The problem with Opium
Opium Poppy
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Papaver Somniferum
Sleeping poppy
Sedation
Pain relief
God’s own medicine
Acts on brain’s
opiate receptor
Endorphins
Endorphins
Morphine
Opium and its derivatives
raw opium extract
Natural components (1800)
morphine
heroin (1898)
codeine
thebaine
Percadan
Routes of Administration
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Upon until 1850
Smoking opium
Landanum: opium dissolved into spiced
wine
Often called opium eaters
Really opium drinkers
Thomas DeQuincey
Confessions of an Opium Eater (1822)
“ I do not readily believe that any
man, having once tasted the divine
luxuries of opium will afterward
descent to the gross and moral
enjoyments of alcohol
I take it for granted that those eat
now who never ate before and those
who always ate now eat more”
Later volume, Miseries of Opium,
detailing his agony of addiction not as
widely remembered.
Samuel Taylor Coleridge
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English Poet
1772-1834
Kubla Khan written in landanum dream
In Xanadu did Kubla Khan
A stately pleasure-dome decree :
Where Alph, the sacred river, ran
Through caverns measureless to man
Down to a sunless sea.
Hector Berlioz
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French Composer
1803-1869
Symphonie Fantastique
Program notes refer to artist
“poisoned with opium” who
has visions, including:
March to the scaffold
Dream of a witches' sabbath
American Civil War
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Hypodermic needle
came into use 1850
Morphine had been
extracted early 1800’s
Thought no addiction
with injection because it
bypassed stomach.
Soldier’s disease among
veterans
Morphine as cure for alcoholism
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Dr. Black (1889)
“morphine calms in place of exciting the
baser passions, and hence is less
productive of acts of violence and
crime. In short, the use of morphine in
place of alcohol is but a choice of evils,
and, by far, the lesser.”
Patent Medicines
Lydia Pinkham’s Vegetable
Compound
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Most successful
patent medicine of
the 1800’s
“Female complaint”
nostrum
15-20% alcohol and
vegetable extracts
Sold until 1968
Many Patent Medicines:
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Contained large amounts of alcohol (up
to 47%)
Narcotics, such as morphine, cocaine,
and opium
Caffeine
Vegetable extracts
Journalists make an impact
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Samuel Hopkins Adams. 1905. The Great American
Fraud. Patent medicines attacked in a series of 11
articles in Collier’s magazine
Upton Sinclair. 1906. The Jungle. Book about the
meat packing industry.
1906: Pure Food and Drug Act passed
Temperance movement
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Concern about the
impact of liquor on
society
Pledge to give up:
Hard spirits only
Beer and Wine too
Total temperance
T totalers
Opium Den
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Drug laws 1870-1890
First anti-drug laws
passed in California
eliminate opium dens
of Chinese immigrants.
Connecticut law:
addicts incompetent to
handle personal affairs.
Harrison Narcotic Act
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Harrison Narcotic Act
Tax act 1914
First national narcotic act
Trumped state laws
Chief proponent was
William Jennings Bryan
Language of Harrison Act
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“An act to provide for the registration
of, and collection of internal revenue,
and to impose a special tax upon all
persons who produce, import,
manufacture, compound, deal in,
dispense, sell, distribute or give away
opium or coca leaves, their derivatives
or preparations, and other purposes.”
Physicians were concerned
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What about our ability to
write Rx for opiates?
Many “medical addicts”
Harrison Act: No problem
Dr’s could register and freely
prescribe opiates as long as
it was “in the course of his
professional practice.”
Harry Anslinger
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Doctor’s rights didn’t
mean much to new
head of the Bureau of
Narcotics.
Part of Treasury Dept.
Started arresting and
charging physicians
How could this be
happening?
What is Addiction?
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Anslinger’s view was that addiction was
a moral weakness.
Doctors are only enabling the addiction.
Doctors should be curing illness, not
perpetuating them.
Addicts need to stop.
Doctors arrested for writing
prescriptions
Behrman Case (1922)
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Prevented M.D.’s from
legally supplying drugs
to addicts for self
administration.
Addicts must be isolated
and hospitalized.
Led to creation of Public
Service Hospitals
Prohibition
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Volstead Act (1920)
Non-medical use of
alcohol prohibited.
Bootleggers
Rum runners
Organized crime saw
profit in distributing
alcohol.
Repeal of Prohibition
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In 1933, FDR signed bill
repealing prohibition.
Organized crime stops
distributing alcohol and
switches to heroin (now
the drug of choice)
Black market.
Addiction becomes
centered in cities.
Public Service Hospitals
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Opening day at
hospital in
Lexington,
Kentucky
(5/15/35)
Beginning of
research on
addiction.
NIDA’s roots
Success of the public hospitals
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Most admissions were voluntary (75%).
70% of those left against medical advice.
Others federal prisoners on drug charges.
