History, Humanities, and Addiction Crises: The US Opioid Epidemic

May 2021
15-minute read

To understand how we got to this critical point, we use the tools of historical analysis to sift through the calamities of Pandora's Box in the hopes of not only seeing what got us here, but what might get us out of here as well.

As a Faculty Fellow at the Humanities Collaborative of EPCC-UTEP for the 2020-2021 academic year, I decided to create a history course especially designed for our students in the medical sciences by focusing on the history of pharmacology and medicine from 1877 to the present day. This is a US history survey class with a strong component in the history of drug use and regulations, medical technologies, the historical impact of diseases, and the history of medicine. The main objective is to promote historical literacy at El Paso Community College by including some topics of interest to our health sciences students that not only fulfill their academic requirements, but that recognize the importance of students’ interests in their education.

With the help of The Humanities Collaborative at EPCC-UTEP, and with the invaluable intellectual and moral support of many faculty members from different departments, I have been able to develop this course. The following pages are just a small example of the type of historical analysis and content included in this course that demonstrate the centrality of humanistic disciplines and how they can offer us valuable intellectual tools to understand our present. In its brevity, this article examines some of the medical, legal and political notions of the use, control, and addiction to opioids during the twentieth century while stressing how those perceptions facilitated several addiction crises in the United States.

On November 24, 2020, Purdue Pharma, the producer of OxyContin, a prescription opioid drug, pleaded guilty in a virtual hearing with a federal judge in Newark, New Jersey to three criminal charges for its role in fueling the opioid crisis in the United States. The company acknowledged paying doctors to persuade their colleagues to prescribe OxyContin through a speaker program, paying an electronic medical records company to send patients’ information to doctors to encourage them to prescribe the opioid, and interfering with the US Drug Enforcement Administration’s (DEA) efforts to control the addiction crisis.1 More specifically, Purdue Pharma acknowledged not disclosing to the authorities over 1.4 million OxyContin prescriptions written by Region Zero HCP (Health Care Provider). In addition, the company “knowingly and intentionally conspired” against the DEA from at least 2007 to 2017 by not reporting the findings of its internal anti-diversion programs while helping HCPs to irregularly prescribe controlled drugs.2

As part of the plea agreement, Purdue Pharma was fined $8.3 billion in penalties and forfeitures, although it seems highly unlikely that the company will effectively pay such an amount since the drug manufacturer is in legal proceedings to declare bankruptcy.3 The company agreed to pay the federal government $225 million while the Sackler family (the owners of the company) agreed to pay another $225 million to settle civil claims.4 However, at the moment, there are no criminal charges against any employee of Purdue or against any members of the Sackler family. Indeed, in a court appearance in December, Dr. Kathe Sackler, a member of the board for almost twenty years, declared "there's nothing I can find that I would have done differently" while David Sackler, a six-year board member, claimed that "the family and the board acted legally and ethically.”5

Nevertheless, the opioid crisis in the US alone has claimed almost 450,000 lives between 1999 and 2018, with an average of 128 deaths per day in 2018 related to opiate overdoses including prescription drugs and legally and illegally manufactured synthetic opioids such as fentanyl.6 According to the US Centers for Disease Control and Prevention (CDC), there were more than 230,000 cases of overdoses involving prescribed opioids such as Oxycontin during the same period.7 Furthermore, the CDC estimates that the cost of healthcare, addiction treatment, loss of productivity, and criminal justice processes linked to the opioid crisis amount to $78.5 billion per year.8 To put this into perspective, that is higher than the 2019 US federal budget for education ($71 billion) and even higher than the $64 billion that the Department of Education requested for the year 2020.9 At this point, one of the many obvious questions is: How exactly did we end up here?

As a historian, I have been closely studying the creation of opium, cannabis, and cocaine drug regulations and trafficking networks in the twentieth century with special attention to Latin America for several years. Although the global regulation of narcotics is extremely complex, studying the differences in how raw materials such as opium, coca and marijuana were regulated versus how manufactured drugs have been regulated can shed some light on our current crisis. This is a crucial and often overlooked dilemma in the history of drug regulation, in particular since manufactured drugs have resulted in widespread addiction in the past.

