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The “Right” and “Wrong” Kind of Addict: Iatrogenic Opioid Addiction in Historical Context

According to deeply-rooted cultural tropes, iatrogenic addiction is usually perceived to be a legitimate way become a drug addict, the “right” or...
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  1. perro-salchicha614
    Last year, Kelly McEvers of NPR’s Embedded podcast introduced us to Joy. Something about Joy seems so ordinary, even familiar. She’s a certified hospital nurse, a mother of three kids, and a former Girl Scouts leader. She’s from Indiana, America’s heartland. She’s even close with her parents. And like many of us, she suffers from chronic back pain. That’s where it all began for her.

    Joy’s story shocks the listener because it contradicts so many stereotypes about drug addiction. She isn’t the sort of character who typically comes to mind when we think of opioid addiction — but she does suffer from addiction to opioids. Badly hurt on the job one day after picking up a fallen elderly patient, Joy became addicted to the powerful opioid Opana to manage her pain.

    Opana is notorious for its extraordinary addictiveness — even compared to other synthetic opioids. The drug is so addictive that according to the FDA, its risks outweigh its benefits because it too often leads to iatrogenic opioid addiction, or addiction by way of medical care.1

    Rather than through so-called “gateway drugs” or thrill-seeking behavior, Joy became addicted to Opana when a doctor prescribed the drug to treat her back pain after her workplace injury. She is one of the many people who become addicted to opioids iatrogenically, through treatment by doctors. Despite CDC guidelines recommending physicians avoid prescribing narcotics for lower back pain so as to prevent iatrogenic addiction, some forty percent of doctors still prescribe painkillers, including opioids, as first remedies for patients’ back pain. Opioid analgesics are currently the most commonly prescribed class of medications in the United States, leading to an iatrogenic addiction rate that may be as high as twenty-six percent of opioid addicts.2

    This is exactly what happened to Joy. By the time her prescription ran out, she had become addicted to the opioids prescribed by her doctor. So she started buying Opana on the street. Joy certainly isn’t a unique case. Many people become addicted to opioids prescribed by their doctors, and are often forced to turn to illegal sources to prevent intensely painful and dangerous withdrawal symptoms after their prescriptions are cut off. When their stories become public, all too often we are shocked by the circumstances that lead such “ordinary” people to become addicted to opioids, the abuse of which entails tremendous social stigma.

    In the midst of an opioid epidemic that is spiraling out of control, cases of iatrogenic addiction among otherwise-ordinary Americans like Joy are increasingly visible reminders that there are many “kinds” of people who suffer from addiction. For example, iatrogenic addiction cases are often set in juxtaposition to those of individuals who become addicted to drugs through thrill-seeking or other risky behaviors.

    According to deeply-rooted cultural tropes, iatrogenic addiction is usually perceived to be a legitimate way become a drug addict, the “right” or justifiable path to addiction, while other routes to addiction create the “wrong” kind of addict. The right kind of addict deserves sympathy and medical help, while the wrong kind of addict should be left to face the consequences of their own choices, according to common sentiment.3

    Traditionally, historians have believed that this delineation of routes to addiction into legitimate and illegitimate categories is a consequence of the Progressive Era-criminalization of narcotic addiction. According to this narrative, the stigmatization of non-iatrogenic addiction has its origins in social policing efforts like the Harrison Narcotic Act of 1914 and the concurrent professionalization attempts by groups like the American Medical Association.4

    This argument unintentionally implies that the time before the early twentieth-century criminalization was a kind of “golden age,” when narcotics addicts were not implicitly segregated into classes of legitimacy based on their route to addiction. During this golden age, it follows, most physicians seem to have treated all addicts alike with common compassion through public health measures like addiction maintenance programs, akin to today’s methadone clinics.5 This precludes cases like that of Joy, who seem ordinary save for their “legitimate” addiction, because all kinds of addicts would have been treated with egalitarian compassion and medical attention. Sadly, this past is simply a pleasant fiction.

    Really, the segregation between the “right” and the “wrong” kinds of addicts is not a modern innovation at all. In fact, it has been a central characteristic in the American conception of drug addiction in the United States since the earliest recorded opiate addiction crisis, which emerged in the American medical consciousness during the 1830s.

