A display of several apothecary bottles containing drugs, on shelf of Eimer and Amind (?) drugstore, 1940. Source: Library of Congress

The Habit

Opioid Addiction in America
As the opioid epidemic continues, Surgeon General Dr. Jerome M. Adams said this week that Americans should carry and learn to use naloxone, an overdose antidote. In this episode, Nathan, Ed and Brian look at America’s long history with opioids – like opium, morphine and heroin. They’ll discuss how late 19th century doctors spurred the nation’s first addiction crisis and how race and class have shaped our perception of addicts and addiction.
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FEMALE SPEAKER: Major funding for BackStory is provided by an anonymous donor, the National Endowment for the Humanities, the University of Virginia, The Joseph and Robert Cornell Memorial Foundation, and The Arthur Vining Davis Foundation.

BRIAN: From the Virginia Foundation for the Humanities, this is BackStory.


NATHAN: Welcome to BackStory, the show that explains the history behind today’s headlines. I’m Nathan Connelly.

BRIAN: I’m Brian Balogh.

ED: And I’m Ed Ayers. If you’re new to the podcast, Nathan, Brian, our colleague, Joanne Freeman, and I are all historians. And each week, we explore the history of a topic that’s in the news.

NATHAN: Brian and Ed, I’m going to start off today with some old-time recipes. I talked to a historian named David Courtwright recently. He was doing some archival research a while back, and happened to thumb through some 19th-century cookbooks. He noticed something a little odd.

DAVID COURTWRIGHT: What you discover right away is that they’re not just about how you make the beans, or how you make the porkchops. There’s always a section of medical recipes in the back.

NATHAN: Now, some of these 19th-century home cures might sound pretty familiar. Think about your grandmother’s chicken soup for a cold, for instance, or herbal tea to settle an upset stomach. Whatever your home cure is, there’s one ingredient Courtwright mentioned that is not on the menu today.

DAVID COURTWRIGHT: Often, they would contain opium as one of the ingredients.

NATHAN: Throughout the 19th century, the US imported boatloads of opium from Turkey. Medical opium was perfectly legal and easy to get.

DAVID COURTWRIGHT: People could buy– in many places, they could buy opium just over the counter.

NATHAN: In an age with few effective medications, opium was marketed as a relief for almost every condition under the sun. Harper’s Weekly called it “the poor child’s nurse.” It was used to soothe teething babies, or a child’s hacking cough.

It also took the edge off migraines and menstrual cramps. It relieved insomnia, and what was then called “melancholy.” Courtwright says even an unpleasant side effect of the drug, constipation, became a selling point.

DAVID COURTWRIGHT: People suffered terribly from diarrhea and dysentery, and opium constipates. It alleviates the symptoms of these diseases. It brings relief, it allows people to rest and quit dehydrating.

NATHAN: Opium didn’t just suddenly appear in the 19th century. It’s been in mankind’s medicine cabinet for thousands of years.

DAVID COURTWRIGHT: Oh, going back to ancient times. But in the United States, it’s clear from medical correspondence in the 17th and 18th century that this was an indispensable part of the pharmacopeia.

NATHAN: All of this is to say that opium, and the many narcotics derived from it, which we call opiates or opioids, have been a part of American medicine for a very, very long time. Opium, morphine, codeine, and heroin, along with their 20th-century descendants like oxycodone and fentanyl, all belong to this family of narcotics.

ED: Now, opioids are tremendously effective as painkillers, but they can also be tremendously addictive.

FEMALE SPEAKER: The abuse of opioids remains a major public health concern around the country.

MALE SPEAKER: More people are dying now from drug overdoses than from car crashes and gun homicides combined.

MALE SPEAKER: This is a public health epidemic, but it is completely man-made.

MALE SPEAKER: Opioid addiction is now officially an epidemic in Virginia.

MALE SPEAKER: How did it get so bad so quickly?

FEMALE SPEAKER: How can we get the doctors in hospitals to stop over-prescribing these addictive drugs?