In fact, marijuana, coca, and opium (derived from the opium poppy) are plants found in nature that have been subjected to a perhaps stricter control than manufactured drugs. In this article, I focus on two aspects that have facilitated this outcome. The first one is the assumption that the technical and scientific processes of chemical and pharmaceutical industries were superior to those based on the natural extraction of narcotics; therefore, manufactured substances have often been considered non-habit-forming drugs.10 This is despite the fact that many man-made narcotics are opium-based substances that have been created by intensifying the natural properties found in plants. The second aspect of this dilemma is that the use of plants such as marijuana, coca and opium has been repeatedly associated with uneducated, “uncivilized,” foreign or native (in colonial structures) subjects who were considered racially and mentally inferior by European and US medical and political elites during the early twentieth century.11

One of the pivotal moments for my research and for the history of global drug regulations was the creation of a US empire in the aftermath of the Spanish-American War (1898). After defeating the Spanish in the Philippines, the US led a brutal occupation of the country against the nationalist forces that resulted in the deaths of at least 250,000 civilians, the widespread use of torture including the “water cure” (the US’ earliest documented use of waterboarding), the US annexation of the country, and the prohibition of opium dens in the new colony.12 When the US replaced the Spanish authorities with its own, American missionaries, doctors and political authorities including the governor of the Philippines and future US president William Howard Taft successfully lobbied Theodore Roosevelt’s administration to end the opium monopoly that the Spanish had established on the islands.13

The US’ Opium Commission, established in the new territory to study the opium question, openly blamed the Chinese community within the country as the main cause of drug addiction in the Philippines and by extension in the US. Newspapers in the United States and the Philippines quickly embraced this explanation, exemplified by a New York Times article that voiced American popular feelings under the title, “Best Way to Deal with Evil.”14 This article and many others perpetuated the stereotype of the Chinese as opium smokers and corruptors of morality while anti-opium advocates linked the drug trade and drug use to human trafficking and in particular to the victimization of white women.15 Although US missionaries might have had genuine moral concerns about local populations and drug abuse, prohibitionist advocates often relied on white missionary demagogy and racial overtones against drug users to push for drug control.16 In a broad interpretation, US drug addict stereotypes at the turn of the twentieth century could be generalized as such: Chinese “coolies” were considered opium smokers, African Americans were cocaine users, and “lazy” Mexicans were seen as marijuana smokers.17

These stereotypes not only deeply shaped the US drug control apparatus, facilitating the stereotypes of drug addiction, but also fueled anti-immigration sentiments, furnishing rhetorical arguments to the nativist groups that lobbied for the passage of the immigration acts in the early 1920s.18 In any case, after the opium ban in the Philippines, the US engaged in a diplomatic effort that resulted in the first international conference regarding drug control, the 1909 Shanghai Opium Commission, and in the first such treaty, the 1912 Hague Treaty. This was an early attempt to regulate the global production of opium. Nationally, the US passed the Food and Drug Act of 1906 and the Harrison Act of 1914 that regulated the use of morphine, heroin, and cocaine.

As with opium, marijuana prohibition in the US was directly linked to racial fears against another foreign population: Mexicans. Interestingly, El Paso, Texas, was the first municipal administration in the nation to ban cannabis in 1915 following a series of newspaper articles that identified marijuana as a dangerous substance that could cause violence. Indeed, marijuana was often portrayed in newspapers as a drug capable of causing “insanity,” and was falsely identified as having originated in Mexico and as the “Mexican drug,” including a 1913 article in The El Paso Times that claimed that it [marijuana] frequently ended in “homicidal and suicidal mania.”19 Two decades of portraying Mexicans as marijuana smokers and as dangerous subjects and a campaign of fear against cannabis led by Harry Anslinger facilitated the passage of the Marijuana Act of 1937. Anslinger, the Director of the newly formed Federal Bureau of Narcotics, published an article in 1937 titled “Marijuana, Assassin of Youth,” while the previous year, Director Louis J. Gasnier “gifted” American audiences Reefer Madness, a movie in which marijuana use was the direct cause of suicide, insanity, and homicide.20

The criminalization of marijuana and its inclusion among Schedule I of the UN controlled substances (reserved for the most dangerous and addictive substances including LSD and heroin) is part of this legacy. By comparison, OxyContin has been classified as a Schedule II substance under the UN Psychotropic Treaty of 1971. It seems clear that in our highly technological society and with the medical and scientific breakthroughs of the past century, we tend to trust chemical and scientific processes over natural pharmacopeia. However, it is also true that the pharmaceutical industry has been progressively involved in the creation of national and international drug regulations since the interwar years and often offered their scientific expertise while persuading national governments to protect the industries’ economic interests.21 Unfortunately, that confidence in manufactured drugs and the political and economic influence of pharmaceutical companies have sometimes led to nefarious outcomes. Following are just a few notorious examples:

The first alkaloid that was successfully extracted from plants was morphine. In the early nineteenth century, Friedrich Wilhelm Sertürner, a German apothecary, successfully isolated the substance from the opium poppy and after experimenting with the drug, warned of its addictive properties.22 Morphine was initially used as a painkiller and as a cure for opium addiction, but with the introduction of hypodermic syringes in the 1850s and physicians’ extensive use during the Austro-Prussian, Franco-Prussian and the US Civil Wars, the drugs’ popularity for recreational purposes increased during the following decades.23

