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Setting Today’s Opioid Epidemic in Historical Context

We are living in a time of epidemic. Since the turn of the twenty-first century opioid addiction has skyrocketed in America, filling the news with harrowing scenes of desperation and tragedy and bringing enough death to change mortality rates and, some argue, swing presidential elections. It is difficult to get the full measure of such a catastrophe while it is still happening, yet most observers agree that the epidemic stemmed, at least in part, from a sharp increase in prescriptions and sales of pharmaceutical (legal) narcotics in the 1990s and 2000s—most infamously, Purdue Pharma’s OxyContin, a long-acting form of oxycodone, which was misleadingly and intensely marketed as bearing little addiction risk. Painkillers were eagerly embraced by formerly chary medical professions who had recently, for other reasons, become newly attentive to the importance of pain management even as they were squeezed for the resources necessary to do the job properly. Opioids thus found their way to countless medicine cabinets bearing a dubious medical seal of approval. Pain patients as well as their curious families and friends gained access to drugs whose risks had been partially hidden from them. We have been living with the consequences ever since.

This consensus history of the epidemic’s origins and causes is closely tied to the consensus political responses to the crisis. New supplyside regulations, for example, make sense if pharmaceutical sales and prescribing have run amok. And shifting from punishment to new medical treatments such as buprenorphine maintenance makes sense if addicts are innocent victims ensnared in the web of commercial opioids. The first draft of history matters.

But where you choose to start a story matters enormously, and this one did not begin in the 1990s. In truth, today’s opioid epidemic is merely the latest of several waves of addiction to pharmaceuticals that have swept across America over the past 150 years.

The first wave took place in the late nineteenth century, the result of too-free physician prescribing and poorly regulated legal drugstore sales of opiates and cocaine. The resulting epidemic of addiction to pharmaceuticals ebbed after a few decades, when medical reforms reduced prescribing and narcotic marketing and sales were restricted by a brand-new federal regulatory state (notably, the Food and Drug Administration and what eventually became the Federal Bureau of Narcotics).

But these reforms did not address all addiction. With narcotic commerce flowing so bountifully, opiates and cocaine were also used without medical approval by what early twentieth century reformers sometimes called the “dangerous classes”: working-class or poor men and women, often the children of immigrants, subsisting in the informal economy of major cities. Unaffected by protective legislation which only applied to medicinal narcotics, these communities were targeted instead by a new punitive policing that held them morally culpable for their addiction. Later, similar circumstances confronted the African Americans who increasingly lived in these neighborhoods during and after World War II.

Addiction also continued to be a problem for legal, medically-sanctioned pharmaceuticals as well. Physicians and patients eagerly embraced new synthetic sedatives (barbiturates, tranquilizers) and stimulants (amphetamines) as they became available in the early twentieth century, helping them become some of America’s most widely used medicines. By the 1950s, some fifty doses were sold annually for every man, woman, and child in the U.S. Because addiction had become so closely associated with heroin and the racially stigmatized urban poor, authorities were reluctant to acknowledge it when it cropped up amo

ng the doctor-visiting classes and their beloved pharmaceuticals. They were even more reluctant to impose restrictions on booming drug markets. The consequences were predictable: by the end of World War II the news was once again full of drug-induced addiction and death. In 1953, fatal overdoses from barbiturate alone killed a higher percentage of Americans than prescription opioids did in 2014.

It was not until the “third-wave” consumer movement of the late 1960s and 1970s that real restraints were imposed on the market for pharmaceutical sedatives and stimulants. In a radical policy shift, the medicines were placed under the authority of the (new) Drug Enforcement Administration, which had unrivalled power to police each step of the pharmaceutical commodity chain. Medical reforms, meanwhile, reduced prescribing. And thanks in part to civil rights activism, the new regime’s benefits extended, at least partially, beyond relatively privileged pharmaceutical users: new laws favored treatment, not just punishment, and even allowed for the maintenance of addicts with the long-acting opioid methadone. Together these approaches essentially re-created the regulatory apparatus that had been successful in ending the first wave of addiction to pharmaceutical opiates and cocaine: strong consumer protections plus treatment for those harmed.

But this arrangement did not last. In fact, it began to unravel almost as soon as it had been put in place. The first to go were relatively humane responses to non-medical drug use. New York governor Nelson Rockefeller’s 1973 “Attila the Hun” laws sparked a nationwide race to impose the harshest punishments, the brunt of which targeted urban racial minorities. This approach reached peak intensity during the so-called “crack” cocaine crisis of the 1980s, contributing to the emergence of a mass incarceration so racially disparate that Michelle Alexander has called it the New Jim Crow. The other shoe dropped in the 1980s, when anti-regulatory zeal reached a pharmaceutical industry determined to rebuild the immensely profitable market for psychoactive drugs. One eventual winner was new narcotics like OxyContin which, like fellow celebrity drug Prozac, was touted as a technological triumph that had vanquished old problems of addiction. Such claims were believable at a time when addiction had, once again, become a scourge popularly and politically associated with the racially stigmatized urban poor rather than white middle-class users of pharmaceuticals.

And that brings us to today’s opioid epidemic. But after our historical journey it looks quite different. The opioid epidemic is not an unprecedented and aberrant tragedy, and today’s opioid addicts are not uniquely innocent and in need of protection and care. Our current crisis is just the latest of multiple waves of addiction (to pharmaceuticals as well as illicit substances) that have flourished in a culture where drugs are judged less by their pharmacology than they are by the social standing of the people who sell and use them. Regulating the drug industry and providing care rather than punishment for opioid addicts are still laudable and effective responses. But they no longer seem sufficient without an explicit plan to apply them more widely—to a wider range of pharmaceuticals, and to drug users without access to pharmaceuticals. To treat today’s epidemic as a singular phenomenon means leaving in place the basic cultural and legal framework that, for over a century, has ensured that while we battle one addiction epidemic the next one is always brewing.

David Herzberg is an Associate Professor of History at the University of Buffalo. His book Happy Pills in America: From Miltown to Prozac was published in 2009.