Historical Perspectives of Opiate Use

I find the history of drug use quite fascinating. Here’s a brief history focusing on one class of drug.

Opiate, or opioid, refers to any drug, either natural or synthetic, that has properties similar to opium or its main active ingredient, morphine. Opium comes from one type of poppy, Papaver Somniferum.

Opium was used by the Summarian and Assyrian civilisations as long ago as 4,000 B.C. It is mentioned in Egyptian medical scrolls dating to 1550 B.C. Greek and Roman physicians made medical use of opium. The use of opium spread from the Middle East with the expansion of the Islamic religion. While the Koran forbade use of alcohol and other intoxicants, opium was not banned. When tobacco smoking was banned by a Chinese emperor in 1644, the Chinese invented the practice of opium smoking.

Europeans became aware of opium in the early 1500s, the drug being imported from the East. Opium use in Britain dramatically increased in the 19th century. It was available as a medicine in many formulations from food stores, pubs, and even peddlers on the street. The most popular form was laudunum, which was opium dissolved in alcohol. Preparations were even made for children and babies, e.g. Streets’s Infant Quietness. Opium use spread to all levels of British society. The Fens area of Eastern England became specially known for its opium production. Opium was sold on market days, in shops and by travelling salesmen.

Writer Samuel Taylor Coleridge was so addicted to opium that in one attempt to break his habit he hired a man to follow him about and prevent his entry into any druggist’s store. Other well-known opium users were Thomas De Quincey, who wrote the classic Confessions of an English Opium-Eater, author Wilkie Collins, and poets Lord Byron, Percy Shelley, and John Keats.

In 1803, Frederick Sertuerner isolated a potent alkaloid from opium he called morphine, after Morpheus, the God of sleep and dreams. Morphine remained more under the control of the medical profession and was not sold in shops like opium. Morphine was more commonly used by upper and middle classes, since the lower classes seldom saw a doctor.

In the 1830s, a Temperance Movement developed in the UK that campaigned against the recreational use and sale of alcohol and promoted total abstinence. Public concern over opiates, which was influenced by the Temperance Movement, was directed at opiate use by the lower classes. It was believed that working women in industrial towns doped their babies when they went to work. The upper classes could have their addictions, but not the working class, who needed to be protected from themselves.

It was estimated that between 16,000 and 26,000 shops sold opiates in Britain in the 1850s. One London chemist had 378 different opiate preparations on his shelf. In 1868, Parliament passed the Pharmacy Act, which restricted the sale of drugs to Pharmacist’s shops. It was harder for the masses to get drugs but use by the upper classes did not change. Although consumption fell, it returned to normal levels with a few years of the Act.

The invention of the hypodermic syringe in the 1850s strongly influenced use of morphine, since doctors realised that intravenous injections gave more rapid and intense responses when compared with previous routes of administration. The rapid pain-relieving properties of injectable morphine made it the treatment of choice during recovery from serious wounds.

However, withdrawal from the drug was often more difficult than recovery from the wound. Morphine dependence was so common during the American Civil War, it became known as Soldier’s Disease. Opium was cultivated in both Union and Confederate territories. It was used to treat endemic dysentery, and as a preventive against malaria and diarrhoea. By 1906, there were 50,000 patent medicines containing opiates in the U.S.

China had long exercised the upper hand in economic relations with the West. Silks, tea, fine pottery, and other items flowed West, but China needed little itself. Attempts to redress this balance provided a major impetus for Western expansion. The growing popularity of opium smoking provided a partial solution to trade imbalances with China.

Throughout the 18th century, the British East India Company had a monopoly where they bought opium from farmers (particularly from India) and then sold it to independent wholesalers. Opium production provided a living for peasants, merchants, bankers, and government officials. Exports to China earned hard currency, reducing the trade imbalance. Monopolising opium buying in India provided revenue for hard-pressed colonial administrations.

Official China considered opium smoking a moral vice and an economic threat. In 1729, Peking issued an Imperial Edict against the practice, but this had little effect. Further Imperial edicts in 1796 and 1799 led to the development of a thriving illicit drug trade. In 1838, a new Imperial commissioner tried to control trafficking in Canton. This precipitated the Opium War with Britain and an embarrassing defeat. In subsequent years, the Imperial government could not enforce dictates against the drug. By the turn of the century, opium permeated all aspects of society and economy.

The cultural impact of Chinese opium smoking was felt further afield. The Californian gold rush of 1848 created a high demand for Chinese mine workers. Some had smoked opium before leaving for America, but their new harsh working circumstances were conducive to addiction. Many Westerners believed overwrought reports concerning the spread of the opium habit. Although grossly exaggerated, fears about the opium den’s effect upon young white men and women fed resentment against the Chinese.