Another famous example is cocaine. First isolated in 1859, it was first used as a cure for morphine and alcohol addiction and was enthusiastically supported in the 1880s by Sigmund Freud, the father of psychoanalysis. Freud used the drug for therapeutic purposes and prescribed it to his patients; he even published a series of articles in the mid 1880s exalting cocaine’s anti-depressant and analgesic properties.24

Just a little over a decade later in 1898, the German-based company Bayer commercialized heroin as a non-habit-forming over-the-counter drug that was used to replace morphine in cough suppressants and as a treatment for morphine addicts.25 The drug could be easily purchased in the famous Sears and Roebuck catalogue alongside cocaine and morphine. By the turn of the century, the company sold a heroin kit with a syringe, two needles and two vials of heroin packed in an elegant case for $1.50 until the Harrison Act made all of these drugs illegal.26

However, perhaps the most important example for illustrating the role of pharmaceutical companies in fueling drug abuse and the difficulties of controlling manufactured drugs is the case of amphetamines. In 1929, biochemist Gordon Alles discovered beta-phenyl-isopropylamine (amphetamine) while searching for an ephedrine substitute and obtained a patent in 1932.27 The drug was initially used to treat narcolepsy and depression and its use quickly skyrocketed during WWII when the Allied forces and the Axis Powers used it as a performance-enhancer, boosting the drug’s popularity in the aftermath of the war. A conservative estimate of amphetamine production in the US in 1945 calculated a production of 30 million tablets per month, with half a million Americans using it as an anti-depressant and a weight loss drug (even though at the time the former use was non-authorized).28 By then, up to 16 million men in the army had been exposed to Benzedrine (amphetamine sulfate), and the consumption rate in the US was greater than 2 tablets per day for every person in the country.29 Pharmaceutical companies continued to expand the market on amphetamines during the 1950s through aggressive marketing, all while opposing regulations. In fact, when in 1961 the UN passed the Single Convention—a landmark drug control treaty—in an effort to limit the agricultural production of raw materials such as coca and opium, the pharmaceutical industry actively lobbied the organization, avoiding the ban on psychotropics until the 1971 UN Convention on Psychotropic Substances.30

As a consequence, pharmaceutical companies continued to flood the market with amphetamines, antidepressants and barbiturates. The drugs’ propensity for addiction fueled the traffic of cocaine, heroin and cannabis from countries in South Asia and Latin America as US demand for those drugs increased.31 In a sad omen to our current opioid crisis, by the late 1960s, the FDA reported that the yearly production of amphetamines had reached 8 to 10 billion tablets and estimated that perhaps as many as half of them were diverted from medical channels.32 

Our current opioid epidemic started during the late 1990s in a similar fashion, when pharmaceutical companies aggressively promoted opioids among doctors and HCPs, claiming that those pain relivers were not addictive.33 Pharmaceutical companies have continued to promote the use of opioids for the last two decades through false premises and with unethical marketing strategies—at least in the case of Purdue Pharma—while once again creating a drug abuse crisis. Certainly, the medical and pharmaceutical industry has saved millions of lives thanks to advances such as anesthesia, penicillin, vaccines and sanitarian practices, increasing life expectancy in much of the world. However, pharmaceutical companies are primarily private corporations that respond to economic incentives rather than to the interests of communities. In addition, the US drug control strategy has focused almost exclusively on the reduction of raw materials such as opium, marijuana and coca cultivations without much regard for reducing domestic consumption. Pharmaceutical companies are often directly and indirectly fulfilling the demand for all sorts of narcotics through legal and semi-legal channels and easily shape or weaken narcotic regulations based on their interests. Perhaps a more compassionate approach that prioritizes the societal cost of drug abuse and that recognizes the suffering of drug addicts and their loved ones over private profits could avoid future disasters, and perhaps a continual examination of our history could also help us avoid these pitfalls in the future.