    In 1833, the editor of the Boston Medical and Surgical Journal published an impassioned circular at the behest of a patient, a woman whose case was “of the most touching character.” He described with great empathy his efforts to cure the woman of her addiction to opium, which was iatrogenic in nature. The editor took pains to make sure his readers understand that the “lady” became addicted in the course of a doctor’s treatment for “nervous irritation,” a diagnosis that could not sully her character because physicians would have considered it appropriate for a woman.6

    This legitimate route to addiction was what prompted the editor to pen this extraordinary article, which he opened by imploring his colleagues: “Is there any sure and safe method of curing a person of the habit of opium eating?”7

    Tucked away in this relatively long editorial, in which the author expends about half of his words painstakingly validating the character of the patient on whose behalf he writes, is perhaps the earliest account in the historical record of the “wrong” kind of patient. The editor explains:

    When we allude to opium eaters, we mean those only who took it originally as a medicine for some nervous affection, and continue it from necessity, rather than from choice; — who take it, not to intoxicate, but to strengthen and balance the nervous system and enable them to attend to business, and to appear like other people. Of those who take opium for purposes of unnatural excitement and inebriation, we have no knowledge. They need less of our sympathy, and would excite us less to exertions in their behalf.”8
    If one reads on, subtle, implicit gender and racial biases that inform the above statement become explicit. The woman in question, the legitimate “opium eater,” was the archetype of antebellum domesticity. She was a young “wife and mother, a neighbor and friend,” whom opium had made its “slave.” Because she otherwise fulfilled contemporary gender conventions dictating what middle-class white women should ideally be, the woman’s case called out “most loudly for the sympathy and aid of the humane physician.”

    By using language like “slave,” which readers likely would have taken as the author equating opium eating with racial slavery, the author also implies that legitimate opiate addicts must be white. Readers would have felt revulsion at this woman’s case, because through no fault of her own, opiate addiction had stripped her of an elevated status as a middle-class white woman and reduced her to a position of degradation, according to antebellum gender and racial constructs.9

    But what about the others, the illegitimate abusers of opium? They were not worthy of the physician’s empathy or help, both because of how they came to be addicted, and because they did not meet the expectations of antebellum gender and racial conventions of domesticity.

    This 1833 editorial suggests that from the earliest moments in the saga of opioid addiction in America, a central characteristic of the conception of addiction has been the delineation of legitimate and illegitimate pathways to addiction. Iatrogenic addiction has always been the “right” way to become addicted, rendering patients like the woman in this editorial worthy of empathy and medical assistance. And non-medical routes to addiction have always been the “wrong” way, making “drug addicts,” as these sufferers are often described, unworthy of assistance.

    Fast-forward to today, and Joy, the woman profiled in Embedded, has become the modern “legitimate” addict. Like the woman in the 1833 editorial, Joy seems to reach all the markers of modern domesticity – the kids, the Girl Scout troop. She’s even a nurse, an occupation historically associated with nurturing women. Like the woman in the editorial, Joy also became addicted iatrogenically. Perhaps the reason Joy seems so ordinary, or familiar, when we hear about her story is because there have always been women who became addicted to opioids the “right” way, just as there have always been those who became addicted the “wrong” way.

    Although at first glance Joy’s story shocks because it seems to defy archetypes about opioid addiction, historical analysis suggests that there have always been the dueling, interdependent molds of legitimate and illegitimate addiction in our conception of drug addiction. These tropes did not emerge during the Progressive Era-origins of the war on drugs. They’re much older. As the 1833 appeal in the Boston Medical and Surgical Journal illustrates, there have always been the “right” and the “wrong” kind of addicts.

    Notes
    1. Opana is so addictive that on June 8, the FDA took the unprecedented measure of requesting that drug manufacturer Endo Pharmaceuticals pull the drug from the market, after years of expert warnings. This extraordinary step was the first time the FDA has asked a pharmaceutical company to pull an opioid from pharmacy shelves as a public health measure. Return to text.
    2. As the authors of this study point out, the cause of addiction is tough to measure, and various studies estimate that the iatrogenic addiction rate in the U.S. stands between one and twenty-six percent. Dan N. Longo, Nora D. Volkow, and A. Thomas McLellan, “Opioid Abuse in Chronic Pain — Misconceptions and Mitigation Strategies,” The New England Journal of Medicine 374, no. 13: 1269. DOI: 10.1056/NEJMra1507771. For further analysis of iatrogenic addiction rates see: Gillian A. Beauchamp, Erin L. Winstanley, Shawn A. Ryan, and Michael S. Lyons, “Moving Beyond Misuse and Diversion: The Urgent Need to Consider the Role of Iatrogenic Addiction in the Current Opioid Epidemic,” American Journal of Public Health 104, no. 11 (November 2014): 2023-2029. Return to text.
    3. See also: David S. Musto, “Iatrogenic Addiction: The Problem, Its Definition and History,” Bulletin of the New York Academy of Medicine 61, no. 8 (October 1985): 705. See also: Beauchamp et al., “Moving Beyond Misuse and Diversion,” 2023. Return to text.
    4. David T. Courtwright, Dark Paradise: A History of Opiate Addiction in America, Enl. ed. (Cambridge, MA: Harvard University Press, 2001), Chapter 5: The Transformation of the Opiate Addict, especially 122-3. See also: Caroline Jean Acker, “From All Purpose Anodyne to Marker of Deviance: Physicians’ Attitudes Towards Opiates in the US From 1890 to 1940, in Roy Porter and Mikulas Teich, Drugs and Narcotics in History (Cambridge, UK: Cambridge University Press, 1995), especially 123-4. See also: Musto, “Iatrogenic Addiction,” 705, and David T. Courtwright, “Preventing and Treating Narcotic Addiction — A Century of Federal Drug Control,” The New England Journal of Medicine 373, no. 22: 2095-2097. Return to text.
    5. For an excellent account of narcotic addiction maintenance programs in the early twentieth century, see: David T. Courtwright, “The Hidden Epidemic: Opiate Addiction and Cocaine Use in the South, 1860-1920,” (1983), History Faculty Publications, Paper 3. 
Return to text.
    6. For an introduction to this idea, see: Cynthia Eagle Russett, Sexual Science: The Victorian Construction of Womanhood (Cambridge, MA: Harvard University Press, 1989). Return to text.
    7. Anonymous, “Opium Eating,” Boston Medical and Surgical Journal, September 4 1833, 66. Return to text.
    8. Ibid. (Italics my own.) Return to text.
    9. Ibid. Return to text.