Opiate-containing patent medicines proliferated on both sides of the Atlantic during the 19th century. However, American legislators began to see opium as a dangerous Oriental custom that was threatening the morality of their people. The moralistic propaganda of the Temperance Movement began to include anti-drug statements.

‘To get this heroin supply the addict will not only advocate public policies against the public welfare, but will lie, steal, rob, and if necessary commit murder. Heroin addiction can be likened to a contagion. Suppose it were announced that there were more than a million lepers among our people. Think what a shock the announcement would make. Yet drug addiction is far more incurable than leprosy, far more tragic to its victims, and is spreading like a moral and physical scourge.’ Richard Pearson Hobson, anti-drug campaigner.

A growing concern about morphine and opium addiction in the US added to the pressure for new legislation. It is estimated that there were 250,000 problem opiate users at the turn of the century. In 1914, the Harrison Narcotic Act in the US effectively banned the use of opium and morphine. But there was one major omission: heroin.

Heinrich Dreser had synthesised diacetylmorphine in 1898, which he called heroin because of its heroic possibilities for treatment. The company Bayer marketed it for coughs, for which it was effective with less side effects than morphine. After the passing of the Harrison Act, regular users of other opiates and cocaine switched to heroin. The drug was not considered addictive for some time. Intravenous injection of heroin became increasingly popular in the US from the mid-1920s.

In 1924, the US Government banned the import and manufacture of heroin and banned its prescribing totally from medical practice. The US Supreme Court had earlier (in 1919) banned doctors from prescribing other opiates to addicts for maintenance of their addiction—doctors were liable to prosecution if they tried to help their dependent patients. The rhetoric of anti-drug campaigners helped to influence public opinion about heroin and other opiates.

Opiate use, in particular heroin use, was driven underground.  A moral panic about heroin developed across the nation—the drug was credited with a bottomless capacity for evil. The first Commissioner of the Bureau of Narcotics, Henry Anslinger, had a tough approach to addiction. He led the fight against drugs, relying on a simple principal:

‘We intend to get the killer-pushers and their willing customers out of buying and selling drugs. The answer to the problem is simple – get rid of drugs, pushers and users. Period.’

For many years to come, application of the criminal law, rather than any sort of medical treatment, was to be America’s prime response to its opiate problem. An American-inspired international narcotics control movement developed, beginning with a meeting in Shanghai in 1909 and the First Opium Convention in The Hague in 1912. American attitudes and prejudices were to play a significant role in shaping international drug policy in the coming decades.

In the UK, emergency drug controls were introduced under the wartime Defence of the Realm Act in 1916, restricting possession of cocaine to doctors, pharmacists, and vets. Opiates were not its central concern. The Dangerous Drugs Act of 1920, forced upon the country by the pressure of international obligations, made it illegal to possess opiates and cocaine unless they had been supplied or prescribed by a doctor. A further Act in 1923 provided for heavier penalties for infringements.

Due to ambiguities in these Acts centred around prescribing, the Home Office asked the Ministry of Health to provide guidelines. This resulted in the Rolleston Report of 1926, which concluded that when an opiate addict could not easily be got off drugs, it was medically legitimate to continue with maintenance prescribing. Addiction was classed as a disease and a drug could be prescribed to ‘relieve a morbid and overpowering craving.’

The Rolleston report also concluded that opiate addiction was rare in Britain, with the majority of addicts being introduced to the drug in the course of medical treatment. The scale of the opiate problem in Britain at this time was certainly far lower than that seen in the US.

The Report’s recommendations were accepted by the Home Office, and Britain settled down for about 40 years to a way of dealing with opiates which came to be known as the ‘British System’. Individual private practitioners prescribed drugs to their addict patients without fear of prosecution. Whilst possession of opiates without a prescription was still the subject of criminal law, the number of prosecutions was remarkably low. For the so-called manufactured drugs heroin, morphine and cocaine, the number was 45 in 1926 and it did not exceed a hundred until 1964 (101).

The bureaucracy created in Britain to support the implementation of the Dangerous Drugs Act was much more amateurish and passive than the style of operation occurring in the States. By 1929, the Federal Narcotics Agency in the States employed 250 agents and enjoyed a generous budget. In the UK, the Home Office Drugs Branch was for many years staffed by only two inspectors. The senior Home Office official responsible for overseeing Britain’s drug policies was also charged with the responsibility for the protection of wild birds.

After the Second World War, the heroin problem escalated greatly in both the US and UK, with the former being at least ten years ahead. The Mafia became the main suppliers in America, with the main route for heroin entering the country being from Turkey via France and Italy. This was the so-called ‘French Connection’.

