The current opioid epidemic is a moving target, and we will need to wait for future historians to fully evaluate its causes and impact. But it has already had a vast impact on American society. Since its inception in the early 21st century, nearly a half million deaths have occurred. In 2017 alone, 70,000 Americans died, exceeding the death rates from HIV at the height of that epidemic.[i]
Over recent decades, a central aspect of studies in the history of medicine and public health has focused on epidemics. Past epidemics elucidate the widest range of biological, social, cultural, and political forces that account for outbreaks of disease and how societies have responded. A related set of investigations have sought insights from historical epidemics to inform contemporary health policy. As a result of these trends, it is not surprising that the current opioid epidemic has attracted attention to historical research on drugs, addiction, and public policy. These studies illuminate critical obstacles to the reduction of drug use, substance use disorders (SUDs), and the suffering and death they cause. They also point to potential strategies and priorities for addressing the ongoing opioid epidemic.
The Problem of Pain
From a historical perspective, pain and its medical treatment has been a persistent problem of medical care. Debates about pain in the U.S. have been deeply political, and raised difficult questions about who in society is deserving of empathy and care.[ii] Periods of liberal opiate use in medicine, such as the late 1800s and early 2000s, were implicated as iatrogenic drivers of drug epidemics in subsequent years.[iii] Eras of restricted opiate use repeatedly sparked concerns about undertreating pain in the severely ill, as well as in populations that have historically been denied palliation—such as women, minorities, and people in under-resourced regions of the world. These swings between under- and overtreatment reveal important gaps in our understanding of pain as a complex, biosocial phenomenon.[iv] The current opioid epidemic can only be understood in the context of this deep historical ambivalence about how to properly manage acute and chronic pain.[v]
Among the most powerful forces driving the current opioid crisis is the aggressive marketing and promotion of prescription opiates. Indeed, this epidemic may represent one of the most insidious cases of pharmaceutical fraud and misconduct in U.S. history. Industry marketing pioneer Arthur Sackler developed innovative and aggressive strategies to promote products directly to prescribing physicians through advertising and a vast, highly trained sales workforce.[vi] Utilizing these approaches, the Sackler heirs’ company, Purdue Pharma, exploited physicians’ desire for a non-addictive “magic bullet” for pain, and forcefully hyped their product oxycodone (OxyContin) in a wide array of professional venues.[vii] Their tactics are representative of a global pharmaceutical industry that has historically wielded impressive political power in the context of modest regulatory oversight.
The Power of Stigma
Even though physicians and public health experts have strongly argued that addiction is a disease for more than a century, the current epidemic makes clear that SUDs have not garnered the attention and resources required to treat them effectively, despite the recent development of many evidence-based medical treatments. Persistent stigmas surrounding substance use as an individual moral failure or vice have impeded our ability to respond effectively, even when there is broad medical consensus that substance use disorder is a chronic, relapsing disease. The historical nomenclature of substance use such as “addict,” “abuser,” “junkie,” “clean,” and “dirty” reflect strongly pejorative notions of addiction.[viii] Stigmatizing depictions of drug use in journalism and popular media continue to dehumanize those who use addictive drugs. Shifting portrayals of addiction across historic drug epidemics show that stigmatizing representations of drug use are intertwined with broader prejudices based on race, class, and gender. In the 19th century, upper-class, white women who used opium and morphine were typically depicted in sympathetic but highly gendered victimization narratives. In contrast, Chinese immigrants who smoked opium in the early 1900s; African American men (many of whom were veterans) who turned to heroin in the 1950s and 60s; and poor, minority, pregnant women who became dependent on crack cocaine in the 1980s were vilified as threats to the social order. Narratives of the contemporary opioid emphasize an “epidemic of despair” in white, deindustrialized and rural communities. This common portrayal elides a much longer and more complex opioid epidemic that includes drug-related deaths in impoverished and dispossessed communities of color and indigenous communities.[ix], [x]
The Harms of Criminalization
The intensive race-based criminalization of drug use over the course of the twentieth century has led to mass incarceration in the U.S.[xi] Deeply xenophobic portrayals of Chinese immigrant laborers who smoked opium in the 1920s bolstered political consensus to begin regulating opiates and other addictive drugs. During the Prohibition era, law enforcement exercised new police powers to aggressively target and incarcerate African Americans and other minorities for drug-related crimes. These practices intensified during the War on Drugs of the 1970s and 80s, which fueled the rise of mass incarceration.[xii] This legacy of criminalization continues to shape punitive discourses and policies around drug use that disproportionately affect minority communities today.
