in part, because these opium-based drugs became harder to get. In 1906, after massive public outrage surrounding a Collier’s magazine series on the deceitful and harmful practices of the patent medicine industry, Congress passed the Food and Drug Act. For the first time, according to a Food and Drug Administration history, medications had to be sold according to standards of purity and strength, and ingredients like opium had to be clearly listed on the label.
From there, the supply of opium and medications made with the drug became increasingly tight. The 1914 Harrison Act required anyone selling opiates or cocaine to register with the federal government, and in 1924, heroin was made entirely illegal for the first time. The drug remained in the background, particularly in jazz and Beatnik subcultures, according to Frontline, before erupting into epidemic proportions again in the 1970s. That epidemic, Caulkins said, was again disrupted by a restriction in supply.
But there’s more to the dynamics of an epidemic than how hard it is to get a drug. Caulkins and his colleagues have found that drug use spreads in a similar way that a new brand of shoes or a new style of cellphone might take hold as a trend. Early adopters try it first. In any epidemic, some proportion of these early adopters will dislike a new drug, Caulkins said. They might act as a brake on the drug’s spread by telling friends to stay away, but their influence isn’t as long-lasting as the influence of those who did enjoy the drug.
“When you’re happy with a product, you like to tell your friends about it,” Caulkins said.
But there’s a natural endpoint to the spread. Over the years, as the negative effects of a drug become more obvious, people see users as an advertisement against the drug, not for it. In that sense, the widely publicized deaths from heroin or pills adulterated with fentanyl and other powerful additives could be a deterrent, Caulkins said. [10 Interesting Facts About Heroin]
“If this trend of adulterated, counterfeit pills that have fentanyl in them continues, pills may develop a bad reputation as something that’s actually quite dangerous,” Caulkins said.
The silver lining of opioids is that, unlike cocaine or methamphetamines, there is a medical treatment for opioid addiction. Drugs like methadone and buprenorphine can dampen cravings for opioids without causing a high, so that addicts can function on a daily basis, Caulkins said. These treatments have been shown to extend the life span of addicts and to help them hold down jobs, he said. That’s “a very powerful tool” that hasn’t been available for other epidemics, like the cocaine epidemic of the 1980s, he said.
However, no treatment can fully restore an opioid addict to the level of health they had before becoming addicted, Caulkins said. That’s why preventing new users from starting the drugs is such a driving goal for public health officials. Part of that process is raising the alarm about the pitfalls of these drugs, just as the young laudanum-drinking woman did in the pages of The British Journal of Psychiatry 128 years ago.
“There are roughly the same number of opioid prescriptions in the U.S. as there are guns, and opioid prescriptions kill more people than guns. That includes accidents or suicides,” Caulkins said. “If you or someone you know brings an opioid prescription into the house, you should think of it as bringing a gun into the house. That is the level of dangerousness.”