The American problem really took off in the 1960s with the increased supply of cheap black-market heroin. There were about 50,000 heroin addicts in 1960 and this number rose to 500,000 by 1970. Heroin use became increasingly associated with ethnic minorities and urban poverty. The drug rooted itself in social deprivation. Property crime became an integral part of the American heroin epidemic and occurred at a level never seen before.

The American government responded by passing a number of severe laws, starting with the Boggs-Daniel Bill of 1956 that included provision of the death penalty for selling heroin to minors. A ten-year minimum spell of imprisonment was mandated for a second offence of possessing heroin (or marijuana). The rate of imprisonment for drug-related offences rose sharply and prisons started to overflow with drug users. Massive resources were directed towards blocking supply of drugs and punishing people who supplied or used drugs.

Experts generally agree that increases in punishment level did not alter the dynamics of black-market operations or the demand for drug. The closing of the ‘French Connection’ and suppression of heroin production in Turkey as a result of UN pressure probably led to the fall in the number of heroin addicts seen in the mid-1970s. However, the vacuum in supply was filled by Burma—which forms part of the Golden Triangle with neighbouring areas of Thailand and Cambodia—and later by Afghanistan.

In the UK, there were only 94 heroin addicts registered on the Home Office Index in 1960. Some observers ascribed this low number to the so-called ‘British System’, which allowed addicts to receive prescriptions from doctors, and argued that this prevented an illegal market becoming established in the country.

However, there was a substantial increase in the number of registered heroin addicts in the 1960s (2240 in 1968). This increase was due in part to the spill from the lax prescribing of a small number of medical practitioners in London. The Rolleston system was failing. The new heroin addicts were younger, and they were into buying and selling drugs. Some sought out doctors who they could pressurise into providing prescribed heroin.

The government set up a new Committee, chaired by Sir Russell Brain, to look into the situation. The report published in 1961 concluded that there should be no major departure of the recommendations of the 1926 Rolleston report. However, the Committee reconvened due to the deteriorating situation and published a second report in 1965. This second report confirmed the basic Rolleston Principle that a doctor, acting in good faith, should be allowed to prescribe addictive drugs to an addict. It reasserted that:

‘… the addict should be regarded as a sick person, he should be treated as such and not as a criminal, provided he does not resort to criminal acts.’

However, the 2nd Brain Report also made recommendations that restricted prescribing to doctors specially licensed by the Home Office and practising from agreed premises. Special NHS clinics were set up in 1967 that prescribed heroin. From 16th April 1968, ordinary medical practitioners could no longer prescribe heroin to addicts. Over the next ten years or so, these NHS clinics shifted over to prescribing oral methadone, rather than heroin, following ideas from America. The level of heroin prescribing has been very low ever since.

The rate of increase in registered heroin addicts was fairly slow during the 1970s, but grew rapidly during the 1980s—the so-called 1980s heroin epidemic. There was a large increase in illicitly manufactured drug: supplies initially came from Turkey and Hong Kong, then from South-East Asia, later Iran and Pakistan next. Today, a high proportion of heroin comes from Afghanistan.

The number of addicts known to the Home Office (mostly heroin addicts) grew from 2,400 in 1979 to around 18,000 in 1990 and almost 45,000 by 1996. A new generation of heroin user smoked the drug, although many of these switched later to injecting. Like America, the drug became associated with poverty and unemployment. Acquisitive crime increased as heroin users sought to support their habit.

In the early 21st century, there were thought to be 200,000 – 250,000 people suffering from a serious problem with illicit drugs in the UK—some people argued that this figure should have been doubled. Heroin was one of the problem drugs in the majority of these instances.

President Richard Nixon appointed Dr. Jerome Jaffe as America’s first ‘Drug Czar’. He increased the number of heroin addicts in federally funded treatment from around 20,000 in 1971 to 60,000 a year later. The availability of oral methadone played an important role in the expansion of treatment services in the US. The expansion of methadone-based treatment in the UK occurred later and more slowly.

The AIDS epidemic of the late 1970s had a strong influence on drug policy. The realisation that the virus could be transmitted between addicts by needles and other paraphernalia, and that it could spread by sexual transmission to the wider population, stimulated attempts to get more people into treatment.

The UK reacted to the AIDS epidemic by greatly expanding community projects that provided clean needles and syringes and taught safe injecting practices. The teaching of safe sex and provision of condoms was also a key element of the approach. The American authorities have generally seen this harm minimisation as ‘looking too like connivance and a compact with the heroin devil.’