BRIAN: In the past few years, opioid addiction has turned into a major public health crisis. The number of fatal overdoses has quadrupled since 1999, killing more than 33,000 Americans in 2015 alone. Politicians in both parties have vowed to combat the epidemic. Maryland and Florida have even declared states of emergency, and at least one town recently sued a pharmaceutical company for damages.

Today on the show, we’re going to look at two earlier opiate addiction epidemics. One in the 1870s, and then another in the early 20th century. We’ll also look at the often porous boundary between prescription drugs and street drugs.


NATHAN: First, I want to return to my conversation with David Courtwright. He talked about cookbooks, sure, but also about the role of doctors in opiate addiction. Courtwright says there was a sudden spike in opiate use after the Civil War. Per capita use tripled between the 1870s and 1890s. It was, in fact, the country’s first medical addiction crisis, and it’s easy to find the cause.

DAVID COURTWRIGHT: Well, in two words, morphine injection.

BRIAN: Morphine was one of the first opiates. When injected into a patient’s bloodstream, it was much more powerful than opium pills or powders. And thanks to the spread of syringes, morphine soon flowed into wide use.

DAVID COURTWRIGHT: In 1860, most American physicians did not have a hypodermic syringe or know how to use it. By 1880, virtually all of them did. That’s the difference. And they used it as a kind of magic wand for the treatment of pain. There are many, many cases where there wasn’t much they could do to get at the underlying cause of the disease. But here, alas, was something that would alleviate the pain, bring sleep, soothe the patient, and they used it.

NATHAN: Now, for as long as Americans have been using opiates, there had always been some patients who became addicted.

ED: And Nathan, there are certainly a lot of people in pain in the 19th century. I know that during the Civil War, army doctors passed out opium and morphine pills to wounded soldiers, so that after the war, many veterans were addicted. So much so that opiate addiction was sometimes called “The Army Disease.”

NATHAN: That’s right, Ed. A lot of people were in pain. Courtwright says in the years after the war, soldiers weren’t the only ones who struggled with morphine addiction.

DAVID COURTWRIGHT: By the 1870s and 1880s, the vast majority, say 60%, 70% of the addicts in the United States reported by pharmacists and physicians, were female.

NATHAN: Female?

DAVID COURTWRIGHT: Right. Women were doctors’ best customers. The majority of patients doctors saw in the late 19th century were female. And they suffered from a set of conditions such as dysmenorrhea, or painful childbirth, that men did not experience. So to say it simply, there were more ways to become addicted if you were female.

NATHAN: And were they using the word “addiction” in the medical publications, or in the kind of common language about these kinds of concerns?

DAVID COURTWRIGHT: No. That’s actually a very interesting question. Trying to figure out the terminology of addiction in the 19th century is like trying to nail jelly to the wall. “Morphine eating.” “Morphinisim.” “Habit” was extremely common, so one often reads of the “opium habit,” or the “morphine habit.”

“Addiction” does not really become common until the 1910s and 1920s. So you’ll pick up a medical journal in, say, 1925, and it’s about addiction. You pick up one in 1875, and it’s about the opium habit, or the morphine habit.

NATHAN: Now, I have to imagine that that race also had something to do in determining who the typical addict might be when it concerned opiates. Is that fair to say?

DAVID COURTWRIGHT: It’s fair to say if you conjoin race and economics. If you put the question this way, which racial group in the United States in 1900 had the lowest rate of narcotic addiction? The answer is African-Americans. The majority of African-Americans were poor, and they didn’t have access to regular medical care, in many cases.

And while that may not have been good for them in some respects, it did, ironically, confer a certain immunity against medical addiction. Narcotic addiction was primarily a white and a Chinese problem. Chinese, because of course, many of the indentured Chinese laborers were opium smokers.

NATHAN: Right. So you’ve painted a pretty stark picture here, where you have the arrival of hypodermic applications of opium. With white women, it sounds like, being the predominant abusers of the medication by the time you get to the 1870s and 1880s.

DAVID COURTWRIGHT: Well, I wouldn’t necessarily say “abusers.”