    Jonathan Jones is a PhD in history candidate at Binghamton University. He researches opiate misuse in the U.S., especially its origins in the nineteenth century. His dissertation, “A Mind Prostrate: Physicians, Opiates, and Insanity in the Civil War’s Aftermath” is a study of the Civil War-era opiate addiction epidemic, tracing how physicians responded to opiate “insanity” among war survivors by attempting to radically reform American medicine. His other research and teaching interests include the history of medicine, women, and gender. You can reach him by email at jjones19@binghamton.edu.

    Original Source

    Written by: Jonathan Jones, Jul 25, 2017, The “Right” and “Wrong” Kind of Addict: Iatrogenic Opioid Addiction in Historical Context, Nursing Clio
    Kathy1221 likes this.

Comments

  1. profesor
    Very good article. One thing I disagree with is the "Opana is so addictive" phrasology, as if addictiveness is an isolated property of certain opioids/opiates. Opiates boost stamina considerably, dismiss fatigue, and enable motivation and focus; at least in oral prescription strength. These secondary benefits get users addicted, even when they never take doses strong enough to "nod off". And the cutting of suspected addicts off from opiates is under-emphasized. THIS is at least as big a problem as carelessly prescribing them in the first place. The fact doctors can't even try to wean patients off slowly is a sick practice, practically throwing addicts to street dealers. Education about opiate addiction, even among medical practitioners is so, so bad.
      perro-salchicha614 likes this.
    1. dyrt
      u r so right! I became as addicted to tylenol 3 as to any stronger opiate, because it took my perception of pain away it allowed me to become a better version of myself and then when I brought up getting sick when I didn't have it to my Dr he cut me off, throwing me to the street!
    2. FalcoHere
      Not only this, but also the fact that doses are prescribed to be taken around a similar time every day. This causes the body to rely on it’s opioid receptors to be activated at a certain time each day to achieve internal homeostasis.
  2. Blueeyes
    Like Joy, I too am an opiate addict of iatrogenic nature. I am a survivor of 5 back surgeries, a mom and a nurse. I am 8 years clean but at times still miss the mental boost and increased stamina I would get when I would starve myself and chew up my hydrocone then several years later the morphine pills so I got the rush along with the pain control. My addiction was completely sustained by one physician, I was lucky and never forced to go buy it off the streets but I have had close friends, also nurses, with back injuries that had to buy theirs for an elevated price illegally off the street. Not to dismiss anyone else truly wanting to get clean but I have had problems in the past attending NA meetings with addicts of recreational drugs, folks who chose to play with drugs and got caught in the ugly web of addiction. I almost unconsciously elevate myself to a "better" status as addiction was/is not one of choice. I know deep in my heart this wrong. I am no better. I am just as guilty, I knew what I was doing and even though my mind said "No what the hell are you doing" when I chose to chew up pills that my body demanded. It took locked down rehab and methadone to get me clean and by the will of God and my stubbornness I pray that I can be clean until the day I die. I do not know why I shared this but the story of an "alright" vs a "not alright" addiction moved me and brought my guilt to the surface. Just for today I am clean.... (NA motto)
  3. Addydawn
    So glad to see an article referring to a great deal of the opiod addiction by what it truly is. The word "iatrogenic" is perfect. That is exactly what it is and I have been referring to it as such. The word iatrogenic is used when something is caused by the medical community. For example, if someone has a catheter placed in the urethra and the patient develops a urinary tract infection, it is said to have been iatrogenically caused. Well, doctors are prescribing the opiates and patients are becoming addicted. It is an iatrogenic problem and the medical community needs to find ways to correct it. I can recall, in the past, doctors who saw their patients becoming addicted and out of fear for their medical license, they were terminating patients cold turkey. It was very wrong. Now, at least, they realize that they need to take some accountability in helping patients. It appears that a number of doctors are becoming certified to prescribe suboxone.
  4. Yellow Brick Reality
    I am an iatrogenic patient that was cut 1/2 off diazepam methadone and hydrocodone at the sane time when my prescribing doctor quit.
    This was in May of this year.
    I'm the perfect example of how this problem still exists right here in middle America! Ohio to be exact.
    I'm thankful I didn't have a dealer or know of a source. I spent the entire month of June in severe dangerous withdrawals under a "doctors care" for this. I'm continuing forced withdrawals currently.
    During that month I racked my brain thinking of everyone I knew who might know someone, who knew someone that could get me anything to ease my suffering.
    I have so much to lose not that we all don't. (I'm a 45 year old nurse myself.)
    I know there is no difference between us. The medical community absolutely owes iatrogenic patients a slow taper option when they refuse to continue a prescription for narcotics. One that works with the patient directing their own slow taper schedule.

