Over the next four weeks, we're gonna be looking at opioids, a class of drugs originally derived from the opium poppy. We're gonna talk about the history of these drugs, the science of how they work, their potential for abuse, and how we help people recover from addiction.

Opioid drugs can be very, very dangerous, but they can also be extremely useful. According to one researcher, and I'm quoting, "To understand the popularity of a medicine that eased, even if only temporarily, coughing, diarrhea, and pain, one only has to consider the living conditions at the time." Until the 20th century, cholera and dysentery regularly ripped through communities, its victims often dying from debilitating diarrhea. Diseases like dropsy, consumption, ague, and rheumatism were very common. Opioids could be used to treat all of these things. But the line between useful treatment and harm is very blurry when it comes to opioids, and while they can be very effective in some respects, they can easily become deadly. The history of opioids are the topic of this week's Healthcare Triage.  

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This episode is brought to you in part with generous support from the National Institute of Healthcare Management.  

Humans have known about opioids and their pain-relieving and euphoria-inducing properties for a long, long time. We've known about them pretty much as long as we've been writing stuff down, and maybe even longer than that. As far as back 3400 BC, records indicate the poppy was grown in lower Mesopotamia. Sumerians called it "Hul Gil," or "the joy plant." By 1300 BC, Egyptians were growing fields of it, and the opium trade was in full force all over the Mediterranean world.

The Greek physician Hippocrates, who you might know from his Hippocratic Oath, used opioids to treat a number of diseases. Alexander the Great brought opium to Persia and India. In the 1300s, though, opium sorta disappeared for a couple centuries in Europe. Evidently, the Holy Inquisition didn't care too much for its use. Opioids had some undesirable social outcomes like addiction and withdrawal, and besides, it came from foreign lands, and during the Inquisition, anything foreign was pretty much the work of the devil.

By the 1500s though, smoking opium was picking up again in Portugal. Laudanum was invented by Swiss polymath physician Paracelsus in the late 16th century. Paracelsus made his laudanum with a bunch of weird ingredients, like crushed pearls and musk, but the real power of it was the potent combination of opium and alcohol.

By the 1600s, England started importing opium from colonies in India. By the 1700s, the Dutch and the English were shipping it to China. The Chinese Ching Dynasty emperors tried to outlaw opium use, but it was unbelievably popular, and it was extremely profitable for the European merchants who were importing the stuff to China. In fact, it was so profitable that the English were willing to go to war with China, not once, but twice, to keep the opium trade in business. Not only did these wars allow the English to keep the opium trade open in China, they set the stage for European powers to force the Chinese to sign all kinds of unfavorable trade deals. The British got an indefinite lease on Hong Kong, for example, which they would hold on to for over a hundred years, not returning the island to Chinese control until 1997.

The 19th century saw a lot of advances in the science of opioids. In 1803, Friedrich Serturner, in Germany, discovered the active ingredient in opium: morphine. He managed to extract this active alkaloid, which allowed for much more potent opioids to enter the market. In 1827, E. Merkin company began manufacturing morphine commercially, and in 1843, Alexander Wood figured out that you can inject morphine with a syringe. It was three times stronger when administered that way. These new opioid drugs had even more analgesic power, but they also had more powerful side effects, including euphoria and the addiction that could result from it. In 1895, Heinrich Dressi of the Bayer company discovered that diluting morphine with acetyls produced a drug with fewer side-effects.

They coined the term "heroin" and started producing it commercially a few years later. In the early 1900s, free samples of heroin were sent to morphine addicts by mail to help them quit. As you can imagine this didn't work out so well. Heroin addiction grew rapidly, and in 1905, Congress banned opium use in the United States. In 1910 the Chinese convinced the British to take down the India-China opium trade. In the United States, the Harison Narcotics Act of 1914 took aim at doctors to slow the use of narcotics. About 10 years later, the Treasury Department's narcotics division banned all legal narcotics sales. This didn't stop its use though.

An underground economy in drugs arose to meet the demand for illegal opium and heroin throughout the United States. These drugs had become a growing source of profit for organized crime during the 20th Century. In 1973 president Nixon had the Justice Department create the Drug Enforcement Administration to bring all the power of drug enforcement into one agency.

The War on Drugs kicked into high gear. In the 80's and 90's, the United States tried to strangle the drug trade wherever it was flourishing, with arguably little effect. Around this time the most recent wave of opioid misuse began.

In the medical community, the belief that use of opioids to control pain might be safe and effective was gaining traction. In 1980, Dr. Jane Porter argued in the New England Journal of Medicine that only four out of 12,000 patients who used narcotics became addicted.

Another study published in the journal Pain in 1986 said that only two of 24 patients who had used narcotics for years had had any difficulties. This, coupled with the growing recognition that doctors were under-treating pain, led to increased use. By 1996, the American Pain Society labeled pain the fifth vital sign. and any doctor will tell you that pain measurement became an integral part of any clinical visit.

The pharmaceutical industry brought their weight to bear as well. They created and marketed new drugs, and funded lobbying organizations, like the American Academy of Pain Management

and the American Pain Society in an attempt to ease the regulation of opioid drugs.

But concerns began to arise that pharmaceutical companies and researchers were overstating the safety of these medications. In 2007, the maker of Oxycontin pled guilty to misleading regulators, doctors, and patients about the risk of addiction and potential for misuse of the drug. They were forced to pay about $600 million as a result. Other narcotic manufacturers paid huge fines for questionable marketing and misleading claims about safety.

In 2003, the New York Times reported that more than 20% of young adults abused prescription pain medication in the United States. Even so, the drumbeat continued for more and more treatment of pain. Ironically we've been here before in the United States.

This is actually the third wave of opioid abuse in the US. The first occurred in the late 1800s, when Bayer started making heroin. It was being used more and more often for a wide variety of health problems.

Huge amounts of money were being made and misuse was rampant. Policy responded by taxing the drugs, regulating their use, and treating addiction more widely.

Following World War Two, the United States saw a second wave of abuse. Veterans of that war, the Korean War, and the Vietnam War were addicted in large numbers. In response, the government passed laws allowing addicts to be hospitalized involuntarily. Methadone clinics were set up, and the DEA began to respond to the drug trade.

Today we face similar problems. Opioids now cause more deaths than any other drugs. People in the United States consume 99% of the world's hydrocodone, 80% of the world's oxycodone, and 65% of the world's hydromorphone.

Here's the problem: pain is real. It's far too often, but opioids are dangerous and it's becoming clear that they don't work that well for chronic pain. We need to help people who are addicted curb their overuse and also find alternatives for people who are suffering.

Healthcare Triage is supported in part by viewers like you through Patreon.com, the service that allows you to support the show through a monthly donation.

We'd especially like to thank our Research Associates Joe Sevits and M.T. and our Surgeon Admiral Sam. Thanks, Joe, MT, and Sam! More information can be found at Patreon.com/healthcaretriage.