DAVID COURTWRIGHT: Remember, these are people who are basically sick. They have chronic conditions of one kind or another. They didn’t all become addicted. Some of them simply took opiates for a brief period of time and then got better, and quit taking the drug, and they were fine. Others continued taking the drug, and they became addicts. To apply the word “abuse” to that– these were people who wandered into a trap.

NATHAN: Did these doctors notice that some of their patients had become dependent on morphine?

DAVID COURTWRIGHT: Yes. You can infer that from complaints that you read in medical journals. So doctors were starting to wake up to the fact that they had a problem. So you’ll come across articles which say, don’t ever leave the hypodermic syringe with the patient.

Try to disguise the medication, so that should a person have surgery or have some other kind of long-term recovery, they might become physically dependent on a narcotic. But if they don’t connect the withdrawal symptoms to the medicine, as you might call it, then they’re probably not going to continue.

NATHAN: Now, you had mentioned that there was a danger if patients became aware that it was the morphine on its own that was providing the relief, and they might find other ways of getting access to the drug. Was there a kind of underground economy, even in medical-grade morphine or opium at this time?

DAVID COURTWRIGHT: No, not really. Not for the medical patients. So yes, there is an underground traffic in drugs like opium that has been prepared for smoking. So if that was your opiate of choice, then yes, there were criminal networks and black markets, and so on.

But if you’re a 45-year-old white woman who realizes that you have a problem, then what you’re going to do is you’re going to seek out an accommodating pharmacist or physician. There are plenty of people who would be willing to provide you with the drug, because the truth is that there’s no steadier customer than an addict.

You might have an old prescription, which a pharmacist will sort of wink and nod, and continue to honor that old prescription. Even though it’s tattered, and it’s falling to pieces, and it’s yellow with age, but they’ll go ahead and continue to fill the prescription. So as a rule, medical addicts in the 1870s and 1890s did not yet have to resort to the black market, and it’s very interesting what does not happen. In the late 19th century, no one is particularly interested in throwing Civil War veterans or sick old ladies into prison.

NATHAN: Right.

DAVID COURTWRIGHT: There’s no drug war. Chinese opium smokers and members of the white underworld, such as gamblers and prostitutes, who also took up the practice of smoking opium at the very end of the 1860s and into the 1870s, those people were worthy of contempt.

NATHAN: Now, there’s a law that’s passed by Congress in 1909, The Opium Exclusion Act. Was that the law that ultimately helped to rein in some opium use?

DAVID COURTWRIGHT: Some opium use, yes. That law was very specifically designed to prohibit the importation of opium that had been prepared for smoking, for the opium pipe. It did not apply to medicinal opium imports, most of which were converted into morphine. And certainly didn’t have anything to do with the medical prescription of morphine. However, the situation had changed by 1909, and we do know that doctors were writing fewer prescriptions–


DAVID COURTWRIGHT: –for opium and morphine. Oh, because they’d learned their lesson. Hey, it’s good to know that people learn their lessons.

NATHAN: Indeed.

DAVID COURTWRIGHT: This is a very common thing with medications. Doctors tend to be enthusiastic about new drugs, and sometimes, these new drugs are overused. For example, Valium in the 1970s. Or in our own time, prescription opioids, which is part of the reason we have this crisis has come back. But it starts in the journals, and then by the 1890s, medical students are being warned.


DAVID COURTWRIGHT: I remember reading one source where a doctor is complaining that medical students today have been so thoroughly warned about the dangers of narcotic administration that patients are suffering the agonies of hell for want of an eighth of a grain of morphine. This critic thought the pendulum had actually swung too far in the other direction. That too many doctors had become wary.

Word was out in the medical profession, and the newer generations of physicians were more circumspect in their prescribing. Not only that, but they had other things that they could prescribe. I mean, the most obvious example is aspirin, which became commercially available in 1899. So if somebody shows up with aches and pains, rather than give them laudanum, or opium, or even morphine, prescribe aspirin.

NATHAN: Are there any lessons we can draw from the 19th century opioid crisis that might inform how we approach the current crisis?

