Sertürner purified one of the active alkaloids from the opium poppy and named it morphine, after the Greek god of sleep and dreams, Morpheus. Morphine was given that name because of its propensity for inducing drowsiness. It also stimulates receptors in the human central nervous system involved in perception of pain, and so it has analgesic effects. And it can elevate mood - produce euphoria. Thus morphine - and later its many derivatives and congeners - was added to the list of things we now called "mood-altering substances."
Morphine was brought to market by Merck, the German chemical company, in 1827. Then in 1874 Charles Romley Alder Wright, a British chemist and physicist, was tinkering with morphine and added two acetyl groups to the molecule, creating diacetylmorphine.
When injected intravenously diacetylmorphine has a more rapid onset of action than morphine and is more potent (a smaller dose is required to produce an effect of the same magnitude).
Heinrich Dreser, a chemist working for Bayer (another German chemical company) continued testing diacetylmorphine, and Bayer brought the drug to market in 1888 as a cough suppressant and pain reliever under the trade name Heroin. Twenty-five years later, recognizing its potential for causing addiction, Bayer withdrew it from the market.
Most Americans think of heroin as an illegal drug because it has that status in the United States. By contrast it is used medicinally in the United Kingdom and is superior to some other agents because of its rapidity of onset of action and its more favorable side effect profile.
In the U.S. it is on Schedule I of the Drug Enforcement Administration's list of controlled substances. Schedule I is supposed to be reserved for drugs that are considered dangerous and have no recognized, legitimate medical use. As heroin does not meet the second criterion (except by arbitrary and unscientific edict), it does not belong on Schedule I.
Since the 19th Century we have developed many synthetic derivatives of the substances isolated from the opium poppy, and we call them, collectively, opioids. Although at one time such substances could be purchased without prescription in the US, at present only codeine (the other active alkaloid from the opium poppy) can be obtained without prescription, and only in certain formulations, from some pharmacies, in about a dozen states.
Given that people have been cultivating opium for at least 5,000 years, it is interesting to contemplate the fact that some mood-altering substances humans have derived from plants (opium, coca) are considered to have such high potential for abuse and addiction that they are very strictly controlled, while others (alcohol by fermentation of the sugars in plants, and tobacco) are regulated but easy to purchase legally. Addiction to opioids and cocaine and addiction to alcohol and nicotine have many similarities, and all of these substances can be damaging to health and lethal in overdose.
We experimented with prohibition of ethanol in the US, and that is viewed by most as having been a spectacularly unsuccessful experiment.
And that brings us into the 20th Century, when we decided that opioids should be available only by prescription. This means that if you have need of the most effective of the pain relievers, you must consult a physician. That is obviously rather arbitrary. Stressful day at work? If you go home and have a glass or two of wine to relax and unwind, that is considered no problem, and meets a common definition of moderate drinking. If instead you wanted to have 5 or 10 mg of oxycodone, that is considered a very serious problem. You can, I suppose, guess that I don't see a substantive difference. But I can order wine by the case and have it delivered to my house. If I tried to order oxycodone by the case for personal use, my medical license and controlled substances permit would be gone in a flash.
Sociologists and criminologists use the term "social problems" to describe a vast array of societal ills, and misuse of opioids is, in my view, a social problem. Many things that are social problems cross the very blurred lines and are also viewed as medical problems, and of course misuse of mood-altering substances can be regarded as a medical problem. But in its strictest sense, it is only the complications of the misuse that are medical problems: overdose, infectious complications of injection drug use, etc.
In my specialty (emergency medicine) we find ourselves addressing social problems a great deal of the time, both because the profession has "medicalized" many social and behavioral problems and because the emergency department is often the place to which people turn for help when they have no idea what to do.
The truly vexing thing about opioid abuse as a social problem is that doctors are getting blamed for creating it.
Dude! Seriously? Abuse of, and addiction to, opium has been around for millennia. This is not our fault. Blame it on something that, in pharmacology, is called the "fallacy of the specific."
