The importance of opium to medicine until modern times was so great that in the Nineteenth Century the accepted medical abbreviation for tincture of opium was GOM, standing for "God's own medicine." It relieved pain, stopped vomiting or diarrhea, induced sleep, and calmed the insane at a time when few of the medicines prescribed by either physicians or folk healers had any real beneficial effects.

Extracted from the unripe seed capsule of the poppy Papaver somniferum, opium is a sub¬stance that contains several drugs, including morphine and codeine. The opium may then be air dryed into granules and powdered for medicinal use or it may be boiled down, filtered through cheesecloth, and cooked into a thick, sticky paste that hardens into blocks of smoking opium.

During the Nineteenth and early Twentieth Centuries, virtually every pharmacy, grocery, and general store in America sold over-the-counter preparations of opium such as Dover's Powder, Godfrey's Elixir, Ayer's Cherry Pectoral, and Mrs. Winslow's Soothing Syrup. They were sold as teething syrups and colic cures for infants, as cures for diarrhea, upset stomach, gas, menstrual cramps, colds, tuberculosis, and cancer, and as pain killers. There were hundreds of such preparations on the market without any restriction on their sale.

Although the use of opium in various tonics and elixirs was very widespread in the United States and Europe, opium smoking was almost unheard of. Even in England, where use of the more popular smoking opium had become popular with such literary figures as DeQuincey, Byron, Shelley, Dickens, Coleridge, and Browning, the opium was swallowed and not smoked.

The British East India Company had acquired a monopoly on opium produc¬tion in India in 1757 and had promoted the use of alcohol and opium in India and China. In 1833 the British government took over control of the opium trade in China. When the Chinese government tried to block the opium trade, the British used military force to maintain the profitable commerce. Two wars were fought to maintain the opium trade with China -- the First Opium War from 1839 to 1842 and the Second Opium War from 1856 to 1860. The British laid the ground during this period for the image of the Chinese opium addict -- a habit imported into China at the cost of two wars and vigorously promoted by the British government. Less than fifteen years later there was an anti-opium campaign underway in Britain. In 1906 the British government ended its opium trade with China, but Chinese opium users continued using the drug, so an illicit trade quickly replaced the old trade monopoly.

In the United States the Civil War introduced many people to the use of morphine through the newly invented hypodermic needle. Despite an early belief by physicians that morphine was not as addictive as opium and the further belief that drugs given by injection could not be addictive, morphine addiction among soldiers became so common that opiate addiction was nicknamed the "soldier's disease." Most opiate addicts, however, were still those addicted to the patent medicines. Addiction was more common among the rich than the poor and more common among women than men. The majority of opiate addicts were able to live ordinary lives despite their addiction.

Construction of the transcontinental railroads brought large numbers of Chinese laborers to the United States after the Civil War; many of them were opium smokers. Because the Chinese laborers were greatly in demand to build the rail roads, this practice seemed to arouse no public concern. When the massive railroad construction came to an end and Chinese began to compete with whites in the job market, strong anti-Chinese feeling emerged in the United States, especially in California, where the largest numbers of Chinese had settled. Opium was pictured as part of a Chinese underworld of crime, gambling, and prostitution. In particular, opium was pictured as the means by which sinister Orientals lured white women into prostitution—addiction to opium being the bond that held them in "white slavery" (see Figure 10.6). Anti-opium laws were passed as a part of a general pattern of anti-Chinese legislation.

Meanwhile, another front had raised American concern about opium. The United States had acquired the Philippine Islands as a result of the Spanish-American War and was faced with a population in which opium use was widespread. The Spanish had operated a system of licensed clinics providing opium to addicts legally, not unlike modern methadone programs. Bishop Charles H. Brent and Dr. Hamilton Wright were appointed to study alternatives to the licensing system. They soon expanded their mission to examine the opium problem throughout the Orient. In 1905 Congress outlawed opium, except for medical purposes, in the Philippines.