DAVID COURTWRIGHT: Well, the most obvious lesson is that physicians are educable. They were able to bring peer pressure to bear. If one looks at the medical literature, this is years before the federal government gets around to passing legislation, there’s a kind of self-criticism and internal indictment that’s going on.

Doctors who shoot first and ask questions later are lazy, they’re incompetent, they’re behind the times. They’re bad doctors. Bad doctors can kill you, and other doctors are saying that in the medical literature of the late 19th century. And so there’s a kind of shaming that’s going on.

NATHAN: In a lot of ways, it’s a remarkable window back into a period that might not be as different as we’d like to let on.

DAVID COURTWRIGHT: That’s absolutely right. And it’s also the case that not everyone who uses these drugs necessarily gets into trouble. I mean, there are lots of folks who are pain patients who take hydrocodone or oxycodone. They don’t doctor shop. They follow the directions.

They don’t get into trouble, and they significantly improve their lives. It’s not the case that everyone necessarily goes off the rails, which is one of the things that makes this problem so difficult. People are different.

Their social circumstances are different. Their doses are different. Their underlying medical conditions are different, so you’re going to get different outcomes. That’s the way the world is.

But unfortunately, we do know that a significant minority of people who are prescribed powerful prescription opioids do develop serious problems. That was the case in the late 19th century. It is the case, unfortunately, in the early 21st century as well.


NATHAN: David Courtwright is a historian at the University of North Florida, and author of Dark Paradise: A History of Opiate Addiction in America.


ED: It’s time to take a short break. When we get back, we’ll hear about the role of the South in creating products that many people discovered they just couldn’t live without. But first, a word from today’s sponsor.

BRIAN: We’re back talking about the history of addiction in America.

NATHAN: Talking to David Courtwright, I was struck by how many of the addicts in the late 19th century, indeed, the vast majority, were upper- and middle-class white women. And I later learned that most of them were from the South.

ED: Yeah, I guess I wasn’t as surprised, Nathan. Because the New South, as we call the era after Reconstruction, was a place sort of perfectly suited for this kind of addiction. You had the sudden availability of all kinds of products that had never been available before. And all these general stores, and railroads, and mail order, and all these things were coming up.

And so you have a lot of people thinking, well, what can I do to take care of myself? You go back and look at the newspapers of the New South Era, they’re just filled with patent medicine ads. And there’s a lot of self-medication going on. Whether it’s the relatively elite white women, maybe widows. The South has been devastated by the Civil War, of course.

But it’s also the case that the South is looking for other forms of stimulants. This is kind of striking. This is the same era that the cigarette machine is invented here in Virginia, and they could roll 100,000 cigarettes in a day. And the tobacco industry as we know it really takes off.

And it’s also the time that Coca-Cola is invented as a headache remedy, mainly because it has a whole lot of stimulants in it. And the very earliest ones do have coca in it, the origins of cocaine. But a lot of caffeine as well, and a lot of sugar as well.

At the same time this is all happening, the South is also the place that institutes prohibition earlier than the rest of the country. It’s partly because of the religious tradition, but it’s also because the sudden prevalence of alcohol. And these potent, new mass-produced and mass-distributed forms are also a new threat.

BRIAN: Well, and what strikes me about what you said, much of which I’d never thought about, Ed, is the stark division between what turns out to be illegal, eventually, in the early 20th century, and what turns out to be the most legitimate and important business of the South across the 20th century. And the line is really pretty blurry, in terms of actual physical addiction, by the tune of modern science.

ED: And what they have in common, Brian, is that cigarettes and Coca-Cola, but also alcohol, are on a continuum with morphine of degrees of addiction. And what Courtwright’s interview helps us understand is a lot of it depends on the channels and the social sanction by which these addictive substances come.

So it’s interesting how quickly people react. At the same time this is all happening, there’s a scare in the South about this new substance that’s supposedly leading black men to behave irrationally. Cocaine. So you can find these campaigns to stamp out cocaine use in the same society that, just around the corner, would have this morphine abuse, and that is producing these addictive substances for the rest of the world.