Treatment: detox and abstinence
90% of those who completed treatment
relapsed within a few years.
Revolving door: addict detox, reduce
tolerance, restart habit when released.
Heroin problem gets worse
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Stronger laws
More punishment
Stop using
1951 Boggs Act set
minimum sentences
1956 Narcotic Drug
Control Act made
penalties stiffer.
Robinson vs California (1963)
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Supreme Court finds
that addiction is a
disease.
Support from AA.
Alcoholism began to
be seen as disease.
Heroin addiction not
that different.
Narcotic Addict Rehabilitation Act
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Congress passed act in 1966, following
Supreme Court decision.
Sought to rehabilitate rather than imprison.
Short and long-term care.
Develop new treatment programs.
End dependence on addictive drugs
End susceptibility to addiction
Comprehensive Drug Control Act 1970
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Controlled substance act
Five schedules, I – V
More stringent regulations
Penalties for possession and sale
Moved from Treasury to Justice
In 1988, cabinet level drug “czar”
To be continued
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Treatment for heroin addiction
Heroin treatment
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In 1965, treatments
were still detox and
abstinence.
Pubic Service Hospitals.
Revolving door.
Didn’t offer much hope.
Relapse or death most
likely outcomes.
Therapeutic Communities
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Synanon most famous.
Founded by Chuck
Dedrich
Life in Synanon
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Detox on your own. No medical help.
Commit yourself to total abstinence
Community would work on rebuilding you.
Start at lowest rung of social ladder.
Move up a step as more trust in gained.
Become a supervisor or mentor.
Reenter society in stages.
Success of communities
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Work well for those who stay in program.
Most dropouts happened during the early
stages (50-90%).
Begin to work outside, go to school.
Many didn’t want to leave.
Dependence transferred to the community.
A few communities turned into cults.
Daytop Village: success story
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Daytop is based on the
therapeutic community
(TC) concept: a highly
structured, family
environment where
positive peer interaction
is emphasized. Separate
and individualized
programs are available
for adolescents, adults,
and all family members.
Limitations of TC’s
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Not for everyone.
Radical change in living circumstances.
Dropout rate high during early stages.
What if you had a large number of
people needing services?
More rapid return to society.
Vietnam Veterans
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Vets served in area ready
access to heroin.
Thousands were coming back
with addiction.
1970 alone, 100 O.D. deaths.
1971 VA set up 32 clinics
across the US to treat
returning vets.
What would be the treatment?
Counter culture
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Another group of concern
were the hippies.
Experimented with many
drugs, including Speed.
Abbie Hoffman: “Speed kills”
Transition junkies turned to
heroin.
Revolving door only path?
Enter Methadone
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Methadone is a synthetic opiate
Developed during the 1940’s
Opiate agonist
Fills the receptor sites.
Takes the place of heroin.
Eliminates drug hunger
Prevents withdrawal.
New idea: Maintenance
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Rather than detox and abstinence.
Substitute methadone for heroin.
Maintain the patient on methadone.
When the time is right and patient is
ready, withdraw the methadone slowly.
No dramatic withdrawal.
Eventually drug free.
Dole and Nyswander
First treatment program using using methadone maintenance
Advantage of Methadone
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Legal and inexpensive
Accurate dose and purity
Reduce criminal activity
Slower acting
Last 24 hours
Given oral dose in orange juice
Methadone as the “hook”
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Get addicts into treatment
Drug screenings
Provide them with other services
Job training
Individual and family counseling
Parenting skills
“Focus and families” (video)
Success of methadone
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70% of addicts who stayed in the
program stopped IV drug use
Reduction in drug related problems
(80 to 25%)
Reduction in criminal activity
(20 to 10%)
Slight increase is employment
Short comings of methadone
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Moral question: not drug free
Perpetuate addict mentality
Substitute another drug or activity
Methadone entering black market
Attracts only 20% of addict community
Other treatments
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Naltrexone
Opiate antagonist
Block effect of
opiates if taken
Takes away the high
Reduces triggers
Used for other drugs
and gambling
Harm Reduction
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For those addicts who continue to use
IV drugs, how can we make use safer?
Needle exchange programs
Lower risk of infections: HIV
Reduce the sharing of needles
Make information available about
treatment, safe sex, etc.
What about heroin maintenance?
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Dutch, Swiss
North America's first clinical trial of prescribed
heroin begins today
VANCOUVER (February 9, 2005) –
Enrolment begins here today in North America's first clinical
trial of prescribed heroin for people with chronic heroin
addiction who have not been helped by available treatment
options.
The North American Opiate Medication Initiative (NAOMI) is
a carefully controlled (clinical trial) that will test whether
medically prescribed heroin can successfully attract and
retain street-heroin users who have not benefited from
previous repeated attempts at methadone maintenance and
abstinence programs.
Opium Trade Routes