The Barriers to Addiction Treatment
The criminalization of drug use and its associated stigmas explain in part the critical inadequacies and inequities in our current treatment of SUDs.[xiii] Despite the development of effective medical treatments for SUDs over the last half century, these treatments are stigmatized and widely inaccessible, especially in poor and minority communities. In the 1960s, methadone was administered in highly surveilled public clinics in poor urban neighborhoods, reinforcing powerful associations between substance use, race, poverty, and crime.[xiv] Today, methadone, buprenorphine, and other SUD therapies are unavailable to most people with SUDs, including those who are incarcerated in the U.S. Access to effective medical treatment in poor, rural regions of the country that are among the hardest hit by the current opioid crisis remains severely limited. Barriers to accessing SUD treatment is especially ironic given the widespread marketing of oxycodone and other addictive substances.
The opioid crisis reveals longstanding weaknesses in our biomedical paradigm; entrenched forms of stigma and prejudice around pain and addiction; and broader vulnerabilities in our social and economic infrastructure.[xv] Observing these deeply historical structural problems, cultural biases, and social determinants of the current epidemic is daunting.
Nonetheless, understanding these historical legacies may offer a clearer agenda to guide clinical and policy responses. Because of a long history of criminalizing drug use, medical and public health infrastructures—both for treatment and prevention— remain wholly inadequate. Pain and addiction, both highly stigmatized conditions, have historically been marginalized within biomedicine and public health. Further, chronic, relapsing conditions, such as SUDs, present particular problems within biomedicine because they require integrated social and economic support beyond the clinic. Contemporary health disparities are powerfully augmented by these historical failures. Insights from the history of epidemic disease offer an opportunity to enhance treatment and prevention in innovative, effective, and humane ways.
[ii] Wailoo K. Pain: A Political History. Baltimore: Johns Hopkins University Press; 2014.
[iii] Courtwright D. Dark Paradise: A History of Opiate Addiction in America. Cambridge, MA: Harvard University Press; 2001.
[iv] Jackson J. Stigma, Liminality, and Chronic Pain: Mind-Body Borderlands. American Ethnologist. 2005; 32(3): 332-353.
[v] Meldrum M. A Capsule History of Pain Management. JAMA. 2003; 290(18): 2470-2475.
[vi] Podolsky SH, Herzberg D, Greene JA. Preying on Prescribers (and Their Patients) — Pharmaceutical Marketing, Iatrogenic Epidemics, and the Sackler Legacy. N Engl J Med. 2019 May 9; 3380(19): 1785-1787.
[vii] Meier B. Pain Killer: An Empire of Deceit and the Origin of America’s Opioid Epidemic. New York: Random House; 2018.
[viii] Botticelli MP, Koh HK. Changing the Language of Addiction. JAMA. 2016 October 4; 316(13): 1361-1362.
[ix] Garcia A. The Pastoral Clinic: Addiction and Dispossession Along the Rio Grande. Berkeley: University of California Press; 2010.
[x] Jalal, Hawre et al. “Changing Dynamics of the Drug Overdose Epidemic in the United States from 1979 through 2016.” Science. 2018; 361(6408): 1-6.
[xi] Provine DM. Unequal Under Law: Race in the War on Drugs. Chicago: University of Chicago Press; 2007.
[xii] Alexander M. The New Jim Crow: Mass Incarceration in the Age of Colorblindness. New York: The New Press; 2012.
[xiii] Campbell N. Discovering Addiction: The Science and Politics of Substance Abuse Research. Ann Arbor: University of Michigan Press; 2007.
[xiv] Hansen H, Roberts SK. Two tiers of biomedicalization: Methadone, buprenorphine, and the racial politics of addiction treatment. Advances in Medical Sociology. 2012; 14: 79-102.
[xv] Dasgupta, Nabarun, Leo Beletsky, and Daniel Ciccarone. Opioid Crisis: No Easy Fix to Its Social and Economic Determinants. Am J Public Health. 2018; 108(2): 182-186.