The fallacy of the specific means that one should never assume - because the assumption will usually be wrong - that a drug will do one thing, its intended effect. In this case, opioids relieve pain, but they also have effects on mood. Those latter effects get some people into trouble, because they like that feeling, and they may start using a drug for relief of pain and then use it partly to relieve pain and partly to feel good more generally, and before you know it they are using it as much for mood elevation as for pain relief, or even entirely for mood elevation, without even realizing that is happening. And then they may find themselves using it to keep from getting symptoms of withdrawal from the drug. A person may find anything from a general unease to restlessness, cramps, vomiting, diarrhea, and sweats occurring because the nervous system has gotten used to the drug, and now it's not being provided. Then the addict is using the drug not to feel good but to keep from feeling terrible.
Legal acquisition of opioids requires consultation with a physician, and a prescription, and many addicts start with prescribed opioids and end up using far too much of them and engaging in all sorts of deceptive behaviors to get them from insufficiently wary (or blatantly unethical) doctors, or they switch to illicit sources and start snorting, smoking, or injecting heroin. So ... let's blame the doctors for this social problem.
That's right. The problem of abuse of and addiction to mood-altering substances has been part of the human condition for thousands of years, and modern medicine has been around for about a century, but it's doctors' fault.
Believe it or not, I have no problem understanding this. You see, I have been married for more than 30 years, so I have grown quite accustomed to accepting blame for problems that are not my fault, apologizing for them, and doing my best to fix them.
And I am willing to do the same thing here. But not without pointing out the obvious: it really isn't my fault. And no, I'm not even going to lay the blame at the doorstep of all the well-meaning but seriously misguided regulators who have been telling us how to practice medicine all the years I have been a doctor, first telling us we under-treat pain and then telling us we have turned America into a nation of addicts. And I'm not going to blame the ridiculous, single-minded focus on patient satisfaction, which has led so many doctors to have, at the center of every encounter with a patient, the goal of finding out what the patient wants or expects and giving it to him whether it's a good idea or not.
Nope. It's not the regulators and administrators, and it's not the weak-willed tendency of doctors just to give patients whatever it takes to make them happy.
What is it, then?
Human existence is miserable. Not for everyone, but for a sizable minority of us. And that's what mood-altering substances are all about. We smoke tobacco; we drink beer, wine, and liquor; and we use opioids and other potentially dangerous drugs like cocaine - all to find a temporary escape from the misery, or at least drudgery, of human existence.
Are opioids really more dangerous than alcohol? Spend a few hours searching for good statistics, and you will find plenty about the number of lives ruined and deaths caused by alcohol abuse. Alcohol and opioids have much in common and many differences. In the emergency department I see dozens of people who've died or been snatched from the jaws of death after an opioid overdose for every one person who dies suddenly from consuming too much alcohol in a single episode. So the opioid-related deaths really get our attention, especially as they often involve young people who had previously been healthy.
Here's what's unique about opioids: they have a legitimate medical use - relief of severe pain - coupled with effects that lead to misuse, and we have given authority over their legal availability to physicians.
With authority comes responsibility. But there's a catch. I have authority over the decision about who needs strong pain medicine. I do not have authority - or control - over what is done with the opioid after the patient gets it from the pharmacy. Can I peer deep into a patient's psyche and tell who might abuse the drug? I think I'm pretty good at that, but that is part of the art of medicine and not the science, at least for now.
I like to think that, as a practitioner of medicine as an art, I'm much closer to Renoir than to the kindergartner trying to color inside the lines. But I will not always be right. And if you expect doctors always to be right in the decisions they make about prescribing these drugs, you have wildly unrealistic expectations.
At its foundation this is more a social problem than a medical problem. My colleagues and I will do all we can to help to solve it. But we didn't create the problem, and we cannot solve it alone. I am pleased to report that my patients are catching on. More and more often when I ask someone with an illness or injury that is painful, "Do you think you will need something stronger than acetaminophen or ibuprofen for pain relief?" the patient's answer is no.
We all need a lot more insight. I'll do my part. You do yours.
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