So yeah, Brian, it’s kind of surprising. We don’t really think about the South being sort of awash in consumer goods, but they are not only consumers of things like this new morphine, but they are producers of these addictive substances that really flow into the bloodstream of the whole nation, and later, the whole world.

NATHAN: Well, that’s the thing about– if you think about cigarettes, and Coca-Cola, and obviously, morphine. I mean, these are various substances that are only talked about as being addictive at different points in American history. It’s only recently, relatively, that we talk about the addictive power of sugar.

Or certainly, nicotine addiction is an emergency on a national scale, relative to the 1970s and 80s. But it’s not that way in the 1950s. And so I think it’s a powerful indicator of the fact that even addiction is something that is not simply relegated to the body of the person using the substance. That it is a social and a cultural phenomenon.

BRIAN: Stigmatized or legitimated.

NATHAN: Right.

BRIAN: And Nathan, you’ve also pointed to the social nature of science and medical science itself. Because back in the 1880s and 1890s, they were just beginning to recognize, through experience, and probably because of the population they were dealing with of white women, that this was, as they would call it “habit-forming.” But they certainly weren’t terribly worried about the addictive quality of nicotine at that time.

NATHAN: Right.

BRIAN: And what has happened with our growing concern with health and well-being over the course of the 20th century is that we have become more and more precise. The tools to measure addiction have become more and more precise. And we are actually able now, through scientific experiments, to show the addictive qualities of many of these substances, that for much of the 20th century, were considered completely legitimate, and even healthful.

ED: You know, it’s a fact that humans are physiologically inclined to become addicted to different kinds of substances. Throughout history, people have looked for different substances that will make them feel good in the short term, with not really an understanding of what the long term might be like. As historians, we’re not much inclined to look for constants in human history. We’re always struck by the change.


BRIAN: That’s boring.

ED: But here’s a case that American history shows you both those things. That the physiological longing to dull various kinds of sensations matches this kaleidoscope of changing social situations. And that’s what we see in the history of addiction. Is that there’s always an impulse, a pulling toward it, but there’s always a difference supplying of that longing. And what that supply shows is the way society itself is changing.

BRIAN: It’s time for another break. When we get back, the creation of the 20th century junkie. But first, this quick message.


BRIAN: Hey, podcast listeners. We have two quick announcements for you about how you can be involved in BackStory.

NATHAN: We’re working on a show about military enlistment, so we’re curious. If you’re an active service member or a veteran, why did you join up? What drew you to the armed forces? We want you to share your stories.

You can record yourself on your smartphone or computer and send it to us at backstory@virginia.edu. Or you can just write us and tell us about it. Just don’t forget to include your name and where you’re from. We’re looking forward to hearing from you.

ED: Our second announcement is our new online book club that we’re calling BookStory. Each month, moderator Melissa Gismondi will select a new history book to discuss with club members. When you sign up, you’ll receive a welcome packet, an excerpt of the book, and access to a private Facebook Discussion Group.

At the end of each month, we’ll host a Facebook Live Discussion with the book’s author. BookStory is partnering with the website DelanceyPlace. All proceeds go towards supporting children’s literacy projects. So go to backstoryradio.org and sign up today.

BRIAN: We’re back. Earlier, we talked about how doctors were the source of opiate addiction in the late 19th century. As we mentioned, this was before there was a clear understanding of the physiology of addiction, and that’s reflected in the language of the time. Addicts simply had opium or morphine “habits.”

ED: But that changed in the early 20th century, when addiction became criminalized over fears of recreational drug use. People once thought to have “habits” now became known as “junkies.”

NATHAN: In the 1920s, a Philadelphia hospital opened a narcotics ward for recovering addicts. The patients were monitored while they suffered through withdrawal from morphine and other drugs. Once those symptoms stopped, the addicts were pronounced cured and sent home.

Historian Caroline Jean Acker reconstructed the lives of several hundred of these patients. One of them was a fellow she calls James Martin. He was a working-class white man who lived in New York City near Chinatown. In 1908, the then 21-year-old Martin went on a double date that changed his life.