Written by Freddy Jaimes Jaimes, Faculty Fellow
El Paso Community College, The Humanities Collaborative at EPCC-UTEP

Bibliography
1.  Geoff Mulvihill, “OxyContin maker Purdue Pharma pleads guilty in criminal case,” AP News, November 24, 2020, https://apnews.com/article/purdue-pharma-opioid-crisis-guilty-plea-5704ad896e964222a011f053949e0cc0.
2.  U.S Department of Justice, Plea Agreement with Purdue Pharma LP, Rachael A Honig, Gustav W. Eyler, and Christina E. Nolan, Newark, NJ:  https://www.justice.gov/opa/press-release/file/1329576/download, 15, 16 e/f, 17.   
3.  Patrice Taddonio, “As Purdue Pharma Agrees to Settle with the DOJ, Revisit Its Role in the Opioid Crisis,” PBS Frontline, October 21, 2020, https://www.pbs.org/wgbh/frontline/article/as-purdue-pharma-agrees-to-settle-with-the-doj-revisit-its-role-in-the-opioid-crisis/
4.  Mulvihill, “Purdue Pharma pleads guilty.”
5.  Brian Mann, “Sacklers Deny Wrongdoing During House Panel Over Purdue Pharma Oxycontin Sales,” NPR, December 17, 2020, https://www.npr.org/2020/12/17/947064266/sacklers-to-face-house-panel-over-purdue-pharma-oxycontin-sales
6.  “Opioid Overdose,” Centers for Disease Control and Prevention, US Department of Health and Human Services, accessed December 14, 2020,  https://www.cdc.gov/drugoverdose/epidemic/index.html.
7.  “Overview,” January 15, 2021, https://www.cdc.gov/drugoverdose/data/prescribing/overview.html#:~:text=From%201999%20to%202018%2C%20more,in%202018%20than%20in%201999.
8.  “Opioid Overdose Crisis,” National Institute on Drug Abuse, National Institutes of Health, accessed December 14, 2020,  https://www.drugabuse.gov/drug-topics/opioids/opioid-overdose-crisis.
9.  US Department of Education Fiscal Year 2020 Budget Summary, accessed December 14, 2020, https://www2.ed.gov/about/overview/budget/budget20/summary/20summary.pdf.
10.  William B. McAllister, Drug Diplomacy in the Twentieth Century: An International History (London and New York: Routledge, 2000), 226-230.
11.  This is particularly evident in discussions on the quasi-medical use of natural pharmacopeia in regard to the use of opium and coca in McAllister, Drug Diplomacy, 29, 53.
12.  For an overview of the U.S. colonialism in the Philippines, see Paul A. Kramer, The Blood of Government: Race, Empire, the United States, and the Philippines (Chapel Hill: The University of North Carolina Press, 2006).
13.   See Anne L. Foster, “Opium, the United States, and the Civilizing Mission in Colonial Southeast Asia,” Social History of Alcohol and Drugs, Volume 24, No 1 (Winter 2010): 6-19.
14.  See “Commission Recommends a Monopoly in the Islands: Best Way to Deal with Evil,” The New York Times, September 22, 1904, 9.
15.  Timothy A. Hickman, The Secret Leprosy of Modern Days: Narcotic Addiction and Cultural Crisis in the United States, 1870-1920 (Amherst: University of Massachusetts Press, 2007).
16.  Mc Callister, Drug Diplomacy.
17.  David F. Musto, The American Disease: Origins of Narcotic Control (New York and Oxford: Oxford University Press, 1999), 6, 219, 220.
18.  C.M. Goethe, “Quotas,” The New York Times, September 15, 1935.
19.  “The Mexican Opium,” El Paso Morning Times (El Paso, TX), July 24, 1913.
20.  Harry Jacob Anslinger, “Marijuana, Assassin of Youth,” The American Magazine Vol. 124, no. 1 (July 1937) and “Reefer Madness,” directed by Louis J. Gasnier (1936; G&H Productions, Motion Picture Ventures), film.
21.  Suzanna Reiss, We Sell Drugs: The Alchemy of US Empire (Oakland: University of California Press, 2014), 219.
22.  Michael C. Gerald, The Drug Book: From Arsenic to Xanax, 250 Milestones in the History of Drugs (New York: Sterling, 2013), 86.
23.  Hickman, Secret Leprosy, 2.
24.  Joseph F. Spillane, Cocaine: From Modern Medical Marvel to Modern Menace in the United States, 1884-1920 (Baltimore and London: Johns Hopkins University Press, 2000), 18, 20.
25.  Gerald, The Drug Book, 124.
26.  Joe McKendry, “Sears Once Sold Heroin,” The Atlantic, March 2019 issue, https://www.theatlantic.com/magazine/archive/2019/03/sears-roebuck-bayer-heroin/580441/.
27.  Gerald, The Drug Book, 184.
28.  Nicolas Rasmussen, “America’s First Amphetamine Epidemic 1929–1971: A Quantitative and Qualitative Retrospective With Implications for the Present,” American Journal of Public Health, Vol 98(6) (June 2008): 974–985, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2377281/#r22.
29.  Ibid.
30.  McCallister, Drug Diplomacy, 209.
31.  McCallister, Drug Diplomacy, 218- 219.
32.  Rasmussen, “Amphetamine Epidemic."
33.  “Opioid Overdose Crisis,” National Institute on Drug Abuse.



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