In 1906 Bishop Brent wrote to President Theodore Roosevelt urging that the United States sponsor a meeting of the great powers to do something about the opium problem in Asia. Brent argued that the U.S. prohibition in the Philippines could only work if the problem in China was also solved. A conference was organized to be held in 1909 in Shanghai, China.

Many American leaders felt that the United States would be embarrassed at the Shanghai Conference by the fact that there was no anti-opium law in the United States except for state laws in New York, California, and a few other states. Hamilton Wright became a major leader in seeking a U.S. anti-opium law. His warnings against opium were full of racial slurs against the Chinese. This effort met with success and, just before the Shanghai Conference, the Smoking Opium Exclu¬sion Act was passed, banning the importation of opium for non-medical use. On this note of triumph for the American anti-opium movement, Bishop Brent was elected chairman of the Shanghai Conference.

In 1910 the Foster Bill, drafted by Dr. Wright, was introduced in Congress. This bill would have severely controlled the opium trade. Opposed by the phar¬maceutical industry and by those who felt that it would be an unconstitutional expansion of federal police powers, the Foster Bill was defeated despite President Roosevelt's efforts to gain passage.

In 1914 Congress passed the Harrison Act, a somewhat less severe measure than the Foster Bill but similar in its main provisions. This bill, however, had been expanded to include cocaine as well as opium and heroin. Although written as a tax measure to regulate the trade in opium, heroin, and cocaine, the Harrison act was enforced as if it were a prohibition. Enforcement was placed in the hands of the Internal Revenue Service (IRS).

Although the Harrison Act provided that physicians, dentists, and veterinarians could still prescribe heroin "in the course of his professional practice only," the IRS held that prescribing opiates for an addict was not proper professional practice and therefore was not allowed under the Harrison Act. Physicians who prescribed opiates must show good faith by decreasing the dosage periodically. The medical profession opposed such regulation of medical practice by the IRS and, at first, the Supreme Court agreed with the physicians. Eventually, however, the Supreme Court came to support the IRS rulings, and physicians who maintained addicts were subjected to prosecution and imprisonment.

In 1918, after 3 years of enforcing the Harrison Act, the secretary of the treasury appointed a blue-ribbon committee under the chairmanship of Con¬gressman Homer Rainey to examine the drug problem and the effectiveness of the Harrison Act. The committee found that the "wrongful use" of opiates had in¬creased, not decreased, since passage of the Harrison Act, that a national organiza tion of "dope peddlers" was developing in America, and that the "underground" traffic in opiates was about equal to the legitimate medical traffic. Having thus documented the failure of the prohibition effort, the committee urged more of the same, calling for stricter law enforcement and for passage of state laws modeled on the Harrison Act. The committee also recomended that medical treatment of addicts be provided by federal and local governments because the success of stricter laws would eliminate heroin and opium supplies and leave 1 million desperate addicts in need of treatment.

In the years that followed a great deal was done to toughen drug law enforce¬ment. In 1920 a separate Narcotics Division was set up in the Treasury Department to take over enforcement of the Harrison Act from the IRS. The new Narcotics Division launched an expensive campaign to close down clinics that were maintain¬ing addicts and to prosecute physicians who were writing prescriptions for addicts. Thus the black market gained an ever-growing clientele for its impure product as addicts were deprived of legal sources of pure heroin or morphine.

In 1930 a further reorganization of the Treasury Department's anti-drug efforts created the Federal Bureau of Narcotics. The first commissioner of this newly created bureau was Harry J. Anslinger. Like many of the bureau's agents, Anslinger was a former prohibition agent. For many years to follow his was to be one of the most influential voices in determining national (and international) drug policy—a voice that promoted every myth of the demon drugs and the dangerous dope fiends, that called always for total prohibition and strict law enforcement.

Effects of Heroin and Other Narcotics

What are the effects of heroin that have made it one of the most feared drugs in our society? To understand heroin, it must first be understood that all of the opiates (or narcotic analgesics) have essentially the same effects. They differ mainly in their potency (i.e., in how large a dose is required in order to produce those effects). They also may differ somewhat in how quickly they produce effects and in how long the effects last. The effects of heroin (an illicit drug) and morphine (a prescription drug), for instance, are exactly the same, but it takes less heroin to produce the effects, and the heroin may produce the effects somewhat more rapidly.