CAROLINE JEAN ACKER: He wanted to impress the people he was with, and so he said, I know where there’s an opium den. Let’s go smoke some. And he found it made him feel really good, so he started going back, and back.

ED: But in 1909, just a year after Martin developed his habit, the federal government banned the importation of what it called “smoking opium.” The law deliberately targeted recreational use of the drug. It did not ban opium or morphine used in medicine.

CAROLINE JEAN ACKER: So for someone like James Martin, he had become addicted to opium, and suddenly, he had no access to it. But guess what was pretty easy to get on the street in those days? At pharmacies, still completely legally sold, except in a few localities? Heroin. So he began sniffing heroin as a substitute for the opium. James Martin changed his drug use behavior in specific response to the passage of legislation.

NATHAN: Heroin, an opioid derived from morphine, didn’t start out as a street drug. It started out as a pharmaceutical drug. The German company Bayer developed heroin in the 1890s and sold it over-the-counter as a cough suppressant. The American Medical Association approved heroin for general use in 1986, and urged doctors to prescribe it instead of morphine, believing it to be less addictive. Physicians gave it to both children and adults.

CAROLINE JEAN ACKER: Remembering that this is a time when tuberculosis was still the leading cause of death, coughing was an important prevalent symptom, a distressing one, and it seemed like a drug that would calm that would be useful. And it certainly made people feel better. But you didn’t have to have a cough to feel better from heroin.

NATHAN: Right.

ED: Pharmaceutical heroin was twice as powerful as morphine. And though Bayer promoted it as a safer, non-addictive substitute for morphine, heroin was even more addictive. And the drug’s easy availability produced a thriving black market for recreational users, especially after the federal government banned smoking opium.

CAROLINE JEAN ACKER: And so for example, teenage boys in pool halls were snorting heroin. Sniffing it up into the nose and into the bloodstream, and quite quickly into the brain, and produce a wonderful feeling. A kind of a rush, and a feeling of utter, utter calmness. So this pattern of use was spreading, it was popular, it was causing alarm.

NATHAN: And Congress responded to that alarm with a landmark law known as the Harrison Narcotic Act of 1914.

CAROLINE JEAN ACKER: And this act outlawed the non-medical use of a set of drugs, including morphine, heroin, and cocaine. And again, this was targeted specifically at use associated with entertainment districts, and largely working-class neighborhoods. Optimists believed that you simply keep the drugs from being imported and no one can get them, and the drug use problem will disappear. We’ve banned this, the problem’s going to go away. But it quickly became evident that the problem wasn’t in fact going away.

NATHAN: In the 1920s, a physician named Lawrence Kolb tried to figure out why banning drugs didn’t seem to eliminate drug use. He classified addicts into two types.

CAROLINE JEAN ACKER: And the main distinction was, people– he really used the term “innocent.” People who accidentally became addicted because they had chronic pain, their physician was prescribing it for them, and they were becoming addicted. And Kolb had complete sympathy for them, and felt they just deserved support, and maybe even it made sense for them to have a doctor-managed continuing supply of morphine.

NATHAN: In other words, medical addicts. So that’s type 1.

CAROLINE JEAN ACKER: But the main category he singled out was what he called type 2, and these were people who started using the drug for pleasure and became addicted. It was never any medical issue at all, as far as he was concerned, that drove them to the use. But he believed that the people who became heroin addicts were born with a certain kind of vulnerability that made them susceptible to having a much more powerful response when they encountered heroin, and then sliding into addiction.

NATHAN: So given Kolb’s categories, you might say that James Martin is more of a type 2 user?

CAROLINE JEAN ACKER: Absolutely. Exactly right. He engaged in this bad behavior, which became criminal once the Harrison Narcotics Act was passed. There was serious classism built into Kolb’s definition. His class background was modest, and he typified the addict who became this conundrum over the course of the middle decades of the 20th century. How do we deal with this?

ED: Kolb’s views on addiction shaped public health policy for decades. His understanding of type 2 addiction also provided the intellectual underpinnings for the War on Drugs, federal drug laws that criminalized addicts like James Martin. Acker says that Martin went through detox and withdraw several times, and struggled with his addiction for at least 15 years. We don’t know what happened to him after that, but we do know that he represents a new kind of addict in the American imagination, a “junkie.”

