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Opioids, Overdose, Abstinence—A Historically Deadly Combination

Updated: Aug 13, 2023

Editor’s Note: Today’s post comes from contributing editor Brooks Hudson, a PhD student in history at Southern Illinois University.

We have told ourselves the “opioid crisis” is an exception to past drug scares. In the past century, the narrative goes, we relied on law enforcement and punishment to curb widescale drug use, but our country now has turned over a new leaf—one centered on public health and compassion. Had it not been for Purdue Pharma, a uniquely bad actor, the spread of addiction and overdose deaths would have never occurred.

None of this is true. Rhetorically, yes, smart politicians now deemphasize the punishment aspect in public speeches. But law enforcement plays a greater role than ever before in regulating the use of drugs—from the zealous policing of some people who use illegal drugs to expansive prescription monitoring programs and from the detailed cataloging of the dosage of Americans’ medications to DEA to threats to doctors who fail to obey their dictates. Such strict and exacting regulations often leave elderly patients and patients with chronic pain out in the cold unable to secure necessary drugs. Yet, at the same time, prohibitionist drug control measures have also done little to stop the proliferation of black-market drugs.

Far from being a deviation, this has long been the norm and with often devastating results. Regardless of your thoughts about current events, this post will let us look back and travel to the past to try to clarify why overdose deaths continue to increase now despite a dramatic recent decrease in opioid prescriptions. And why this situation unlikely to change under current conditions. For about the last century, the United States government has abided by a philosophy that seems to prioritize drug abstinence and the strict policing of drug use at the expense of saving lives. To investigate this continuity, I will briefly examine two episodes: a 1930s critique of an early version of the war on drugs and the government’s opposition to needle exchanges during the AIDS epidemic of the 1980s.

Points Hudson Title Card Opioids

Left: A 10 milligram OxyContin pill. Source: Wikimedia Foundation.

Where We are Today

If there is compassion or priority given to public health, it is hard to know where to look. Recent headlines from around the country, for example, proclaim: “Alabama is prosecuting a mom for taking prescription medication while pregnant” or “Atlantic City Is Just The Latest Place To Shut Down Its Needle Exchange Amid a Deadly Rise in US Overdose Deaths.” Or the American Medical Association being forced issuing statements about seemingly obvious truths: “Why denying addiction treatment in jails, prisons is inhumane.” More broadly, the healthcare system only provides treatment to about ten percent of people with addictions. These continuing inequities might strike many reasonable people as the antithesis of compassion.

In thinking about the ongoing opioid crisis, what I find most interesting about the hatred directed at the Sackler family is that even their most vocal critics concede that hoping to see them behind bars is nothing more than wishful thinking—a revenge fantasy that will disappoint and will certainly not bring back the countless people who have died. But here is the question that intrigues me: let us assume for a moment that Purdue Pharma was somehow uniquely evil and was merely a criminal enterprise on par with El Chapo’s cartel—an idea, by the way, recently entertained by a book review in the New York Times. Isn’t it the federal government’s most elementary responsibility to protect its citizens from internal and external threats?

This gets to the heart of the matter. If, as critics contend, the company or family were really responsible for half a million deaths, and they face few consequences, is the problem maybe not the Sacklers, but, instead, the blinding reality that the justice system is a farce? The wealthy, it seems, can be indirectly responsible for homicides on a mass scale while the lives of poor people can be ended or ruined for mere drug possession. The crushing weight of America’s long war on drugs has often seemed to fall hardest on the shoulders of regular people who use drugs.

Morphine in the 1930s

Dr. Henry Smith Williams, in his book Drug Addicts Are Human Beings (1937), witnessed the origins of something that seems utterly normal to us today: law enforcement officers as guardians of medicine who substitute their own judgement for that of doctors or patients. Williams recounted his experiences and those of his colleagues dealing with early federal drug laws. Dr. Williams’s brother, Edward Hunting Williams, in fact, was the leading authority about opioid addiction at the time, and he was arrested by narcotics officials after a paid informant faked symptoms to secure morphine. Dr. Henry Smith Williams was not an apologist for illegal drug use; he abhorred it. Professionally, he was known as tame and not polemical. And yet, he was convinced that law enforcement’s role in medicine was so egregious that he titled his book’s first chapter, “The American Inquisition.”

Williams pinpointed where, in his opinion, things first went awry: an “advisory code” developed to enforce the Harrison Narcotics Act, which eliminated doctors as the final arbiters over medicine. He hoped, perhaps too optimistically, that others would also see how the code, in his words, “transcend[ed] the power of the statute” and created an absurd situation that gave agents of the state—uneducated in drugs or medicine—the authority to substitute their judgement over the opinions of trained medical doctors. At one point, Williams wryly snickered, if these men with guns understood medicine so well, we should hand them a scalpel and let them perform surgery.