The main effects of any of the opiates are the relief of the subjective experience of pain and the production of drowsiness or sleep. These drugs do not so much block the experience of pain as they make the person less aware of and less concerned about the pain. They are most effective with steady, continuous pain, which the user seems to almost forget about. Sharp, irregular, or "shooting" pain is not as effec¬tively relieved by the narcotics.

Heroin, or any other opiate, produces a dreamy, mentally slow feeling. In the experienced user this state of CNS depression is usually perceived as very pleasant and euphoric. Novice users more often feel deeply depressed and unhappy. These mood changes are not entirely predictable, however, and some users will experience euphoria the first time, while experienced users will still sometimes experience a depressed mood from taking heroin.

The opiates suppress a number of basic drives. The opiate user experiences reduced aggressiveness, reduced appetite, and reduced sex drive. Males usually become mostly, if not totally, impotent; they experience difficulty in achieving or maintaining an erection and are often incapable of orgasm. Contrary to the myth of the violent and rapacious addict (the "sex-crazed dope fiend"—see Chapter 13), the heroin addict is more likely to be passive and sexless. It is when the heroin is not available and withdrawal begins that the addict may become violent, and it is during withdrawal illness that the heroin addict often becomes very sexually active as the sex drive reasserts itself.

The opiates curtail the passage of food through the digestive system by slowing or stopping the contractions of the stomach and intestines and decreasing the excre¬tion of digestive juices. It is for this reason that the opiates have long been used in the treatment of diarrhea. The heroin user, of course, develops constipation and, in heroin addicts, this becomes a chronic condition. Nausea and vomiting are also often produced by heroin. Even experienced heroin users will suffer some nausea every time they take heroin.

Opiates cause the muscular walls of the cutaneous blood vessels to relax, producing vasodilation—an increase in the diameter of the inside of the vessel. As a result, blood pressure is lowered somewhat. Increased blood flow through these vessels causes flushing and warmth of the skin, especially of the face, neck, and upper chest; itching and perspiring often also result from this increased flow of blood. As more warmth is carried to the skin and radiated out of the body, the body temperature is lowered—while the user feels hot.

Other physical effects of heroin and the opiates include reduced urinary output, slowed respiration, and constriction of the pupils of the eyes, which results in the classic symptom of "pinpoint pupils" and hypersensitivity to light. The opiates also depress the brain's cough center, thus suppressing coughing. It was for this reason that heroin was first marketed as a cough medicine.

“Heroin Overdose”

Hundreds of people die each year whose cause of death is listed as "heroin overdose." Are these people really dying from heroin overdose? There is considerable evidence now available that indicates that this is not the case. These deaths may represent "allergic reactions" to the street drugs or some component in them, they may result from interactions with other drugs (especially alcohol)being taken at the same time with the other drug as the primary cause of death, or they may be some as yet unexplained reaction to mixtures of substances sold on the street as heroin. These deaths remain in many ways quite mysterious. A thorough discussion of this mystery may be found in Brecher (1972). Remember, however, that these deaths are probably not actual heroin over¬doses because of the relatively high tolerance for heroin among experienced users and because actual heroin overdose is readily and effectively treatable.

Addiction and Withdrawal

At one time, it was generally accepted that heroin use led inevitably to physical addiction and compulsive drug taking. Today, we know that this was just one more of the myths about heroin. Zinberg (1979) and his associates have demonstrated that many persons have used heroin periodically and, in many cases, frequently over periods of years without becoming addicted. We do not know at this time whether such non-addicted heroin users are the rare exception to the rule or are the rule to which the addicts are the exception. It is worth noting, perhaps, that before passage of the Harrison Act most opiate users were not addicts, despite the very widespread use of opium, morphine, and heroin in various forms.