    There needs to accountability for cutting patients off and having their addictions hit the streets. The only way a true change like this is usually (not always) made is by successfully suing physicians and proving neglect and harm.
    For instance; if the week or so after these severe cuts were made in my case, I committed suicide. I also would have needed to leave proof such as I leave a letter saying I just couldn't do it, specifically because of the drastic cuts made to 3 narcotics at one time. Then my family pursues a large law suit against the doctor and the practice and wins.
    These types of successful lawsuits circulate quickly in those circles. Then doctors make a shift away from such practices.
    The shift now is on prescribing too many narcotics and being held responsible for the overdoses.
    It's a lose lose situation for everyone. But we are the ones who ultimately pay the biggest price of all!
    Sorry for ranting this really angers me.
  5. Addydawn
    I remember when the pharmaceutical representatives were coming into doctors offices and telling them that OxyContin was different and that patients wouldn't become addicted because of the formulation. Doctors, however, were discovering that patients were becoming addicted and were telling demanding about needing their medication. This scared some doctors because they feared for their medical licenses. I saw doctors cutting patients off cold turkey and not offering detox or rehab. All they could think about was themselves. Very selfish. After all, they weren't the ones suffering. I remember working in a physical therapy office and this was after working for a while as an addictions therapist. I saw doctors cutting patients off and I even asked if they were going to recommend treatment. They didn't care. Doctors do realize now that they have a responsibility in this because they could be sued. So it boils down to losing their license or being sued. Both can be catastrophic for a doctor. I truly believe that if a doctor is going to stop medication, they should taper it or offer a detox alternative. Many doctors are now trying to get certified to prescribe suboxone. The problem with that is it's another way for the doctors to legally make good money by keeping patients on it indefinitely although it is meant to be tapered.
  6. Barliman
    One aspect of this problem is that back pain is usually persistent and difficult to treat. Whats more the allopathic medical profession has few solutions to it, and surgery for it is usually good at correcting abnormal anatomy, but poor at relieving symptoms.
    I have had back pain for nearly 30 years- starting with a major disc prolapse at the base of the spine, then evolving in to upper back and neck pain.

    Now in this context prescribing opioids for anything but infrequent, intermittent usage at times of severe pain is asking for trouble. Tolerance will develop and then the patient is stuck with nothing that will work. Then we get these crazy stories of doctors acting to cut their patients off medication abruptly-- an action that can only be described as unethical and incompetent.
    In back pain, as a rule most of the pain is of muscular origin and associated with spinal malalignments (which the chiropractors call subluxations). In fact most of the referred pain is also connected to this problem (piriformis syndrome in leg pain and scalene spasm in radiating arm pain.

    I am actually an allopathic doctor myself, but it has taken me a hell of a long while to realise that my profession is woefully undereducated when it comes to the muscular origins of most back pain, and utterly at a loss when it comes to addressing these problems (you cant treat successfully that which you cannot diagnose).

    It is unreasonable that this state of affairs exists as the most significant book on this subject (Travell & Simons' Myofascial Pain and Dysfunction) was written in the 1960's and one of its authors pioneered much of the medical understanding of this area through her work on John F Kennedy- her patient. However, most doctors are unaware of it.
  7. Yellow Brick Reality
    @Barliman
    So what are the main courses of back pain treatment for an allopathic doctor such as yourself?
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