CAROLINE JEAN ACKER: What happened was that heroin became referred to as “junk,” and that partly reflected the kind– I mean, some of these patients I studied had a real sense of self disgust at what had happened to them, and that their sense had just become enslaved to this drug. It was so associated with the addicts that it became a label for them. And the “junkie” became a profound symbol of deviance to mainstream conventional Americans.

BRIAN: So the way in which the junkie is being targeted as a kind of side of regulation, does that provide any kind of reveal about the nature of addiction itself?

CAROLINE JEAN ACKER: I think it reveals more about the nature of American society, and to some extent, societies in general. And that is the need to find some explanation for problems. So we have this recurring pattern of a panic about a drug, overreaction, and perhaps not as much social learning as would be good for us.

ED: US drug policy has always drawn a hard and fast line between pharmaceutical and recreational users. Between legal and illegal drugs. But given what we know about the physiological nature of addiction, a 19th-century morphine addict isn’t all that different from a 20th-century heroin addict.

BRIAN: Acker says at least some people are starting to understand this. In addition to her academic work, she spent many years working with heroin addicts, and she sees some hopeful signs.

CAROLINE JEAN ACKER: I think that we’ve had an amazing breakthrough in the understanding of drug use behaviors and how to respond to them. In the context of the crisis of AIDS, and the recognition that HIV could be transmitted through sharing syringes, activists sprang up to set up syringe distribution programs to ensure a sterile supply of syringes to injectors. And some people thought this was the craziest thing in the world.

What? You know they’re just going to use them to shoot up heroin. But from a public health point of view, it made perfect sense. Because it was interrupting the transmission of a pathogen from one body to another body.

BRIAN: AIDS activists carried out this work, even when it was against the law.

CAROLINE JEAN ACKER: In this context, they developed relationships with drug users. Trusting relationships. People who had– junkies, injectors, who had been treated terribly by the medical establishment, by social service organizations. Who didn’t want to work with anyone, who was an active drug user.

And so we’re learning that there’s this disdain of the user, and the refusal to work with them until they stop using is counterproductive. That you really can construct productive relationships and help people get better for them.

BRIAN: Carolyn Jean Acker is Professor Emerita of History at Carnegie Mellon University, and author of Creating the American Junkie: Addiction Research in the Classic Era of Narcotic Control.


NATHAN: So I wanted to come back to this point that was raised by Carolyn Acker, and that you actually pointed to as well, Ed, about this moral divide around how reformers think about addiction. I mean, this is one of those things that keeps coming back in period after period. That there is a way in which the way we talk about these addictions has a direct impact with how we decide to marshal resources to deal with them.

ED: Yeah, Nathan. I’m actually struck by once policymakers decide who is the object of their attention, then they decide what words they’re going to use. If it’s people that you think are drug abusers for some fault that’s their own, then there’s a war on drugs. It’s their responsibility to “Just Say No.”

If on the other hand, these are people that you think of as victims in some ways, as people who have been lured into drug abuse, then they deserve treatment. And once you head down one of those roads, the language you use seems to reinforce the presupposition with which you began.

NATHAN: Right.

BRIAN: And I’m struck by the role that physicians, doctors play throughout. Right? They inadvertently create quite a bit of addiction in the late 19th century by using opiates to relieve pain for all kinds of maladies. Yet, it’s doctors who, in many ways, sound the warning bell about the potential of addiction through their inadvertent actions.

We have also Dr. Lawrence Kolb, who simply pronounces on the kind of division that Ed just talked about, “innocent users,” as he puts it. And then we have those “bad people.” The pleasure-seekers who are using the same drugs, but somehow, it’s their own fault. And what we see again and again is that these distinctions just don’t hold up over time, yet, we keep repeating them and reinforcing them.