Nevertheless, we do know that many, and probably most, persons who use heroin repeatedly eventually become addicted to it. Psychological dependence re¬sults from reliance on heroin's tranquilizing or drive-reducing effects, while physi¬cal dependence develops because the body has adjusted to operating on the de¬pressed state caused by from the heroin and cannot operate normally in the absence of the drug. Unlike the many bad movies and television shows in which one of the support¬ing characters is turned into an addict by a single heroin injection, physical depen¬dence can only result from repeated, frequent doses of the drug. If the body is not allowed to return fully to its normal state between doses, it begins to adapt to the presence of the drug. Digestion is carried on by a slowed down gastrointestinal system, and blood pressure and body temperature return to normal despite dilation of the blood vessels in the skin. Now, if the drug is absent, the body suffers; its acquired state of normalcy in the presence of the drug is thrown off by the absence of the drug.

About 4 to 6 hours after the last dose, a heroin addict begins to experience a craving for another dose. If that dose is not available, the first stages of withdrawal illness (or abstinence syndrome) will soon follow. Approximately 8 to 12 hours after the last dose, the addict begins to experience yawning, perspiring, runny nose, watering eyes, nervousness, and a craving for sweets. During the next 36 hours, these symptoms will be joined by restlessness, irritability, muscle tremors, loss of appetite, dilated pupils, muscle aches and pains, and piloerection (hairs standing out from the body, giving the skin the "gooseflesh" appearance of a plucked bird).

As the withdrawal illness reaches it peak, 48 to 72 hours after the last dose of heroin, the sufferer experiences all the symptoms previously mentioned plus hot and cold flashes, abdominal cramps, sneezing and cold symptoms, nausea, vomiting, diarrhea, spontaneous ejaculations in men and orgasms in women, rapid heartbeat and respiration, and high blood pressure. The combination of failure to eat and fluid loss through vomiting, diarrhea, and perspiring results in rapid weight loss and abnormalities in the biochemical makeup of body fluids.

Once this peak period of symptoms has passed, the symptoms gradually sub¬side. About 10 days after the last dose, the obvious symptoms will have disap¬peared. For up to 10 weeks after the last dose, however, blood pressure, heart rate, respiratory rate, body temperature, and pupil diameter will all remain abnormal. At first, they will be above normal and then, at the end of the syndrome, they will drop below normal for a few weeks.

As severely unpleasant as the heroin withdrawal illness is, it is not as severe as it has often been depicted in motion pictures, television, or novels. It is not a life-threatening condition. Heroin withdrawal is far less severe than alcohol or barbiturate withdrawal, both of which are life-threatening illnesses. Naturally, per¬sons who have been conditioned by the media to expect extremely severe illness will experience such subjective illness and will behave like the characters they have seen going through withdrawal in movies. Fortunately for treatment personnel who must deal with patients in withdrawal, most addicts know better from seeing others undergo withdrawal illness.

All of the opiates produce essentially the same withdrawal syndrome, but they differ in how long the illness lasts. Meperidine, for instance, produces a withdrawal illness with onset about 3 hours after the last dose and peaks in 6 to 12 hours; it is completely over in 5 days. Methadone withdrawal, on the other hand, does not begin until about 24 hours after the last dose, peaks in 1 week, and gradually diminishes over the next 2 weeks.

References

Brecher , E. M. (1972). Licit and Illicit Drugs. Boston: Little, Brown.

Courtwright, D. T. (2001). Forces of Habit: Drugs and the Making of the Modern World. Cambridge, MA: Harvard University Press

Duncan, D. F., White, J., and Nicholson, T. (2003). Using internet-based surveys to reach hidden populations: Case of nonabusive illicit drug users. American Journal of Health behavior, 27, 208-218. Available online at http://www.duncan-associates.com/hiddenpop.pdf.

Zinberg, N. E. (1979). Nonaddictive opiate use. In: R. L. Dupont, A. Goldstein, and J. O'Donnell (Eds.), Handbook on Drug Abuse. Washington, DC: U.S. Government Printing Office.

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