Williams contended that authorizing law enforcement to police drug use and that promoting abstinence—especially in the case of morphine— solved zero problems. And, instead, he argued, such laws created many more problems, particularly needless suffering in treatable patients. He wrote:

The salient condition that confronts us is the existence of a vast company of persons who are addicted to the daily use of drugs that they cannot abandon without being subjected to physical and mental torture. A considerable percentage of these, if forcibly deprived of the [morphine], will die. Many more will come deadly close to the danger line. All will suffer intensely. Deprivation of the drug will no more cure them permanently of the craving for it, than shutting a duck away from water will cure the duck of the swimming habit or urge to swim.”

What made his position so convincing were excerpts from case files of patients that showed before-and-after pictures of the ruined lives of people who used drugs. It became clear to Williams that abstinence policies and strict policing often harmed people—including those who sought them for therapeutic purposes.

HSWilliams Case Study 1

Dr. Henry S. Williams, Case Study 1, from Drug Addicts are Human Beings (pp. 74–75).

HSWilliamsCaseStudy2-3

Dr. Henry S. Williams, Case Study 2 & 3, from Drug Addicts are Human Beings (pp. 75–76).

Despite Dr. Williams’s rather blithe attitude about the dangers of illicit sex work, he is broadly sympathetic to the people in these case studies. After recounting the facts of Case 1, for example, he asks, “Does this not clearly show the degrading power of drugs?” He answers: “Indirectly, yes, but you miss the point if you suppose that it was the taking of drugs that caused degradation.” He blamed the subject’s problems on the inability to legally obtain the desired drugs:

“There is every probability that he would still be a respectable and respected teacher had he been able to secure the morphine he had come to need in any legitimate way, at a reasonable cost. His descent was due to the embargo on such attainment. Not morphine, as such, but the difficulty in securing the drug except illegally and at a prohibitive price.”

HSWilliamscase5

Dr. Henry S. Williams, Case Study 5, from Drug Addicts are Human Beings (pp. 77).

Dr. Williams’s Case 5, on the other hand, highlighted the persistent problem of chronic pain patients unable to find treatment. The injured women, Dr. Williams wrote, was “suffering perpetual agony, unless under the pain-quelling influence of morphine. And no physician dares to give the medicine regularly for fear of being arrested.”

Needle Exchanges in the 1980s

Moving forward about five decades, political attitudes about abstinence-only drug policies and the seeming hatred of drug users became the norm. Maia Szalavitz’s recent book Undoing Drugs: The Untold Story of Harm Reduction and the Future of Addiction—the topic’s most definitive history thus far—spotlights her own intravenous drug use during the AIDS crisis. Writing that she avoided contracting the HIV virus mostly by chance, she expresses her anger that basic information about how to stay alive or how to understand safer ways to use drugs were nonexistent or unavailable at the time.

San Fran Needle Exchange

San Francisco needle exchange program in 1988. Image courtesy of the San Francisco AIDS Foundation.

Moreover, the government, which is typically the go-to entity for keeping citizens alive, actively fought harm reduction measures by community groups like needle exchanges. Of course, needle exchanges save lives. Yet, in 1988, at the height of the crisis, Congress passed a ban on funding for needle exchange programs. The bill’s lead sponsor, Republican Senator Jesse Helms explained his rationale (as quoted by Szalavitz): “[N]eedle exchanges undercut the credibility of society’s message that drug use is illegal and morally wrong.”

At the recent 2021 AIHP Edward Kremers Seminar in the History of Pharmacy and Drugs, Szalavitz turned to the question of the “opioid crisis” and the Sackler family’s responsibility. She responded with frustration about this issue, saying:

I have to say I am so tired of blaming the Sacklers for this. I think they are awful. I think pharma is bad and wrong and they did terribly deceptive marketing. However, since we cracked down on prescription opioids . . . by sixty percent or more in the last ten years, opioid overdose rates doubled. It was even higher than when prescriptions were increasing because we did not reduce harm; we increased harm. We pushed people from safe medical supplies onto the streets because ‘these drugs are evil, so you can’t have them anymore.’ And ‘oh, addiction will just go away, if we cut everybody off.’

Conclusion

Maia Szalavitz makes a point similar to Henry Smith Williams in the 1930s. Regardless of bad actors or even criminals engaged in the drug trade, the government has continually chosen to rely on prohibitionist and criminalization policies proven to be ineffective again and again. These measures often provide little, if any, benefit to people who use drugs and, in turn, cause frequent suffering. To what end? As Szalavitz repeats to “send a message,” specifically that maintaining an intolerance toward drug use and users is preferable to saving lives.

The “do no harm” approach, promoted by Williams and Szalavitz acts as an implicit threat to all drug enforcement, requiring people to ask basic questions like: how does society benefit from caging drug users? What public health aims are achieved by warehousing citizens for years on end isolated from their friends and family? How does punishment advance the well-being of individuals? The answers to these questions seem self-evident to me: punishment provides no discernible benefit to society or public health; and, in fact, punishment for drug use diminishes human potential and makes a mockery out of the notion of American justice itself.

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