NATHAN: In spite of the role that doctors play, one could argue that they’re not the be-all and end-all of the problem, nor the only ones who can level a solution here. Right? I mean, if you think about the larger policy atmosphere around the current crisis, doctors can certainly try to decrease the volume of opioids in circulation.

But it sounds like there really is a kind of cultural question, and really, a historical question that we need to be able to speak to here. Which is, how exactly do we establish and create a sense of social responsibility around addiction and drug use? What kind of political institutions or conversations have to happen to change the way that we respond, as a society, to this problem?

BRIAN: Nathan, I don’t disagree with what you just said. I do want to complicate it a little bit. I do believe that a century of scientific research into the physiology of addiction has lent some real authority to treatment plans, and approaches that are really quite different than “lock them up, and throw away the key.”

NATHAN: Right.

BRIAN: And I do think that has had an impact on giving policymakers different options in how to treat the problem of addiction. Now, whether they take advantage of that, that’s another matter.

NATHAN: You can’t argue with the science. I would only argue for more social science. Certainly, the disempowerment and poverty in rural America has been part of the ongoing and developing narrative about the opioid crisis in America. One could argue that there is even a racial divide in terms of how we think about rural and urban drug use. The only thing I would also add to that is that, again, what creates the political will to deal with these problems cannot be overlooked.

Just in the case of the 1980s. In 1986, driven in large part by the Reagan Administration, you see the Anti-Drug Abuse Act that was supported by Ronald Dellums, a Democratic Congressman from California, African-American, 15 members of the Congressional Black Caucus. And that bill introduces 100-to-1 disparity sentencing between crack and powder cocaine.

Now, this isn’t about opioids, but it’s certainly about the ways in which disempowered communities feel the need to stretch and reach for very draconian measures to deal with the violence, the under-employment, and the lingering problems that emerge around the drug crisis in major American cities.

ED: You know, it’s hard to find a silver lining to this very sad story, which has ravaged so many lives over such a long period of time. But it may be that as the problem seeps into other sectors of the society, and other parts of the geography of the country, that people may begin to shift their thinking about just what drug addiction means. Where it comes from, what causes it. And the less that it’s identified with any particular ethnicity or any particular geography, it seems to be a problem maybe the whole country needs to mobilize against.

BRIAN: I actually think as more families experience with a relative or a friend the inadvertent addiction that can occur from using these very powerful drugs, even when prescribed by a doctor, they will adopt what I would call a much more forgiving attitude towards what we need to do about these addictions.


ED: That’s going to do it for us today, but you can keep the conversation going online. Let us know what you thought of the episode, or ask us your questions about American history. You’ll find us at backstoryradio.org, or send an email to backstory@virginia.edu. We’re also on Facebook, Tumblr, and Twitter at BackStory Radio. And if you liked the show, feel free to review it an Apple Podcast. Whatever you do, don’t be a stranger.

BRIAN: This episode of BackStory was produced by Andrew Parsons, Bridget McCarthy, Nina Earnest, Emily Gadek, and Ramona Martinez. Jamal Millner is our Technical Director, Diana Williams is our Digital Editor, and Joey Thompson is our Researcher.

Our theme song was written by Nick Thorburn. Other music in our show came from Podington Bear, Ketsa, and [? Gizarre. ?] And thanks to the Johns Hopkins University Studio in Baltimore.

NATHAN: BackStory is produced at the Virginia Foundation for the Humanities. We’re a proud member of the Panoply Podcast Network. Major support is provided by an anonymous donor, the National Endowment for the Humanities, the Provost’s Office at the University of Virginia, The Joseph and Robert Cornell Memorial Foundation, and the Arthur Vining Davis Foundations.

FEMALE SPEAKER: Brian Balogh is Professor of History at the University of Virginia, and the Dorothy Compton Professor at the Miller Center of Public Affairs. Ed Ayers is Professor of the Humanities, and President Emeritus at the University of Richmond. Joanne Freeman is Professor of History and American Studies at Yale University. Nathan Connolly is the Herbert Baxter Adams Associate Professor of History at the Johns Hopkins University. BackStory was created by Andrew Wyndham for the Virginia Foundation for the Humanities.