Lessons from ‘Dark Paradise’ on the Opioid Crisis

By Roger Chriss, Columnist

The book “Dark Paradise: A History of Opiate Addiction in America” by David Courtwright lives up to its title. Starting as far back as the Revolutionary War, Courtwright gives substance and statistics about opioids in the United States. The book clearly shows that America has had one ongoing opioid crisis for its entire history.

Courtwright starts with the premise that “Over and over again the epidemiological data affirms a simple truth: those groups who, for whatever reason, have had the greatest exposure to opiates have had the highest rates of opiate addiction.”

He also takes pains to show how the demographics of addiction shifted over time, moving from men to women and back to men, from the upper class to the working class to immigrants and back again. Seemingly new twists and turns in the present opioid crisis are actually just variations on an old theme.

Addiction rates and trends from 100 years ago seem all too familiar. Courtwright tells us there were about 313,000 opium and morphine addicts in America prior to 1914, with many of them concentrated in the South. But who became addicted was different.

“The outstanding feature of nineteenth-century opium and morphine addiction is that the majority of addicts were women,” wrote Courtwright. “It was principally in those suffering from chronic ailments that use of these drugs led to addiction.”

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At the time, opioids were used to treat everything from ennui and anxiety to social performance and sleep -- disorders that nowadays would be treated with other medications. The causes cited are also familiar. “In addition to laziness and incompetence (by physicians), greed was cited as a reason for continued abuse” and 19th century pharmacists “were notorious for their willingness to supply a user; opium and morphine were their bread and butter, and there is no steadier customer than an addict.”

The underground trade in opioids was already a major problem at the turn of the 20th century: “The ingenuity of the opiate smugglers knew no bounds. One supercargo reportedly packed $500 worth of opium into the false bottom of a snake cage.”

As they have today, lawmakers and policymakers responded vigorously, but often with hidden agendas and dubious statistics. In the 1910s, physician and scientist Hamilton Wright used scare tactics to push for legislation on domestic narcotic trafficking. Andrew DuMez of the Treasury Department used “grossly inaccurate” figures about addicts. And Congressman Henry Rainey tried to convince the American public “that addiction was a problem of massive dimensions.”

By the early 20th century, “Opium and morphine had fallen into such disfavor that some physicians began to worry that they might be withheld in even the most dire cases.” Then as now, lawmakers were often behind the curve on the crisis and used fear to advance personal agendas.

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This raised concerns that are echoed today about opioid medications. “The present generation (of doctors) has been so thoroughly warned, both by teaching at college and by observation,” wrote New Hampshire physician Oscar Young in 1902, “that now they are in many instances so very afraid to give it, even for the worst pain, that the patient suffers agonies worse than any hell for want of one-eighth of a grain of morphine.”

The opioid pendulum had shifted so much by 1920 that the American Medical Association warned that opiates should not be denied to patients suffering from conditions “such as cancer, and other painful and distressing diseases.”

Although this new conservatism greatly reduced rates of iatrogenic addiction caused by medical treatment, opioids continued to be a problem, especially as heroin spread from New York City to the rest of the nation. Courtwright notes that “heroin addicts typically became addicted in adolescence or early adulthood” and that their addictions were rarely iatrogenic in nature.

Heroin succeeded in a way that no other illicit drug had before: “Heroin was the illicit drug par excellence. It spread throughout the country during the 1920's and 1930's because dealers and their customers came to appreciate its black-market virtues.”

World War II interrupted virtually all aspects of life in the United States, including opioid abuse and addiction. But developments in pharmaceutical research contributed to changes as well. “Indeed, one of the reasons why medical morphine addiction largely vanished during the twentieth century was that physicians had so many alternatives for inducing sleep, soothing nerves, and brightening mood.”

Interestingly, in the 1950s, “No one, least of all federal agents, regarded the use of opiates to alleviate intense, pathological suffering as inappropriate or illegal.”

But then heroin surged in popularity in the 1960’s. Courtwright carefully assembles statistics on addiction rates. There were an estimated 120,000 heroin addicts in the 1950’s. The number rose to 315,000 in late 1969 and by the end of 1971 there were 560,000 heroin addicts. That number has remained relatively stable. Today the National Institute on Drug Abuse estimates that there are 591,000 heroin addicts in the United States.

But there was little data on overdose fatalities until the 1970’s. Courtwright reports that heroin-related deaths rose from 1,980 in 1990 to 3,980 in 1996, double the peak death rate in the 1970’s. A key factor in the increasing fatality rate was the combined use of heroin with other drugs.

With the development of methadone maintenance in the 1960's, a new approach to heroin and other forms of opioid addiction arose. “Enforcement must be coupled with a national approach to the reclamation of the drug user himself,” said President Richard Nixon in 1971. But despite its documented effectiveness, Courtwright notes that methadone “never emerged as a coherent national response to heroin addiction.”

The history of opioids in “Dark Paradise” ends at the start of the 21st century. The book does not mention the rise of OxyContin, the movement to treat pain as a vital sign, or the recent spikes in opioid-related overdoses. Nor does it discuss the appearance of Mexican black tar heroin, illicitly manufactured fentanyl or darknet drug markets.

But it does tangentially address what works and what doesn’t. The “War on Drugs” has failed repeatedly, as have policies to criminalize addiction or institutionalize addicts. The three approaches that would probably do the most to help end the opioid crisis -- securing the medical opioid supply against theft and diversion, disrupting the illegal supply by attacking distribution networks, and providing treatment to the addicted -- have never really been tried with any consistency.

Courtwright notes at the opening of “Dark Paradise” that “what we think about addiction very much depends on who is addicted.” But he also shows that we prefer to do very little beyond what is ideologically appealing or politically expedient. Instead, we keep trying the same things over and over and then act surprised when we get the same results. This is more commonly known as the definition of insanity than of paradise, dark or otherwise.

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Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.