The Response - 15

The History of Opioid Addiction
Opioid addiction first emerged as a serious problem in the United
States after the Civil War, when opioids were prescribed widely to
alleviate acute and chronic pain. Iatrogenic addiction was by far the
most common form of addiction (White 1998). By the late 19th
century, two-thirds of those addicted to opioids were middle- and
upper-class white women, a fact Brecher and the editors of Consumer
Reports (1972, p. 17) attribute to "the widespread medical custom of
prescribing opiates for menstrual and menopausal discomfort, and
the many proprietary opiates prescribed for 'female troubles.'" Only
one-third of those addicted to opioids at that time became addicted
due to nonmedical opioid use mainly among Chinese immigrants
and members of the Caucasian "underground" such as prostitutes,
gamblers, and petty criminals.
The chronic nature of opioid addiction soon became evident,
however, because many people who entered sanatoriums for a cure
relapsed to addictive opioid use after discharge. By the end of the
19th century, doctors became more cautious in prescribing morphine
and other opioids, and the prevalence of opioid addiction decreased.
Most Americans regarded opioid abuse as socially irresponsible and
immoral. It is noteworthy, however, that heroin, introduced in 1898
as a cough suppressant, also began to be misused for its euphoric
qualities, gradually attracting new types of users. This development,
along with the improvement of the hypodermic needle in 1910-1920,
had a profound effect on opioid use and addiction in the 20th century
(Courtwright 2001).
The size and composition of the U.S. opioid-addicted population
began to change in the early 20th century with the arrival of waves of
European immigrants. Most people addicted to opioids in this period
were young men in their 20s described as "down-and-outs" of recentimmigrant European descent who were crowded into tenements
and ghettos and acquired their addiction during adolescence or
early adulthood. They often resorted to illegal means to obtain their
opioids, usually from nonmedical sources and specifically for the
euphoric effects.
The initial treatment response in the early 20th century continued to
involve the prescriptive administration of short-acting opioids. By the
1920s, morphine was prescribed or dispensed in numerous municipal
treatment programs (Courtwright, et al. 1989). At around the same
time addiction to opium, cocaine, and heroin, along with drug-related
crime, especially in poor urban communities, started drawing the
concerns of political, religious and social leaders. The tolerance and
empathy shown toward Civil War veterans and middle-aged women
evaporated. Negative attitudes toward and discrimination against new
immigrants likely worsened the stigma of addiction. Immigrants and
others addicted to drugs were viewed as a threat. Society's response was
to turn from early forms of treatment to law enforcement (Brecher
and Editors 1972; Courtwright 2001; Courtwright, et al. 1989).

The shift in the composition of opioid-addicted groups coincided
with hardening attitudes toward these groups, leading some
researchers to conclude that stigmatization of people with addiction
disorders and their substances of abuse reflected, at least in part,
class and ethnic biases. A portion of U.S. society appeared to view
with disdain and fear the poor White, Asian, African-American,
and Hispanic people with addiction disorders who lived in the inner
city ghettos (Courtwright 2001, et al. 1989).
By the mid-1960s, the number of middle-class young White
Americans using heroin was on the rise, as was addiction-related
crime. This corresponded to the U.S. military involvement in
Vietnam where 25 to 50% of American enlisted men in Vietnam
were believed to have used or become addicted to heroin.
Serendipitously, the fear that the majority of these Vietnam veterans
would return home and continue to abuse heroin did not come to
fruition.
In 1962, Dr. Vincent P. Dole, a specialist at The Rockefeller
University, became chair of the Narcotics Committee of the Health
Research Council of New York City. He received a grant to establish
a research unit to investigate the feasibility of opioid maintenance. In
preparing for this research, he read "The Drug Addict as a Patient"
by Dr. Marie E. Nyswander (Nyswander 1956), a psychiatrist with
extensive experience treating patients who were addicted to opioids.
She was convinced that these individuals could be treated within
general medical practice. She also believed that many would have
to be maintained on opioids because a significant number of people
who attempted abstinence without medication relapsed, in spite of
detoxifications, hospitalizations, and psychotherapy (Brecher and
editors 1972; Courtwright, et al. 1989). Their research represented a
groundbreaking shift in drug addiction treatment.
By the 1980s, an estimated 500,000 Americans used illicit opioids
(mainly heroin), mostly poor young minority men and women in
the inner cities. Although this number represented a 66% increase
over the estimated number of late 19th-century Americans with
opioid addiction, the per capita rate was much less than in the
late 19th century because the population had more than doubled
(Courtwright, et al. 1989). Nevertheless, addiction became not only a
major medical problem but also an explosive social issue (Courtwright
2001; Courtwright, et al. 1989).
In 2002 the passage of the Drug Addiction Treatment Act (DATA2000), an amendment to the Controlled Substance Act, allowed
physicians for the first time in over a century to treat patients with
an opioid use disorder in the privacy of their office, using appropriate
opioids. The passage of the Comprehensive Addiction and Recovery
Act (CARA) expanded this ability to Certified Registered Nurse
Practitioners and Physician Assistants. Providers are mandated to
become certified, licensed and follow specific guidelines in their
treatment of opioid use disorder.

Continued on page 16

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