A Magic Wand

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.

[MUSIC PLAYING]

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?

[MUSIC PLAYING]

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.

[MUSIC PLAYING]

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.”

NATHAN: OK.

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–

NATHAN: Why?

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.

NATHAN: OK.

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.

[MUSIC PLAYING]

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

[MUSIC PLAYING]

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.