Opiates are amazing. They make dentistry not a horror movie, make a broken bone something you can tolerate while waiting in the ER, and kept your great-grandpop from going into shock after being shelled in the trenches of Ypres. Opiates are also amazingly addictive. The government estimates that roughly 1.9 million Americans were hooked on opiates in 2013. Use and abuse in America has reached epidemic levels, prompting the Centers for Disease Control and Prevention to issue a new set of recommendations from the CDC to control how doctors are distributing the drugs.
The recommendations came out yesterday, but this problem isn’t new: Opiates have always oscillated between medicine and drug. Their regulatory history reflects the precarious balancing act between help and harm—one that the CDC’s new recommendations will address, but never solve.
Whether humans first used opiates to soothe pain or create pleasure is akin to asking about the precedence of chickens or eggs. In the wild, opiates come from poppies, the “joy plant” that ancient Sumerians cultivated as far back as 3400 BC. Fast forward to 1908 in the United States, when Theodore Roosevelt appointed a physician named Hamilton Wright as the United States’ first Opium Commissioner.
“Of all the nations of the world,” Wright opined to the New York Times, “the United States consumes most habit-forming drugs per capita.” At the time, approximately one in every 400 Americans was addicted to opium. Two thirds of those users were women.
So in 1914, the US passed the Harrison Act. The new rules required everyone in the opium and cocaine supply chains (except physicians) to pay taxes and register with the government. When the Supreme Court ratified the rule in 1919, it banned doctors from giving opiates to addicts except to wean them off.
In some ways, that law was pretty effective.
“This is one of those examples where changes in medical practice changed the population of who is addicted,” says Nancy Campbell, a researcher specializing in the history of drug regulation at Rensselaer Polytechnic Institute in Troy, New York. The number of white, upper class women hooked on opiates dropped. “They either switched, died, or withdrew,” Campbell says. But illegal drug use grew—especially among black and poor white communities.
Opium was out, but opiates were still all the rage. The US government spent much of the 20th century trying to regulate them (along with a bunch of other drugs)—the Heroin Act of 1924, the Boggs Act of 1951, the Controlled Substance Act of 1970, and plenty of other laws. In the meantime, pharmaceutical companies developed a plethora of opiates: Heroin was one. So was morphine, Oxycontin, Percoset, and Vicodin.
Prescription opiate use simmered for decades. But in 1990, an influential Scientific American article “The Tragedy of Needless Pain” kicked off a paradigm shift within the medical community. The article argued that many Americans suffered from undue pain, from old injuries or recent surgeries or misidentified ailments. Further, the author said the medical community was overreacting to fears that prescribing morphine would lead to addiction. The chronic pain movement was born.
And a few years later, so was an epidemic of opioid abuse. Not that ignoring chronic pain is the solution. It’s a real thing: The CDC estimates that over one in ten Americans deals with chronic pain. But it is also loosely defined—any sensation, annoying to excruciating, that lasts longer than six months counts. Which is how it should be, says Campbell. After all, doctors are supposed to minimize pain—and as a painkiller, opioids are unmatched. “The problem is they are also double-edged swords,” says Campbell. “The difference between therapeutic dose and dangerous dose is relatively thin.” Opioid prescriptions skyrocketed.
“Now,” Campbell says, “people are realizing that expansion has gone too far.” Between 1999 and 2014, 165,000 people died from prescription opiates.
The CDC’s latest recommendations are an attempt to reel those prescriptions in. Notably, one of the first recommendations is to treat chronic pain without opioids when possible. The rest of the recommendations add checkpoints—treatment goals, going over harms and risks, three month check-ins—aimed at breaking the standardized prescription procedures that plague the overburdened health care system.
But after wading through the history of opioids in America, you can see how that might not do the trick. Yes, physicians are going to pay attention to anything the CDC says, but whether or not it affects anybody’s treatment options is another matter. Campbell says most of the physicians aware of this problem have already started cutting back their care. Which does not mean the CDC’s recommendations will fall on deaf ears, but probably some that could have heard the message sooner.
By Nick Stockton - The Wire/March 16, 2016
Art, Photos: 1-MichaelGeorge blog